2021 OPEN ENROLLMENT GUIDE - Madison Team Members - UnityPoint Health Total Rewards

 
2021 OPEN ENROLLMENT GUIDE - Madison Team Members - UnityPoint Health Total Rewards
2021 OPEN
              ENROLLMENT
              GUIDE

              Madison Team Members

003465h4h-1 09/20 CS
2021 OPEN ENROLLMENT GUIDE - Madison Team Members - UnityPoint Health Total Rewards
TABLE OF CONTENTS
For your convenience, we’ve linked each section to its corresponding page in this guide.
Simply click on the section you want to learn more about, and you’ll be taken to the correct page.

Hello.........................................................................................................................................................................1
Enrollment and Eligibility......................................................................................................................................2
What’s New for 2021..............................................................................................................................................4

                      My Benefits
                      Compare Your Plans.............................7                                    Accidental Death and
                      2021 Quartz Tiered Plan Q&A............8                                            Dismemberment................................27
                                                                                                          Accident Coverage............................27

     6
                      Out of Area Dependent
                      Coverage.............................................14                             Critical Illness......................................28
                      Health Savings Account.....................18                                       Hospital Indemnity Insurance...........30
                      Dental Coverage................................19                                   Short-Term Disability..........................31
                      Vision Coverage.................................20                                  Long-Term Disability..........................31
                      Flexible Spending Accounts.............22                                           Legal Service.......................................32
                      Life Insurance......................................24                              Retirement Savings............................32

                      My Well-Being                                                                              My Growth and Development
                      Paid Time Off.................................... 34                                       Education Assistance..................39
                      Paid Parental Leave Policy.............. 35

 33                   Adoption Assistance....................... 35
                      Care@Work....................................... 36
                      Team Member Discounts............... 36
                                                                                           38
                      OnPoint for Health........................... 37

Cost Breakdown.................................................................................................................................................. 43
Vendor Contact List............................................................................................................................................. 45
Availability of Summary Health Information.................................................................................................... 45
ERISA Disclosure Notice..................................................................................................................................... 46
Special Enrollment Rights.................................................................................................................................. 46
Premium Assistance Under Medicaid
The Children’s Health Insurance Program (Chip)........................................................................................... 47
Women’s Health and Cancer Rights Act of 1998 (WHCRA).......................................................................... 49
2021 OPEN ENROLLMENT GUIDE - Madison Team Members - UnityPoint Health Total Rewards
2021 OPEN ENROLLMENT | 1 |

hello.
         As a team member at UnityPoint Health, we’re proud to offer you a
         comprehensive Total Rewards program. Total Rewards is the value provided
         to our team members and their families throughout their career at UnityPoint
         Health by combining Compensation, Benefits, Personal Growth and
         Development, Recognition, Well-Being and Purpose into one, simple program.

         How to Use this Guide
         We know there is a lot of information in this guide, and you might be
         feeling a little overwhelmed. We put together a few tips for how to get the
         most out of this guide as you’re preparing to select your benefits.
          	Use the Table of Contents
             We know you likely won’t need every benefit we offer. To quickly get
             to the information you care about most, reference this guide’s Table of
             Contents. We’ve included links, so you simply have to click on the title
             you want to learn more about it, and you’ll automatically be taken to
             that section.

          	Know Where to Get the Most Up to Date Information
             Some people like to print this document off, so that they can review
             it with their spouse or domestic partner. Please remember that these
             enrollment guides are sometimes updated throughout the year. For the
             most up to date information, head to unitypoint.org/totalrewards. This
             site is completely accessible from home, so you can easily review this
             information on your personal computer, smartphone or tablet, too.

          	AskHR is Here to Help!
             The AskHR team is comprised of your fellow UnityPoint Health team
             members, and they are experts on all our benefit offerings. If you have
             questions about anything in the enrollment guide, reach out to AskHR by
             creating a case in Lawson or by calling (888) 543-2275.

         This booklet highlights the main features of the benefit plans sponsored by
         UnityPoint Health. Full details of these benefits are contained in the legal
         documents governing the plans. If there is any discrepancy or conflict between
         the plan documents and the information presented here, the plan documents will
         govern. In all cases, the plan documents are the exclusive source for determining
         rights and benefits under the plans. UnityPoint Health reserves the right to change
         or discontinue the plans at any time with appropriate notification. Participation in
         the plans does not constitute an employment contract. UnityPoint Health reserves
         the right to modify, amend, or terminate any benefit plan or practice described in
         this booklet. Nothing in this booklet guarantees that any new plan provisions will
         continue in effect for any period. Plan documents are available at
         unitypoint.org/totalrewards or by calling the AskHR at 888-543-2275.
2021 OPEN ENROLLMENT GUIDE - Madison Team Members - UnityPoint Health Total Rewards
2021 OPEN ENROLLMENT | 2 |

Enrollment and Eligibility
Eligible team members will be able to participate in Open Enrollment from Tuesday, October 27 – Tuesday,
November 10. You will complete the enrollment process within the Lawson platform. You can find a link to
Lawson and instructions for how to enroll on the Total Rewards Site. We encourage you to complete your
enrollment in Lawson by 5 p.m. on Tuesday, November 10.
Who is Eligible
You are eligible to enroll in UnityPoint Health benefits if you are in a benefits-eligible status. You are eligible for
benefit coverage if you are a:

