complete health benefits guide for employees

Transcript

1 UC Health MEDICAL, DENTAL AND MORE 2019 A Complete Guide to Your and Welfare Benefits

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3 Listed below are telephone numbers and website addresses for some of the resources UC employees routinely use. MEDICAL PLANS CORE, UC Care, UC Health Savings Plan (Anthem Blue Cross) ucppoplans.com 844-437-0486 Health Savings Account (with UC Health Savings Plan) 866-212-4729 healthequity.com/ed/uc Kaiser Permanente—California (Kaiser, Optum Behavioral Health) Kaiser: 800-464-4000 my.kp.org/universityofcalifornia Optum: 888-440-8225 liveandworkwell.com (access code: 11280) UC Blue & Gold (Health Net, MHN Behavioral Health) Health Net: 800-539-4072 healthnet.com/uc MHN: 800-663-9355 (WHA, Optum Behavioral Health) Western Health Advantage WHA: 888-563-2252 choosewha.com/uc Optum: 888-440-8225 liveandworkwell.com (access code: 11280) OTHER HEALTH PLANS Delta Dental PPO 800-777-5854 deltadentalins.com/uc ® USA DeltaCare 800-422-4234 deltadentalins.com/uc Vision Service Plan 866-240-8344 vsp.com DISABILITY, LIFE AND ACCIDENT INSURANCE Accidental Death & Dismemberment Life (Basic, Core, Supplemental, Dependent) 800-524-0542 prudential.com/uc Business Travel Accident ucal.us/businesstravel Disability (Basic, Voluntary Short-Term, Voluntary Long-Term) 800-838-4461 (claims) mylincolnportal.com

4 OTHER PLANS ARAG Legal Insurance araglegalcenter.com (access code: 11700uc) 800-828-1395 Auto/Homeowner/Renter 866-680-5142 calcas.com/uc Flexible Spending Accounts (Dependent Care and Health) 800-482-4120 wageworks.com/ucfsa Bright Horizons Care Advantage careadvantage.com/universityofcalifornia 888-748-2489 Nationwide Pet Insurance petinsurance.com/uc 877-738-7874 UC EMPLOYEE WEBSITE UCnet ucnet.universityofcalifornia.edu UC BENEFITS OFFICES Berkeley Riverside 510-664-9000, option 3 951-827- 476 6 Davis San Diego 53 0 -752-17 74 858-534-2816 Davis Health San Diego Health 916-734-8099 619-543-3200 Hastings College of the Law San Francisco 415-565-4703 41 5 - 476 -1 4 0 0 Irvine San Francisco Health 949-824-5210 415-353-4545 Irvine Health Santa Barbara 714-456-5736 805-893-2489 Los Angeles Santa Cruz 310-794-0830 831- 459 -201 3 Los Angeles Health Lawrence Berkeley 310-794-0500 National Lab 510-486-6403 Merced 209-355-7178 ASUCLA 310 -825-7055 Office of the President 855-982-7284

5 Chapter Title Welcome to the UC Welcome to the University of California! As a University of California employee, you help shape the quality of life for people throughout California and around the world. Every faculty and staff member plays an important role in UC’s mission of education, research and public service; UC’s high-quality, comprehensive benefits are among the rewards you receive in return. These benefits are an important part of your total compensation. Our health and welfare benefits program provides both choice and value to meet the needs of our diverse workforce. We know that making benefits choices can be a bit overwhelming. So we have tools and information to help you make the right choices for you and your family. This booklet offers a comprehensive overview of your health and welfare benefits options, including details about eligibility, enrollment and the plans available to you. It also explains how life changes and changes in your employment status can affect your Your Benefits at a Glance (included in benefits. Keep this booklet, and your Welcome Kit), for future reference. UCnet (ucnet.universityofcalifornia.edu) offers additional tools and information, along with ongoing updates about your benefits. Visit UCnet whenever you have questions about your benefits or want to make changes. You can also call your local Benefits Office or any of the plans. You’ll find their contact information on the insert at the front of this booklet. The information in this booklet reflects the terms of the benefit plans as in effect Jan. 1, 2019. Please note that this is a summary of your benefits only; additional requirements, limitations and exclusions may apply. Refer to applicable plan documents and regulations for details. The applicable policy issued by the carrier and the University of California Group Insurance Regulations and other applicable UC policies will take precedence if there is a difference between the provisions therein and those of this document. 1

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7 Chapter Title Table of Contents Table of Contents General Eligibility Rules for UC Health and ... 43 Legal Insurance 5 ... Welfare Benefits ... 45 Pet Insurance ... 16 Enrollment 46 ... Family Care Resources ... 19 Medical Plans ... 47 Tax-Savings Programs ... 24 ... 47 Health Flexible Spending Account Dental Plans ... 48 Dependent Care Flexible Spending Account 28 ... Vision Plan ... 51 Legal Notifications 31 ... Disability Insurance 51 ... Participation Terms and Conditions 31 ... Basic and Voluntary Disability ... 52 HIPAA Notification of Medical Program Eligibility ... 53 Notice Regarding Administration of Benefits ... 34 Life Insurance 34 ... Basic and Core Life Insurance 35 ... Supplemental Life Insurance ... 37 Dependent Life Insurance ... 39 Accidental Death and Dismemberment Insurance 41 ... Business Travel Accident Insurance 3

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9 Chapter Title General Eligibility Rules for UC Health and Welfare Benefits General Eligibility Rules for UC Health and Welfare Benefits REQUIREMENTS FOR EMPLOYEES IN PER DIEM, UC offers three benefits packages—Full, Mid-Level and Core. Your eligibility for a particular benefits package depends on the CASUAL/RESTRICTED (STUDENTS), BY AGREEMENT AND type of job you have, the percentage of time you work and the SEASONAL APPOINTMENTS length of your appointment. CORE BENEFITS The eligibility requirements are listed below. See the chart on You are eligible for Core Benefits if you are appointed to work at pages 10 to 12 for a list of the benefits available to you, based on least 75 percent time for at least three months. the level of benefits for which you qualify. ELIGIBLE FAMILY MEMBERS REQUIREMENTS FOR EMPLOYEES IN CAREER, ACADEMIC, LIMITED, PARTIAL-YEAR CAREER, CONTRACT You may enroll one eligible adult family member in addition AND FLOATER APPOINTMENTS to yourself. Your children are also eligible for enrollment as outlined below. FULL BENEFITS E LI G I B LE A D U LT You are eligible for Full Benefits if you are an active UCRP 4 member, an active Savings Choice participant or have begun the You may enroll your spouse or an eligible domestic partner. 90-day election period during which you can choose between 1 No declaration form or documentation is needed to initially Pension Choice and Savings Choice. enroll your domestic partner, but you will be asked to submit There are two ways to qualify for these primary retirement - documentation after enrollment (see “Supporting Documenta benefits: tion” in Benefits for Domestic Partners) to establish ongoing eligibility for health and welfare benefits. To be eligible for • You are appointed to work in a retirement-eligible position at health and welfare benefits, your domestic partnership must 2 or least 50 percent time for a year or more meet one of the following requirements: You complete 1,000 hours in a retirement-eligible position • • Registered with the State of California or other valid within a rolling 12-month period (750 hours in certain jurisdiction OR 3 ). instances • Able to meet the requirements on page 13 for a partnership MID-LEVEL BENEFITS that has not been registered, with appropriate supporting You are eligible for Mid-Level Benefits if: documentation upon request Please note: Enrolling your domestic partner in health benefits You are appointed to work 100 percent time for at least three • and successfully completing the eligibility verification process months but for less than one year or will establish your partner as your survivor for UC Retirement • You are appointed to work at least 50 percent time for a year Plan benefits, subject to additional eligibility requirements. or more in a position that does not qualify you for the primary retirement benefits noted above. CORE BENEFITS You are eligible for Core Benefits if you are appointed to work at least 43.75 percent time. 1 In a few specifically defined situations, UC employees may be eligible to participate in UC health and welfare benefits while being enrolled in a non-UC retirement plan. Eligible employees may have been covered by entities that were acquired by the University and/or they may have opted to remain in a previous public retirement plan at the time of UC employment. 2 Or your appointment form shows that your ending date is for funding purposes only and that your employment is intended to continue for more than a year. 3 If you’re a member of the Non-Senate Instructional Unit, you qualify for participation in the Retirement Choice Program after working 750 hours in an eligible position within a 12-month period. 4 An adult dependent relative is not eligible for coverage in UC plans unless enrolled prior to Dec. 31, 2003 and continuously eligible and enrolled since that date. Also, remember: If your eligible adult dependent relative is still enrolled in the plan, you cannot enroll your spouse or domestic partner. The eligible adult may be enrolled only in the same plans as you. See the chart on page 10 for more information on eligible plans. 5

10 Chapter Title General Eligibility Rules for UC Health and Welfare Benefits General Eligibility Rules for UC Health and Welfare Benefits TAX IMPLICATIONS OF ENROLLING A DOMESTIC PARTNER ELIGIBLE CHILD In most cases, your domestic partner and your partner’s children You may enroll your eligible children up to age 26 in the same do not automatically qualify as your dependents under the plans as those in which you enroll. A disabled child may be Internal Revenue Code (IRC). That means any UC contribution covered past age 26, if the carrier approves. You may also enroll toward their medical, dental and vision coverage will be consid - your legal ward up to age 18 in the same plan(s) as those in - ered “imputed income” or taxable income for federal tax purpos which you enroll. The Family Member Eligibility chart on pages 13 and 14 gives the eligibility criteria for children, stepchildren, es. This income is reflected in your annual W-2 statement. grandchildren, disabled children and legal wards. You may enroll - If your domestic partner and partner’s children or grandchil your eligible domestic partner’s child or grandchild, even if you dren are your dependents as defined by the IRC, you are not do not enroll your partner. subject to imputed income on UC contributions toward health coverage for these family members. In order to be eligible for UC-sponsored coverage, your grandchild, step-grandchild, legal ward or overage disabled In order for your payroll records to accurately reflect this tax child(ren) (see Family Member Eligibility chart) must be claimed dependency, you’ll need to report it to UC. For UCPath, indicate as a tax dependent by you or your spouse. Your eligible the tax status of your partner and/or partner’s children when domestic partner’s grandchild must be claimed as a tax enrolling them in benefits. If you enrolled through At Your dependent by you or your domestic partner. Also eligible are Service Online (AYSO), you will receive form UPAY 886 children UC is legally required by administrative or court order Declaration of Tax Dependency ( ) from UC Human Resources each to provide with group health coverage. November if you have imputed income. (You may also receive Your children (or legal ward) are eligible for only the plans for the form if you enrolled in benefits through AYSO in 2018, which you are eligible and in which you have enrolled (See before your location transitioned to UCPath.) Complete the “Benefits Overview,” pages 10–12). form and submit it to your local Payroll Office. Except as provided in the following paragraph, application for UC’s contribution for medical, dental and vision coverage is coverage beyond age 26 due to disability must be made to the not considered imputed income for California state income tax plan 60 days prior to the date coverage is to end due to the purposes if you and your domestic partner have registered your child reaching limiting age. If application is received within this partnership with the state of California. Also, if your partner’s timeframe but the plan does not complete determination of the child is considered your stepchild under state law, federal child’s continuing eligibility by the date the child reaches the imputed income will not apply to UC’s contribution toward the plan’s upper age limit, the child will remain covered pending the child’s coverage. plan’s determination. The plan may periodically request proof If you enrolled your family members in benefits through UCPath, of continued disability, but not more than once a year after the you indicated whether your partnership was registered with the initial certification. Disabled children approved for continued state of California during the enrollment process. If you enrolled coverage under a University-sponsored medical plan are eligible in benefits through AYSO, you must notify your local Benefits for continued coverage under any other University-sponsored Office that your partnership is registered with the state of dental, vision or AD&D plan. If enrollment is transferred from California. Use form UPAY 850 ( Enrollment, Change, Cancellation one plan to another, a new application for continued coverage or Opt Out—Employees Only ), available online at ucal.us/ is not required; however, the new plan may require proof of UPAY850 or from your local Benefits Office. continued disability, but not more than once a year. Also, if your domestic partner is covered as your family member If you are a newly hired employee with a disabled child over age and the two of you marry, be sure to inform UC so that imputed 26 or if you acquire a disabled child over age 26 (through income and state taxes no longer apply. For UCPath, you can marriage, adoption or domestic partnership), you may also apply update your information in your online account. For AYSO, for coverage for that child. The child’s disability must have begun notify your local Benefits Office by submitting form UBEN 850, prior to the child turning age 26. Additionally, the child must available at ucal.us/UBEN850. have had continuous group health coverage since age 26, and you must apply for University coverage during your Period of Initial Eligibility. The plan will ask for proof of continued disability, but not more than once a year after the initial certification. OTHER ELIGIBILITY RULES AND INFORMATION NO DUPLICATE COVERAGE UC rules do not allow duplicate coverage. This means you may not be covered in UC-sponsored plans as an employee and as an eligible family member of a UC employee or retiree at the same time. 6

11 Chapter Title General Eligibility Rules for UC Health and Welfare Benefits If you are covered as an eligible family member and then become If you complete a 90-day waiting period, coverage is effective • on the 91st consecutive calendar day after the date the eligible for UC coverage yourself, you have two options: enrollment form is received. You can opt out of your own employee coverage and remain • FAMILY MEMBERS covered as another employee’s or retiree’s family member or When you have a family status change, coverage begins on the • You can enroll in your own coverage; before you enroll, first day you have a new family member—such as a spouse, though, you must make sure the UC employee or retiree domestic partner, newborn or newly adopted child. who has been covering you disenrolls you from his or her UC-sponsored plan. If you are already enrolled in adult plus child(ren) or family Family members of UC employees may not be enrolled in more coverage, you may add additional children, if eligible, at any time than one UC employee’s plan. For example, if spouses both work after their PIE. for UC, their children cannot be covered by both parents. If duplicate enrollment occurs, UC will cancel the plan with later enrollment. UC and the plans reserve the right to collect CONTINUING ELIGIBILITY reimbursement for any duplicate premium payments due to the UC bases your ongoing eligibility for benefits on your average duplicate enrollment. 5 over a 12-month, standard measurement hours of service period (SMP). UC’s SMP for monthly-paid employees is Nov. 1–Oct. 31; for bi-weekly paid employees, the SMP includes ELIGIBILITY VERIFICATION the pay periods inclusive of those same dates (for example, in 2019, it runs Nov. 4, 2018 until Nov. 2, 2019). When you enroll anyone in a plan as a family member, you must provide documentation specified by the University verifying that If your hours during the SMP meet the threshold to be offered - the individual(s) you have enrolled meet the eligibility require coverage, then that coverage must be offered, and if accepted, ments outlined above. The plan may also require documentation will be provided during the subsequent stability period, verifying eligibility status. In addition, the University and/or the regardless of your number of hours during the stability period plan reserve the right to periodically request documentation to (as long as you remain employed). UC’s standard stability period verify the continued eligibility of enrolled family members. for all employees is Jan. 1–Dec. 31. UnifyHR, which administers the family member eligibility If your hours during the SMP do not meet the threshold, then all verification process, will send you a packet of materials to help coverage ends on Dec. 31. you complete the verification process. If you fail to provide the The required average hours of service threshold is: required documentation by the deadline specified in these materials, your family member(s) will be disenrolled until verification is provided. Individuals who are not eligible family Appointment Type Average Hours Threshold members will be permanently disenrolled. 17.5 hours per week Career, Academic, Limited, Partial-Year You also may be responsible for any UC-paid premiums due to Career, Contract, Floater enrollment of ineligible individuals. Per Diem, Casual/Restricted (students), 30 hours per week By Agreement or other flat-dollar payments, Seasonal WHEN COVERAGE BEGINS The following effective dates apply provided the appropriate enrollment transaction (electronic or paper form) has been completed within the applicable enrollment period. If you enroll during a Period of Initial Eligibility (PIE), coverage • 5 Defined as all hours on pay status (including hours on call, hours on paid for you and your family members is effective the date the PIE vacation, paid holiday, paid sick leave, paid sabbatical, paid jury duty, or any starts. other paid leave) as well as hours on unpaid leave protected by the federal Family & Medical Leave Act, unpaid jury duty, and unpaid leave protected by the • If you enroll during Open Enrollment, the effective date of Uniformed Services Employment & Reemployment Rights Act. May also include coverage is the date announced by the University. In most up to 501 hours during the SMP due to “employment break periods” of at least cases, it is the January 1 following Open Enrollment. 4 consecutive weeks (e.g., academic breaks, etc.). 7

