X U Employee Benefits Guide avier

X

avier

U

niversity

of Louisiana

Employee Benefits Guide

January 1, 2016—December 31, 2016



Medical

X avier

U niversity of Louisiana

Chapel

As a valued employee of Xavier University of Louisiana, you are eligible for a comprehensive benefit package. This booklet contains valuable information about each of the benefits offered. You’ll also find several important notices enclosed that Xavier University of Louisiana is required to distribute annually.

Dental

Vision

Cancer Plan

Life/AD&D

Flexible

Spending

LTD

Short Term

Disability

(Voluntary)

403(b)

&

Matching and

Supplemental



Contact Information

Refer to this list when you need to contact one of your benefit providers. For general information, contact Eustis

Benefits or the Office of Human Resources.

Medical HumanaPPO ……….….……...…………………………..……………………………..……...………………………………..pages 4 -9

Group Policy Number: 680135

Subscriber Number: refer to your ID card

Provider Phone Number: (866) 427-7478

Provider Web Address: www.myhumana.com

Dental - HumanaDental ………………………………..………………………………………………………..……………………………page 10




Provider Web Address: www.HumanaDental.com

Vision - HumanaVision ……………………………………………………..………………………………………………………………….page 11




Provider Web Address: www.HumanaVisionCare.com

Flexible Spending Account (FSA) - Humana ………………………………………..…………………………………………………page 12


Provider Web Address: www.myhumana.com

Cancer Insurance – Transamerica Worksite Marketing ……………...……………………………………………………….page 12

Group Policy Number: G000011062


Provider Web Address: www.transamericaemployeebenefits.com

Life/AD&D - Humana ……………………………………………………...……………………...……………………………………………page 13



Long Term Disability – Reliance Standard ………………...………...………….…………...……..………………………………page 14



Retirement / 403(b) Matching & Supplemental Retirement Plans – TIAA CREF ..…..………………………………page 14


Provider Web Address: www.tiaa-cref.org/xula

Retirement / 403(b) Matching & Supplemental Retirement Plans – VOYA………..

..…..……………………………….page 14

Provider Phone Number: (800) 873-2161 or (504) 620-5560

Provider Web Address: www.voyaretirementplans.com

Any claims or benefit questions may be referred to Eustis Benefits. Jodi Yuspeh may be reached at 504-586-3167 or jyuspeh@eustis.com

.

2

Benefits Frequently Asked Questions

When am I eligible for coverage?



You are eligible for coverage on the first of the month after your date of hire. You are eligible for Long Term

Disability coverage after one year of employment.

Who may I cover under the Benefits Plan?



You may cover you and your eligible dependents under the Medical, Dental, Vision and or Voluntary Life plans.

Xavier University automatically enrolls you in the Basic Life and Long Term Disability benefit.



Eligible dependents include your legal spouse, and child(ren) under the age of 26. Dependent children may be covered until the age of 26 regardless of marital status and student status. In certain cases, stepchildren may be covered. Please contact Eustis Benefits or the Office of Human Resources with any questions regarding eligible dependents.

Can I elect different coverages for members of my family?



You may choose to cover any eligible dependent under any plan as long as you are enrolled in that plan. For example, you may cover yourself only under the Medical plan, and you and your children under the dental plan.

Can I make changes during the year?



You may not make any changes during the year unless there is a qualifying event. Open enrollment is the time to elect benefits and/or make any changes for the January 1 – December 31 Plan Year. You may not switch

Medical plans during the Year.



Qualifying events include things such as marriage, death, divorce, birth of a child or loss of other coverage.

Questions regarding changes to your elections should be directed to Eustis Benefits or the Office of Human

Resources.

How do I locate providers who are in-network?

 Visit www.myhumana.com

to locate medical providers who participate in Humana’s Choice Care (CHC) network. Visit www.HumanaDental

to locate dental providers. Visit www.HumanaVisionCare

to locate vision providers. You are not required to use a network provider, but using a network provider will allow you to maximize the level of benefits received.

What is the Super MOOP?



Starting in 2014 there will be a federally mandated maximum out-of-pocket (MOOP) limit that health insurance plans cannot exceed. All health insurance plans with non-grandfathered status, both fully insured and selffunded must have the MOOP include all member cost sharing for medical and pharmacy (excluding premiums, balance billing amounts for non-network providers, or spending for non-covered services). Cost-sharing includes all copayments, deductibles, and coinsurance amounts for medical, behavioral health and pharmacy amounts.

The inclusion of copayments in the MOOP will likely be a change to your plan.

3

Humana will continue to be the provider for Xavier University of Louisiana’s Medical plans for the 2016 Plan Year. There are five plans from which to choose: Ochsner TotalCare Plan, HDHP,

Simplicity Plan, Base Plan and Enhanced Plan.