Full-time                                                     Part-time
                                                              Part-time team member who is regularly scheduled
Full-time team member who is regularly scheduled to
                                                              to work 32-63 hours or more per pay period. (0.4 -
work 64 hours or more per pay period. (0.8 - 1.0 FTE)
                                                              0.79 FTE)

Dependents
In most cases, you can also cover your eligible dependents. You must provide a valid Social Security Number
and proof of eligibility (for example: birth certificate/adoption papers, marriage license/federal tax return).
Eligible dependents will not be enrolled unless you provide a valid Social Security Number and proof of
eligibility. You can review the details for submitting that information here.
Eligible dependents include:
 	Spouse/partner (if legally married under federal law)
 	Civil union partner (if legally recognized by a government authority)
 	Domestic partner (if applicable)
 	Common law spouse (if applicable)
 	Your children under age 26. “Children” are your biological children, children for whom there are parental
   responsibility documents issued by a court, legally adopted children, children of a current same-gender
   domestic partner or current civil union partner, children legally placed for adoption or foster care, children
   for whom there is a Qualified Medical Child Support Order (QMSCO), and stepchildren as long as the team
   member and parent are married.
 	Unmarried children of any age who are unable to support themselves because of a physical or mental
   disability, are not covered by other government programs, were covered under the plan prior to age 26, and
   are wholly dependent upon the participant for support and maintenance.
Domestic Partner Imputed Income
If you choose to add your domestic partner to your medical and/or dental coverage, you will be responsible
for imputed income tax on the difference in the employer premium for the additional coverage. Please contact
AskHR with questions or for additional details.
2021 OPEN ENROLLMENT GUIDE - Madison Team Members - UnityPoint Health Total Rewards
2021 OPEN ENROLLMENT | 3 |

Making Benefit Changes Outside of Open Enrollment During the Year
Based on IRS rules, you can generally make changes during the year only if you have a qualifying life event
that impacts your family or employment status. For example, loss of health coverage, birth of a child(ren),
marriage or, changes in residence. In order to make changes mid-year, you’ll need to complete a “life event” in
Lawson and submit any requested documents within 30 days of that life event in order to change your benefits.
Team members can contact AskHR if they have questions regarding life events. If you transfer employment
to another UnityPoint Health affiliate, your benefits will continue unchanged if you continue to meet eligibility
requirements. You cannot make changes to your benefit elections if you transfer employment as this is not a
qualifying event for making changes during the year.

      If you have questions about eligibility
      or how our benefit programs work that
      are not addressed in this guide, please
      contact AskHR.
2021 OPEN ENROLLMENT GUIDE - Madison Team Members - UnityPoint Health Total Rewards
2021 OPEN ENROLLMENT | 4 |

What’s New for 2021?
Enroll at Home
 With the recent Lawson upgrade in September, you are now able to easily access Lawson remotely to enroll
  in your benefits from home! Take advantage of this tip sheet to learn how to access Lawson remotely and
  begin your benefits enrollment process.
  –	To access Lawson remotely, you will need to make sure you are enrolled in multifactor authentication first.
     Use this tip sheet to learn how to enroll if you haven’t done so already.
		 •	If you have questions about this process, please contact IT at 800-681-2060.

Medical Plan Changes
 UnityPoint Health will continue to pay most of the premium cost for medical coverage. For 2021, team
  members will not experience an increase in employee premiums from 2020 to 2021.

Vision Plan Changes
  Standard progressive glasses lenses will now be covered up to $140, plus 20%, when purchasing in-network.
   This is an increased benefit of $90.
  Youth polycarbonate (up to age 19), level 1 progressives, and level 2 progressives are now covered in full.
  Due to the increased benefits, there will be a slight increase in premiums.
  You can find all of the increased vision benefits, on page 20 and 21.

New Vendor for Life, Accidental Death & Dismemberment (AD&D), and Long-Term Disability (LTD) Insurance
 An important part of your financial wellness is helping to make sure you’re protected financially against the
  unknown. UnityPoint Health recognizes the importance of Life and Accidental Death & Dismemberment
  coverages. That’s why we chose The Prudential Insurance Company of America (Prudential) as our new Life,
  Accidental Death & Dismemberment (AD&D), and Long-Term Disability (LTD) insurance provider starting
  January 1, 2021.
  –	As part of this change, you will be prompted to enter new elections for Life Insurance, Accidental Death &
     Dismemberment (AD&D), and Long-Term Disability (LTD) Buy-Up during your open enrollment process.
		 •	Due to this, make sure to review your current benefits within Lawson, prior to making your 2021 Open
      Enrollment elections. Use this tip sheet to learn how to view your current benefits.
		 •	Prudential will take over all current 2020 elections. If you elect the same amount this year, you will not
      need to go through Evidence of Insurability (EOI).