12 General Eligibility Rules for UC Health and Welfare Benefits General Eligibility Rules for UC Health and Welfare Benefits WHEN COVERAGE ENDS Unless a child is eligible to An eligible child turning age 26. continue coverage because of disability, coverage ends at the The termination of coverage provisions established by the end of the month in which the child reaches age 26. This rule University are summarized below. applies to your biological and adopted children, stepchildren, grandchildren, step-grandchildren and your domestic partner’s DISENROLLMENT DUE TO LOSS OF ELIGIBLE STATUS children or grandchildren. Certain coverage may be continued If you are an employee and lose eligibility, your coverage and under COBRA or they may seek individual coverage, including that of any enrolled family members ends at the end of the through the healthcare marketplace (coveredca.com). month in which eligible status is lost. Eligibility ends at the end of the A legal ward turning age 18. OTHER DISENROLLMENTS month in which the legal ward turns 18. Your legal ward may If you are enrolled in a health and welfare plan that requires continue certain coverage under COBRA or they may seek premium payments, and you do not continue payment, your individual coverage, including through the healthcare coverage will be terminated at the end of the last month for marketplace (coveredca.com). which you paid. Coverage for the family member Death of a family member. You and/or your family members may be disenrolled if you and/or ends at the end of the month in which the death occurs. It is a family member misuse the plan, as described in the Group important to contact your local Benefits Office for further Insurance Regulations. Misuse includes, but is not limited to, assistance in the event of an enrolled family member’s death. actions such as falsifying enrollment or claims information; CONTRACT TERMINATION allowing others to use the plan identification card; intentionally enrolling, or failing to disenroll, individuals who are not/no longer Health and welfare benefits coverage is terminated when the group eligible family members; threats or abusive behavior toward plan contract between the University and the plan vendor is terminated. providers or representatives. Benefits will cease to be provided as specified in the contract and you may have to pay for the cost of those benefits incurred after LEAVE OF ABSENCE, LAYOFF, CHANGE IN EMPLOYMENT the contract terminates. You may be entitled to continued benefits STATUS OR RETIREMENT under terms described in the plan evidence of coverage booklet. (If Coverage may end when you go on unpaid leave or leave UC you apply for an individual conversion plan, the benefits may not employment. For information about continuing your coverage be the same as you had under the original plans.) in the event of an authorized leave of absence, layoff, change OPPORTUNITIES FOR CONTINUATION of employment status or retirement, contact the person who handles benefits for your location. If you separate from UC employment, generally, your UC-sponsored benefits will stop. If you retire from UC, see FAMILY CHANGES THAT RESULT IN LOSS OF COVERAGE the Group Insurance Eligibility Factsheet for Retirees and Eligible If your familly member loses eligibility, you must complete the (available on the UCnet website at Family Members appropriate transaction to remove him or her from coverage ucnet.universityofcalifornia.edu/forms/pdf/group-insurance- within 31 days of the eligibility loss event. eligibility-factsheet-for-retirees.pdf) for more details. Divorce, legal separation, termination of domestic COBRA (Consolidated Omnibus Budget Reconciliation Act partnership, annulment. Eligibility for your spouse or domestic If you or any family member(s) lose eligibility for of 1985): partner and any children for whom you are not the legal parent/ UC-sponsored medical, dental and/or vision coverage, you may guardian ends on the last day of the month in which the event be able to continue group coverage through COBRA. occurs. Your legally separated spouse, former spouse or former If you are enrolled in the Health Flexible Spending Account (FSA) domestic partner and the former partner’s child or grandchild and you leave UC employment during the plan year, you may be may continue certain coverage under COBRA (Consolidated able to continue your participation under COBRA through the Omnibus Budget Reconciliation Act of 1985) or they may seek end of the current plan year (December 31) by making direct, - individual coverage, including through the healthcare market after-tax payments to your account. place (coveredca.com). If a settlement agreement between you and your legally separated/former spouse or domestic partner If you lose eligibility, the COBRA administrator will send you a requires you to provide coverage, you must do so on your own. “Qualifying Event Notice,” which explains the procedure for continuing your participation. If your family member loses eligibility, you must request COBRA through your local Benefits Office. More information about COBRA continuation privileges is available online at ucal.us/COBRA or from your Benefits Office. 8

13 General Eligibility Rules for UC Health and Welfare Benefits FOR MORE INFORMATION Conversion/Portability: Within 31 days after UC-sponsored coverage ends (if your participation has been continuous), you Participation Terms and Conditions on page 51 • may be able to convert your group coverage to individual policies or continue (“port”) your group coverage. See the • Benefits for Domestic Partners specific plan sections which follow for details. Your local benefits office • Also, you may wish to contact the California Department of Managed Health Care at www.dmhc.ca.gov or 888-466-2219 to determine whether you are eligible for HIPAA Guaranteed Issue individual plan coverage or Covered California, California’s health insurance marketplace, at www.coveredca.com or 800-300-1506 to review options for purchasing individual plan coverage. ELIGIBILITY FOR STATE PREMIUM ASSISTANCE If you are eligible for health coverage from UC, but cannot afford the premiums, some states have premium assistance programs that can help pay for coverage from their Medicaid or Children’s Health Insurance Program (CHIP) funds. If you live in California, you can contact the California Medicaid (Medi-Cal) office for further information via email ([email protected] ca.gov) or visit their website (dhcs.ca.gov). If you live outside of California, go online to ucal.us/chipra for a list of states that currently provide premium assistance. You can also contact the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services at cms.hhs.gov; 877-267-2323, ext. 61565. 9

14 Benefits Overview Benefits Overview Full Core During PIE During OE 90-Day Wait¹ Automatic With SOH² Premium Paid By Benefits Packages HEALTH CARE Mid-Level When You May Enroll Medical³ You Choice of various options depending on your address, including health maintenance and • • • • • organization (HMO), preferred provider organization (PPO) or a PPO with a health UC savings account. See page 19. Medical—CORE UC • • • • • • Fee-for-service plan with a high deductible. See page 19. Dental³ Choice of two plans: Delta Dental PPO, a fee-for-service plan, or DeltaCare® USA, a UC • • • dental HMO (network available in California only). Both cover preventive, basic and prosthetic dentistry, as well as orthodontics. See page 24. Vision³ UC Plan covers a variety of vision care services including eye exams, corrective lenses and • • • frames. See page 28. DISABILITY INSURANCE 4 Basic Disability Provides basic coverage when unable to work due to pregnancy/childbirth or due to a UC • • • • disabling injury or illness not related to work. Pays 55% of eligible earnings for up to six months ($800 monthly maximum), after a waiting period. See page 31. 5 Voluntary Short-Term and/or Voluntary Long-Term Disability Provides short-term and/or long-term coverage for disabilities that are and are not related to work, such as pregnancy/childbirth, injury or illness. Supplements employer- You paid Basic Disability and other sources of disability income you may receive (e.g., • • • • • Worker’s Compensation or Social Security), up to 60% of eligible earnings ($15,000 maximum monthly benefit). Enroll in Voluntary Short-Term Disability, Voluntary Long-Term Disability or both. See page 31. Workers’ Compensation UC • • • • Provides state-mandated coverage for work-related injuries. PIE: Period of Initial Eligibility OE: Open Enrollment SOH: Statement of Health 1 The 90-day waiting period is available when the PIE is missed. See page 19. You may need to pay part of your premiums on an after-tax basis. 2 If you do not enroll during the PIE, you may apply for coverage by submitting an evidence of insurability/statement of health. The carrier may or may not approve your enrollment based on medical information in your application. 3 When you enroll in any UC-sponsored medical, dental or vision plan, you will not be excluded from enrollment based on your health, nor will your premium or level of benefits be based on any genetic information or pre-existing health conditions. The same applies to your eligible family members. 4 Employees are not covered under California State Disability Insurance for period of employment at UC. 5 If you have a pre-existing condition which causes you to be disabled in your first year of coverage, your Voluntary Long-Term Disability benefits will not be payable. For more information, see the insurance carrier’s summary plan description and . Your Guide to UC Disability Benefits 10

15 Benefits Overview Benefits Packages Mid-Level Core When You May Enroll During PIE During OE 90-Day Wait Automatic With SOH Premium Paid By Full LIFE AND ACCIDENT INSURANCE Basic Life Provides employees eligible for Full Benefits with life insurance equal to annual base UC • • salary, up to $50,000. Coverage is adjusted if appointment is less than 100% time. See page 34. Core Life UC Provides employees eligible for Core or Mid-Level Benefits with $5,000 of life insurance. • • • See page 34. Supplemental Life Provides employees with additional life insurance at group rates. Coverage up to four You • • • • times annual salary (to $1,000,000 maximum). See page 35. Basic Dependent Life You Provides $5,000 of coverage for employee’s spouse or domestic partner and each child. • • • • See page 37. Expanded Dependent Life You Covers spouse or domestic partner for 50% (up to $200,000) of employee’s Supplemental • • • • Life amount. Covers each child for $10,000. See page 37. Accidental Death & Dismemberment (AD&D) You may enroll at any time. Provides up to $500,000 protection for employee and family You • • • • for accidental death, loss of limb, sight, speech or hearing, or for complete and irreversible paralysis. See page 39. Business Travel Accident UC Provides up to $500,000 of coverage when an employee travels on official UC business. • • • See page 41 for enrollment instructions. OTHER BENEFITS Legal Enrollment may be offered during Open Enrollment in some cases. Provides basic legal You • • • • assistance for consultation/representation, domestic, consumer and limited defensive legal services and identity theft benefits. See page 43. Pet Insurance You • • • You may enroll at any time; see page 45. Automobile and Homeowner/Renter You may enroll at any time. Individually underwritten plan provides coverage for cars, You • • • boats, motorcycles, homes and apartments. Carrier underwriting requirements must also be met. Family Care Resources You Provides access to prescreened caregivers, pet sitters, tutors and other family services. • • • You may enroll at any time; see page 46. Statement of Health PIE: Period of Initial Eligibility OE: Open Enrollment SOH: 11

16 Chapter Title Benefits Overview Benefits Overview TAX-SAVINGS PROGRAMS Full Mid-Level Core When You May Enroll During PIE Benefits Packages 90-Day Wait Automatic With SOH Pretax Salary Reduction During OE General Purpose Health Flexible Spending Account (Health FSA) Lowers taxable income by allowing payment for up to $2,650 of eligible out-of-pocket • • • • • • health care expenses on a pretax basis. See page 47. Dependent Care Flexible Spending Account (DepCare FSA) Lowers taxable income by allowing payment for up to $5,000 ($2,500 if married and filing • • • • • • a separate income tax return) of eligible dependent care expenses on a pretax basis. See page 48. PIE: Period of Initial Eligibility OE: Open Enrollment SOH: Statement of Health 12

17 Chapter Title Benefits Overview AD&D Eligibility Medical Dental Vision ELIGIBLE FAMILY MEMBERS May enroll in Legal Dependent Life 1 Eligible Legal Spouse • • • • • • Domestic Partner A domestic partnership is eligible if it is: • Registered with the state of California or • A valid union, other than a marriage, entered into in another jurisdiction and recognized in California as substantially equivalent to a California registered domestic partnership or • Unregistered, but meets all of the following criteria: – Parties must be each other’s sole domestic partner in a long-term, committed relationship Eligible • • • • • • and must intend to remain so indefinitely – Neither party may be legally married or be a partner in another domestic partnership – Parties must not be related to each other by blood to a degree that would prohibit legal marriage in the State of California – Both parties must be at least 18 years old and capable of consenting to the relationship – Both parties must be financially interdependent – Parties must share a common residence 2 To age 26 Biological or adopted child, stepchild, domestic partner’s child • • • • • • 2 Grandchild, step-grandchild, domestic partner’s grandchild • Unmarried To age 26 • Living with you • • • • • • • Supported by you or your spouse/domestic partner (50% or more) • Claimed as a tax dependent by you or your spouse/domestic partner Legal ward • Unmarried Living with you • To age 18 • • • • • • Supported by you or your spouse/domestic partner (50% or more) • • Claimed as your tax dependent Court-ordered guardianship required • 1 A legally separated or divorced spouse is not eligible for UC-sponsored coverage. 2 Domestic partner must be eligible for UC-sponsored health coverage. 13

18 Chapter Title Benefits Overview Benefits Overview ELIGIBLE FAMILY MEMBERS Dental Vision Dependent Life AD&D Legal Medical Eligibility May enroll in Overage disabled child (except a legal ward) of employee Unmarried • • Incapable of self-support due to a mental or physical disability incurred prior to age 26 • Enrolled in a UC group medical plan before age 26 and coverage is continuous or, if you are a newly eligible employee with, or have newly acquired, a disabled child over age 26, the child must have had continuous coverage since age 26 Age 26 • • • • • • or older • Chiefly dependent upon you, your spouse or eligible domestic partner for support (50% or more) • Claimed as your, your spouse’s or your eligible domestic partner’s dependent for income tax purposes or eligible for Social Security income or Supplemental Security Income as a disabled person. The overage disabled child may be working in supported employment that may offset the Social Security or Supplemental Security Income • Must be approved by the carrier before age 26 or by the carrier during your PIE if you are a newly eligible employee or if you newly acquire a disabled child over age 26 14