Ochsner TotalCare HMO Plan – Ochsner Network ONLY

Plan Service Employee Responsibility

Office Visits

Preventive Services

$30 copay for Primary Care Physicians / $60 copay for Specialists

Covered at 100%, no copay required adult and child physical exams, routine child immunizations, routine lab tests and x-rays

Deductible $0 for an Individual/$0 for a Family

Coinsurance

Maximum Out-of-Pocket

100% - After the deductible is met, eligible charges are covered at 100% by

Humana (excluding copays)

$3,500 Individual/$7,000 Family (includes deductible, copays)

Super MOOP

(Maximum Out-of-Pocket)

$6,250 Individual/$12,500 Family (includes MOOP, Rx MOOP, deductible & copays)

Emergency Room Copay

Urgent Care Copay

$250 copay per visit; waived if admitted into the hospital

$50 copay per visit

Inpatient Hospital

Outpatient Hospital

$300 copay per day/Max 3 days

$300 copay per surgery

X-ray and Laboratory Services

Prescription Drug Coverage

Routine/Diagnostic services are covered at 100%

Advanced Imaging (PET, MRI, CAT, SPECT) – 100%

Tier 1 – (low-cost generic drugs) - $10 copay

Tier 2 – (higher-cost brand name drugs) - $30 copay

Tier 3 – (higher cost drugs, both generic and brand name) - $50 copay

Tier 4 – (highest cost drugs) – 25% coinsurance

Specialty Drugs – 35% coinsurance or 25%

(when filled via a preferred network specialty pharmacy)

Mail Order – 2.5 times Retail Copay

Rx MOOP $3,500 Individual/$7,000 Family(Max Out of Pocket)

N/A Out-of-Network Benefits

*Please refer to your Humana Summary of Benefits for additional details on this plan.

Ochsner TotalCare Payroll Contributions

Coverage Type

Employee Only

Employee + Spouse

Employee + Child(ren)

Family (Employee+Spouse+Child(ren)

Coverage Type

Employee Only

Employee + Spouse



Bi-Weekly Contribution per Paycheck

$33.39

$324.35

$295.52

$469.99

Monthly Contribution per Paycheck

$66.78

$648.69

$591.03

$939.99

4

High Deductible Health Plan (HDHP)

Plan Service

Office Visits

Preventive Services

Employee Responsibility

Deductible, then 100% for Primary Care Physicians and Specialists


Deductible

Coinsurance

Maximum Out Of Pocket


Urgent Care Copay

Inpatient Hospital

Outpatient Hospital


$1,500 for an Individual

$3,000 for a Family


Humana


$3,000 for a Family (includes deductible)

Deductible, then 100%




Routine/Diagnostic services are covered at 100% after Deductible

Advanced Imaging (PET, MRI, CAT, SPECT) – 100% after Deductible

Prescription Drug Coverage Deductible, then 100%

Out-of-Network Benefits

Deductible - $4,500 Individual, $9,000 Family

Coinsurance – 70% / 30%

Out-of-Pocket Maximum - $7,000 Individual, $14,000 Family (includes deductible)


HDHP Payroll Contributions

Coverage Type

Employee Only

Employee + Spouse



Coverage Type

Employee Only

Employee + Spouse




$43.49

$344.41

$390.73

$502.31


$86.99

$688.82

$781.46

$1,004.63

5

Simplicity Plan

Plan Service

Office Visits

Preventive Services

Deductible




$0 for an Individual

$0 for a Family

Coinsurance


Super MOOP (Maximum Outof-Pocket)


Urgent Care Copay

Inpatient Hospital

Outpatient Hospital


Humana



$375 Copay per visit; waived if admitted into the hospital

$100 Copay per visit

$700 Copay, max 3 days

$700 Copay





Advanced Imaging (PET, MRI, CAT, SPECT) – $375 Copay




Tier 4 – (highest cost drugs) – 25% coinsurance

Specialty Drugs – 35% coinsurance or 25%

( when filled via a preferred network specialty pharmacy)


Rx MOOP $5,000 Individual/$10,000 Family (Max Out of Pocket)


Coinsurance – 50%

Out-of-Pocket Maximum - $15,000 Individual, $30,000 Family (includes deductible)


Simplicity Plan Payroll Contributions

Coverage Type

Employee Only

Employee + Spouse



Coverage Type

Employee Only

Employee + Spouse




$45.23

$348.02

$317.74

$508.32


$90.46

$696.04

$635.48

$1,016.65

6

Base Plan

Plan Service

Office Visits

Preventive Services

Deductible

Coinsurance

Maximum Out-of Pocket





$3,750 for a Family

(copays do not apply)



$3,000 Individual/$6,000 Family

(includes all copays except for Rx)


Super MOOP

(Maximum Out-of-

Pocket)

Emergency Room Copay $100 copay per visit; waived if admitted into the hospital

Urgent Care Copay

Inpatient Hospital

$40 copay per visit

100% after Deductible

Outpatient Hospital 100% after Deductible









Specialty Drugs – 35% coinsurance, 25%


Mail Order – 2 times Retail Copay

Rx MOOP $3,500 Individual/$7,000 Family (Max Out of Pocket)


