employee benefits guide - mindshare group · employee benefits guide ... (sec. 125) 14 commuter...

Effective November 1, 2017 to October 31, 2018

Employee Benefits Guide

For more information, visit www.mindsharegroup.com/teamsanjose

WELCOMETeam San Jose is pleased to provide you and your eligible family members with comprehensive employee benefits that help you and your family to stay healthy, feel secure and maintain a positive work/life balance.

Table of Contents

Eligibility 5

Enrollment 6

Medical Insurance 7-10

Health Plan Resources for Blue Shield Members 11

Dental Plan 12

Vision Plan 13

Flexible Spending Account (Sec. 125) 14

Commuter Benefits (Sec. 132) 15

Income Protection Plans 16

Supplemental Protection Plans 17

Additional Benefits 18-19

Financial Benefits 20

Legal Notices 21-25

Glossary of Terms 26

Carrier Contacts / Member Services Inside back cover

This benefits guide is intended to provide a convenient summary of the Team San Jose benefit plans. It is not intended to be a legal document. If there are any inconsistencies between the information in this brochure and the plan documents or contracts, the plan document and contracts will prevail. All benefits, and your eligibility for benefits, are subject to the terms and conditions of the benefit plans, including group insurance contracts. Team San Jose reserves the right to modify or terminate any of the described benefits at any time and for any reason. This guide is not a guarantee of current or future employment or benefits.

Medicare Rx StatementIf you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, a federal law gives you more choices about your prescription drug coverage. Please see the Annual Medicare Prescription Drug Notice in the Legal Notices section of this booklet for more details.

Team San Jose: 2017-2018 Employee Benefits Guide 5

Who Is Eligible and When?You are eligible to enroll in group benefits effective the 1st of the month following your date of hire if you are a non-union employee working 30 or more hours per week. Eligible dependents include your spouse or domestic partner, and children up to age 26. Proof of eligibility for dependents must be provided at the time of enrollment.

Cost SummaryTeam San Jose pays 90% of employee premiums and 65% of spouse and/or dependent premiums for most medical plans, with an additional “buy up” PPO plan available. The company pays 90% of employee premiums and 65% of spouse and/or dependent premiums for Dental and Vision plans. Team San Jose also pays 100% of the premiums for Term Life and Disability Insurance for employees.

Making ChangesUnless you experience a life-changing qualifying event, you cannot make changes to your benefits until the next open enrollment period. Qualifying events include:

• Marriage, divorce or legal separation• Birth or adoption of a child• Change in child’s dependent status• Death of a spouse, child or other qualified dependent• Spousal loss of other coverage

You can make changes consistent with your life event within 30 days of the event. If you miss the 30 day period you will have to wait until the next open enrollment to change your benefits.

Where to Get More Information For more information about your benefits, including plan summaries and documents, please visit: www.mindsharegroup.com/teamsanjose.

Eligibility

Team San Jose: 2017-2018 Employee Benefits Guide6

When to EnrollNew employees must enroll within 14 days following the date of hire. Coverage is effective 1st of the month following the date of hire.

How to EnrollMaxwell Health is your personal benefits portal, and can be accessed at https://app.maxwellhealth.com/member/login.

Step 1: Your username and temporary password will be emailed from [email protected]. The first time you login, you will be prompted to change your password. Note: If you forgot your password, click “I forgot my password” and follow the steps to reset.

Step 2: Review and update your personal account information.

Step 3: Add/review/verify dependent information. Note: Add your dependent information such as name, date of birth and social security number in order to review costs for additional coverage.

Step 4: Elect/ confirm your health benefits and coverage level.

Step 5: Review your cart once completed, and confirm by clicking “Final Review”

Step 6: Complete any required forms (electronic signature).

Step 7: A pop-up will let you know that your elections have been submitted. Click OK and you’re done!

After You EnrollAfter you enroll, you will receive ID cards from the medical plan you select. The HR team will provide you with a MetLife dental card. When you receive your ID card, confirm that all information is accurate. If not, contact HR or the carrier.

You will not receive an ID card for VSP Vision coverage. If you need to access care, your provider should be able to verify coverage using your social security number.

If you register at the carrier websites, you can go online and create your own ID card. If you lose your ID card, go online to the carrier website or call the member services number for your insurance carrier to request a new one. There is a list of contacts located in this booklet.

Enrollment

Maxwell Health


Plan TypesHMO – Health Maintenance OrganizationA type of health insurance plan that usually limits coverage to care from the specific medical group of your Primary Care Physician (PCP), which includes other contracted specialists, hospitals and other facilities which are contracted through that same medical group.

• Requires you to select a primary care physician who will provide all your basic health services and give you a referral if you need to see a specialist.