Life Insurance Changes
 	For this years open enrollment only, as a one-time offering, employees may add or increase their voluntary
   employee life coverage (not to exceed the guarantee issue limit of the lesser of 3X Base Annual Earnings
   (BAE) or $350,000) without evidence of insurability. Elected amounts in excess of the plan guarantee issue
   limit are subject to EOI.
  –	We are removing the “lesser of 50%” component of the voluntary spouse life plan. It will now be a flat
     $50,000 guarantee issue limit with the ability to purchase, in increments of $10,000, up to $100,000
     maximum.
  –	For this years open enrollment only, as a one-time offering, employees may add or increase voluntary
     spouse/domestic partner life coverage up to $50,000, in increments of $10,000, without EOI. Elected
     amounts in excess of the plan guarantee issue limit are subject to EOI.
2021 OPEN ENROLLMENT GUIDE - Madison Team Members - UnityPoint Health Total Rewards
What’s New for 2021? continued                                                               2021 OPEN ENROLLMENT | 5 |

  IMPORTANT REMINDERS:
  Paid Time Off
   	Negative PTO Balances: Effective April 18, 2020, all team members were provided the option to go negative
     up to 40 hours in their PTO Banks. Team members will be able to have a negative PTO balance until
     December 31, 2020. Starting January 1, 2021, team members will need to begin to work their way out of any
     negative balance and any additional time needed for a holiday or approved time off will be unpaid.
   	Bank Limit Increase: As a reminder, due to the COVID-19 pandemic, we made a temporary change to the
     PTO bank limit:
    –	Effective March 29, 2020, we raised the PTO Bank limit from 320 hours to 400 hours. This allows for team
       members to bank an additional 80 hours of PTO. We will reinstate the 320-hour limit on July 3, 2021.
  		 •	Team members will be able to use hours above 320 until 7/3/2021. Any hours above 320 as of 7/3/2021
        will be forfeited.
      After 7/3/2021, team members will no longer accrue PTO beyond 320 hours
  		•	
  2021 PTO Cash
   	Election period is October 27-November 10, 2020.
   	Benefit eligible supervisors and non-management team members can sell up to 40 hours, in 5-hour
     increments, per payout date for a total of 80 hours in 2021.
    –	The 40 hours per payout date for a total of 80 hours in 2021, is in response to the COVID-19 crisis. The
       annual cash out maximum of 40 hours will be reinstated for 2022 PTO Cash.
   	Payouts will occur on the February 5, 2021 paycheck and/or the July 9, 2021 paycheck.
  2021 Wellness Credit
  To earn the credit, you and your spouse or domestic partner that is enrolled in a UnityPoint Health medical plan
  must complete the following requirements:
      omplete an annual physical with your primary care provider (PCP) between December 1, 2019 –
  1. C
     November 30, 2020.
      omplete the 2020 online Health Risk Assessment (HRA) through the OnPoint for Health portal between
  2. C
     October 1, 2020 – December 31, 2020.
2021 OPEN ENROLLMENT GUIDE - Madison Team Members - UnityPoint Health Total Rewards
MY BENEFITS
Medical, dental and vision coverage, life and
disability insurance, and programs to help
save for the future, such as 401(k) and Health
Savings Account (HSA)
2021 OPEN ENROLLMENT GUIDE - Madison Team Members - UnityPoint Health Total Rewards
MY BENEFITS | 7 |

      CompareYour
     Compare  YourMedical
                  Medical Plans
                          Plans
                                                                              Tiered Plan (Traditional HMO)               High Deductible Health Plan
                                                                                                               In-Network
             Annual Deductible (Single/Family)                                         $1,000/$2,000                               $2,500/$5,000
             Annual HSA Contribution*                                                        N/A                                    $750/$1,500
             Coinsurance                                                                     20%                                         0%
             Ded/Coins Max Out of Pocket                                               $2,000/$4,000                                     N/A
             Med Exp Max Out of Pocket                                                 $5,350/$10,700                              $2,500/$5,000
              Physician Services
             Office Visit                                                                $30 Copay                               No charge after Ded
             Specialty Visit                                                             $60 Copay                               No charge after Ded
             E-visit                                                                     No charge                               No charge after Ded
              Emergency Services
             Urgent Care                                                                 $60 Copay                               No charge after Ded
             Emergency Room                                                             $250 Copay                               No charge after Ded
              Hospital Services
             Inpatient Services                                                      20% Coins after Ded                         No charge after Ded
             Delivery & Newborn Charges                                              20% Coins after Ded                         No charge after Ded
             Outpatient Services                                                     20% Coins after Ded                         No charge after Ded
              Diagnostic Services
             Lab & X-Ray                                                                 No charge                               No charge after Ded
             MRI/PET/CAT Scan                                                           $150 Copay                               No charge after Ded
              Behavioral Health
             Inpatient Services                                                      20% Coins after Ded                         No charge after Ded
             Transitional                                                            20% Coins after Ded                         No charge after Ded
             Outpatient Services                                                         $30 Copay                               No charge after Ded
              Other Services
             Durable Medical Equipment                                                   20% Coins                               No charge after Ded
             Therapy Services                                                            $30 Copay                               No charge after Ded
              Pharmacy Benefits                                            Meriter UW Pharm         Other Pharm

             Tier 1                                                           $15 Copay             $20 Copay                    No charge after Ded
             Tier 2                                                           30% Coins             30% Coins                    No charge after Ded
             Tier 3                                                           50% Coins             50% Coins                    No charge after Ded
             Specialty                                                        30% Coins                                          No charge after Ded
             Max Out of Pocket (Single/Family)                                         $2,000/$4,000                                     N/A
              Additional Benefits
             Preventive Services                                                         No charge                                   No charge
              Employee Bi-Weekly Rates (26 pay periods)
             Years of Service                                                  0-9          10-19          20+             0-9         10-19           20+
             Employee                                                        $48.78        $44.63        $41.86          $34.23        $30.07        $27.30
             Employee + 1                                                   $109.75       $105.60        $102.83         $70.14        $65.98        $63.21
             Family                                                         $158.53       $148.84        $140.99        $119.18       $109.49       $101.64