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20 Enrollment Enrollment To be certain you get the benefits coverage you want, you should During this family member PIE, some plans allow you to also enroll yourself and your eligible family members when you first enroll yourself and/or any other eligible family member who was become eligible. not already enrolled during an earlier PIE. See the plan-specific sections at the back of this booklet. Remember that family Your For step-by-step instructions on how to enroll, see members are only eligible for coverage in medical, dental, vision, Benefits at a Glance , which you received in your Welcome Kit. legal, AD&D and dependent life coverage and must be enrolled in the same plans in which you are enrolled. WHEN TO ENROLL OTHER ENROLLMENT OPPORTUNITIES DURING A PERIOD OF INITIAL ELIGIBILITY (PIE) A PIE is a time during which you may enroll yourself and/or your If you don’t enroll in benefits during your initial 31-day period eligible family members in UC-sponsored health and welfare of eligibility, you may be able to enroll yourself and your family plans. A PIE generally starts on the first day of eligibility—for members in some plans at other times, including: example, the day you are hired into a position that makes you OPEN ENROLLMENT eligible for benefits. It ends 31 days later. Usually held in the fall, Open Enrollment is your annual You should enroll online and complete the transaction by the opportunity to make changes to your benefits, including: last day of the applicable PIE. Paper enrollment forms are Transferring to a different medical or dental plan • available and need to be received at the location noted on the form by the last day of the applicable PIE. (If the last day falls • Adding or disenrolling eligible family members on a weekend or holiday, the PIE is extended to the following Enrolling in or opting out of UC-sponsored medical, dental • work day.) and vision plans and You may enroll your eligible family members during the 31-day Enrolling or re-enrolling in the Health and Dependent Care • PIE that begins on the first day the family member meets all Flexible Spending Accounts eligibility requirements. If your enrollment is completed during your PIE, coverage is effective the date the PIE began. Changes made during Open Enrollment are effective January 1 of the following year. Not all plans are available during every The PIE to enroll newly eligible family members starts the day Open Enrollment. your family member becomes eligible: WHEN YOU HAVE A FAMILY CHANGE For a spouse, on the date of marriage. • When you have a new family member, such as a spouse, domestic • For a domestic partner, on the date the domestic partnership partner, newborn or newly adopted child, you may enroll yourself, is registered or the date that you verify that the partnership the new family member and any other eligible family members not meets UC’s criteria (see page 13). already enrolled in your UC-sponsored health plans. Other plans have different rules; see the plan-specific sections in this guide • For a newborn child, on the child’s date of birth. for details. • For an adopted child, the earlier of: If you are enrolled in a UC-sponsored medical plan, you may the date the child is placed for adoption with you, or – transfer to a different plan. You may also enroll in or increase – the date you or your spouse/domestic partner has the legal your Supplemental Life insurance and Dependent Life insurance right to control the child’s health care. during this eligibility period (however, restrictions apply to A child is “placed for adoption” as of the date you assume and Dependent Life insurance). There is no opportunity to enroll in retain a legal obligation for the child’s total or partial support Voluntary Short-Term or Voluntary Long-Term Disability in anticipation of the child’s adoption. insurance. If the child is not enrolled during the PIE beginning on that You have 31 days from the date your new family member becomes date, there is an additional PIE beginning on the date the eligible to enroll the new member or to make any permitted plan adoption becomes final. changes (for example, 31 days from the day you marry or your For a legal ward, the effective date of the legal guardianship. • child is born). Enrollment is not automatic. Employees who manage their benefits through UCPath may enroll family Where there is more than one eligibility requirement, the PIE members online. Employees who manage their benefits begins on the date all requirements are satisfied. 16

21 Enrollment through AYSO must complete a UPAY 850 form (available OTHER SPECIAL CIRCUMSTANCES online at ucal.us/UPAY850 or from your Benefits Office) to For medical, dental and vision coverage, you may enroll without enroll the new family member. waiting for the University’s next open enrollment period if you are otherwise eligible under any one of the circumstances below: You will be required to complete the Family Member Eligibility Verification process after enrolling the new family member. If • You or your eligible family members are not currently enrolled you do not respond by the given deadline, your new family in UC-sponsored medical, dental or vision coverage and you member may be disenrolled from the plans. or your eligible family members become eligible for premium assistance under the Medi-Cal Health Insurance Premium WHEN YOU LOSE OTHER COVERAGE Payment (HIPP) Program or a Medicaid or CHIP premium If you decline UC-sponsored coverage because you and/or your assistance program in another state. Your PIE is 60 days from family members are covered elsewhere, and you later lose the the date you are determined eligible for premium assistance. other coverage, you may be eligible to enroll yourself and/or If the last day of the PIE falls on a weekend or holiday, the PIE your eligible family members in a UC-sponsored plan. The same is extended to the following work day if you are enrolling with is true if you are enrolled in another employer-sponsored plan paper forms. and the employer stops contributing to the cost of the coverage. A court has ordered the University of California to provide • coverage for a dependent child under your UC-sponsored For medical, dental and vision coverage, you may enroll without medical, dental or vision plan pursuant to applicable law. The waiting for the University’s next open enrollment period if you child must meet UC eligibility requirements. have met all of the following requirements: IF YOU ARE A NEW FACULTY MEMBER • You were covered under another health plan as an individual or dependent, including coverage under COBRA or CalCOBRA Newly appointed faculty members who don’t enroll within 31 days (or similar program in another state), the Children’s Health of their start date have a second period of eligibility that begins Insurance Program or “CHIP” (called the Healthy Families on the first day of classes for the semester or quarter in which the Program in California), or Medicaid (called Medi-Cal in appointment starts or the first day the faculty member arrives at California). the campus, whichever comes first. • Coverage under another health plan for you and/or your eligible family members ended because you/they lost eligibility under the other plan or employer contributions toward coverage under the other plan terminated, coverage under COBRA or CalCOBRA continuation was exhausted, or coverage under CHIP or Medicaid was lost because you/they were no longer eligible for those programs. • You properly file an enrollment form with the University during the 31-day PIE which starts on the day after the other coverage ends. Note that if you lose coverage under CHIP or You may need to provide proof Medicaid, your PIE is 60 days. of loss of coverage. Appeals Any appeals regarding coverage denials that relate to eligibil - ity or enrollment requirements are subject to the University of California Group Insurance Regulations. To obtain a copy of the Eligibility Claims Appeal Process, please contact the person who handles benefits for your location. 17

22 Chapter Title Chapter Title Body Copy 18

23 Chapter Title Medical Plans Medical Plans Full, Mid-Level, Core Benefits packages: IF YOU MOVE OUT OF A PLAN’S SERVICE AREA If you move out of a plan service area, or will be away for more You and your eligible family members Who’s covered: than two months, you and your eligible family members must transfer into a different plan available in your new location. If Who pays the premium: You and UC, for most plans you later return to your original location, you will have a Period of Initial Eligibility to enroll in a plan of your choosing available in Medical coverage is one of the most important benefits that the original location. UC offers you and your eligible family members, and UC makes medical coverage as accessible and affordable as possible. - UC offers a range of high-quality medical plans with comprehen WHAT THE PLANS COVER sive coverage so you can choose the coverage that best meets UC’s medical plans provide comprehensive coverage, including your needs. doctor visits, hospital services, prescription drugs and behavioral You should carefully evaluate your family circumstances and plan health services. Preventive care such as physical exams and costs before selecting medical plan coverage. If you need more immunizations are free of charge in all plans; some restrictions, information about a specific medical plan, you’ll find telephone such as using in-network providers, may apply. numbers and links to all the plans’ websites on the inside cover of There are no exclusions for pre-existing conditions. this guide. An overview of the plans UC offers is on pages 20 to 22. The In addition to the general eligibility rules beginning on page 5 chart on page 23 provides a comparison of the plans. and plan eligibility rules found in each plan’s evidence of coverage booklet, the following rules and information apply to UC medical plans. COST OF COVERAGE Your medical plan’s monthly cost depends on: ELIGIBILITY The plan you choose • The medical plans you’re eligible for are based on whether your overall benefits package is Full, Mid-level or Core. • Whether you choose to cover yourself only or yourself and other family members and If you are eligible for coverage, you must take action to enroll. Your annual full-time equivalent salary • You may enroll in certain medical plans only if you meet the Premium costs are available online at ucal.us/medicalpremiums plan’s geographic service area criteria. included in your Which Medical Plan is Right for You? and in Welcome Kit. If you or a covered family member is enrolled in Medicare, you are not eligible for the UC Health Savings Plan due to IRS rules Please note: if you are represented by a union, your premiums that do not allow Medicare members to make or receive are subject to collective bargaining and may be different from contributions to a Health Savings Account. those posted or printed. Your premiums are available when you sign in to At Your Service Online or the UCPath portal or talk to WITH A 90-DAY WAITING PERIOD your Benefits Office. If you miss your initial enrollment period, you may enroll yourself and/or your family members in medical coverage at any time by submitting an enrollment form to your Benefits Office. Your medical coverage will become effective 90 calendar days from the date your form is received. Your premiums will be paid on an after-tax basis until the following January 1. 19

24 Chapter Title Medical Plans Medical Plans HEALTH MAINTENANCE ORGANIZATIONS (HMO) You must live (or work, depending on the plan’s rules) in the plan’s service area to be eligible. Service areas are established HMOs require you to choose a primary care physician (PCP) from by ZIP codes; you cannot use a P.O. box to establish eligibility. their network of providers to coordinate your care. To see a If you want to know whether your ZIP code is in a plan’s service specialist, you must have a referral from your PCP. The HMO area, check the plan’s website or call the plan directly. covers your expenses only if your PCP has authorized the services, unless it’s an emergency. You pay a copayment for some products UC’s HMOs are available to employees living and working in and services, and there is no annual deductible. certain counties in California only. UC’S HMO Offers a tailored network of medical groups, doctors and hospitals, and includes all of UC’s medical centers UC Blue & Gold HMO and medical groups. For more information, see healthnet.com/uc Kaiser Permanente—CA Offers a closed network, meaning you must use only Kaiser doctors and hospitals. For more information, see kp.org/universityofcalifornia Western Health Advantage Provides a regional network of medical groups, doctors and hospitals in the following areas: Davis/Sacramento (including UC Davis Health System); Marin, Napa, Solano, Sonoma and Yolo counties; and some zip codes in Colusa, El Dorado and Placer counties. For more information, see choosewha.com/uc PREFERRED PROVIDER ORGANIZATIONS (PPO) Anthem Blue Cross is the administrator of medical, behavioral health and prescription drug benefits for UC’s PPO plans. The PPOs offer a broad network of providers and allow you the administrator of your plan processes claims, creates a network flexibility to see non-network providers if you wish. You don’t of health care providers or pharmacies and sets clinical policies need a referral to see your primary care doctor or specialists. and guidelines. Usually, you must meet the plan’s deductible and then you pay coinsurance, which is a percentage of the cost of services. You pay a smaller percentage for in-network providers. UC’S PPO UC Health Savings Plan This is a high-deductible PPO plan with a Health Savings Account (HSA), which you can use to pay your eligible medical expenses. UC contributes to the HSA and you can, too—federal tax-free. You pay the cost of medical services until you meet the deductible, then you pay a percentage of the cost of services, with lower costs when you use in-network providers. You own the HSA, so the money goes with you if you leave UC. You can continue to contribute to it as long as you are enrolled in a qualifying high deductible health plan. For more information, see ucppoplans.com and learn.healthequity.com/uc/hsa This is a PPO plan with three tiers. If you use providers in the UC Select Network, which includes UC medical UC Care center doctors, hospitals and other facilities as well as select providers near other UC locations, you pay copayments for services. If you use other providers in the Anthem Preferred network, you pay 20 percent coinsurance once you’ve met the deductible. You pay a higher deductible and a greater percent of the coinsurance if you use a provider outside the network. For more information, see ucppoplans.com CORE Fee-for-Service Plan This is UC’s catastrophic coverage plan. You can choose any doctor, hospital, clinic or behavioral health provid - er, but you pay less if you use a provider in the Anthem Blue Cross PPO network. After you have met the plan’s annual deductible, the plan pays for part of the cost of services. If you use non-network providers, you must pay for services up front and submit a claim; you receive reimbursement if the plan covers the service. For more information, see ucppoplans.com 20

25 Chapter Title Medical Plans Whether you are eligible to make contributions to an HSA ABOUT THE UC HEALTH SAVINGS PLAN (HSP) WITH • HEALTH SAVINGS ACCOUNT (HSA) The amount of the eligible contribution to the HSA for any • calendar year The Health Savings Account (HSA), which is part of the UC • The withdrawal of any excess contributions Health Savings Plan (HSP), lets you pay for your out-of-pocket health care expenses with tax-free contributions from you and How funds in your HSA will be spent • from UC. You cannot delegate these responsibilities to the University or to HealthEquity. As the HSA owner, you are responsible for With the HSA, administered by Health Equity, you can use the reporting all contributions and distributions to the IRS on your funds at any time for qualified medical expenses or save them for Form 1040. future health care needs. You file claims directly with Health Equity. Your HSA account balance rolls over annually; you keep the balance in the account, even if you don’t use it or leave UC. When you’re ready to use your funds for qualifying medical expenses, BEHAVIORAL HEALTH AND SUBSTANCE ABUSE BENEFITS you can take them out of your HSA without paying any federal taxes. You earn interest on your account, and can invest any funds Behavioral health and substance abuse coverage is provided by in excess of $1,000—the same way you invest funds in retirement Optum Behavioral Health for employees and retirees enrolled in: savings accounts, except interest accrues federal tax-free. Contributions and earnings are subject to California income tax. • Kaiser Western Health Advantage • For 2019, the IRS allows HSA contributions up to $3,500 for single/individual coverage and up to $7,000 for family coverage (if Kaiser members have access to Kaiser’s integrated behavioral you are covering at least one family member), inclusive of UC health services as well as Optum in-network services. Kaiser contributions. UC contributes up to $500 for individual coverage and Optum do not coordinate care or costs of behavioral health and up to $1,000 for all other coverage levels, depending on the services. Each plan has specific requirements. Kaiser members effective date of your HSP coverage. You can also contribute with should understand plan and authorization guidelines when they pretax payroll deductions, subject to payroll deadlines. You are consider their options for behavioral health services. responsible for making sure the combined HSA contributions are within the IRS limits. Individuals age 55 and older can make an UC Blue & Gold HMO members have behavioral health and additional “catch-up” contribution of $1,000. For UCPath, the substance abuse coverage provided by Managed Health additional contribution can be made through your online account. Network (MHN, a Health Net company). For At Your Service Online, you’ll need to submit the UPAY 850 form (ucal.us/UPAY850). If you enroll in the UC Health Savings Behavioral health and substance abuse coverage is provided by Plan anytime after January, UC’s contribution to your HSA will be Anthem Blue Cross for employees and retirees enrolled in: prorated for the calendar year. The proration schedule is available CORE • online (ucnet.universityofcalifornia.edu/compensation-and- benefits/health-plans/medical/hsa-proration-schedule.html). • UC Care • UC Health Savings Plan (HSP) To be eligible for the HSA, you must enroll in the UC Health Savings Plan. You also must have a valid Social Security number The first three in-network outpatient mental health visits are covered and U.S. address to establish your HSA. In addition, you cannot at no cost to you for UC Care. enroll in UC’s or in any general-purpose Health Flexible Spending Account. If you enroll in CORE, UC Health Savings Plan or UC Care, you have access to both in-network and out-of-network behavioral If you or your dependent(s) are enrolled in Medicare, you cannot health services. All other plans have in-network benefits only. enroll in this plan, according to the IRS. Due to the UC contribution to your HSA, if you cover a family member and the family member is enrolled in Medicare, you cannot enroll in this plan unless you disenroll your Medicare-enrolled family member from your UC LIVING WELL PROGRAM coverage. Remember that the entire UC contribution is deposited automatically at the beginning of the year and is based on your UC is committed to the well-being of employees and their coverage level. family members and supports healthy living through the systemwide UC Living Well program. Here are a few things to keep in mind if you become an HSP member. As an HSA owner, you must decide: UC Living Well offers faculty, staff and retirees access to programs, activities and resources that support healthy lifestyles. 21