• Generally defined copayments for office visits and hospital stays

• Generally will not cover out-of-network care except for emergencies

• May require you to live and work within the service area

PPO – Preferred Provider OrganizationA type of health plan that contracts with medical providers, such as hospitals and doctors, to create a broad network of participating providers

• You pay less if you use providers that belong to the plan’s network

• You do not have to choose a primary care physician

• You have the freedom to seek care from any medical provider but you will pay more if you see an out of network provider

• No referral needed to see specialists

Finding a Doctor or Facility In-NetworkStaying in network is key to limiting your costs on your health plan. If you are already a Blue Shield member, you can register and log in at www.blueshieldca.com. There are three simple steps:

Step 1: Click Find a Doctor

Step 2: Select one of the options (Doctors, Primary Care Physicians, Facilities, etc,)

Step 3: Enter the name of the medical provider and select Search

You can also contact Member Services using the number on the back of your Blue Shield member ID Card.

If you are not yet a Blue Shield member you can also search without logging in. You’ll need to enter your ZIP code and select the plan type: either 2017 Small Business Full PPO or 2017 Small Business HMO Access+.

Choose WiselyYour health plan affects many things, including how much choice you have in health care providers, what kind of care you receive, where you receive care, and how you will pay for your care.

It is vital that you evaluate your health plan options carefully and choose the one that best fits your needs. Here are some key elements to consider:

• Does the plan have the doctors and hospitals I want or need?

• Does the plan do a good job of preventing as well as treating illness?

• What do current members or co-workers think of the health plan?

• Does the plan meet my budget?

Medical Insurance


Medical Insurance

Blue Shield of California

Blue Shield Base PPO Plan Gold Full PPO 250/30

Blue Shield “Buy-Up” PPO Plan Platinum Full PPO 150/15

In-Network Out-of-Network In-Network Out-of-Network

DEDUCTIBLE$250 individual

$500 family$500 individual

$1,000 family$150 individual

$300 family$300 individual

$600 family

OUT-OF-POCKET MAXIMUM$6,800 individual

$13,600 family$10,000 individual



$16,000 family

COINSURANCE 20% 40% 10% 40%

OFFICE VISIT

$30 primary care (ded waived)

$50 specialist (ded waived)

40% after deductible

$15 primary care (ded waived)

$30 specialist (ded waived)


PREVENTIVE CARE NO CHARGE NOT COVERED NO CHARGE NOT COVERED

CHIROPRACTIC50% (ded waived) up to

12 visits/year50% (ded waived) up to



12 visits/year

ACUPUNCTURE $25 copay 40% after deductible $25 copay 40% after deductible

DIAGNOSTICS

20% after deductible for labs and xrays;

$100 copay + 20% for complex imaging

40% after deductible; Blue Shield max payment $350

10% after deductible for labs and xrays;

$100 copay + 10% for complex imaging

40% after deductible; Blue Shield max payment $350

HOSPITAL

INPATIENT

OUTPATIENT



40% after deductible; Max payment $2,000/day inpatient or $350/

day max payment outpatient



40% after deductible; Max payment $2,000/day inpatient or $350/

day max payment outpatient

URGENT CARE $30 copay (ded waived) Not covered $15 copay (ded waived) Not covered

EMERGENCY ROOM $200 (waived if admitted) + 20% after deductible $100 (waived if admitted) + 10% after deductible

PRESCRIPTION DRUGS (30 DAY SUPPLY)

Tier 1 (Generic) $15 copay Tier 2 (Preferred Brand)

$40 copay Tier 3 (Non-Preferred)

$60 copay Tier 4 (Specialty) 30% to a maximum of $250 per

prescription

Not covered

Tier 1 (Generic) $5 copay Tier 2 (Preferred Brand)

$30 copay Tier 3 (Non-Preferred)

$50 copay Tier 4 (Specialty) 30% to a maximum of $250 per

prescription

Not covered

MAIL ORDER (90 DAY SUPPLY)2x regular prescription

copayNot covered

2x regular prescription copay

Not covered

* See carrier plan documents for further details.

These tables provide an overview of the benefits and coverage for each plan. You should also review the detailed carrier documents for each plan, available online via Maxwell Health, or at www.mindsharegroup.com/teamsanjose.


Medical Insurance




Blue Shield Platinum Access+ HMO 0/20

In-Network Only

DEDUCTIBLE NONE


$3,500 family

COINSURANCE NONE

OFFICE VISIT$20 copay primary care

$40 copay specialist

PREVENTIVE CARE NO CHARGE

CHIROPRACTIC $15 copay up to 15 visits/year

ACUPUNCTURE $15 copay

DIAGNOSTICS$10 copay lab

$30 copay x-ray $30 Free Standing Location / $100 Hospital complex imaging

HOSPITAL

INPATIENT

OUTPATIENT

$500 per admit

$100 per procedure ambulatory surgery center; $150 hospital

URGENT CARE $20 copay

EMERGENCY ROOM $200 copay (waived if admitted)

PRESCRIPTION DRUGS (30 DAY SUPPLY)

Tier 1 (Generic) $5 copay Tier 2 (Preferred Brand) $15 copay Tier 3 (Non-Preferred) $25 copay

Tier 4 (Specialty) 20% to a maximum of $250 per prescription

MAIL ORDER (90 DAY SUPPLY) 2x regular prescription copay

Kaiser 30 Plan

In-Network Only

DEDUCTIBLE NONE


$6,000 family

COINSURANCE NONE

OFFICE VISIT$30 copay primary care

$30 copay specialist

PREVENTIVE CARE NO CHARGE

CHIROPRACTIC $15 copay up to 20 visits/year (combined with acupuncture)