Coinsurance – 70% /30%

Out-of-Pocket Maximum - $6,000 Individual, $12,000 Family (excludes deductible)


Base Plan Payroll Contributions

Coverage Type

Employee Only

Employee + Spouse



Coverage Type

Employee Only

Employee + Spouse




$85.18

$278.55

$177.85

$381.35


$170.36

$557.09

$355.70

$762.70

7

Enhanced Plan

Plan Service

Office Visits

Preventive Services

Deductible




$750 Individual/$1,500 for a Family

Coinsurance


Super MOOP

(Maximum Out-of-Pocket)


Urgent Care Copay




$4,000 Individual/$8,000 Family

(includes MOOP, Rx MOOP, deductible & copays)

$150 copay per visit; waived if admitted into the hospital

$75 copay per visit

Inpatient Hospital 100% after Deductible

Outpatient Hospital 100% after Deductible

X-ray and Laboratory Services Routine/Diagnostic services are covered at 100% after Deductible


Prescription Drug Coverage Tier 1 – (low-cost generic drugs) - $10 copay



Specialty Drugs – 35% coinsurance, 25%



Rx MOOP $3,500 Individual/$7,000 Family(Max Out of Pocket)

Out-of-Network Benefits Deductible - $2,250 Individual, $4,500 Family

Coinsurance – 70% /30%

Out-of-Pocket Maximum - $12,000 Individual, $24,000 Family (excludes deductible


Enhanced Plan Payroll Contributions

Coverage Type

Employee Only

Employee + Spouse



Coverage Type

Employee Only

Employee + Spouse




$102.03

$341.79

$216.92

$466.43


$204.06

$683.59

$433.85

$932.86

8

What are the differences between the Ochsner Total Care HMO Plan, HDHP Plan, the Simplicity Plan, the

Base Plan and the Enhanced Plan?

Office Visit Copays



Ochsner TotalCare HMO Plan has $30 Primary Care Physician copay and $60 Specialist copay



HDHP you pay the deductible, then covered 100% for Office Visits



Simplicity Plan has $25 copay for Primary Care Physicians and $65 Specialist copay



Base Plan has $30 Primary Care Physician copay and $40 Specialist copay



Enhanced Plan has a $25 Primary Care Physician copay and $40 Specialist copay

Prescription Drug Copays



Ochsner TotalCare Plan HMO has $10/$30/$50/25%/35% copays and coinsurance, $3,500 Out Of Pocket Max



HDHP you pay the deductible then covered 100% for Prescriptions



Simplicity Plan has $10/$40/$70/$25% /35% copays and coinsurance, $5,000 Out of Pocket Max



Base Plan has $15/$30/$50/35% copays and coinsurance, $3,500 Out of Pocket Max



Enhanced Plan has $10/$25/$40/35% copays and coinsurance, $3,500 Out of Pocket Max

Deductible



Ochsner TotalCare HMO Plan has $0 deductible



HDHP Plan has $1,500 individual, $3,000 Family deductible



Simplicity Plan has no deductible



Base Plan has $1,250 Individual and $3,750 Family deductible



Enhanced Plan has $750 Individual and $1,500 Family deductible

Inpatient Hospital Procedures



Ochsner TotalCare HMO Plan has $300 copay per day, maximum 3 days



HDHP you pay the deductible then covered 100%



Simplicity Plan $700 copay per day, maximum 3 days



Base Plan is subject to deductible and then covered at 100%



Enhanced Plan is subject to deductible and then covered at 100%

Super MOOP



Ochsner TotalCare HMO Plan has $6,250 individual, $12,500 family



HDHP you pay the deductible then covered 100%, there is no Super MOOP



Simplicity Plan has $6,250 individual, $12,500 family



Base Plan has $6,250 individual, $12,500 family



Enhanced Plan has $4,000 individual, $8,000 family

Payroll Contribution



Please refer to each individual plan summaries for Payroll Contribution details

9

Humana will again provide Dental benefits to employees of Xavier University of Louisiana.


Calendar Year Deductible $50 for an Individual

$150 for a Family

(waived for Preventive Services)

Preventive Services

Basic Services

Major Services

Covered at 100%

Oral examinations, x-rays, cleanings

Covered at 80% after Deductible

Fillings, oral surgery, extractions

Covered at 70% after Deductible

Crowns, Dentures, Endodontics (root canals),

Bridgework

Orthodontia

Annual Maximum

Out-of-Network

Covered for dependent children to age 20

Covered at 50% up to $2,500 lifetime maximum per eligible dependent child

$2,500 per member

Claims are paid at the maximum allowable fee. Any charges above the maximum allowable fee may be balance-billed to the employee by the Provider.

Please refer to your Humana Summary of Benefits for additional details on this plan.