26 Chapter Title Medical Plans Medical Plans You may be able to convert your coverage to an individual policy UC Living Well includes: if you apply within 31 days of the date your UC-sponsored Campus and health system wellness activities • coverage or COBRA continuation coverage ends. Conversion options are generally more expensive and may provide fewer • Programs and support from UC’s benefits providers benefits than UC-sponsored plans. See your medical plan Preventive exams and screenings through UC’s health plans • booklet or call your plan for more information. You may also • Disease management programs offered by UC’s medical plans seek individual coverage, including through the healthcare to help manage chronic conditions such as diabetes and heart marketplace (coveredca.com). disease Participation in on-site campus and health system wellness FOR MORE INFORMATION programs varies by location; contact your location’s wellness coordinator for details. Evidence of Coverage booklets for all of UC’s medical plans are available online at ucal.us/EOCs or from the carriers (see front For more information, visit the UC Living Well website of booklet for contact information). (uclivingwell.ucop.edu). If you have other questions about your medical benefits, including services, benefits, billing and claims, call the medical plan directly. GENERAL INFORMATION TIPS: CHOOSING A PRIMARY CARE PHYSICIAN (PCP) UC’s HMO plans require you to select a primary care physician If you want lower monthly premiums: (PCP). You may choose a different PCP for each family member • UC Health Savings Plan with HSA or the same PCP for the entire family. You may choose a CORE • pediatrician as the PCP for your child(ren). If you use your work Kaiser Permanente • address to qualify for a plan, you must pick PCPs in the service • Western Health Advantage area of your work address. If you want more flexibility in choosing doctors: If you or your eligible family members do not select a PCP, your medical plan will assign one to you. You may change your PCP at UC Health Savings Plan with HSA • any time by calling the plan directly. UC Care • CORE • If you want to receive care from a particular doctor, you should call the plan or check the plan’s online doctor directory to confirm If you want predictable costs: that the doctor is in their network and accepting new patients. UC Blue & Gold HMO • Kaiser Permanente • ID CARDS • Western Health Advantage Once you enroll, the medical plan will send identification cards for you and your enrolled family members. Although you’re covered If you reside or have a child in college outside California: as soon as you enroll, it may take 30 to 60 days for the plan to • UC Health Savings Plan have a record of your membership and send your ID card(s). If you • UC Care need immediate services before you receive your card, first check CORE • with your plan to see if it has a record of your enrollment; if not, contact your Benefits Office. You may also be able to download If you want one doctor to manage all your care: and print a temporary card from your carrier’s website. UC Blue & Gold HMO • WHEN COVERAGE ENDS Kaiser Permanente • Western Health Advantage • Please note that if you lose eligibility for medical coverage while you are hospitalized or undergoing treatment for a medical condition If you want access to UC medical centers and doctors: covered by your medical plan, benefits will cease and you may have UC Health Savings Plan • to pay for the cost of those services yourself. If you or a family • UC Blue & Gold HMO (if you are within service area) member loses eligibility for medical coverage, you can, however, continue coverage under COBRA (Consolidated Omnibus Budget UC Care • Reconciliation Act of 1985) for a period of time. If you are laid off, Western Health Advantage • you may transfer to UC’s lowest cost medical plan through COBRA. CORE • 22

27 Chapter Title Medical Plans Medical Plans Your Cost for Prescription Drugs: Your Monthly Generic/Brand/ UC MEDICAL PLANS Premium Non-formulary Best Fit for People Who: Your Costs for Services CORE $0 $$$+ Want to pay no monthly premium • 20% You may use any doctor. • Want protection for catastrophic care Except for certain preventive services, you • Are willing to risk incurring high pay the full cost until you out-of-pocket costs - reach the $3,000 deduct Want direct access to many providers • ible. Then you pay 20%. without need for referrals UC Blue & Gold HMO Want lower premium and cost per • $$ $ Retail (30-day supply) Must use custom network $5/$25/$40 service No deductible; you pay a of providers, except in Are comfortable with HMO model: • copay for office visits and Mail order (up to 90 days) emergencies primary care physician manages care; $10/$50/$80 hospital stays; most other no out-of-network coverage services have no charge. Are content with the selection of • community providers Want lower premium and cost per • $ $ Retail (30-day supply) Kaiser Permanente—CA Must use network providers, $5/$25/NA service No deductible; you pay a except in emergencies Are comfortable with getting medical • Mail order (31–100 days) copay for office visits and care only within the Kaiser system $10/$50/NA hospital stays; most other services have no charge. UC Care Want direct access to many providers • Retail (30-day supply) $$$ $/$$ without a referral May use any doctor without $5/ $25/ $40 UC Select Network referral from a primary care Want no deductible and fixed copay • providers: no deductible, Mail order (up to 90 days) physician; you pay copayment for for using providers in the UC Select and copay for office visits $10/$50/$80 UC Select Network providers; network and hospital stays; Anthem in-network providers cost less Preferred providers: • Want coverage when you are traveling than out-of-network providers. calendar year deductible or living abroad and then 20% coinsurance; You and/or your family members live • out-of-network: calendar outside California year deductible and then 50% coinsurance. • $$$ UC Health Savings Plan $ Full cost up to deductible; Want lower premium and broad access to providers May use any doctor without then 20% at in-network You have higher out-of- referral from primary care pharmacies; 40% at • Are able to risk incurring greater pocket costs until the non-network pharmacies physician; in-network providers out-of-pocket costs deductible is met; you pay cost less. Health Savings Account coinsurance thereafter. You Want tax-free savings for current and • (HSA) covers part of annual may make pretax contribu- future health care costs deductible before PPO tions to the Health Savings coinsurance applies. Want direct access to many providers • Account to help pay your without need for referrals out-of-pocket costs. Want lower premium and cost per • $ $ Retail (30-day supply) Western Health Advantage $5/$25/$40 Must use network providers, service No deductible; you pay a except in emergencies • Are comfortable with HMO model: copay for office visits and Mail order (up to 90 days) primary care physician manages care; $10/$50/$80 hospital stays; most other no out-of-network coverage services have no charge. $ Lowest costs in relation to all plans $$ Mid-range of costs in relation to all plans $$$ Highest costs in relation to all plans 23

28 Chapter Title Dental Dental Full Benefits packages: Delta has more than 43,000 PPO dentists in California and 270,000 nationwide. To see a list of Delta Dental PPO dentists, Who’s covered: You and your eligible family members visit the Delta Dental website: www.deltadentalins.com/uc. Who pays the premium: UC Delta’s Premier dentists are not in the PPO network but have agreed to accept a reduced fee for services and also will complete Proper dental care plays an important role in your overall health. and submit claim forms for you. Delta Dental covers 75 percent That’s why UC provides dental coverage for you and your family, of basic dentistry costs if you use a Premier dentist, up to $1,500 including routine preventive care and fillings, oral surgery, per year. dentures, bridges and braces. You have a choice of two plans, a PPO and an HMO. If you go to a dentist not affiliated with Delta Dental, the plan will cover 75 percent of allowed basic dentistry costs, up to The following rules and information about UC’s dental plans are $1,500 per year. However, you may have to pay the dentist’s in addition to the general eligibility rules beginning on page 5. total fee and then submit your claim form to Delta Dental for reimbursement. Non-Delta Dental dentists have not agreed to Delta Dental’s allowed costs and are free to bill you for any dif - ference between what Delta Dental pays and the submitted fee. ELIGIBILITY ® USA DELTACARE You are eligible to enroll in dental coverage only if you have Full ® Benefits. USA is a dental HMO that provides you and your DeltaCare family with comprehensive benefits and easy referrals to If you are eligible for dental benefits, you must take action to specialists. You must live in California to enroll. enroll. The plan stresses preventive care, so many preventive services ® USA only if you meet the plan’s You may enroll in DeltaCare are provided at no cost. Other services are provided for modest geographic service area criteria. copayments with no deductibles or annual plan maximum. IF YOU MOVE OUT OF A PLAN’S SERVICE AREA When you enroll, you select a network dentist to provide all ® USA plan service area, you and If you move out of a DeltaCare your basic dental services and to refer you to specialists when ® your eligible family members must transfer into a different plan USA network consists of private- necessary. The DeltaCare available in your new location. If you later return to your original practice dental facilities that have been screened by Delta location, you will have a Period of Initial Eligibility to enroll in a Dental for quality. Some areas of California have more network plan of your choosing available in the original location. providers than others, so be sure there are dentists available in your area before choosing this plan. You are required to obtain covered services through your assigned network dentist, except for emergency services or those preauthorized in writing by UC’S DENTAL PLANS Delta Dental. DELTA DENTAL PPO You may change your dentist at any time by calling the Delta The Delta Dental PPO plan, available worldwide, provides you and Care Customer Service number to request the change. Visit ® your family with the flexibility to choose any licensed dentist or USA website (www.deltadentalins.com/uc) for the DeltaCare specialist. Your share of the cost of services depends on whether a list of participating dentists. you use a dentist in Delta Dental’s PPO network or an out-of- network dentist. If you choose a PPO dentist from Delta Dental’s network, you BENEFITS AND SERVICES will usually pay less for services, so it makes sense to use a PPO For a comparison of benefits and services, see the chart on dentist. In-network PPO dentists agree to accept a reduced fee pages 25 to 27. for services, and the dentist will complete and submit all claim forms for you at no charge. Preventive dentistry (exams and If you need major dental work, such as a crown, dentures or oral cleanings) is free of charge. After a small deductible, basic surgery, you and/or your dentist should contact your plan to file dentistry (such as fillings and extractions) is covered at 80 a pre-determination before you begin treatment to confirm that percent, and most other dental care is covered at 50 percent, the procedure is covered and to determine your portion of the up to $1,700 per year. cost for services. 24

29 Chapter Title Dental COST OF COVERAGE FOR MORE INFORMATION Evidence of Coverage booklets are available online at UC pays 100 percent of your monthly dental plan premium. UC’s ucal.us/EOCs. contribution toward the monthly cost is determined by UC and may change or stop altogether. You pay a certain percentage or If you have other questions about your dental benefits including copayment for some services. services, benefits, billing and claims, call the plan directly. Delta Dental PPO 800-777-5854, www.deltadentalins.com/uc WHEN COVERAGE ENDS ® USA DeltaCare OPPORTUNITIES FOR CONTINUATION 800-422-4234, www.deltadentalins.com/uc If you or a family member loses eligibility for dental coverage, you can continue coverage under COBRA for a period of time. There is no conversion option for dental coverage. ® Delta Dental PPO Plan USA HMO Plan DENTAL SERVICES DeltaCare 1 Worldwide Service Area California only Preventive Dentistry No deductible Copayments apply as noted Cleaning of teeth — prophylaxis cleanings You are covered at 100% (up to 2 times in a 100% up to 2 times in any 12-month period; calendar year; additional cleanings by report) additional cleanings when necessary: $45 copayment for adults, $35 copayment for children 100% (2 routine and 2 non-routine exams per 100% Oral examinations calendar year; additional routine exam is covered for members with identified risk factors) Emergency office visit for pain relief 100% 100% Topical fluoride treatment 100% (includes cleaning; up to 2 times in a 100% (up to 2 times in any 12-month period calendar year) through age 18) Space maintainers 100% (through age 12) 100% X-rays (full mouth, bitewings, other films) 100% (full mouth x-rays limited to 1 set in any 100% (full mouth x-rays limited to 1 set in 5 years unless necessary) 12-month period) Pit and fissure sealants (under age 16 only) 100% PPO/75% Premier for first permanent 100% for first permanent molars through age 9 molars through age 9 and second permanent and second permanent molars through age 15 molars through age 15 1 Nationwide—Delta Dental PPO, Delta Dental Premier and non-Delta dentists (licensed); Worldwide—Coverage available only from non-Delta dentists (licensed). 25

30 Chapter Title Dental Dental ® DeltaCare DENTAL SERVICES USA HMO Plan Delta Dental PPO Plan Deductible applies. Basic Dentistry Copayments apply as noted. 80% PPO/75% Premier Fillings 100% for standard benefit 1 80% PPO/75% Premier (general Local—100%. General and intravenous Anesthesia sedation—100%; limited to medically necessary anesthesia for covered oral surgery) extractions Prosthetic appliance repair 80% PPO/75% Premier 100% Extractions 100% if uncomplicated (not covered if done only 80% PPO/75% Premier for orthodontics) 80% PPO/75% Premier $15 copayment for impactions; other covered Oral surgery services at 100% Endodontics 80% PPO/75% Premier $20–$60 copayment for each canal; other covered services at 100% 2 Periodontics $100 copayment per quadrant for surgery 80% PPO/75% Premier (mucogingival and osseous gingival); $150 copayment for soft tissue graft procedures; periodontal maintenance: 100% for 1 in each 6-month period; additional maintenance when necessary: $55 copayment Relining—100% (limited to 1 in any 12-month Denture Relining and Rebase 80% PPO/75% Premier period). Rebase—$20 copay Major Dentistry Deductible applies. Copayments applied as noted. Crowns 50% $50 per unit copayment ($150 extra charge for precious metals) After an annual deductible of $50 per person 50% 100% for standard benefit Inlays/onlays TMJ Disorder Benefits 50% up to $500 for all benefits in a 100% Temporomandibular joint (TMJ) lifetime (not applied to calendar year dysfunction: occlusal devices/occlusal maximum). Deductible applies. guards (night guards) Prosthetic Dentistry Deductible applies. Copayments apply as noted. Standard, full or partial dentures Upper—$65 copayment per denture 50% Lower—$65 copayment per denture (extra charge for precious metals) Removable partial denture with flexible base—$115 Bridges 50% $50 per unit copayment (extra charge for precious metals) Implants 50% Not covered Total Benefit $1,700 if a Delta Dental PPO dentist is No maximum (Total benefit for preventive, basic and major used; otherwise $1,500 per person per dentistry, and prosthetic dentistry) calendar year 26