ACUPUNCTURE $15 copay up to 20 visits/year (combined with chiropractic)

DIAGNOSTICS$10 copay lab

$10 copay x-ray $50 copay complex imaging

HOSPITAL

INPATIENT

OUTPATIENT

$400 per day

$200 per procedure

URGENT CARE $30 copay

EMERGENCY ROOM $100 copay (waived if admitted)

PRESCRIPTION DRUGS (UP TO 100 DAY SUPPLY)Tier 1 (Generic) $10 copay

Tier 2 (Brand/Specialty) $35 copay after $250 prescription deductible

MAIL ORDER (UP TO 100 DAY SUPPLY) Same as regular prescription copay


Medical Insurance

Kaiser Permanente



Kaiser doctors and facilities must be used exclusively when you enroll in the Kaiser plan. For a list of plan providers, see www.kp.org or call 1-800-278-3296.


NurseHelp 24/7Experienced nurses can help you figure out how you can care for yourself, evaluate treatment options, and help you determine whether to see a doctor – all at no charge.

Get immediate answers and reliable information about:

• Minor illnesses and injuries

• Chronic conditions

• Medical tests and medications

• Preventive care

Call (877) 304-0504 to talk to a nurse anytime, day or night.

TeladocTeladoc is a convenient way to access U.S. board-certified doctors 24/7/365 to resolve many of your non-emergency medical issues through phone or video consults. For HMO and PPO members the co-pay is $5 per consult.

Use Teladoc:• For treatment of minor medical conditions, such

as cold and flu symptoms, allergies, urinary tract infections, respiratory infections, and more

• If you’re considering the ER or urgent care for a non-emergency

• When on vacation, a business trip, or away from home

• For short-term prescription refills

Visit Teladoc.com/bsc to set up an account. You can also call Teladoc at 1-800-Teladoc. Once your account is set up you can request a consult anytime you need care.

HealHeal is a service for Blue Shield PPO members that lets you see a doctor at a time and place that’s best for you – home, office or hotel (currently available in the Bay Area and parts of Southern California). You’ll be treated by doctors in Blue Shield’s PPO network for the cost of a regular office visit co-pay. Doctors are available 8 a.m. to 8 p.m. daily.

You can schedule a visit by:

• Calling Heal at (844) 644-4325

• Going to https://getheal.com/

• Downloading the Heal app to your iPhone or Android smartphone.

Member Discount ProgramsBlue Shield offers a variety of member discounts on massage sessions, gym memberships, LASIK eye surgery, and weight management programs. Online discounts of up to 40% off retail items include vitamins and supplements, yoga and fitness equipment, and more.

Member discounts available:• Alternative Care Discount Programs

• Hearing aid discounts

• Weight Watchers

• 24 Hour and ClubSport Gym memberships

Go to www.blueshieldca.com/wellnessdiscounts for more information.

Health Plan Resources for Blue Shield Members



Dental Plan MetLife PPO $2500In-Network Dentists Out-of-Network Dentists

Annual Deductible (Waived for Preventive) $50 per person, $150 per family $50 per person, $150 per family

Annual Maximum $2,500

Preventive and Diagnostic Oral exams and cleanings once every six months. Fluoride, sealants for molars, x-rays, periodontal maintenance.

$0 $0

Basic Services Fillings, simple and surgical extractions, root canals, crown repairs.

10% 10% of R&C**

Major Services Crowns, dentures, bridges, implants

40% 40% of R&C

Orthodontia Dependent children are covered until the end of the month of their 19th birthday or until their 23rd birthday if unmarried, full time students.

50% 50%

Orthodontia Lifetime Maximum $1,000

Monthly Premium

Employee Only $62.59

Employee + Spouse $136.69

Employee + Child(ren) $134.34

Family $228.86

Employee Cost Per Pay Period

Employee Only $3.13


Employee + Child(ren) $15.69

Family $32.23

Dental Plan

MetLife

** R&C Plan benefits for out-of-network services are based on a percentage of the Reasonable and Customary (R&C) Charge. If you choose a dentist who does not participate in the network, your out-of-pocket expenses may be more, and you may be responsible for paying any difference between the dentist’s fee and your plan’s payment for the approved service.Pediatric Dental: If you are enrolled in a Blue Shield medical plan and have dependents under the age of 19, pediatric dental benefits are embedded in your health plan as required by the Affordable Care Act. TSJ’s MetLife Dental Plan offers substantially more robust dental benefits. (Note: Pediatric Dental is not included in TSJ’s Grandfathered Kaiser plan.)

In order to take full advantage of your dental plan, you should verify your dentist’s participation in MetLife’s dental network. You can go online to www.metlife.com/mybenefits or call MetLife at 1-800-942-0854.

In-Network vs.Out-of-NetworkAlways use in-network dentists to pay the least out-of-pocket for dental services. Participating dentists have agreed to accept negotiated fees as payment in full for services provided to plan members. If you choose to see an out-of-network dentist your costs may be higher, and an out-of-network dentist may balance bill you for the difference between the contracted allowance and their fee.