Dental Plan Employee Contributions

Coverage Type

Employee Only

Employee + Spouse



Coverage Type

Employee Only

Employee + Spouse




$16.24

$32.44

$34.33

$53.76


$32.47

$64.87

$68.66

$107.52

10

Humana will provide Vision Benefits for the 2016 Plan Year.


Vision Exam

Frames

$10 copay

$45 Wholesale Allowance + 20% retail discount

Covered after $15 copay Lenses – Single vision,

Bifocal, Trifocal

Lens Options

Contact Lenses

Copays differ

Conventional - $110 allowance + 15% off balance

Medically Necessary – Covered at 100%

Benefit Frequency

Out-of-Network

Exams – once every 12 months

Lenses/Contact lenses – once every 12 months

Frames – once every 12 months

Allowance for benefit

Please refer to your Humana Summary of Benefits for additional details on this plan.

Vision Plan Employee Contributions

Coverage Type

Employee Only

Employee + Spouse




$2.65

$5.03

$5.29

$7.94

Coverage Type

Employee Only

Employee + Spouse




$5.29

$10.05

$10.58

$15.87

11

You may choose to make pre-tax contributions, through payroll deduction, to a Flexible Spending Account. You have the option to contribute to a Medical Expense Reimbursement Account and/or a Dependent Care Expense Account.



Funds in the Medical Expense Reimbursement Account may be used to pay for medical expenses not paid for by your insurance – expenses such as deductibles, copays and prescription drugs. You may contribute a maximum of $2,550 per year to this account.



Funds in the Dependent Care Expense Account may be used to pay certain expenses to care for eligible dependents who live with you while you are at work. An example of such an expense is child care for children under the age of 13. You may contribute a maximum of $5,000 per year to this account if you are single or you are married and filing a joint tax return, or $2,500 if you are married, filing separate tax returns (per IRS guidelines).

IMPORTANT: Please keep the following in mind when making an election!



You are required to designate a pre-tax contribution at the beginning of the Plan Year. This contribution MAY

NOT be changed during the course of the year.





You will be able to rollover up to $500 from 2016 to 2017.

Contact Human Resources to elect FSA contributions.

You have the option to enroll in a Cancer policy that will pay you a direct benefit in the event that you are diagnosed with and treated for Cancer. This policy pays independently of any other Insurance policy. There are two plans available – Plan I and Plan II. Available only at open enrollment.

Plan Service

Wellness Benefit

Plan I Benefit

$50 per Calendar Year for cancer screening

$100 per day; up to 90 days

$1,000

Plan II Benefit

$100 per Calendar Year for cancer screening

$200 per day; up to 90 days

$2,000

Hospital Confinement

First Occurrence Benefit (lump sum benefit paid at time of initial diagnosis)

Radiation and Chemotherapy

Coverage Type

Individual

Single-Parent Family

Up to $10,000 of actual charges Up to $20,000 of actual charges


Plan 1 Plan 2

$8.57

$9.70

$15.55

$17.64

Family

Coverage Type

Individual

Single – Parent Family

Family

$15.51


Plan 1

$17.14

$19.39

$31.01

$28.21

Plan 2

$31.10

$35.27

$56.42

12

Xavier University of Louisiana provides Basic Life/AD&D Insurance to eligible employees. This benefit is provided at no cost to the employee.

The amount of insurance is equivalent to the employee’s annual base salary. Please contact the Office of Human Resources for specific information. Please make sure that the Office of

Human Resources has updated Beneficiary information on file.

Eligible employees may elect to participate in Voluntary Life insurance. Insurance may be purchased on the employee, his/her spouse and/or dependent children.

Voluntary Life/AD&D Benefit – Employee

Increments of $10,000 to a Max of $500,000

Guarantee Issue - $50,000 – Any amount elected over $50,000 will need medical questions for approval.

Voluntary Life/AD&D Benefit - Spouse

Increments of $5,000 to a Max of $250,000 or half of Employee Benefit

Guarantee Issue - $25,000 – Any amount elected over $25,000 will need medical questions for approval.

Voluntary Life Benefit – Dependent Child(ren) – eligible to age 19 or 26 if full-time student

$10,000 Flat Benefit per Child

Benefit Provisions – Employee, Spouse and Dependent Child(ren)

Benefit Reductions

Accelerated Death Benefit

Benefits reduce to 65% of original elected amount at age

65; 50% of original elected amount at age 70; 35% of original elected amount at age 75

For any covered member who is diagnosed with a terminal illness, 50% of the Life Benefit may be accessed to a Max of $250,000. The Life Benefit will be decreased by the amount of the Accelerated Death Benefit.

Coverage terminates at Retirement or upon Termination of Employment unless coverage is ported at time of separation from the University.

Please refer to your Humana Certificate of Coverage for more details.