* UnityPoint Health-Madison contributions will be applied to your Fidelity HSA account beginning the first pay period of 2021. You must be actively employed and enrolled in
the High Deductible Health Plan, and have an open HSA through Fidelity on the date of the contribution. NOTE: If you enroll into an HSA after the first of the year, the
UnityPoint Health contribution will be prorated based on your benefit eligibility date.
This Benefit Summary is intended to highlight the benefits provided in these plans. Please see your policy, including the Certificate of Coverage and Schedule of Benefits
(SOB) for detailed coverage information, limitations and exclusions.
2021 OPEN ENROLLMENT GUIDE - Madison Team Members - UnityPoint Health Total Rewards
MY BENEFITS | 8 |

                                    UnityPoint Health - Madison
                                  2021 Quartz – Tiered Health Plan
For questions contact Quartz Member Services: 1-800-362-3310, Pharmacy Services: 1-888-450-4884,
Behavioral Health: 1-800-683-2300 or Website: www.QuartzBenefits.com
______________________________________________________________________________________________

Office Visits and Services:

Q. What will a Primary Care Provider (PCP), Optometrist, Behavioral Health or Chiropractor office visit cost
when utilizing a Quartz network:
A. If it is billed for Affordable Care (ACA) preventative services – $0 copay
   If it is billed for an office visit – $30 copay

Q. What will I pay if I see a Specialist, when utilizing a Quartz network specialist?
A. $60 copay

Q. What will I pay for Therapy visits such as physical, speech, occupational, habilitative and home therapy?
A. $30 copay

Q. What will I pay for an Immediate/Urgent Care visit?
A. $60 copay

Q. What will I pay for Durable Medical Equipment?
A 20% up to a maximum of $2,700 per member per year

Q. What will I pay for a Hospital Emergency Room visit?
A. $250 copay per visit (1-4), $500 copay per 5th visit and beyond.

Q. If I have an x-ray, will I pay for the Radiologist to read it?
A. No, x-rays are covered in full. NOTE: Specialty Scans (e.g. CAT scan, MRI/MRA and PET scan) will incur
   $150 copay.

Q. Are there any other services that are covered in full, no copay?
A. Yes: lab work, mammograms, prenatal and postnatal maternity care, ultrasounds, immunizations, allergy shots,
   radiation therapy, disposable diabetic supplies, specific oral surgeries and ambulance services are all covered
   in full under the Quartz Tiered plan.

Q. What will I pay if I need to be hospitalized or have outpatient surgery?
A. $1,000 deductible, plus 20% coinsurance up to an additional $1,000 on the remaining balance of the bill. The
maximum out of pocket cost is $2,000 per member, $4,000 per family.
MY BENEFITS | 9 |

Q. What Providers are covered under the Tiered plan?
A. You may see any Quartz network provider, visit https://quartzbenefits.com/findadoctor
   (Services from out-of-network providers are not covered, except for emergencies).

Q. What will I pay for prescription drugs?
A. If you use the Meriter Pharmacy (202 S. Park Street) or any UW Health Pharmacy:
                                    $15 for formulary generic drugs
                                    30% of contracted price for formulary brand drugs ($100 per script limit)
                                    50% for non-preferred drugs

    If utilizing other participating Pharmacy’s:
                                        $20 for formulary generic drugs
                                        30% of contracted price for formulary brand drugs ($300 per script limit)
                                        50% for non-preferred drugs

Q. How can I determine the cost of my formulary brand name prescription drugs with the 30% co-insurance?
A. You may contact Quartz Pharmacy Services at 1-888-450-4884 to provide the approximate cost.

Q. Does the Tiered plan have any out-of-pocket maximums?
A. Yes, members will have an out of pocket maximum on the following:
    - Durable Medical Equipment (DME): $2700 maximum per member per year
    - Inpatient/Outpatient Deductible: $1,000 maximum per member and $2,000 max per family
    - Inpatient/Outpatient Coinsurance - $1,000 maximum per member and $2,000 max per family
    - Prescription Drugs: $2000 maximum per member and $4,000 max per family

    The overall maximum for all services combined is $7,350 per member and $14,700 per family.

Q. Do members on the Tiered plan have access to Virtual Care visits?
A. Yes, you have two options to use for $0 (no copay) per visit:
   • UW Health Care Anywhere –Visit www.UWHealthCareAnywhere.org
   • UnityPoint Health Virtual Care – Visit www.UnityPointVirtualCare.org

       Both provide easy, quick access 24/7, to a medical provider, whenever you or your family needs non-
       emergency care. From the comfort of your home or work, providing video visits using the app on your
       smartphone, tablet or computer equipped with a web camera. Depending on your medical concern, the health
       care provider can provide a diagnosis, suggest follow-up care and prescribe medication, when appropriate, for
       commonly treated conditions such as abdominal pain, allergies, ear pain, sore throat, low back pain, eye
       infections, sprains, minor skin problems and more. Visit their websites to learn more.