31 Chapter Title Dental ® DENTAL SERVICES USA HMO Plan Delta Dental PPO Plan DeltaCare Copayments apply as noted below No deductible Orthodontics All covered family members All covered family members Who is eligible for service Benefit 50% copayment; maximum of $1,500 for $1,000 copayment (plan covers 36 months of usual and customary treatment—a monthly each eligible patient under age 26 and $500 office visit fee of $75 applies after the 36 for each eligible patient age 26 and older months) Special Provisions, Limitations, Exclusions ® Work in progress when you join Only services that you receive on or after your Only services received from a DeltaCare USA provider on or after your effective date effective date of coverage are covered. 3 . of coverage are covered ® If services are expected to be $400 or more, Predetermination of benefits Before any work is done, ask your DeltaCare your dentist files a treatment plan first; Delta USA dentist what the charges will be. If reviews it and notifies you and your dentist of you have any questions about what will be ® covered, call DeltaCare USA. the benefits payable. Alternate treatment provision If more than one professionally acceptable If you select a treatment plan different from ® USA, that customarily provided by DeltaCare and appropriate treatment can be used, Delta you will pay the applicable copayment, plus benefits will be based on the least expensive the additional cost of the alternate treatment. method. Not covered if crown or prosthetic appliance is Not covered if crown or prosthetic appliance is Replacement of crowns, dentures, partial fewer than 5 years old less than 3 years old dentures and bridges Coverage applies worldwide. Plan pays up to $100 in 12-month period for Out-of-area emergencies pain relief when you are more than 25 miles from your dentist’s office. Teeth bleaching Not covered $125 copayment per arch. External bleaching is limited to one bleaching tray per arch per 36-month period; bleaching gel for two weeks of patient self treatment. Tobacco counseling for prevention of oral disease Not covered 100% ® USA booklet. Other limitations and exclusions may apply. See the Delta Dental or DeltaCare NOTE: 1 Disabled members may receive anesthesia for any covered dental service if needed to receive treatment. Preauthorization is required. 2 Combined for basic and major dentistry, TMJ disorder benefits and prosthetic dentistry. 3 ® Exception: DeltaCare USA may cover orthondontia treatment in progress ® for new enrollees/family members if treatment meets specific DeltaCare USA criteria. 27

32 Chapter Title Vision Vision Full Benefits package: If you use a VSP network doctor or provider, you pay only the required copays for covered services and the cost of any services Who’s covered: You and your eligible family members or materials beyond the allowance. Additional discounts are available for services the plan doesn’t cover, including: UC Who pays the premium: • 30 percent discount on additional pairs of glasses, including UC provides the Vision Service Plan (VSP) to enable you and your sunglasses, if purchased from the VSP doctor who provides family to get the vision care you need. VSP is a preferred-provider the member’s eye exam on the same day as the exam. organization with more than 5,000 providers in California • 20 percent discount for additional pairs of prescription glasses and 33,000 nationwide in the Choice network. The vision plan purchased within 12 months following the last covered eye has no exclusions for pre-existing conditions. exam, if purchased from the VSP doctor who provided the exam. • 15 percent discount for contact lens professional services; for example, fittings or adjustments. ELIGIBILITY See the general eligibility rules beginning on page 5. WHEN COVERAGE BEGINS Please see “When Coverage Begins” on page 7 of the Eligibility WHAT THE PLAN COVERS section. • One vision examination per calendar year—including testing and analysis of eye health and any necessary prescriptions for lenses or contact lenses. You pay a $10 copay. COST OF COVERAGE One set of corrective lenses per calendar year—including • UC pays the full cost of the monthly vision plan premium. UC’s single vision, bifocal, trifocal, standard progressive or other contribution toward the monthly cost of coverage is determined complex glass or plastic lenses. Photo-chromatic lenses, by UC and may change or stop altogether. tints and polycarbonate lenses are fully covered if you use a provider in the VSP network. You pay a $25 copay. You pay copays — $10 for a vision exam and, if you need glasses, • One set of frames every other calendar year up to $160. $25 for materials. You also pay for additional care, services or products that VSP does not cover. • Contact lens allowance of $110. If you choose elective contact lenses, you cannot also have frames and corrective lenses covered in the same calendar year. If contact lenses are medically necessary and you use a VSP provider, the WHEN COVERAGE ENDS cost is fully covered. Generally, contacts are covered for those who have had cataract surgery, have extreme acuity OPPORTUNITIES FOR CONTINUATION problems that cannot be corrected with glasses or have some If you or a family member loses eligibility for vision coverage, conditions of anisometropia or keratoconus. you can continue coverage under COBRA. There is no option for • You may also purchase annual supplies of select contact lenses conversion to an individual plan for vision coverage. at a reduced cost. Talk to your VSP provider or see the VSP website (vsp.com) for additional details. • Discounts on laser corrective vision surgery through VSP- FOR MORE INFORMATION contracted laser centers. Call VSP for more information. VSP website: vsp.com • Eye care services for Type 1 or Type II diabetics through the VSP phone: 866-240-8344 Diabetic EyeCare Program. Contact a VSP doctor for more information. VSP Evidence of Coverage Booklet, available online at ucal.us/EOCs. 28

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35 Chapter Title Basic and Voluntary Disability Basic and Voluntary Disability Full, Mid-Level or Core Benefits package: WHEN COVERAGE BEGINS You Who’s covered: You must be actively at work in order for new or increased coverage to be effective. Who pays the premium: You and UC Time away from work for a pregnancy, illness or unexpected injury could mean months without a paycheck. While UC’s basic WHAT THE PLANS COVER employer-paid disability insurance offers some protection—a BASIC DISABILITY benefit capped at $800 per month for six months—it probably won’t be enough to cover your expenses. For a modest monthly UC provides the Basic Disability plan at no cost to you. premium, UC’s Voluntary Disability Insurance replaces much Basic Disability insurance provides coverage if you are unable more of your income—60 percent of your eligible pay up to a to work due to a pregnancy/childbirth or non-work-related benefit of $15,000 per month—for increased financial security disabling injury or illness. It pays 55 percent of your eligible when you need it most. earnings, up to a maximum benefit payment of $800 per month. UC’s disability benefits, along with state-mandated Workers’ The six month benefit period includes a 14-day waiting period Compensation and Social Security disability benefits, create before you begin receiving benefits, and you must use up to a comprehensive safety net, whether for a few months or a 22 days of sick leave, if available. While you’re receiving Basic lifetime. UC’s disability benefits also provide coverage for female Disability income, UC continues to pay its portion of your employees during pregnancy disability and the first few weeks medical premiums. Your Basic Disability income is generally after childbirth. taxable. UC does not participate in the California State Disability VOLUNTARY DISABILITY Insurance (CA SDI) program, although employees who have Voluntary Short-Term Disability (VSTD) and Voluntary Long-Term worked for UC for fewer than 18 months may have some Disability (VLTD) plans work in conjunction with Basic Disability residual CA SDI benefits based on their prior employment. and other sources of disability income (for example, Social Security) you may receive as a result of your pregnancy/ If you are eligible for Full, Mid-Level or Core Benefits, you are childbirth or disabling injury or illness. automatically enrolled in Basic Disability at no cost to you. If you choose to enroll in Voluntary Short-Term Disability (VSTD) and/ VSTD offers more comprehensive coverage than Basic Disability— or Voluntary Long-Term Disability (VLTD), you pay the premium. 60 percent of your eligible earnings, with a maximum benefit of $15,000 per month. The six month benefit period includes a 14-day waiting period before you begin receiving benefits, and you must use up to 22 days of sick leave, if available. This plan is a WHEN TO ENROLL good option to cover short-term needs such as pregnancy, most illnesses, minor surgeries, etc. You are automatically enrolled in Basic Disability, if eligible, on your first day of work. VLTD benefits don’t start until six months after your date of disability or when VSTD benefits end, whichever is later. The For Voluntary Disability Insurance, you need to take action to plan pays 60 percent of your eligible earnings, with a maximum enroll. To obtain coverage without submitting a statement of benefit payment of $15,000 per month, and benefits can last health, enroll during your PIE when you are first eligible. As a until your Social Security normal retirement age, if you qualify. new employee, you may want to consider enrolling in both VSTD This type of plan doesn’t pay for the first six months of disability, and VLTD for the most comprehensive coverage for all types of but offers long-term benefits in cases of catastrophic injury or disabilities. You can discontinue your enrollment in VSTD and/or illness, or permanently disabling conditions. VLTD at any time. You pay the entire premium for VSTD and VLTD. The cost varies ENROLLMENT WITH STATEMENT OF HEALTH depending on your age, salary and your UC Retirement Plan If you do not enroll in VSTD and/or VLTD when you are first hired, eligibility. You may choose to purchase VSTD, VLTD or both. - you must submit an application, along with evidence of insurabil Voluntary Disability income is generally not taxable, since you ity, and be approved by the insurance company in order to enroll. pay the premiums with after-tax dollars. Previous or existing medical conditions may prevent approval if you try to enroll or add coverage outside of your initial period of eligibility. Generally, you cannot enroll in VSTD or VLTD during UC’s annual Open Enrollment or due to family changes. 31

36 Chapter Title Basic and Voluntary Disability Basic and Voluntary Disability Are you considering becoming pregnant? OTHER SOURCES OF DISABILITY BENEFITS • If you think you may become pregnant, it’s wise to sign up for VSTD. For most UC employees may be eligible for other disability benefits, pregnancies, the disability period begins two weeks before including: birth and ends six weeks after birth (eight weeks after birth for a Caesarian section), so a plan such as VLTD, which only Workers’ Compensation, which covers work-related injuries • covers disabilities lasting more than 6 months, wouldn’t pay and illnesses a benefit. Don’t wait until you’re pregnant to enroll. You’ll be UC Retirement Plan Disability Income, which is available to • required to submit a statement of health, and your enrollment UCRP members with five or more years of service credit in application will not be accepted if you’re already pregnant. the event of a permanent or long-term disability (12 months • Do you have a lot of non-negotiable monthly expenses? or longer) If you’ve recently purchased a new house, for instance, you • Social Security disability benefits may not want to risk a long period without income to help pay your mortgage. Enrolling in both VSTD and VLTD provides you • California State Disability Insurance (only if you worked with the most protection for all types of disabilities. outside of UC and paid into the system within the past 18 months) How much sick leave have you accrued? If you have been • with UC for a long time and have a lot of accrued sick leave The Basic and VSTD plans do not pay benefits for work-related that you could use during the first six months of a disability, injuries or illnesses that cause disabilities. Instead, Workers’ or if you are eligible for faculty medical leave, you might only Compensation provides benefits. The VLTD plan pays benefits need VLTD. If you don’t have much, you might consider VSTD. for work-related disabilities only in coordination with Workers’ Compensation. • If you have substantial savings How’s your savings cushion? that could tide you over the first six months of a disability, For Workers’ Compensation claims, UC contracts with a third you might choose VLTD only. If not, you should consider both party administrator to manage its claims. More information is VSTD and VLTD for the most protection. available in the Business and Finance Bulletin BUS 81—Insurance Programs, available on At Your Service, UCPath or from your local Workers’ Compensation Manager. A directory of UC IMPORTANT CONSIDERATIONS AND Workers’ Compensation Managers is available online at LIMITATIO N S TO COVE R AG E ucop.edu/risk-services/staff-contacts/workers-compensation- managers. • The definition of disability changes Definition of disability: with the type of coverage you receive: Any disability income you are eligible to receive from these other sources of disability benefits will be deducted from your – Basic and Voluntary Short-Term Disability—In order to disability benefits payable under UC’s disability plans. If the receive benefits, you must be disabled from your job at UC, other sources of income you receive exceed 60 percent of your based on the demands and duties of your position. eligible income, VLTD will pay a minimum of $100 per month. – Voluntary Long-Term Disability—For the first 24 months of VLTD benefits, in order to receive benefits, you must be disabled from your own occupation, based on the demands HOW THE PLANS WORK and duties that employers (throughout the national economy) ordinarily require for that occupation. From In order to receive disability benefits, you must be under a the 25th month onward, you must be disabled from any doctor’s direct, continuous care. For more information about occupation (throughout the national economy) for which Your Guide to UC Disability Benefits how to apply for benefits, see you are reasonably suited. on UCnet (available with related publications at ucal.us/ (Note that UCRP defines disability differently; for details, disabilitypubs) or contact your Benefits Office. please see “Your Guide to UC Disability Benefits.”) No one type of coverage is right for everyone. It is important that you carefully consider your circumstances and how your selection will affect major events in your life. For example: 32

37 Chapter Title Basic and Voluntary Disability • Pre-existing conditions: WHEN COVERAGE ENDS Once you are enrolled in the VSTD Plan and the Basic Disability Plan, there are no benefits Your coverage stops on your last day actively at work. You may limitations related to pre-existing conditions. Additionally, as not continue these plans through COBRA or convert them to soon as you’ve been covered by the VLTD Plan for more than individual plans. 12 months there are no restrictions or limitations on the VLTD Plan related to the pre-existing condition. However, your VLTD benefits will not be payable if: FOR MORE INFORMATION – Your disability leave is related to a condition you were The following publications are available online at diagnosed with, or had treatment for, in the 90 days prior to ucal.us/disabilitypubs: your initial enrollment in VLTD and – Your disability leave begins within one year of your initial Your Guide to UC Disability Benefits • enrollment into VLTD • Disability Benefits for Faculty You will, however, be eligible for VLTD benefits for conditions • Pregnancy, Newborn Child and Adoption Fact Sheet that were not pre-existing. • Partial Disability: Stay at Work/Return to Work Factsheet VLTD benefits for Mental Illness and Substance Abuse: • • Disability Insurance Policy these issues are generally limited to a 24-month lifetime maximum benefit, unless you remain continuously hospitalized or in an extended treatment plan. COST OF COVERAGE The university provides the Basic Disability plan at no cost to you. You pay a monthly premium if you enroll in voluntary coverage. The premium depends on your UCRP membership, your age and the level of coverage you choose (Voluntary Short-Term Disability, Voluntary Long-Term Disability or both). To estimate your premium, use the online Insurance Premium Estimator (ucal.us/premiumestimator). 33