Voluntary Life/AD&D Rates

Age

<30

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

Dependent Child

How to Calculate Contribution per Paycheck:

(Amount of Life Benefit Amount ÷ 1000) x Rate = Monthly Cost

(Monthly Cost x 12) ÷ 26 = Contribution per paycheck

Rate per Month

$.052

$.076

$.088

$.106

$.179

$.320

$.556

$.780

$1.541

$2.690

$4.851

$4.56 per Family Unit

13

Xavier University of Louisiana provides Long Term Disability Insurance to eligible employees after one full year of employment. This benefit is provided at no cost to the employee. Benefits are available after 90 days of a disability. Please contact the Office of Human Resources or Eustis Benefits for specific information.

Xavier University of Louisiana is offering Voluntary Short Term Disability to eligible employees. This benefit is 100% employee paid. The issue ages are 18 to 70.

There is a Minimum benefit of $300 and maximum benefit of $3,000 per month, not to exceed 60% of base monthly income. The plan provides off-the-job coverage for injuries after 7 days and off-the job sicknesses after 7 days of total disability. This coverage is for disabilities caused by either an accidental injury or sickness. The number of continuous days, beginning with the first day of a total disability, before any monthly benefit amount is payable. Separate elimination periods apply to injury and illness.

The Benefit Period is 3 months. Please contact the Office of Human Resources or Eustis Benefits for specific information.

Non-tobacco coverage, bi-weekly payroll deductions based on monthly premium calculation (monthly calculation = rate x 2)

Age Benefit Amount

BENEFIT:

18-35

$300

$4.95

$600

$8.77

$900

$12.60

$1,200 $1,500 $1,800 $2,100 $2,400 $2,700 $3,000

$16.42

$20.25

$24.07

$27.90

$31.72

$35.55

$39.37

36-45

46-55

56-65

66+

$5.23

$9.34

$13.45

$17.56

$21.67

$25.78

$29.89

$34.00

$38.11

$42.22

$5.56

$10.00

$14.44

$18.88

$23.32

$27.76

$32.20

$36.64

$41.08

$45.52

$6.06

$10.99

$15.93

$20.86

$25.80

$30.73

$35.67

$40.60

$45.54

$50.47

$7.50

$13.87

$20.25

$26.62

$33.00

$39.37

$45.75

$52.12

$58.50

$64.87

Tobacco coverage, bi-weekly payroll deductions based on monthly premium calculation

(monthly calculation = rate x 2)

.

Age Benefit Amount

BENEFIT: $300

18-

35

$600 $900 $1,200 $1,500 $1,800 $2,100 $2,400 $2,700 $3,000

$5.91

$10.69

$15.48

$20.26

$25.05

$29.83

$34.62

$39.40

$44.19

$48.97

36-

46-

56-

66

+

45

55

65

$6.27

$11.41

$16.56

$21.70

$26.85

$31.99

$37.14

$42.28

$47.43

$52.57

$6.67

$12.22

$17.77

$23.32

$28.87

$34.42

$39.97

$45.52

$51.07

$56.62

$7.29

$13.45

$19.62

$25.78

$31.95

$38.11

$44.28

$50.44

$56.61

$62.77

$9.10

$17.08

$25.06

$33.04

$41.02

$49.00

$56.98

$64.96

$72.94

$80.92

14

Available through either TIAA-CREF or VOYA

Xavier University of Louisiana now offers a choice regarding our 403(b) Matching & Supplemental Retirement Plans. All eligible employees have the opportunity to save for retirement by participating in the XAVIER UNIVERSITY 403(b) plans.

You can participate in this plan by making pre-tax contributions.

Not yet contributing to the 403(b) plan?

Note: Upon eligibility it is the responsibility of the eligible employee to inform the Office of Human Resources of any special enrollment circumstance that may waive the two year waiting period for employer match. Proper documentation is required.

To start your contributions to the 403(b) plan, complete and return enrollment forms and salary reduction agreement to the Office of Human Resources.

Please note that in addition to completing and returning a salary reduction agreement, you must also establish an account with the appropriate investment provider that you have selected on the salary reduction agreement and you may also need to provide any additional information that may be required to enroll you in the 403(b) plan.

Already contributing to the 403(b) plan? Great News! You have an opportunity to increase your contributions to the

403(b) Plan.

If you are already currently contributing to the 403(b) plan, you may be able to increase your pre-tax contributions or change providers if you deem appropriate. Please note that you can contribute to both TIAA-CREF and VOYA at the same time or to either of these providers if you prefer, but your total contributions cannot exceed the allowable limits.

Of course, you can keep your contributions at their current level. In the alternative, if your current financial situation means that you need to lower you’re saving for retirement, you can change your contribution rate by completing and returning a salary reduction agreement as described above.

How much can I contribute?

The general limit on salary reduction for 2016 is $18,000 ; however, this amount may be adjusted annually. If you have been employed with the University for 15 or more consecutive years, you may be eligible to contribute up to an additional $3,000 in 2016, based on your prior contributions. For employees age 50 or over, an additional catch up contribution of $6,000 may be contributed for 2016. If you are eligible for both catch-ups, the IRS requires that you first contribute under the 15 Years of Service catch-up before contributing under the Age 50+ catch up. This limit must not exceed the statutory limitation under IRC section 414(v). Each catch-up has its own limits.