.
MY BENEFITS | 10 |

                                UnityPoint Health - Madison
                      2021 Quartz High Deductible Health Plan (HDHP)
                         and Fidelity Health Savings Account (HSA)
For questions contact Quartz Member Services: 1-800-362-3310, Pharmacy Services: 1-888-450-4884,
Behavioral Health: 1-800-683-2300 or www.QuartzBenefits.com
__________________________________________________________________________________________

Q. How does the High Deductible Health Plan (HDHP) work?
A. Members are responsible for paying 100% of covered medical expenses (e.g. prescriptions drugs, office visits,
hospitalization, specialty visits, emergency room, urgent care visits, etc.) up to the deductible ($2,500 for single
coverage and $5,000 for employee+1/family coverage). After you reach the deductible, all other covered medical
expenses will be covered in full by Quartz. To further clarify,
   1) All “covered medical expenses” will go towards the deductible/maximum out of pocket maximum
       ($2500/$5000). Services that are not covered (e.g. cosmetic surgery), will not go toward your
       deductible/maximum out of pocket maximum ($2500/$5000).
   2) The Employee+1/Family deductible out-of-pocket maximum is $5,000. That means one or more family
       members (any combination) must reach the $5,000 deductible before all other covered services are paid 100%
       by Quartz.

Q. What is the maximum out-of-pocket expense for the HDHP?
A. The maximum out-of-pocket expense is the same as your deductible:
      $2,500 for Single coverage
      $5,000 for Employee + 1 and Family coverage

Q. What do members pay for prescription drugs?
A. Members pay 100% of the cost until you reach your deductible as described above. However, Affordable Care
(ACA) preventive care prescription drugs (e.g., women’s FDA approved contraceptive drugs) will be paid by Quartz
in full.

Q. What services are covered in full where I don’t need to pay 100% until I reach the deductible?
A. Affordable Care (ACA) preventive services are covered in full (e.g. annual physicals, mammograms, colonoscopy
   if over age 50, immunizations).

Q. What Providers are covered under the High Deductible Health Plan?
A. You may see any Quartz (Unity) network provider, visit https://quartzbenefits.com/findadoctor
   (Services from out-of-network providers are not covered, except for emergencies).

Q. Do members on the HDHP have access to Virtual Care visits that would apply to the deductible?
A. Yes, you have two options to use for $49 per visit:
   • UW Health Care Anywhere - Visit www.UWHealthCareAnywhere.org
   • UnityPoint Health Virtual Care – Visit www.UnityPointVirtualCare.org

       Both provide easy, quick access 24/7, to a medical provider, whenever you or your family needs non-
       emergency care. From the comfort of your home or work, providing video visits using the app on your
       smartphone, tablet or computer equipped with a web camera. Depending on your medical concern, the health
       care provider can provide a diagnosis, suggest follow-up care and prescribe medication, when appropriate, for
       commonly treated conditions such as abdominal pain, allergies, ear pain, sore throat, low back pain, eye
       infections, sprains, minor skin problems and more. Visit their websites to learn more.
MY BENEFITS | 11 |
How do you determine if the High Deductible Health Plan is right for you?
     1. Compare health insurance plan options available to you.
     2. Annualize the monthly premiums to determine annual premium cost for each plan option.
     3. Calculate your expected medical cost based on each health plan design.
     4. Factor in UnityPoint Health – Madison’s contribution to your HSA to help cover your medical expenses
         under the HDHP.
     5. Consider the tax advantages of contributing to the HSA (contributions are not taxed or are deductible on
         your tax return), earnings are tax-free and withdrawals for eligible medical expenses are tax free).
     6. Understand what it means when electing the HDHP, you must pay 100% of covered medical expenses up
         to the deductible/maximum out of pocket expense ($2,500/Single coverage and $5,000/Employee+1 &
         Family coverage) before the plan begins to pay, with the exception of certain preventive services that the
         ACA requires to be paid by the plan in full.

NOTE: UnityPoint Health - Madison does not sponsor or maintain any HSA for any employee. An HSA is
your personal bank account. The terms of the HSA are contained in your agreement with Fidelity, and your
rights and benefits under the HSA are governed solely by your agreement with Fidelity and by Federal and
state tax laws. UnityPoint Health - Madison does not monitor your eligibility for contributions to an HSA or
the amounts you contribute to the HSA. You are solely responsible for determining whether you are eligible to
contribute to an HSA for any month of the year and for complying with the IRS limits on contributions to an
HSA. You are responsible for ensuring that you use the HSA for eligible medical expenses. UnityPoint Health
– Madison does not provide any investment advice with respect to your HSA.
MY BENEFITS | 12 |

For questions on the Health Savings Account (HSA) contact Fidelity: (1-800-544-3716) or
www.netbenefits.com/unitypoint
----------------------------------------------------------------------------------------------------------------------------------------------
How does the Health Savings Account (HSA) work in conjunction with an HDHP?
     • It’s a health savings account that you use to pay qualified medical (health, dental, vision) expenses for you,
         your spouse and your eligible dependents (domestic partner/child must be your tax dependent to be eligible).
     • Triple tax advantage: contributions, earned interest, and withdrawals for qualified expenses are tax free.
     • You may increase/decrease your payroll contribution amount at any time on Fidelity’s website.
     • There’s no deadline for reimbursing eligible medical expenses, your account can be used for current or future
         eligible medical expenses.
     • Unused money carries over from year to year, there’s no “use it or lose it” rule.
     • Your HSA allows both pre-tax and after tax (tax deductible) contributions.
     • You may choose to invest your HSA dollars.
     • If you are no longer covered under UnityPoint Health – Madison’s HDHP, your HSA stays active and
         remaining funds can still be used for qualified medical expenses in the future.
     • Your HSA is portable. It belongs to you & goes with you, even into retirement.