This table provides an overview of the benefits and coverage for this plan. You should also review the detailed carrier documents available online via Maxwell Health or at www.mindsharegroup.com/teamsanjose.


VSP Choice Plan $10/$10 12/12/24VSP Provider Non-VSP Provider

Well Vision (Regular) Exam – Once Every 12 Months $10 – Exam and Glasses $50 Max Allowance

Prescription Lenses – Once Every 12 Months

Polycarbonate lenses for dependent children Combined With Exam

Single Vision, Lined Bifocal, Lined Trifocal Lenses Combined With Exam $50 - $100 Max Allowance

Standard/Premium/Custom Progressive $50-$160 $75 Max Allowance

Frames – Once Every 24 Months $10 – Materials $70 Max Allowance

Wide Selection – $180 Allowance

Featured Frame Brands – $200 Allowance

Costco Frame – $100 Allowance

Contact Lenses – In lieu of lenses and frames

Fitting & Evaluation – Once Every 12 Months – $180 Allowance Copay varies; to max of $60 $105 Max Allowance

Glasses and Sunglasses: Extra 30% savings on additional glasses and sunglasses, including lens enhancements, from the same VSP provider on the same day as your WellVision exam. Or get 20% from any VSP provider within 12 months of your last. WellVision exam. Extra $20 on featured frame brands. Visit vsp.com/special offers for details.

Retinal Screenings: No more than a $39 copay on routine retinal screening as an enhancement to a WellVision exam.

Laser Vision Correction: Average 15% off regular/ 5% off promotional price. Discounts only available from contracted facilities.After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor.

Monthly Premium

Employee Only $13.11


Employee + 1 Child $20.37

Family (Employee + Spouse + Child(ren) or Employee + Children) $32.30

Employee Cost Per Pay Period

Employee Only $.66


Employee + 1 Child $1.93

Family (Employee + Spouse + Child(ren) or Employee + Children) $4.01

Vision Plan

VSP

* See carrier plan documents for further details.Pedicatric Vision: If you are enrolled in a Blue Shield medical plan and have dependents under the age of 19, pediatric vision benefits are embedded in your health plan as required by the Affordable Care Act. TSJ’s VSP Vision Plan offers substantially more robust vision benefits. (Note: Pediatric Vision is not included in TSJ’s Grandfathered Kaiser plan.)

In-Network vs.Out-of-NetworkIn order to take full advantage of your vision plan and pay the least out-of-pocket, visit a VSP provider. You can find in-network providers online at www.vsp.com or by calling Customer Service at (800) 877-7195. If you receive services from an out-of-network provider you will be responsible for paying at the time of service, and you may then request the allowed reimbursement from VSP.

This table provides an overview of the benefits and coverage for this plan. You should also review the detailed carrier documents available online via Maxwell Health or at www.mindsharegroup.com/teamsanjose.


Flexible Spending Account (Sec. 125)

Navia Benefits Solution

F.S.A. OverviewA Flexible Spending Account (FSA) provides you with an important tax advantage that can help you pay for eligible health care and dependent care expenses with tax-free dollars. Your FSA account runs on the calendar year, beginning January 1st thru December 31st. If you decide to participate, you must re-enroll in the plan(s) each year. By anticipating your family’s health care and dependent care costs for the next year, you can actually lower your taxable income.

How You SaveThe amount you contribute to either or both FSAs is deducted from your paycheck before federal, state, local and social security taxes are withheld. When you have an eligible expense, you are reimbursed from your account and the money is not taxed.

Health Care Reimbursement FSAThe Health Care portion of the FSA enables TSJ employees to pay for certain IRS-approved, out-of-pocket health care and related expenses with pretax dollars. For calendar year 2018, you may contribute up to $2,600 to your Health Care account. You may carryover $500 at the end of the plan year without forfeiture. Qualifying expenses include:

• Medical copayments, deductibles, and prescription drugs costs (Note: Over-the-counter drugs without a prescription are no longer eligible for reimbursement).

• Dental copayments and deductibles, including orthodontia

• Vision copayments and other services, including contact lenses, eye exams and eyeglasses

• Hearing services, including hearing aids and batteries

Dependent Care Reimbursement AccountThe Dependent Care portion of the FSA lets TSJ employees use pretax dollars toward qualified dependent care. For 2018, the maximum amount you may contribute to the Dependent Care FSA is $5,000 (or $2,500 if married and filing separately) per calendar year. Qualifying expenses include:

• The cost of all child care for children under age 13

• The cost for a licensed individual to provide care either in or out of your house

• Nursery schools and preschools (excluding kindergarten)

January 1 through December 31


Commuter Benefits (Sec. 132)

Navia Benefits Solution

OverviewTeam San Jose offers pre-tax commuter benefits for work-related parking and mass transit expenses through Navia’s GoNavia Commuter Benefits program. You can elect up to $255/month pre-tax for transportation and up to $255/month pre-tax for parking.