All employee contributions cannot exceed the allowable limits.

This Notice is not intended as tax or legal advice. Neither your employer nor the investment providers offering retirement savings products under the plan can provide you with tax or legal advice. Employees are encouraged to contact their financial representative or tax professional with any questions.

15

Women’s Health and Cancer Rights Act of 1998

Important Notice

In October 1998, Congress enacted the Women’s Health and Cancer Rights Act of 1998. This notice explains some important provisions of the Act. Please review this information carefully.

As specified in the Women’s Health and Cancer Rights Act, a plan participant or beneficiary who elects breast reconstruction in connection with a mastectomy is also entitled to the following benefits:

1. Reconstruction of the breast on which the mastectomy has been performed;

2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

3. Prosthesis and treatment of physical complications in all stages of mastectomy, including lymphedemas.

Health plans must determine the manner of coverage in consultation with the attending physician and the patient. Coverage for breast reconstruction and related services may be subject to deductibles and coinsurance amounts that are consistent with those that apply to other benefits under the plan.

16

SPECIAL ENROLLMENT NOTICE

This notice is being provided to insure that you understand your right to apply for group health insurance coverage. You should read this notice even if you plan to waive coverage at this time.

Loss of Other Coverage

If you are declining coverage for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

Example: You waived coverage because you were covered under a plan offered by your spouse's employer. Your spouse terminates his employment. If you notify your employer within 30 days of the date coverage ends, you and your eligible dependents may apply for coverage under our health plan.

Marriage, Birth or Adoption

If you have a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, or placement for adoption.

Example: When you were hired by us, you were single and chose not to elect health insurance benefits. One year later, you marry.

You and your eligible dependents are entitled to enroll in this group health plan. However, you must apply within 30 days from the date of your marriage.

Medicaid or CHIP

If you or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or become eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must request enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistance subsidy.

Example: When you were hired by us, your children received health coverage under CHIP and you did not enroll them in our health plan. Because of changes in your income, your children are no longer eligible for CHIP coverage. You may enroll them in this group health plan if you apply within 60 days of the date of their loss of CHIP coverage.

For More Information or Assistance

To request special enrollment or obtain more information, please contact:

Note: If you and your eligible dependents enroll during a special enrollment period, as described above, you are not considered a late enrollee. Therefore, your group health plan may not require you to serve a pre-existing condition waiting period of more than 12 months. Any preexisting condition waiting period will be reduced by time served in a qualified plan.

For More Information or Assistance

To request special enrollment or obtain more information, please contact:

Adicia Waddell, Associate Director of Human Resources

1 Drexel Drive, New Orleans, LA 70125

(504) 520-7537

Note: If you and your eligible dependents enroll during a special enrollment period, as described above, you are not considered a late enrollee. Therefore, your group health plan may not require you to serve a pre-existing condition waiting period of more than 12 months. Any preexisting condition waiting period will be reduced by time served in a qualified plan.

17

18

19

Important Notice from Xavier University of Louisiana

About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Xavier University of Louisiana and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

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

1 Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2 Xavier University of Louisiana has determined that the prescription drug coverage offered by Humana Health

Care is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable

Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a

Medicare drug plan.

When Can You Join A Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from November 15th through December 31st.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current Xavier University of Louisiana coverage may be affected.

If you do decide to join a Medicare drug plan and drop your current Xavier University of Louisiana coverage, be aware that you and your dependents may not be able to get this coverage back.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with Xavier University of Louisiana and don’t join a

Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to join.

20

For More Information About This Notice Or Your Current Prescription Drug Coverage…

Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Xavier University of Louisiana changes. You also may request a copy of this notice at any time.

For More Informa tion About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:



Visit www.medicare.gov

 Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help



Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov

, or call them at 1-800-772-1213 (TTY 1-800-325-

0778).

Remember: Keep this notice. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage, you may be required to provide a copy of this notice when you join to show that you are not required to pay a higher premium amount.

Date:

Name of Entity/Sender:

Contact – Position Office:

Address:

Phone Number:

January 2016

Xavier University of Louisiana

Adicia Waddell

Associate Director of Human Resources

1 Drexel Drive – Box 104

New Orleans, Louisiana 70125

(504) 520 – 7537

21

General Notice of COBRA Continuation Coverage Rights

** Continuation Coverage Rights Under COBRA**

Date of Notice: November 16, 2015

TO: All Employees of Xavier University of Louisiana

FROM: Xavier University of Louisiana

1 Drexel Drive – Box 104

New Orleans, LA 70125

You are receiving this notice because you have recently become covered under a group health plan (the Plan). This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. BOTH YOU AND YOUR

SPOUSE SHOULD TAKE TIME TO READ THIS NOTICE CAREFULLY.

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget

Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. This notice does not fully describe

COBRA continuation coverage or other rights under the plan. For additional and more complete information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.

WHAT IS COBRA CONTINUATION COVERAGE?

COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event,

COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage may be required to pay for

COBRA continuation coverage.

EMPLOYEE

If you are an employee, you will become a qualified beneficiary entitled to elect COBRA continuation coverage if you lose your coverage under the Plan because either one of the following qualifying events happens:

Your hours of employment are reduced, or

Your employment ends for any reason other than your gross misconduct.

SPOUSE

If you are the spouse of an employee, you will become a qualified beneficiary entitled to elect COBRA continuation coverage if you lose your coverage under the Plan because any of the following qualifying events happens:

Your spouse dies;

Your spouse’s hours of employment are reduced;

Your spouse’s employment ends for any reason other than his or her gross misconduct;

Your spouse becomes eligible for Medicare benefits (under Part A, Part B, or both); or

You become divorced or legally separated from your spouse. In the event your spouse, who is the employee, reduces or terminates your coverage under the Plan in anticipation of a divorce or legal separation which later occurs, the divorce

22

or legal separation may be considered a qualifying event even though the coverage was reduced or terminated before the divorce or separation.

DEPENDENT CHILDREN

Your dependent children, including any child born to or placed for adoption with a covered employee during the period of COBRA coverage who is thereafter properly enrolled in the Plan, or a child of the covered employee who is receiving benefits under the Plan pursuant to a qualified medical child support order, will become qualified beneficiaries entitled to elect COBRA continuation coverage if they lose coverage under the Plan because any of the following qualifying events happens:

• The parent-employee dies;

• The parent-employee’s hours of employment are reduced;

• The parent-employee’s employment ends for any reason other than his or her gross misconduct;

• The parent-employee becomes eligible for Medicare benefits (Part A, Part B, or both);

• The parents become divorced or legally separated; or

• The child stops being eligible for coverage under the plan as a “dependent child.”

WHEN IS COBRA COVERAGE AVAILABLE?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, or the employee's becoming eligible for Medicare benefits (under Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event.

YOU MUST GIVE NOTICE OF SOME QUALIFYING EVENTS

For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator in writing within 60 days after the qualifying event occurs. You must provide this notice to Adicia Waddell in the Office of Human Resources. The Plan procedures for this notice, including a description of any required information or documentation, can be found in the most recent Summary Plan Description or by contacting the Plan Administrator. If these procedures are not followed or if the notice is not provided in writing to the Plan Administrator during the 60-day notice period, you will lose your right to elect COBRA continuation coverage.

HOW IS COBRA COVERAGE PROVIDED?

Once the Plan Administrator receives timely notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect

COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. If COBRA continuation coverage is not elected within the 60-day election period, a qualified beneficiary will lose the right to elect COBRA continuation coverage.

COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the employee's becoming eligible for Medicare benefits (under Part A, Part B, or both), your divorce or legal separation, or a dependent child's losing eligibility as a dependent child, COBRA continuation coverage may last for up to a total of 36 months. When the qualifying event is the end of employment or reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event,

COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of

Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the employee’s hours

23

of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months. There are two ways in which this 18-month period of COBRA continuation coverage can be extended.

DISABILITY EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE

If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. The Plan procedures for this notice, including a description of any required information or documentation, the name of the appropriate party to whom notice must be sent, and the time period for giving notice, can be found in the most recent Summary Plan Description or by contacting the Plan

Administrator. If these procedures are not followed or if the notice is not provided in writing to the Plan Administrator during the 60-day notice period and within 18 months after the covered employee’s termination of employment or reduction of hours, there will be no disability extension of COBRA continuation coverage. The affected individual must also notify the Plan Administrator within 30 days of any final determination that the individual is no longer disabled.

SECOND QUALIFYING EVENT EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE

If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the Plan. This extension may be available to the spouse and any dependent children receiving COBRA continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

The Plan procedures for this notice, including a description of any required information or documentation, the name of the appropriate party to whom notice must be sent, and the time period for giving notice, can be found in the most recent Summary Plan Description or by contacting the Plan Administrator. If these procedures are not followed or if the notice is not provided in writing to the Plan Administrator during the 60-day notice period, there will be no extension of

COBRA continuation coverage due to a second qualifying event.

IF YOU HAVE QUESTIONS: Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under ERISA, including

COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security

Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of

Regional and District EBSA Offices are available through EBSA’s website.)

KEEP YOUR PLAN INFORMED OF ADDRESS CHANGES

In order to protect your family’s rights, you should keep the Plan Administrator informed of the current addresses and of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.

PLAN CONTACT INFORMATION

The name of the group health plan and name (or position), address and telephone number of the party or parties from whom additional information about the plan and COBRA continuation coverage can be obtained on request are as follows: Adicia Waddell, Human Resources, 1 Drexel Drive, New Orleans, LA 70125 – (504) 520-7537. Please refer to the

Plan’s most recent summary plan description for any updated Plan contact information.