Eligibility requirements to contribute to the Fidelity-HSA:
    • You must be enrolled in UnityPoint Health – Madison’s High Deductible Health Plan;
    • You cannot be enrolled in any other non-HDHP coverage, either through another employer or someplace else;
    • You may not be entitled to Medicare, Tricare or Tricare for Life or enrolled in Badgercare or Medicaid;
    • You may not be claimed as a dependent on someone else’s tax return; and
    • Neither, you, nor your spouse may be enrolled/participating in an FSA-medical or HRA account. A limited
        purpose FSA or HRA is permitted for dental and/or vision expenses only).

    •    HSA Contribution limits are established by the IRS (indexed for inflation). 2021 limits -
           o Single coverage: $3,600 (This amount includes UnityPoint Health – Madison contributions)
           o Employee+1 & Family coverage: $7,200 (This amount includes UnityPoint Health – Madison
              contributions)
           o Catch-up Contributions (if you are age 55+ at any point in the year) you may contribute an additional
              $1,000.
           o If employee and spouse are both 55 and HSA-eligible, you both may make a catch-up contribution to
              your respective HSA’s.
           o Combined contributions made to your HSA by you and UnityPoint Health - Madison count toward the
              limit.
           o To determine your annual contribution limit, if enrolled in HDHP less than 12 months of the year,
              calculate the pro-rated contribution amount based on actual months of HDHP coverage.
           o To determine your annual contribution limit, if changing coverage during the year, calculate the pro-
              rated contribution amount based on actual months of family coverage and single coverage.
           o It is the employee’s responsibility to monitor their contributions to avoid going over their limit.
           o If you contributed more than the limit allowed, contact Fidelity to request excess funds (refund) before
              the tax-filing deadline to correct the error and pay the tax on the amount over the HSA limit. If you do
              not remove excess contributions by April 15th following the contribution year, you will be subject
              to standard income tax rates plus a 6% penalty.

    •    UnityPoint Health - Madison pays the HSA administrative fees to Fidelity and contributes to Health
         Savings Accounts for active employees with an FTE of 0.4 or greater:
            o UnityPoint Health - Madison contributions are not included in your income (tax-free benefit to your
               HSA).
            o Your 2021 UnityPoint Health contribution will be applied to your Fidelity HSA account beginning the
               first pay period of 2021. (NOTE: If you enroll into an HSA after the first of the year, these amounts
               will be prorated based on your benefit eligibility date.)
                    ▪ $750 - Single coverage
                    ▪ $1,500 - Employee+1 & Family coverage
MY BENEFITS | 13 |
•   Using your HSA for a non-qualified medical expense:
       o Paying for anything other than qualified medical expenses with your HSA, will become taxable
           income;
       o Plus, if you are age 64 or younger, you will pay an additional 20% tax penalty.

•   Limited Purpose Flex Spending Account (FSA)-Medical -
       o Employees enrolled in the UnityPoint Health - Madison HDHP/HSA are not eligible to contribute to
          an FSA-medical plan but may contribute to a Limited Purpose FSA-medical plan.
       o Reimbursement from a Limited Purpose FSA-medical plan is limited to dental and/or vision
          (glasses/contacts) expenses only. Note, if eye exams are a covered benefit under your health plan,
          expenses for eye exams will be denied under the TASC Limited Purpose FSA-medical plan.
       o Dental and vision expenses are covered under your HSA. However, an employee who is contributing
          the maximum limit to their HSA may be looking for additional tax savings by claiming dental and
          vision expenses under a Limited Purpose FSA-medical plan rather than using their HSA for those
          expenses.
       o The Limited Purpose FSA-medical plan has the same “use it or lose it” rules as the traditional FSA-
          medical plan.
       o For employees switching to UnityPoint Health – Madison’s HDHP/HSA during Open Enrollment,
          balances up to $500 remaining in their TASC FSA-medical plan will rollover to the TASC Limited
          Purpose FSA-medical plan. And only dental and vision expenses will qualify for reimbursement in the
          new year.

•   Employees ending employment or becoming benefit ineligible (e.g. FTE below 0.4, layoff):
      o HDHP coverage ends the last day of the month in which your last day of work occurs at a 0.4 FTE or
         greater.
      o Your HSA may stay with Fidelity with no admin fees. Or, you may transfer your Fidelity-HSA to
         another HSA in your name.
      o You will no longer be eligible to make payroll contributions to your HSA.
      o You may continue to contribute (after tax dollars) to your HSA if you are enrolled in a qualified HDHP
         (e.g. under your spouse’s plan or under COBRA).
      o You may continue to use your HSA funds for eligible medical expenses.

•   Tax Reporting
       o HSA contributions (both employer and employee pre-tax) will be noted on UnityPoint Health –
          Madison’s W-2’s.
       o Participants complete IRS Form 8889 and file with their taxes.