Eligible Expenses Include• Bus vouchers and passes used to commute to and

from work; Vanpooling in a “commuter highway vehicle”

• Parking costs associated with a lot at or near the place of business

• Parking costs from a lot that is at or near the place of commute (i.e. rideshare, carpool, vanpool)

Non-eligible expenses include mass transit costs not associated with the commute to work, toll fares used to commute to and from work, and parking costs incurred at your residence.

EnrollmentTo enroll, go to www.naviabenefits.com/participants and select GoNavia Commuter Benefits from the Benefits & Info drop down menu. After you register you will need to place orders by the 20th of the preceding month you would like to participate. This program can be started or stopped at any time and is not part of annual open enrollment.


Income Protection PlansTerm Life and AD&D InsuranceLife and Accidental Death and Dismemberment (AD&D) insurance can help provide financial resources for your loved ones if something were to happen to you. Life insurance is paid to your beneficiaries after your death, while AD&D is paid in the event of an accidental death or for certain accidental injuries. Make sure you have a current beneficiary on record, especially after experiencing a life event such as marriage or divorce. Benefits reduce at age 65 to 65% of the covered amount and again at age 70 to 50%.

Short Term Disability InsuranceShort Term Disability (STD) provides weekly income replacement for employees who become unable to work due to injury or illness, including pregnancy. You must be unable to work for 7 consecutive days or more before the plan will pay. Your disability benefits may be offset by other benefits you receive, such as mandated state disability insurance, sick pay or workers’ compensation.

Long Term Disability InsuranceIf you continue to be disabled for more than 90 days, you may be eligible to receive disability benefits on a monthly basis through the Long Term Disability (LTD) plan. You will continue to receive payments under the LTD plan as long as you are deemed “disabled” until you reach normal Social Security retirement age.

Coverage Benefit Duration Maximum Benefit

Term Life and AD&D2 x your times annual earnings (salary + bonus + commissions)

Paid at time of death or accidental death or dismemberment

$440,000

Short Term Disability 60% of total weekly earningsBegins after 7 consecutive days of

disability up to 90 days$3,465 per week

Long Term Disability 60% of total earningsBegins after 90 consecutive days of disability until normal Social

Security retirement age$15,000 per month

The Standard


Supplemental Income Protection Plans

The Standard

Supplemental Term Life & AD&D Monthly RatesAge Employee Rate (per $1,000) Dependent Rate (per $1,000)

<29 $0.079 $0.074

30 - 34 $0.081 $0.075

35 - 39 $0.088 $0.080

40 - 44 $0.117 $0.107

45 - 49 $0.154 $0.139

50 - 54 $0.242 $0.220

55 - 59 $0.377 $0.352

60 - 64 $0.502 $0.531

65 - 69 $0.870 $0.922

70 - 74 $1.863 $1.974

75+ $6.979 $7.402

Child rate $0.240

** Rates include Term Life Insurance and AD&D

Term Life InsuranceEmployees who want to supplement their group Term Life insurance benefits may purchase additional Term Life insurance coverage at discounted rates for themselves, their spouse/domestic partner, or children up to age 24. You must elect coverage for yourself in order to elect coverage for your spouse/registered domestic partner and/or your child(ren).

You pay the full cost of this coverage through payroll deductions. If you enroll as a new hire you are guaranteed $50,000 of coverage without any medical questions or proof of good health. Any amount over the guaranteed issue amount requires proof of good health by completing an Evidence of Insurability (EOI) form. The EOI form must be approved by The Standard before the higher level of supplemental coverage is effective.

Coverage Maximum Benefit Guaranteed IssueSupplemental Term Life & AD&D –

EmployeeIncrements of $10,000 $300,000 $50,000

Term Life & AD&D – Spouse Increments of $5,000$150,000 (not to exceed the

employee amount)$25,000

Term Life & AD&D – Child(ren) to age 24 Increments of $2,000 $10,000 $10,000


Additional BenefitsEmployee Assistance Program (EAP) The StandardTeam San Jose provides an Employee Assistance Program (EAP) through The Standard. This program offers support, guidance and resources to help you and your family find the right balance between work and home life. These services include:

• Over-the-phone consultation and online access

• Up to 3 face-to-face assessments and consultative sessions per issue

• Unlimited phone access to legal, financial and work-life services

• Child and elder care assistance

• Alcohol and drug abuse counseling

• On-line will preparation

• Information and referrals for education, adoption, pet care, travel, and daily living

You can call (888) 293-6948 to reach EAP Customer Service, or you can go to www.eapbda.com and use the log in ID: standard and password: eap4u.

Identity Theft Protection ServicesID WatchdogTeam San Jose offers a voluntary benefit for protection against identity theft. Identity theft is one of the fastest growing crimes in America, with a new stolen identity every two seconds.