24

Health Insurance Marketplace Coverage Options and Your Health

Coverage

PART A: General Information

Form Approved OMB No. 1210-0149

(expires 1-31-201

7

)

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

Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment-based health coverage offered by your employer.

What is the Health Insurance Marketplace?

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

Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace?

You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?

Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit.

1

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after- tax basis.

How Can I Get More Information?

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

Contact Adicia Waddell, 504-520-5065, awaddel1@xula.edu .

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

Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs.

25

PART B: Information About Health Coverage Offered by Your Employer

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

3. Employer name

Xavier University of Louisiana

4. Employer Identification Number (EIN)

72-12014000

5. Employer address

1 Drexel Drive, Box 104

7. City

New Orleans

10. Who can we contact about employee health coverage at this job?

Adicia Waddell

11. Phone number (if different from above)

504-520-5065

12. Email address awaddel1@xula.edu

6. Employer phone number

504-520-5065

8. State 9. ZIP code

LA 70125

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

 As your employer, we offer a health plan to:

D All employees. Eligible employees are:

Some employees. Eligible employees are:

All Employees working at least 20 hours or more per week

 With respect to dependents:

We do offer coverage. Eligible dependents are:

Your legal spouse and dependent children up to age 26 as defined in the Humana Summary Plan Description

D We do not offer coverage.

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

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

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums.

26

Humana Vitality

27

We will be challenging you in 2016 to become an active partner with

Xavier in controlling our healthcare costs which will affect our renewal for 2017. You will be encouraged to participate in healthcare assessments, biometric screenings, and the Vitality program and personally take initiatives which may reduce the overall costs of our renewal for 2017.

Together, we can make a difference.

28

The information in this Enrollment Guide is presented for illustrative purposes and is based on information provided by the employer. The text contained in this Guide was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies, or errors are always possible. In case of discrepancy between the Guide and the actual plan documents the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and

Accountability Act of 1996. If you have any questions about your Guide, contact Eustis Benefits or the Office of Human Resources.

Benefit Guide Receipt

By signing below, I acknowledge that I have received a copy of the Xavier University of Louisiana’s 2016

Benefit Guide and all corresponding insurance materials.

This guide includes the following IMPORTANT notices:

Women’s Health and Cancer Rights Act of 1998

Special HIPAA Enrollment Notice

Preventive Services

Medicare Part D Notice

Notice of COBRA Continuation Coverage Rights

2015 Annual 403(b) Plan Eligibility Notice

Marketplace Notification

Information on Achieving Silver Status in Humana Vitality Wellness Program

I have read and understand all of the enclosed policies and procedures.

___________________________________

Employee Signature

Employee Printed Name

__________________________

Date

29

X U Employee Benefits Guide avier

avier

niversity

of Louisiana

Employee Benefits Guide

Medical

Dental

Vision

Cancer Plan

Life/AD&D

Flexible

Spending

LTD

Short Term

Disability

403(b)

Contact Information

Benefits Frequently Asked Questions

Ochsner TotalCare HMO Plan – Ochsner Network ONLY

High Deductible Health Plan (HDHP)

Simplicity Plan

Base Plan

Enhanced Plan

Important Notice from Xavier University of Louisiana

About Your Prescription Drug Coverage and Medicare

General Notice of COBRA Continuation Coverage Rights

Continuation Coverage Rights Under COBRA

Health Insurance Marketplace Coverage Options and Your Health

Coverage

PART A: General Information

PART B: Information About Health Coverage Offered by Your Employer

Humana Vitality

We will be challenging you in 2016 to become an active partner with

Xavier in controlling our healthcare costs which will affect our renewal for 2017. You will be encouraged to participate in healthcare assessments, biometric screenings, and the Vitality program and personally take initiatives which may reduce the overall costs of our renewal for 2017.

Together, we can make a difference.

Benefit Guide Receipt

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X U Employee Benefits Guide avier

avier

niversity

of Louisiana

Employee Benefits Guide

Medical

Dental

Vision

Cancer Plan

Life/AD&D

Flexible

Spending

LTD

Short Term

Disability

403(b)

Contact Information

Benefits Frequently Asked Questions

Ochsner TotalCare HMO Plan – Ochsner Network ONLY

High Deductible Health Plan (HDHP)

Simplicity Plan

Base Plan

Enhanced Plan

Important Notice from Xavier University of Louisiana

About Your Prescription Drug Coverage and Medicare

General Notice of COBRA Continuation Coverage Rights

** Continuation Coverage Rights Under COBRA**

Health Insurance Marketplace Coverage Options and Your Health

Coverage

PART A: General Information

PART B: Information About Health Coverage Offered by Your Employer

Humana Vitality

We will be challenging you in 2016 to become an active partner with

Xavier in controlling our healthcare costs which will affect our renewal for 2017. You will be encouraged to participate in healthcare assessments, biometric screenings, and the Vitality program and personally take initiatives which may reduce the overall costs of our renewal for 2017.

Together, we can make a difference.

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Continuation Coverage Rights Under COBRA