•   Fidelity-HSA (1-800-544-3716)
       o Once your HSA is open and contributions begin, you can use it to pay for qualified medical expenses.
       o Three ways to make contributions/deposits: Payroll deductions (pre-tax savings). Or, online using
           your personal checking account or mail in a personal check, both provide a tax savings when filing
           taxes. However, you will not pay Social Security and Medicare taxes (known as “FICA”) and no tax
           will be withheld from your pay when you are contributing on a pre-tax basis. If you contribute on an
           after-tax basis, both income tax and FICA will be withheld from your pay, but you can claim an
           income tax deduction on your tax return after the end of the year.
       o Pay your medical bills using your HSA debit card, online bill-pay from your HSA, pay out of pocket
           and allow your HSA investments to stay in your account and grow for the future or reimburse yourself
           for qualified expenses by requesting a distribution from your HSA, with no deadline.
       o Don’t forget – Save your receipts in case you are audited by the IRS or you wish to claim the expense
           in the future. Fidelity’s portal includes an online storage chest where you can store copies of your
           receipts.
       o Choose a beneficiary when you set up your account. If spouse is the designated beneficiary, your
           spouse will become the owner and assume it as their own HSA. If someone other than a spouse is
           beneficiary, your account will cease to be an HSA. The money in your account will pass to your
           beneficiary(s) or become a part of your estate, and it will be subject to applicable taxes.
       o Fidelity offers investment options if you choose to invest your HSA dollars.

•   To review the IRS list of qualified medical expenses, visit: https://www.irs.gov/pub/irs-pdf/p502.pdf
MY BENEFITS | 14 |

             OUT-OF-AREA DEPENDENT COVERAGE
                                AVAILABLE ON LARGE GROUP HMO PLANS IN WISCONSIN OFFERED BY
                                         QUARTZ HEALTH BENEFIT PLANS CORPORATION.

Do you have a dependent child or grandchild on your plan who lives outside of our service area at least
three months per year? Quartz makes it easy for them to get medical care by providing coverage for office
visits as if they were in-network. Here’s how it works –
⊲     During the portion of the year they are living inside Quartz’s service area, your dependent must seek care with
      in-network providers. The costs will be covered at the in-network level of benefits. Cost-sharing for covered
      services will count towards your out-of-pocket maximum.
⊲     During the three-months or more portion of the year they are living outside Quartz’s service area, they first need
      our okay before getting care from an out-of-network provider. Call (888) 829-5687 and ask for prior authorization
      before making an appointment. Even though the service is out-of-network, the costs will be covered at the
      in-network level of benefits. Allowed amounts for cost-sharing will be based on usual and customary charges.
      Cost-sharing for covered services will count towards your out-of-pocket maximum. Amounts in excess of usual
      and customary charges are your responsibility and do not count toward your out-of-pocket maximum.

Eligible services include –

 Primary care                        Chiropractic                         Behavioral /    In-office therapy services   Routine procedures
                                         care                             mental health                                 and care in office

Other services (outpatient surgery or non-emergency hospitalization, for example) require the dependent to return to
the Quartz service area for care. As a reminder, you or your dependents must show your valid Quartz ID card when
seeking services from any provider.

QUESTIONS? CONTACT CUSTOMER SERVICE AT (800) 362-3310.
QA00797 (0519)
Your health plan is offered by Quartz Health Benefit Plans Corporation.
©2019 Quartz Health Solutions, Inc.                                                                                      QuartzBenefits.com
MY BENEFITS | 15 |