ID Watchdog Basic Plan services include the following:

• Active Credit Monitoring and alerts (TransUnion)

• Basic Identity Monitoring – Social Security Number, Public Records, Licenses, Registrations

• Payday & Non-Credit Loan Monitoring

• High-Risk Application & Transaction Monitoring

• Internet Black Market & Hacker Surveillance

• Fully Managed Resolution Service, with 100% resolution guarantee, and $1M in reimbursement insurance

• 24/ 7 Call Center

Basic Plan Cost:

$8.95 per month or $4.48 per pay period for employee-only coverage

$15.95 per month or $7.98 per pay period for family coverage

Pet InsuranceHealthy PawsHealthy Paws protects four-legged family members from unexpected and often expensive pet medical bills. If it’s an accident or illness (and not a pre-existing condition), the plan covers the treatment. The plan has unlimited lifetime benefits with no cap on claims. Use any licensed veterinarian including specialists and emergency animal hospitals. Team San Jose employees receive a 15% discount on premiums.

Covered services include:

• Diagnostic testing such as x-rays and blood tests

• Hospitalization

• Surgeries

• Prescription medications

• Cancer treatment

• Treatment of hereditary and congenital conditions

• Reimbursed on the actual vet bill

You can enroll in Healthy Paws through TSJ’s unique link using your credit or debit card: https://www.healthypawspetinsurance.com/Benefits/?affid=MBIS&subid=TSJCo&pc=Benefit15


Additional BenefitsTuition Reimbursement Team San Jose provides its employees with a Tuition Reimbursement benefit program.

• Classes/Degree must be job related

• Reimbursement must be pre-approved by Senior Team and HR

• Able to receive up to $1,000 reimbursement per year

• Must demonstrate completion and pass of the course/class

• Submit expense report for reimbursement

For more information, contact HR.

Health and Well BeingTeam San Jose provides its employees with two programs to promote Health and Well-Being.

Health Club Membership Reimbursement • Eligible employees are able to receive $15 per

month reimbursement for Health Club membership

• Submit expense report for reimbursement

Preventive Health Appointment Incentive• Eligible employees are able to receive $25 per year

for having their annual preventive exam

• To request this incentive, employees need to submit a statement from their doctors office indicating they had their preventive exam, to HR within 30 days of the appointment

• Employees will receive a $25 gift card within 30 days of submitting proof of their preventive appointment

For more information, contact HR.


Financial Benefits401k Retirement Plan SecurianTeam San Jose offers a 401(k) retirement plan through Securian Retirement. You are eligible to participate the first of the month following completion of 250 or more hours during three consecutive months, provided that you are at least 18 years of age.

When you participate, Team San Jose matches 100% of the first 3% you contribute and 50% of the next 2% you contribute – a total potential matching contribution of up to 4%. Your deferrals to the plan and all of the matching contributions from TSJ are immediately vested, so it’s an instant 100% return on investment!

• You can make pre-tax and/or after-tax (Roth) contributions, up to 100% of your eligible pay.

• You may defer up to the maximum limits - $18,000 for 2017 (expected to rise to $18,500 in 2018).

• If you are age 50 or older, you may defer an additional $6,000 of “catch-up” contributions.

• You can increase or decrease your contributions as of each payroll period. You may also stop your contributions at any time.

If no indication of how to invest your contributions is made at the time of enrollment, you will be invested by default in the appropriate TargetAge investment allocation, based on your projected retirement age.

To enroll: Enrollment kits are available online at mindsharegroup.com/teamsanjose or contact HR. Beginning January 1, 2018 you can enroll by calling Securian at 1-800-233-2881.

529 College Savings PlanCollege America/American FundsTeam San Jose offers a 529 College Savings Plan through College America/ American Funds to enable employees to take advantage of tax-free earnings in funding a college education.

• Tax Advantages – Earnings grow tax-free and withdrawals also are tax free for qualified education expenses.

• You can use the money to pay for qualified expenses at community colleges, undergraduate and graduate schools, trade schools, or for technical and professional training.

• Covered education expenses include tuition, fees, books and supplies, equipment, room and board

• Investment options through American Funds include Target Date Series, Portfolio Series and a Customized Portfolio for those who want to choose their own investment mix

For more information, contact Andrew G. Eakin, ChFC® Investment Advisor Representative with Signator Investors at Wealth Management Associates 925-217-4234 (Direct Line) or email [email protected]

To enroll: Go online through Maxwell Health at any time to initiate your enrollment.


Legal NoticesThe Health Insurance and Portability and Accountability Act (HIPAA), the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services, and the Department of Labor require that we provide various notices to eligible employees. Many of these notices are included on the following pages, and other notices are available online or upon request.

HIPAA NOTICE OF PRIVACY PRACTICESHIPAA establishes a set of national standards to address the use and disclosure of individual’s health information – called Protected Health Information (PHI). To obtain a copy of the Notice of Privacy Practices (NOPP), or for more information regarding the Plan’s privacy policies or your rights under HIPAA, contact Maria Coraci in HR at [email protected], or call 408-792-4539.

HIPAA SPECIAL ENROLLMENT RULESYou have the right to later enroll yourself and eligible dependents for coverage in the health plan(s) under “special enrollment provisions”, described below:

• Loss of Coverage. If you decline coverage for yourself or your dependents (including your spouse) because of group health plan coverage or other health insurance, you may be able to enroll yourself or your dependents if you or your dependents lose eligibility for that other coverage; or if the other employer stops contributing toward your or your dependents’ other coverage. 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.