38 Chapter Title Basic and Core Life Insurance Basic and Core Life Insurance Full (Basic), Mid-Level (Core) and Core (Core) Benefits package: CORE LIFE If you are eligible for the Mid-Level or Core Benefits package, Who’s covered: You 2 this plan provides $5,000 of life insurance. UC Who pays the premium: Benefits are paid to your beneficiaries if you die while employed or on paid leave, or during the first four months of approved Life insurance provides financial protection for your dependents leave without pay or temporary layoff. Your beneficiaries receive in the event of your death, and can be important to their future these benefits in addition to any other death benefits for which security. UC automatically provides basic life insurance coverage you may qualify. for all eligible employees. And you may be eligible to buy additional coverage for yourself and your family members. UC’s life insurance plans carry no exclusions based on the cause OTHER FEATURES OF THE PLANS of death. They are group term life plans that provide coverage at special rates to group members—in this case, UC employees. LIVING BENEFIT OPTION UC’s life insurance is in effect only as long as you remain The “living benefit” option allows terminally ill employees to an eligible employee, and does not accumulate a cash value receive some of their life insurance benefits before death; the over time. money can be used for any purpose. The insurance company pays you 75 percent of the total coverage amount in a lump sum UC provides a minimum amount of life insurance coverage at no or in 12 equal monthly installments. Benefits paid to your cost to you. The plan and amount of coverage varies, depending beneficiaries at the time of your death are reduced by the on your appointment rate and average regular paid time. amount previously paid to you. See the life insurance plan booklet for more information. EXTENDED DEATH BENEFIT WHEN COVERAGE BEGINS The Basic or Core Life insurance protection may continue up to You must be actively at work in order for new or increased one year beyond the date coverage terminates if you become coverage to be effective. totally disabled while covered under the plan and you are under age 65. You must remain continuously unable to engage in any occupation until the date of death. Protection continues for one year, until you reach age 65 or until your disability ends, WHAT THE PLANS COVER whichever occurs first. BASIC LIFE If you are eligible for the Full Benefits package, this plan provides life insurance equal to your annual base salary, up to COST OF COVERAGE 1 The coverage amount is based on your UC salary and $50,000. appointment rate as of your date of hire or January 1 of the UC pays the entire cost of your coverage for Basic or Core Life current year, whichever is later. insurance. UC’s contribution toward the monthly cost of coverage is determined by UC and may change or stop altogether. Benefits are paid to your beneficiaries if you die while employed or on paid leave, or during the first four months of approved leave without pay or temporary layoff. Your beneficiaries receive WHEN COVERAGE ENDS these benefits in addition to any other death benefits for which you may qualify. You may convert your coverage to an individual policy if you apply within 31 days of the date your UC-sponsored coverage ends. Conversion options are generally more expensive and may provide fewer benefits than UC-sponsored plans. See your plan booklet or call your plan for more information. 1 If you are a member of the California Public Employees’ Retirement System (CalPERS), CalPERS provides $5,000 of coverage and UC provides coverage equal to your annual base salary less $5,000, up to $45,000. 2 This plan does not cover CalPERS members. 34

39 Chapter Title Supplemental Life Insurance Supplemental Life Insurance EXCEPTION TO DUPLICATE UC COVERAGE RULE Full and Mid-Level Benefits package: You Who’s covered: You may be enrolled in Basic Life Insurance, Core Life Insurance or Senior Management Life Insurance and also be Who pays the premium: You covered as a dependent of another UC employee. Eligible employees may supplement their Basic or Core Life BENEFICIARIES insurance coverage by enrolling in this plan and paying monthly premiums. You can choose the amount of coverage that meets You should designate your beneficiaries online by signing in to your needs up to the maximum listed under Coverage Amounts. At Your Service Online. If you don’t name beneficiaries, benefits are paid to the first survivor in this list: • Your legal spouse or domestic partner WHEN TO ENROLL • Your child or children, including your adopted children; if your child is deceased, your deceased child’s share will go to ENROLLMENT that individual’s child or children To obtain coverage without the need for a statement of health, enroll during your first PIE or during a PIE that occurs as the • Your parent or parents result of the acquisition of a new family member. During a PIE • Your sibling or siblings that occurs as the result of the acquisition of a new family member, you can also increase your Supplemental Life If there is no such survivor, any lump sum death payment will be Insurance. Otherwise you can enroll at any time, but a statement paid to your estate. of health will be required. You may change your designated beneficiary at any time using ENROLLMENT WITH STATEMENT OF HEALTH At Your Service Online. Once your new designation is processed, If you do not enroll in the Supplemental Life plan during a period all previous designations are invalid. Changes in your family of eligibility, you must submit an application, along with situation—such as marriage, divorce or birth of a child—do not evidence of insurability, and be approved by the insurance automatically alter or revoke your previous designations. A company in order to enroll. Previous or current medical conditions will also does not supersede a beneficiary designation. Prior may prevent your approval if you try to enroll outside of an designations remain valid until you change your designations eligibility period. online. However, a beneficiary designation may be subject to challenge if it will result in your spouse receiving less than your WHEN COVERAGE BEGINS spouse’s community property share of the benefit. You must be actively at work in order for new or increased If you do not have access to the Internet, you may complete coverage to be effective. If you are on leave for health reasons Designation of Beneficiary form (UBEN 116), available from UC’s on the day you become eligible for Supplemental Life coverage, your Benefits Office. your coverage will start the day after your first full day at work. COVERAGE AMOUNTS You may choose one of several coverage amounts: • $20,000 • One times your annual salary, up to $250,000 • Two times your annual salary, up to $500,000 • Three times your annual salary, up to $750,000 • Four times your annual salary, up to $1 million Coverage is based on your UC salary rounded to the nearest thousand and your appointment rate as of your date of hire or the full-time salary rate for your position as of January 1 of the 35

40 Chapter Title Supplemental Life Insurance Supplemental Life Insurance current year, whichever is later—even if you work part time. If WHEN COVERAGE ENDS your full-time salary rate is reduced, coverage will not be reduced If you leave UC employment, you are no longer eligible for until the beginning of the next calendar year. Supplemental Life insurance. You may port or convert your Benefits are paid to your beneficiaries if you die while enrolled. coverage if you apply within 31 days of the date your They are payable in addition to any other death benefits for which UC-sponsored coverage ends. you may qualify—for example, from the Basic Life insurance plan The portability benefit allows you to continue your current UC or your retirement plan. Supplemental life coverage at Prudential’s Portability group term-life rates, which are lower than the conversion premium rates. A statement of health is not required, but you must submit PL AN FE ATURE S proof of good health satisfactory to Prudential to qualify for preferred rates. There are additional requirements for LIVING BENEFIT OPTION portability. See the Supplemental Life Insurance plan booklet for The “living benefit” option allows terminally ill employees details. covered by the plan to receive a portion of their life insurance You may also convert to an individual policy without a statement benefits before death. The benefit—75 percent of the total of health. coverage, up to $250,000—is paid directly to you in a lump sum or in 12 equal monthly installments. The money can be used for any You have 31 days from the date your coverage ends to submit purpose. The benefit that would otherwise be payable to your application and the appropriate premiums to Prudential. your beneficiaries at death is reduced by this amount. Your life See your Benefits Office for more information. insurance plan booklet has more information. Conversion options are generally more expensive and may WAIVER OF PREMIUM provide fewer benefits than UC-sponsored plans. See your plan If you become totally disabled before age 65 and your disability booklet or call your plan for more information. - continues for six consecutive months, you may qualify for continu ation of life insurance protection without paying the premiums. You must provide written proof of your disability no later than one year after the disability starts and submit proof of your continuing disability each year. Your life insurance will continue until you reach age 70, as long as you remain totally disabled. You may need to continue your premium payments to your Payroll or Benefits Office while your application is pending. See your insurance booklet or call the insurance carrier for more information. COST OF COVERAGE Your cost for Supplemental Life depends on your age and the amount of coverage you purchase. Use the online Premium Estimator for Life Insurance (ucal.us/lifepremiumestimator) to determine your monthly premium. 36

41 Chapter Title Dependent Life Insurance Dependent Life Insurance WHEN COVERAGE BEGINS Full and Mid-Level Benefits package: Your spouse or domestic partner and/or your If your dependent is confined for medical care or treatment, Who’s covered: eligible children your dependent’s new or increased coverage will begin on the first day after medical release. This does not apply to your You Who pays the premium: newborn child. UC offers two plans for insuring your eligible family members. You can enroll your dependents in the Basic Dependent Life plan if you are enrolled in Basic Life or in the Expanded Dependent WHAT THE PLANS COVER Life plan (which provides more coverage) if you are also enrolled BASIC DEPENDENT LIFE in the Supplemental or Senior Management Life plan. You may cover your family members under either plan, but not under both. This plan covers your spouse or domestic partner and/or your eligible children; the benefit is $5,000 for each dependent. See pages 13 and 14 for each family member’s requirements for eligibility. You are the beneficiary if a covered dependent dies. WHEN TO ENROLL EXPANDED DEPENDENT LIFE To obtain coverage for a spouse or domestic partner without the You may choose to cover: need for a statement of health, enroll during your own initial PIE, or if the marriage or partnership occurs later, during the 31-day Your legal spouse or domestic partner with a benefit amount • PIE following the marriage or partnership date. Otherwise they equal to 50 percent of your Supplemental Life insurance can be enrolled only by submitting an application along with amount, up to a maximum benefit of $200,000, and/or evidence of insurability, and the insurance company decides Your eligible children with a benefit of $10,000 each • whether to approve the application. A spouse or domestic partner may not be enrolled during a PIE resulting from the birth You are the beneficiary if a covered dependent dies. You may or adoption of a child. designate someone else to receive benefits if a covered spouse or domestic partner dies. You cannot designate an alternate Children may be enrolled during their PIE or at any time without beneficiary for covered children. Use the Designation of Alternate a statement of health. Beneficiary—Expanded Dependent Life and AD&D Insurance form (UBEN 119), available online at ucal.us/UBEN119. Living Benefit Option: This option allows a terminally ill spouse ELIGIBILITY or domestic partner covered for at least one year to receive If both you and a family member are UC employees, you may some life insurance benefits before death. The benefit— choose to cover yourself under the Supplemental Life plan or, if 50 percent of the total benefit, up to $50,000—is paid directly eligible, under your family member’s Dependent Life plan. You to the spouse or partner in a lump sum or in 12 equal monthly cannot be covered by both plans. installments. The money can be used for any purpose. The benefit that would otherwise be payable to beneficiaries at If you miss your period of initial eligibility, you must submit an death is reduced by the amount paid to the spouse or partner. application along with evidence of insurability when enrolling Your life insurance plan booklet has more information. a spouse or domestic partner. The insurance company decides whether to approve the application. This is not required for children—children may be enrolled at any time. COST OF COVERAGE You may transfer your dependents from the Expanded plan to Use the online Life Insurance Premium Estimator (ucal.us/ the Basic plan at any time. However, to transfer your spouse or lifepremiumestimator) to determine your monthly premium. domestic partner from the Basic plan to the Expanded plan, you must submit an application, along with a statement of health, for that person. 37

42 Dependent Life Insurance Dependent Life Insurance WHEN COVERAGE ENDS FOR MORE INFORMATION If you leave UC employment, you are no longer eligible for Basic This is an overview of your life insurance benefits. You’ll find more information and tools, such as a life insurance needs or Expanded Dependent Life insurance. You may port or convert your coverage if you apply within 31 days of the date estimator, on Prudential’s microsite for UC employees your UC-sponsored coverage ends. (prudential.com/uc). A copy of the life insurance plan booklet is available online at ucal.us/EOCs. If you participate in Prudential’s group term-life Portability benefit for your Supplemental Life insurance (see page 36), you may also continue Dependent Life coverage within the same Portability benefit. See your Benefits Office for more information. You may also convert your Dependent Life to an individual policy without a statement of health if: Your UC-sponsored coverage ends, or • • You become totally disabled and you are covered under the Supplemental Life waiver of premium benefit. You must apply for the conversion option within 31 days of the date your UC-sponsored coverage ends. Conversion options are generally more expensive and may provide fewer benefits than UC-sponsored plans. See your plan booklet or call your plan for more information. 38

43 Accidental Death and Dismemberment Insurance Accidental Death and Dismemberment Insurance accident, or be a high school student and enroll in an institution of Benefits package: Full, Mid-Level, Core higher learning within 365 days of high school graduation. Who’s covered: You and your eligible family members Day Care Benefit: The plan will pay for up to four years of You Who pays the premium: day care expenses (up to the plan limit) for covered children under age 13 if you die due to a covered accident. The financial impact of an accident can be devastating. To help protect you and your family from the financial hardship If you or a covered dependent suffer Repatriation of Remains: of an unforeseen accident, UC offers Accidental Death and an accidental death while at least 100 miles from home, the plan Dismemberment (AD&D) insurance. will pay for covered expenses up to $50,000 to return your body or the body of a covered dependent to your home. Common Disaster Benefit: If you and your covered spouse or WHEN TO ENROLL eligible domestic partner both die within 90 days of the same covered accident, your spouse’s or eligible domestic partner’s You may enroll at any time. principal benefit amount will be increased to equal yours to a maximum of $500,000. The plan will pay a portion of your benefits when Coma Benefit: WHAT THE PLAN COVERS a covered accident renders you or a covered family member The plan provides $10,000 to $500,000 coverage for accidental comatose within 30 days of the accident. death, dismemberment or loss of sight, speech or hearing caused Natural Disaster: The plan will pay an additional 10 percent if by an accident. It offers three levels of coverage: you or a covered family member suffers loss as a result of an Individual coverage for you only • officially declared natural disaster (i.e., storm, earthquake, flood). • Family coverage for you, your spouse or eligible domestic partner and your child(ren) (for employee only): Permanent and Total Disability Benefit • Modified family coverage for you and your child(ren) See plan booklet for details. If you are on leave for health reasons on the day you become eligible for coverage, your coverage starts the day after your first COST OF COVERAGE full day at work. Your cost depends on the level of coverage and coverage THE PLAN OFFERS THESE ADDITIONAL BENEFITS: amount you choose. Use the rate chart online at ucal.us/ The plan pays an additional 10 percent if you Seatbelt Benefit: adanddpremiums to determine your monthly premium. or a covered family member dies in a car accident while using a seatbelt or airbag. : The plan Indemnity for a Child’s Dismemberment or Paralysis WHEN COVERAGE ENDS pays a percentage of the covered amount if an accident causes irreversible paralysis of a covered child. The percentage payable If you leave UC employment, you may convert your coverage to depends on the degree of the paralysis. an individual policy if you apply within 31 days of the date your UC-sponsored coverage ends. The plan will pay up to $10,000 for Rehabilitation Benefit: covered rehabilitative expenses for two years after the date of Conversion options are generally more expensive and may an accident that causes dismemberment or paralysis. Work- provide fewer benefits than UC-sponsored plans. See your plan related injuries covered under Workers’ Compensation or other booklet or call your plan for more information. similar laws are excluded. Education Benefit: Under family or modified family coverage, if you die in a covered accident, the plan pays for your child’s higher education—the lesser of the actual tuition, 5 percent of your coverage amount, or $1,500 annually. The child must be enrolled in an institution of higher learning on the date of the 39