• 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/or your dependents. You must request enrollment within 30 days after the marriage, birth, or placement for adoption.

• Medicaid/ CHIP Event. 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.

Additional information regarding your rights to enroll in group coverage can be found in the applicable group health plan Explanation of Coverage (EOC) or insurance contract.

DISCLOSURE OF GRANDFATHERED STATUSThe Kaiser $30 Copay plan offered by Team San Jose is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (ACA). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that the Kaiser Plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform.

NOTICE OF PATIENT PROTECTIONSBlue Shield HMO and Kaiser HMO plans generally require the designation of a primary care provider. You have the right to designate any primary care provider


Legal Noticeswho participates in our network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider. Until you make this designation, Blue Shield will designate one for you. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact Blue Shield or Kaiser (see last page of this booklet for contact information).

You do not need prior authorization from Blue Shield or Kaiser or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact Blue Shield or Kaiser.

WOMEN’S HEALTH AND CANCER RIGHTS ACTIf you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

• All stages of reconstruction of the breast on which the mastectomy was performed;

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

• Prostheses; and

• Treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other

medical and surgical benefits provided under this plan. See the health insurance plan summaries for details. If you would like more information on WHCRA benefits, you may contact Blue Shield or Kaiser.

NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACTGroup health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT (GINA) DISCLOSUREUnder a federal law called the Mental Health Parity and Addiction Equity Act, and furthered by the Affordable Care Act, many health plans must make sure that there is “parity” between mental health and substance use disorder benefits, and medical and surgical benefits. This generally means that coverage limits applied to mental health and substance use disorder benefits can’t be more restrictive than the coverage limits applied to medical and surgical benefits. The types of limits covered by parity protections include:

• Financial requirements – such as deductibles, copayments, coinsurance, or out-of-pocket limits;

• Treatment limits– such as limits on the number of days or visits covered, or other limits on the scope or duration of treatment (for example, being required to get prior authorization).


To request more information about coverage limitations on your benefits, with must be provided by law, please refer to the health plan’s Explanation of Coverage available online, or contact HR or Mindshare Group (see back page for contact details).

MEDICARE PART D CREDITABLE COVERAGE NOTICEThis notice has information about your current prescription drug coverage through the group health plans offered by Team San Jose and about your options under Medicare’s prescription drug coverage. If you are age 65 or older and eligible for Medicare, 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. Team San Jose has determined that the prescription drug coverage offered by Blue Shield and Kaiser 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 October 15 to December 7. 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 Team San Jose coverage will not be affected. Should you join a Medicare drug plan, you can keep you Team San Jose coverage and your Medicare Part D plan will coordinate with the group plan. Please see your group plan policies for full coordination details. See pages 7- 9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance (available at http://www.cms.hhs.gov/CreditableCoverage/), which outlines the prescription drug plan provisions/options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D.]

If you do decide to join a Medicare drug plan and drop your current Team San Jose coverage, be aware that you and your dependents will not be able to get this coverage back until the next open enrollment period or after a qualifying event, subject to the terms of the group health plan.

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 Team San Jose 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.

Legal Notices


Legal NoticesIf 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. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

Additional InformationMore 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).

Keep this Creditable Coverage notice. If you decide to join a Medicare drug plan, you may be required to provide a copy of this notice to prove you have maintained creditable coverage to avoid paying a higher premium (penalty for non-creditable coverage).

You may request a copy of this notice at any time. Contact HR or Mindshare Group for more information.

PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP, contact your State Medicaid or CHIP office to find out if premium assistance is available. To request contact information for your states Medicaid or CHIP office, please call Mindshare Group at 925-227-9900.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS-NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

HEALTH INSURANCE EXCHANGE NOTICEThis notice provides some basic information about the Health Insurance Marketplace, an alternative place to purchase health insurance coverage. IMPORTANT NOTE: Health Insurance coverage purchased through


an Exchange, such as Covered CA, is individual coverage, not employer sponsored group coverage, and may have lower levels of benefits and smaller provider and facility networks.

What is the Health Insurance Marketplace?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.

The 2018 open enrollment period for health insurance coverage through the Marketplace runs from Nov. 1, 2017, through Dec. 15, 2017. Individuals must enroll or change plans prior to Dec. 15, 2017, for coverage starting Jan. 1, 2018. After Jan. 1, 2018, you can get coverage through the Marketplace for 2018 only if you qualify for a special enrollment period or are applying for Medicaid or the Children’s Health Insurance Program (CHIP).

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. 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 percent (as adjusted each year after 2014) 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. Team San Jose’s health plans meet the “minimum value standard” and provide “minimum essential benefits” to all employees and

dependents, so employees will not qualify for any premium subsidy.

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.

Please visit HealthCare.gov or CoveredCA.com for more information, as well as an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.

UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA) HEALTH INSURANCE PROTECTION.

If you leave your job to perform military service, you have the right to elect to continue your existing employer-based health plan coverage for you and your dependents for up to 24 months while in the military. Even if you don’t elect to continue coverage during your military service, you have the right to be reinstated in your employer’s health plan when you are reemployed, generally without any waiting periods or exclusions (e.g., pre-existing condition exclusions) except for service-connected illnesses or injuries.For further information on USERRA, contact VETS at 1-866-4-USA-DOL or visit its website at http://www.dol.gov/vets. An interactive online USERRA Advisor can be viewed at http://www.dol.gov/elaws/userra.htm.

Legal Notices


Glossary of TermsAD&D (Accidental Death and Dismemberment) A Plan that provides benefits in the event of an accidental death or dismemberment (generally, an accident that results in death, loss of a part of the body, or the loss of use of part of the body)

Beneficiary A person designated by a participant that may become entitled to receive a benefit under the plan.

Claim A bill for medical services rendered.

COBRA Federal law (Consolidated Omnibus Budget Reconciliation Act of 1985) requiring certain employers that offer group health plans to provide continuation coverage to employees and their dependents who incur certain qualifying events.

Coinsurance The amount or percentage that you pay for certain covered health care services under your health plan. This is typically the amount paid after a deductible is met, and can vary based on the plan design.

Copayment (copay) A fixed amount you pay for a covered health care service, usually when you receive the service.

Deductible A specific dollar amount you pay out of pocket before benefits are available through a health plan. Under some plans, the deductible is waived for certain services.

Dependent Individuals who meet eligibility requirements under a health plan and are enrolled in the plan as a qualified dependent.

Evidence of Insurability Proof of good health required by an insurance company before the company will cover them.

Explanation of Benefits (EOB) A statement sent from the health insurance company to a member listing services that were billed by a provider, how those charges were processed and the total amount of patient responsibility for the claim.

HIPAA Authorization Under HIPAA, a document that authorizes the use or disclosure of an individual’s protected health information by a covered entity for any purpose described in the document and meets specific requirements.

Out-of-pocket Expense Amount that you must pay toward the cost of health care services. This includes deductibles, copayments and coinsurance.

Out-of-pocket Maximum (OOPM) The maximum amount you should have to pay for your health care during one year, excluding the monthly premium. After you reach the annual OOPM, your health insurance or plan begins to pay 100 percent of the allowed amount for covered health care services or items for the rest of the year.

Premium Amount of money charged by an insurance company for coverage.

Primary Care Physician (PCP) A doctor that is selected to coordinate treatment under your health plan. This generally includes family practice physicians, general practitioners, internists, pediatricians, etc.

Provider A clinic, hospital, doctor, laboratory, health care practitioner or pharmacy.

Qualifying Life Event A life event designated by the IRS that allows you to amend your current plan or enroll in new health insurance. Common life events include marriage, divorce, and having or adopting a child.

Summary of Benefits and Coverage (SBC) An easy-to-read outline that lets you compare costs and coverage between health plans.

Usual, Customary and Reasonable (UCR) Allowance The fee paid for covered services that is: (1) a similar amount to the fee charged from a health care provider to the majority of patients for the same procedure; (2) the customary fee paid to providers with similar training and expertise in a similar geographic area, and (3) reasonable in light of any unusual clinical circumstances.

Carrier Contacts / Member ServicesFor assistance or questions regarding your employee benefits, please contact Maria Coraci at [email protected] or call (408) 792-4539.

Plan Group Number Website Address Customer Service ClaimsBlue Shield W0033006 www.blueshieldca.com Refer to back of ID card

Kaiser Permanente 628267 www.kp.org 800-464-4000

MetLife Dental 5543656 https://metlife.com/mybenefits 800-275-4638

VSP Vision 12102934 www.vsp.com 800-877-7195

The Standard

• Long Term Disability

• Life and AD&D

• Optional (Voluntary) Life

162174 www.standard.com 800-348-3226

The Standard

• Employee Assistance Program162174

www.eapbda.com Log In ID: standard Password: eap4u

1-888-293-6948

Navia

• FSA and Commuter BenefitsTSJ www.naviabenefits.com 800-669-3539

Securian Retirement – 401(k) 66700 www.SecurianRetirementCenter.com 800-233-2881

College America

529 College Savings PlanN/A

Contact Andrew Eakin, Investment Advisor, Wealth Management Assoc.

925-217-4234

ID Watchdog N/A www.idwatchdog.com 866-513-1518

Healthy Paws Pet Insurance N/A

https://www.healthypawspetinsurance.com/

(for enrollment see page 18) 855-898-8991

Team San Jose Benefits Website | www.mindsharegroup.com/teamsanjose

Resource Contact InformationBenefits Information Website www.mindsharegroup.com/teamsanjose

Maxwell Health – Enrollment Website www.app.maxwellhealth.com

Mindshare Group – Carla Williams 925-227-9900, ext. 104; [email protected]

Blue Shield 24-Hour Nurse Line 877-304-0504

Blue Shield Find-A-Provider – California www.blueshieldca.com/fap

Blue Shield Find-A-Provider – Outside CA http://provider.bcbs.com/

Kaiser 24/7 Advice Nurse 866-454-8855

Mindshare Benefits and Insurance Services, Inc.5980 Stoneridge Drive, Suite 108, Pleasanton, CA 94588License No. 0D75420

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