44 Chapter Title Accidental Death and Dismemberment Insurance Accidental Death and Dismemberment Insurance EXCLUSIONS There are certain exclusions under the AD&D insurance. See your plan booklet for more information. FOR MORE INFORMATION This is only an overview of your AD&D benefits. The AD&D plan booklet, available online at ucal.us/EOCs, provides additional details. 40

45 Chapter Title Business Travel Accident Insurance Business Travel Accident Insurance HOW THE PLAN WORKS Full, Mid-Level, Core Benefits package: When you travel on official university business, you are Who’s covered: You and your traveling companion(s) automatically covered by UC’s business travel insurance when UC Who pays the premium: you make your arrangements through any of UC’s preferred travel agencies found in Connexxus, UC’s systemwide travel UC faculty and staff traveling on official UC business are covered, program. For all other travel, you must register your travel at no cost to you, worldwide 24 hours a day for a variety of online at ucop.edu/risk-services/loss-prevention-control/ accidents and incidents. travel-assistance. Once registered, you will receive confirmation of coverage for your trip and information to use in the event of an emergency. WHAT THE PLAN COVERS You will also receive current travel alerts for your destination and information about changing conditions that may arise The coverage includes: during the course of your travel. The plan also gives you access Accidental death • to general information about your destination, including information about security, health, communications and • Accidental dismemberment technology, transportation, legal, entry and exit, financial, • Paralysis weather and environment, language and culture. • Permanent total disability benefits • Evacuation in the event of a security emergency BENEFICIARIES • Travel assistance services when you are 100+ miles from your home and workplace (see below for more information) For purposes of accidental death benefits, the insurance company automatically designates as your beneficiary the first Your spouse/domestic partner, dependent child(ren) or other survivor in this list: traveling companion are covered when accompanying you on a business trip. • Your legal spouse or domestic partner • Your child or children • Your mother or father TRAVEL ASSISTANCE SERVICES Your sisters or brothers • In addition to insurance protection, the plan gives you access to Your estate • travel services around the world, including: If you wish to designate your beneficiaries differently than this Medical assistance such as referral to a doctor or medical • sequence, you must complete a Faculty Beneficiary Designation specialist, medical monitoring if you are hospitalized, form which can be requested by calling UC Risk Services at emergency medical evacuation to an adequate facility, 510-987-9832. medically necessary repatriation and return of remains Personal assistance such as emergency medication, embassy • Your beneficiary designation remains in effect until it is either and consular information, assistance with lost documents, changed or revoked. It does not automatically end with the emergency message transmission, emergency cash advance, return from a business trip. emergency referral to a lawyer, access to a translator or interpreter, medical benefits verification and assistance with medical claims FOR MORE INFORMATION • Travel assistance, including vehicle return and emergency travel arrangements for the return of your traveling Additional information, including frequently asked questions, a companion or dependents summary of coverage and claim forms is available online at ucal.us/businesstravel 41

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47 Chapter Title Legal Insurance Legal Insurance Full, Mid-Level, Core Assistance with administrative hearings including educational, Benefits package: • building/zoning/easements, Social Security/veterans/ Who’s covered: You and your family members Medicare benefits, and more Domestic violence protective orders • You Who pays the premium: Defense of traffic offenses, including traffic tickets • Most people need legal advice at one time or another, but high • Driving privilege protection - legal fees may prevent you from getting the necessary assis tance. For a small monthly premium, UC offers the ARAG Legal Defense of misdemeanor charges such as trespassing, public • plan, which gives you access to a range of legal services. The intoxication and vandalism plan provides assistance with routine matters and covers most General In-Office—four hours of attorney time per family per • basic legal needs. certificate year for advice, negotiation and service for personal legal matters that are not covered or excluded (includes You may enroll during your PIE. Enrollment may also be offered administrative hearings or sale/purchase of a residence) during Open Enrollment in some cases. ® that • Online legal tools and resources, such as DIY Docs enable you to create documents like a standard will, power of attorney, child medical authorization, HIPAA authorization, WHAT THE PLAN COVERS contractor agreement and more Legal advice, representation and preparation for covered • See the ARAG Legal website or the plan booklet for the full list matters or review of specific documents in-office from an of covered services, plan limitations and exclusions. ARAG Network Attorney Legal advice via phone from ARAG’s nationwide network of • telephone attorneys HOW TO USE THE PLAN Estate planning documents, including wills, trusts, powers of • Before consulting any attorney, call ARAG to be sure the plan serves attorney and healthcare directive you to your best advantage. When you call ARAG, a customer care • Family legal matters, including pre-nuptial agreements, specialist will advise you on the services the plan will cover and divorce (up to a 25-hour cap), separation, annulment, child send you a CaseAssist confirmation package, which includes a custody and support, visitation and/or alimony, adoption, description of coverage and a list of network attorneys available in guardianship/conservatorship, executor appointment, elder your area. care and name change All network attorneys have met ARAG’s requirements and agreed Identity theft protection, including single-bureau credit • to provide the services described in the plan booklet. When you use monitoring, internet surveillance, child identity monitoring, a network attorney, fees for most covered matters are paid in full. full-service identity restoration, lost wallet services, change of 1 address monitoring and identity theft insurance ARAG network attorneys provide services in two ways: • Consumer protection issues including personal bankruptcy, debt collection defense and legal representation for • Telephone: You may call a telephone network attorney who enforcement of warranties or promises in connection with will either work with you over the phone or recommend that lease or purchase of goods or services you meet with an attorney in person. Using telephone network attorneys can help you get the most from the plan. Real estate matters including purchase, sale or refinance, • home equity/construction loans, real estate disputes and Office appointments: The plan covers a wide range of legal • residential contractor disputes matters, most of which are fully paid when you work with a network attorney. For matters not listed, and not excluded, the 2 and audit support Tax planning, preparation • plan provides a general in-office benefit for up to four hours per year. See the plan booklet available online at ucal.us/EOCs for details. 1 Eligibility, coverage, limitations and exclusions are governed by a separate coverage document. Please see the identity theft plan summary for details. If you prefer, you may use an attorney outside the ARAG Network 2 There is a flat $50.00 charge for each personal tax return prepared (federal, on a matter covered under the plan. In that case, the plan state, local), limited to the preparation of tax forms 1040, 1040A or 1040EZ reimburses you up to the benefit amount indicated in the plan (includes Schedule A, Schedule B and Schedule D). If the tax return requires any other schedules, an additional fee of $60.00 per hour will be billed to the booklet. member. If a different type of personal tax return is required, the member will be billed $60 per hour for the preparation of the return and any schedules. 43

48 Legal Insurance Legal Insurance COST OF COVERAGE Your monthly cost depends on whether you choose individual or a family coverage option. See the plan costs online at ucal.us/legal. WHEN COVERAGE ENDS If you leave UC employment, you may convert your coverage to an individual policy if you apply within 31 days of the date your UC-sponsored coverage ends. See your plan booklet or call ARAG for more information. FOR MORE INFORMATION Visit the ARAG website: ARAGLegalCenter.com; enter access code 11700uc. See the plan booklet online at ucal.us/EOCs. Call ARAG: 800-828-1395 or TTD: 800-383-4184, Monday–Friday, 9 a.m.–5 p.m. (PT). 44

49 Pet Insurnace Pet Insurance Full, Mid-Level, Core WHEN COVERAGE ENDS Benefits package: If you leave UC, no action is required and the policy will Who’s covered: Pets owned by you or your eligible family automatically remain active. However, the premium may change members at policy renewal, as group preferred pricing may no longer Who pays: You pay premiums directly to Nationwide apply. Nationwide offers preferred pricing on pet insurance for UC faculty, staff and retirees. Plans are available for dogs, cats, birds, small mammals and exotics (such as reptiles); animals FOR MORE INFORMATION categorized as livestock (including horses) are not eligible. Petinsurance.com/uc You can enroll in pet insurance at any time, and your coverage 877-738-7874 will be effective approximately 14 days after your application is approved by Nationwide. Once enrolled, your policy will renew automatically each year. WHAT THE PLAN COVERS Nationwide offers two benefit options—coverage for accidents and illness or more comprehensive coverage that also includes preventive care and wellness services. For more information about what types of care are covered with each option, visit petinsurance.com/uc. Pre-existing conditions are excluded from coverage. HOW THE PLAN WORKS Learn more and enroll on the Nationwide website at petinsurance.com/uc. To enroll in coverage for your bird, small mammal, reptile or other exotic pet, or to speak to a representative, call Nationwide at 877-738-7874. You’re free to visit any licensed veterinarian, anywhere in the world—even specialists and emergency providers. Simply pay your vet bill and then send Nationwide a claim for reimbursement via mail, email or the free VitusVet mobile app. COST OF COVERAGE Premiums vary depending on your type of pet and where you live, and you’ll pay your premiums directly to Nationwide. 45

50 Chapter Title Family Care Resources Family Care Resources 1 COST OF COVERAGE Benefits package: Full, Mid-Level, Core You and your family members Who’s covered: UC pays the fee that gives you access to the Care Advantage website. You make arrangements with the providers you hire, Who pays: UC pays for access; you pay for care including all payments to them. Finding the right caregivers for loved ones is one of the toughest challenges many working families face. UC offers Bright WHEN COVERAGE ENDS Horizons Care Advantage, a program that helps employees find the right match for their family care needs, including child care If you leave UC employment or move to an ineligible position, centers, nannies, babysitters, elder care planning, pet care, you may convert your Bright Horizons Care Advantage account tutoring/test prep, and more. Their online resources help you to an individual consumer membership for an annual fee (about find quality caregivers—especially on short notice—so that you $140/year). can get to the office or classroom with minimal disruption. Bright Horizons Care Advantage includes access to: FOR MORE INFORMATION • Sittercity, which offers individual in-home caregivers, including babysitters, nannies, senior caregivers, pet sitters, careadvantage.com/universityofcalifornia tutors and housekeepers 888-748-2489 • Years Ahead, which offers a nationwide network of memory and hospice care facilities, independent and assisted living communities, and in-home health care and senior care companions Preferred enrollment at select Bright Horizons centers • nationwide, tuition discounts at partner centers and discounted tutoring and test prep through BrightStudy HOW THE PLAN WORKS On the UC-specific Bright Horizons Care Advantage website (careadvantage.com/universityofcalifornia), you can register for Sittercity and/or Years Ahead. You must register for each separately. Once you’ve registered, you can read provider profiles and reviews to help you find the right caregiver for you. Sittercity allows you to post jobs and providers can respond. Years Ahead offers certified senior care advisers to help you and your family through the process of finding the right caregiver. Bright Horizons Care Advantage also offers preferred enrollment and tuition discounts at some Bright Horizons child care centers and discounts on tutoring and test prep services through BrightStudy. Use the center search locator on the Care Advan - tage website to identify centers near you that participate in preferred enrollment or offer a discount. Sign up online to learn more about BrightStudy, and a representative will contact you to help you find the resources you need. 1 Participation in Bright Horizons Care Advantage is subject to bargaining with individual unions at UC. Contact your local Benefits Office to find out whether your union is participating in Bright Horizons Care Advantage benefit. 46

51 Chapter Title Health and Dependent Care Flexible Spending Account Plans Health and Dependent Care Flexible Spending Account Plans Benefits package: Full, Mid-Level, Core HOW THE PLANS WORK Who’s covered: You determine the annual amount of your contributions to a You plan, subject to the contribution limit for that plan. An equal Who pays : You portion of that amount is deducted from your paycheck and credited to your Health FSA and/or DepCare FSA account. When UC’s Health and Dependent Care Flexible Spending Account you have eligible expenses, you pay them from your account. plans (FSAs) allow you to pay for eligible out-of-pocket expenses for yourself and your eligible family members on a pretax basis. It’s important to estimate your annual expenses carefully, As a result, your salary is reduced before taxes are assessed, and because, based on Internal Revenue Service (IRS) regulations you pay less in taxes. and plan rules, you may need to forfeit unclaimed funds in your account after the closing date for the plan year. Each plan has its own rules, so be sure to read the details about ELIGIBILITY each plan below. You are eligible to enroll in the Health and Dependent Care Flexible Spending Accounts while you are eligible for Full, Mid-level or Core Benefits, except that if you enroll in the UC PLAN ADMINISTRATION Health Savings Plan for your medical coverage, you cannot enroll WageWorks (formerly CONEXIS) is the plan administrator for in the Health FSA. the FSAs; they handle all claims processing and reimbursement. WageWorks must receive claims for a plan year by April 15 of the following year in order to reimburse the expenses; for ENROLLMENT AND CHANGES IN PARTICIPATION example, they must receive claims for the 2019 plan year by April 15, 2020. You may enroll when you first become eligible, when you have an eligible change in family or employment status, or during Open Enrollment. If you enroll in the UC Health Savings Plan for your medical coverage, you cannot enroll in the Health FSA. HEALTH FSA You enroll in the FSAs for the plan year, which ends on December The Health FSA allows you to pay for eligible out-of-pocket 31 of each year. You must re-enroll during Open Enrollment to health care expenses on a pretax basis. The Health FSA covers participate the following year. expenses for yourself, your legal spouse, your children up to age 26 or anyone else you claim as a dependent on your federal You may also change your contribution or cancel participation income tax return. Expenses must meet the requirements of during a 31-day period of eligibility resulting from an eligible Internal Revenue Code (IRC) §213(d) in order to be eligible for change in family or employment status. Midyear changes must reimbursement. be on account of and consistent with the change in status. See for details the Health or DepCare FSA Summary Plan Description Eligible expenses include: regarding what types of changes are allowed. • Copayments and deductibles, but not premiums Enrollment and changes in contributions take effect on the first of • Prescription drugs the month following the action taken, subject to payroll deadlines. • Orthodontia • Eyeglasses and contact lenses • Laser eye surgery • Other health care expenses that are not reimbursed by your medical, dental or vision plan Note that while an expense may be an eligible tax deduction, it may not be an eligible expense under the Health FSA (for example, medical plan premiums). Expenses reimbursed under the Health FSA may not be deducted on your federal income tax form. 47

52 Chapter Title Health and Dependent Care Flexible Spending Account Plans Health and Dependent Care Flexible Spending Account Plans The Health FSA includes a feature that lets you carry over up to expenses are eligible. As noted above, you may be required to $500 of unused funds to the next plan year, as long as you are forfeit some unclaimed funds in your account after the closing enrolled in the FSA through Dec. 31. With the carryover, if your date for the plan year. balance is less than $500, you do not have to rush to spend all of WHEN COVERAGE ENDS OPPORTUNITIES your Health FSA funds or worry about losing money when the FOR CONTINUATION current plan year ends, even if you do not re-enroll for the next If you lose eligibility for the Health FSA, you may continue your plan year. participation through COBRA. However, if you do not re-enroll in the Health FSA, you must have at least $25 remaining in your account after the April 15 deadline to be able to carry over funds to the next plan year. DEPENDENT CARE FSA Funds under $25 are forfeited. If you do not re-enroll, you may only carry over funds (up to $500) for one year. The DepCare FSA allows you to pay for eligible expenses for care of your child or eligible adult dependent on a pretax basis. After You have until Dec. 31 of the plan year to incur eligible expens - you incur eligible dependent care expenses, you submit a claim es. After the April 15 filing deadline, unused funds up to $500 form and receipts for the expenses to WageWorks, the plan will be credited automatically to the next plan year and will be administrator. WageWorks reimburses you through an automatic available for reimbursement in early May. Unused funds greater deposit to your bank or by check. than $500 will be forfeited. ELIGIBLE EXPENSES If you enroll midyear, expenses incurred before the date your Dependent care must be necessary so that you, or you and your enrollment is effective are not eligible for reimbursement. The spouse, can work or look for work. You must have work income effective date generally is the first of the month following your during the year in order to participate in the DepCare FSA. If you enrollment, but it may be later, depending on payroll deadlines. are married, your spouse must also have earned income during If you enroll in the Health FSA, you will be issued a Benefit the year, unless your spouse is incapable of self-care or is a Card that can be used to pay for eligible health care expenses at full-time student. approved health care merchants such as doctors’ offices and If care is provided in a day-care center, the center must charge pharmacies. Instead of paying first and then filing a claim for a fee. If the center cares for six or more children who are not reimbursement, the expenses are automatically deducted residents, it must comply with all state and local licensing laws from your account. In most cases you will need to provide and applicable regulations. WageWorks, the plan administrator, with documentation to substantiate the eligibility of your expenses. Eligible expenses must be for the following eligible family members: Expenses submitted for reimbursement are carefully evaluated against the IRC eligibility requirements. If your expenses are • A child under age 13 in your custody whom you claim as a not clearly eligible according to the IRC, you will need to submit dependent on your tax return; additional information to WageWorks and you may not be reimbursed for these expenses. See the WageWorks website A legal spouse (as defined under federal law) who is physically • Health FSA Summary Plan (wageworks.com/ucfsa) or the or mentally incapable of self-care; and Description for more information. A dependent who lives with you—such as a child over age 13, • a parent, sibling, in-law or other adult—who is physically or CONTRIBUTION LIMITS AND FORFEITURE RULES mentally incapable of self-care, and whom you claim as a You may contribute a minimum of $180 to a maximum of $2,650 dependent on your tax return. annually to your Health FSA. If both you and your spouse are UC employees, you may each contribute up to $2,650. The carryover If care is provided outside the home for a spouse or a family does not count against the $2,650 maximum contribution. You member age 13 or older, either of whom is incapable of self-care, may carry over up to $500 and still elect to contribute $2,650. the spouse or family member must live in your home at least eight hours each day. Be sure to estimate your expenses carefully before enrolling. Unless you experience a permitted status change (see the IRS rules do not allow a DepCare FSA to have a carryover Health FSA Summary Plan Description for details), once elected, feature, but you can incur eligible expenses for reimbursement you cannot change the amount of your contribution if you during the grace period. You must incur expenses between miscalculate your anticipated expenses or misunderstand what Jan. 1 of the plan year and March 15 of the following year in 48

53 Chapter Title Health and Dependent Care Flexible Spending Account Plans order to be eligible for reimbursement. Any claims for DEPCARE FSA AND DEPENDENT CARE TAX CREDIT expenses incurred during this period must be submitted by the Your participation in the DepCare FSA may or may not provide filing deadline, which is April 15 following the plan year. The more tax savings than using the federal dependent care tax credit. period from Jan. 1–April 15 is called the claims “run-out Any payment from the DepCare FSA reduces, dollar for dollar, period,” which provides additional time to submit eligible the expenses eligible for the dependent care tax credit. Your tax expenses incurred during the prior plan year. savings from the FSA depend on your particular tax situation. For a general comparison of the DepCare FSA with the tax credit, see Expenses incurred after your DepCare FSA participation ends the DepCare FSA Summary Plan Description . are not eligible for reimbursement. If you enroll midyear, expenses incurred before the date your enrollment is effective If you need specific advice about how the DepCare FSA applies are not eligible for reimbursement. The effective date generally to your tax situation, please consult a tax adviser. is the first of the month following your enrollment, but may be later depending on payroll deadlines. Expenses submitted for reimbursement are carefully evaluated WHEN COVERAGE ENDS against the IRC requirements for eligible expenses. If your If you lose eligibility for DepCare FSA, contributions and expenses are not clearly eligible according to the IRC, you will coverage end. There are no options to continue or convert your need to submit additional information to WageWorks and you coverage. may not be reimbursed for these expenses. In some cases, you may need a tax adviser’s statement certifying the eligibility of the expense. FOR MORE INFORMATION See the WageWorks website (wageworks.com/ucfsa), IRS Publication 503, Child and Dependent Care Expenses (available This is only an overview of the Health and DepCare Flexible DepCare FSA Summary Plan on the IRS website at irs.gov) or the Spending Account plans. Be sure to review the Summary Plan Description for more information. Descriptions, available online at ucal.us/EOCs. Additional information about the FSA plans is available on the WageWorks CONTRIBUTION LIMITS AND FORFEITURE RULES website (wageworks.com/ucfsa). When you enroll in the DepCare FSA, you determine how much you want deducted from your monthly pay, from a minimum of $180 per year ($15 per month) to the least of: $5,000 per plan year ($2,500 if you are married and filing a • separate income tax return); Your total earned income; or • • Your spouse’s total earned income. (You may not contribute to the DepCare FSA if your spouse’s earned income is $0 and your spouse is capable of self-care or is not a full-time student.) The maximum contribution to the DepCare FSA is the same regardless of your marital status or the number of eligible dependents. If your spouse is also eligible to participate in UC’s or another employer’s dependent care FSA, your combined contributions cannot exceed the contribution maximum. Be sure to estimate your expenses carefully before enrolling. Unless you experience a permitted status change (see DepCare FSA Summary Plan Description for details) once elected, you cannot change the amount of your contribution due to miscalculating your anticipated expenses or to misunderstanding what expenses are eligible. The IRS requires that you forfeit any unclaimed funds in your account after the closing date for the plan year. 49

54 Chapter Title Chapter Title Body Copy 50

55 Chapter Title Legal Notifications Legal Notifications PARTICIPATION TERMS AND CONDITIONS • By enrolling individuals as your family members you are certifying that those individuals are eligible for coverage Your Social Security number, and that of your enrolled family based on the definitions and rules specified in the University members, is required for purposes of benefit plan administra - of California Group Insurance Regulations and described tion, for financial reporting, to verify your identity, and for in UC health and welfare plan eligibility publications. You legally required reporting purposes all in compliance with are also certifying under penalty of perjury that all the federal and state laws. information you provide regarding the individuals you enroll is true to the best of your knowledge. If you are confirmed as eligible for participation in UC-sponsored If you enroll individuals as your family members you must • plans, you are subject to the following terms and conditions: provide, upon request, documentation verifying that those • With the exception of benefits provided or administered individuals are eligible for coverage. The carrier may also by Optum Behavioral Health, UC-sponsored medical plans require documentation verifying eligibility. Verification require resolution of disputes through arbitration. With documentation includes, but is not limited to, marriage or regard to each plan, by your written or electronic signature, birth certificates, domestic partner verification, adoption it is understood and you agree that any dispute as to papers, tax records and the like. medical malpractice—that is, as to whether any medical If your enrolled family member loses eligibility for UC- • services rendered under the contract were unnecessary sponsored coverage (for example because of divorce or loss or unauthorized or were improperly, negligently of eligible child status) you must notify UC by de-enrolling or incompetently rendered—will be determined by that individual. If you wish to make a permitted change in submission to arbitration as provided by California law your health or flexible spending account coverage you must and not by a lawsuit or resort to court process, except as notify UC within 31 days of the eligibility loss event; for California law provides for judicial review of arbitration purposes of COBRA, eligibility loss notice must be provided proceedings. Both parties to the contract, by entering to UC within 60 days of the family member’s loss of coverage. into it, are giving up their constitutional right to have However, regardless of the timing of notice to UC, coverage any such dispute decided in a court of law before a jury for the ineligible family member will end on the last day of the and instead are accepting the use of arbitration. For more month in which the eligibility loss event occurs (subject to any information about each plan’s arbitration provision please see continued coverage option available and elected). the appropriate plan booklet or call the plan. • Making false statements about satisfying eligibility UC and UC health and welfare plan vendors comply with • criteria, failing to timely notify the University of a family federal/state regulations related to the privacy of personal/ member’s loss of eligibility, or failing to provide verification confidential information including the Health Insurance documentation when requested may lead to de-enrollment of Portability and Accountability Act of 1996 (HIPAA) as the affected family members. Employees/retirees may also be applicable. To fulfill the responsibilities and perform the subject to disciplinary action and de-enrollment from health service required under contracts with UC, health plans and benefits and may be responsible for any cost of benefits associated service vendors may share UC member health provided and UC-paid premiums due to misuse of plan. information between and among each other within the • Under current state and federal tax laws, the value of the limits established by HIPAA and federal/state regulations for contribution UC makes toward the cost of health coverage purposes of health care operations, payment, and treatment. provided to domestic partners and certain other family A member’s requested restriction on the sharing of specified members who are not “your dependents” under state and protected health information for health care operations, federal tax rules may be considered imputed income that payment, and treatment will be honored as required by HIPAA. will be subject to income taxes, FICA (Social Security and • By making an election with your written or electronic signature Medicare), and any other required payroll taxes. (Coverage you are authorizing the University to take deductions from your provided to California registered domestic partners is not earnings (employees)/monthly Retirement Plan income (retirees)/ subject to imputed income for California state tax purposes.) designated bank account (direct payment retirees) to cover your If you specifically ask UC representatives to intercede on your • contributions toward the monthly costs (if any) for the plans you behalf with your insurance plan, University representatives have chosen for yourself and your eligible family members. You will request the minimum necessary protected health are also authorizing UC to transmit your enrollment demographic information required to assist you with your problem. If data to the plans in which you are enrolled. more protected health information is needed to solve your • You are subject to all terms and conditions of the UC- problem in compliance with state laws and federal privacy sponsored plans in which you are enrolled as stated in the plan laws (including HIPAA), you may be required to sign an booklets and the University of California Group Insurance authorization allowing UC to provide the health plan with Regulations. 51

56 Legal Notifications Legal Notifications relevant protected health information or authorizing the If you do not enroll yourself and/or your family member(s) in health plan to release such information to the University medical coverage within the 31 days when first eligible, within a representative. special enrollment period described above or within an Open Enrollment period, you may be eligible to enroll at a later date. Actions you take during Open Enrollment will be effective • However, even if eligible, each affected individual will need to the following January 1 unless otherwise stated—provided complete a waiting period of 90 consecutive calendar days all electronic and form transactions have been completed before medical coverage becomes effective and employee properly and submitted timely. premiums may need to be paid on an after-tax basis (retiree premiums are always paid after-tax). Otherwise, you/they can enroll during the next Open Enrollment Period. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) NOTIFICATION FOR MEDICAL To request special enrollment or obtain more information, PROGRAM ELIGIBILITY employees should contact their local Benefits Office and retirees should call the UC Retirement Administration Service Center If you are declining enrollment for yourself or your eligible family (800-888-8267). - members because of other medical insurance or group medi cal plan coverage, you may be able to enroll yourself and your Note: If you are enrolled in a UC medical plan you may be able to 1 in a UC- sponsored medical plan if you eligible family members change medical plans if: or your family members lose eligibility for that other coverage • you acquire a newly eligible family member; or (or if the employer stops contributing toward the other coverage for you or your family members). You must request enrollment • your eligible family member loses other coverage. within 31 days after you or your family member’s other medical coverage ends (or after the employer stops contributing toward In either case you must request enrollment within 31 days of the the other coverage). occurrence. In addition, if you have a newly eligible family member as a In addition to the special enrollment rights you have under result of marriage or domestic partnership, birth, adoption, HIPAA, the University’s Group Insurance Regulations (GIRs) or placement for adoption, you may be eligible to enroll your permit you to change medical plans under certain other newly eligible family member. If you are an employee you may conditions. See UC GIRs for additional detail, available at be eligible to enroll yourself, in addition to your eligible family ucnet.universityofcalifornia.edu. member(s). You must request enrollment within 31 days after the marriage or partnership, birth, adoption, or placement for adoption. If you decline enrollment for yourself or for an eligible family member because of coverage under Medicaid (in California, Medi-Cal) or under a state children’s health insurance program (CHIP) you may be able to enroll yourself and your eligible family members in a UC-sponsored plan if you or your family members lose eligibility for that coverage. You must request enrollment within 60 days after your coverage or your family members’ coverage ends under Medicaid or CHIP. Also, if you are eligible for health coverage from UC but cannot afford the premiums, some states have premium assistance pro - grams that can help pay for coverage. For details, contact the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services at www.cms.gov or 1-877-267-2323 ext. 61565. 1 To be eligible for plan membership, you and your family members must meet - all UC employee or retiree enrollment and eligibility requirements. As a condi tion of coverage, all plan members are subject to eligibility verification by the University and/or insurance carriers, as described above in the participation terms and conditions. 52

57 Legal Notifications NOTICE REGARDING ADMINISTRATION OF BENEFITS By authority of the Regents, University of California Human Resources, located in Oakland, administers all benefit plans in accordance with applicable plan documents and regulations, custodial agreements, University of California Group Insurance Regulations, group insurance contracts, and state and federal laws. No person is authorized to provide benefits information not contained in these source documents, and information not contained in these source documents cannot be relied upon as having been authorized by the Regents. Source documents are available for inspection upon request (800-888-8267). What is written here does not constitute a guarantee of plan cover - age or benefits—particular rules and eligibility requirements must be met before benefits can be received. The University of California intends to continue the benefits described here indefinitely; however, the benefits of all employees, retirees and plan beneficiaries are subject to change or termination at the time of contract renewal or at any other time by the University or other governing authorities. The University also reserves the right to determine new premiums, employer contributions and monthly costs at any time. Health and welfare benefits are not - accrued or vested benefit entitlements. UC’s contribution to ward the monthly cost of the coverage is determined by UC and may change or stop altogether, and may be affected by the state of California’s annual budget appropriation. If you belong to an exclusively represented bargaining unit, some of your benefits may differ from the ones described here. For more information, employees should contact their Human Resources Office and retirees should call the UC Retirement Administration Service Center (800-888-8267). In conformance with applicable law and University policy, the University is an affirmative action/equal opportunity employer. Please send inquiries regarding the University’s affirmative action and equal opportunity policies for staff to Systemwide AA/EEO Policy Coordinator, University of California, Office of the President, 1111 Franklin Street, 5th Floor, Oakland, CA 94607, and for faculty to the Office of Academic Personnel and Programs, University of California, Office of the President, 1111 Franklin Street, Oakland, CA 94607. 53

58 UC Health 23M 2001 1/19 MEDICAL, DENTAL AND MORE 2019 A Complete Guide to Your and Welfare Benefits

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