                                         No Discriminación & Acceso a Lenguajes
Quartz es el nombre de la marca de un grupo de compañías               nacionalidad, edad, discapacidad o sexo, puede presentar un
comprometidas para su salud: Quartz Health Benefit Plans               reclamo a la siguiente persona –
Corporation, Quartz Health Insurance Corporation, Quartz                  Kristie Meier, Oficial de Control / Compliance Officer
Health Plan Corporation, y Quartz Health Plan MN Corporation.             840 Carolina Street
Estas compañías son entidades legales separadas. En esta                  Sauk City, WI 53583
notificación “nosotros” nos referimos a todas las compañías               Teléfono: (800) 362-3310
de Quartz.                                                                TTY: 711 o toll-free (800) 877-8973
Para asistencia entendiendo estos materiales en otro idioma               Fax: (608) 644-3500
que no sea inglés, llame al (800) 362-3310 y un representante             Correo electrónico: AppealsSpecialists@quartzbenefits.com
de Servicio al Cliente lo asistirá. Usuarios TTY deben llamar al       Puede presentar el reclamo en persona o por correo postal,
711 o al (800) 877-8973.                                               fax o correo electrónico. Si necesita ayuda para hacerlo,
Nosotros cumplimos con las leyes federales de derechos                 Kristie Meier, Oficial de Control / Compliance Officer, está a
civiles aplicables y no discriminamos por motivos de raza,             su disposición para brindársela. También puede presentar
color, nacionalidad, edad, discapacidad, o sexo.                       un reclamo de derechos civiles ante la Oficina de Derechos
Proporcionamos asistencia y servicios gratuitos a las personas         Civiles (Office for Civil Rights) del Departamento de Salud
con discapacidades para que se comuniquen de manera eficaz             y Servicios Humanos de EE.UU. (Department of Health and
con nosotros, como los siguientes –                                    Human Services), de manera electrónica a través del portal
                                                                       electrónico Office for Civil Rights Complaint Portal, disponible
J Intérpretes de lenguaje de señas capacitados                         en ocrportal.hhs.gov/ocr/portal/lobby.jsf o por correo postal
J Información escrita en otros formatos (letra grande, audio,          a la siguiente dirección o por teléfono a los números que
   formatos electrónicos accesibles, otros formatos)                   figuran a continuación –
Proporcionamos servicios lingüísticos gratuitos a personas                U.S. Department of Health and Human Services
cuya lengua materna no es el inglés, como los siguientes –                200 Independence Avenue, SW
J Intérpretes capacitados                                                 Room 509F, HHH Building
J Información escrita en otros idiomas                                    Washington, D.C. 20201
                                                                          (800) 368-1019; (800) 537-7697 (TDD)
Si necesita recibir estos servicios, comuníquese con el
Departamento de Servicio al Cliente de Quartz al (800) 362-3310.       Puede obtener los formularios de reclamo en el sitio web
                                                                       hhs.gov/ocr/office/file/index.html
Si considera que Quartz no le proporcionó estos servicios o lo
discriminó de otra manera por motivos de origen étnico, color,         Quartz en ciertos estados es un emisor Calificado de Planes
                                                                       de Salud en el Mercado de Seguros Médicos. Para conocer
                                                                       más visite la página web del Mercado de Seguros Médicos en
                                                                       HealthCare.gov.
                 For help to translate or understand this, please call (800) 362-3310, TTY: 711 / (800) 877-8973.
Spanish – Este Aviso contiene información importante. Este aviso       Chinese – 本通知含有重要的訊息 本通知對於您透過 Quartz
contiene información importante acerca de su solicitud o cobertura
a través de Quartz. Preste atención a las fechas clave que contiene    所提 出的申請或保險有重要的訊息 請在本通知中查看重要的
este aviso. Es posible que deba tomar alguna medida antes de           日期 您可能要在特定的截止日期之 前採取行動,以保留您的
determinadas fechas para mantener su cobertura médica o ayuda          健康保險或有助於省錢 您有權利免費以您的母語得到幫助和
con los costos. Usted tiene derecho a recibir esta información
y ayuda en su idioma sin costo alguno. Llame al (800) 362-3310.
                                                                       訊息 請致電 (800) 362-3310:711 / (800) 877-8973.
TTY / TDD: 711 / (800) 877-8973.                                       Russian – Настоящее уведомление содержит важную
                                                                       информацию. Это уведомление содержит важную информацию
Hmong – Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb.
                                                                       о вашем заявлении или страховом покрытии через Quartz.
Tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim
                                                                       Посмотрите на ключевые даты в настоящем уведомлении.
ntawv thov kev pab los yog koj qhov kev pab cuam los ntawm Quartz.
                                                                       Вам, возможно, потребуется принять меры к определенным
Saib cov caij nyoog los yog tej hnub tseem ceeb uas sau rau hauv
                                                                       предельным срокам для сохранения страхового покрытия или
daim ntawv no kom zoo. Tej zaum koj kuj yuav tau ua qee yam uas
                                                                       помощи с расходами. Вы имеете право на бесплатное получение
peb kom koj ua tsis pub dhau cov caij nyoog uas teev tseg rau hauv
                                                                       этой информации и помощь на вашем языке. Звоните по телефону
daim ntawv no mas koj thiaj yuav tau txais kev pab cuam kho mob los
                                                                       (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
yog kev pab them tej nqi kho mob ntawd. Koj muaj cai kom lawv muab
cov ntshiab lus no uas tau muab sau ua koj hom lus pub dawb rau koj.   Laotian        – ແຈ້ງການສະບັບນ
                                                                                                    ີ້ ມ  ້ ມ
                                                                                                       ີ ໍຂ    ີ່ີ ໍສາຄັນ.
                                                                                                            ູ ນທ
Hu rau (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
                                                                           ແຈ  ້ ງການສະບັບນ              ີ້ ມ
                                                                                                            ີ ໍຂ  ້ ມ
                                                                                                                    ູ ນທ        ີີ່ ໍສາຄັນກ     ີ່ ຽວກັບໃບສະຫມັກ ຼືຫ
Vietnamese – Thông báo này cung cấp thông tin quan trọng. Thông            ການຄ     ້ ມຄອງຂອງທ                 ີ່ ານຜ      ີ່ ານ Quartz. ຊອກຫາວັນທ                     ີ ໍສາຄັນ
báo này có thông tin quan trọng bàn về đơn nộp hoặc hợp đồng
bảo hiểm qua chương trình Quartz. Xin xem ngày then chốt trong
                                                                             ໃນຫນັງສ    ຼື ແຈ     ້ ງການສະບັບນ                     ີ ້ .ທ
                                                                                                                                        ີ່ ານອາດຈ    ໍ າເປ   ັ ນຕ ້ ອງປະຕ  ິ ບັດຕາມເວລາ
                                                                       ີ່ີ ທກ ໍ ານ   ົ ດໄວ   ້ ີ່ີທແນ  ີ່ ນອນເພ        ີ່ຼື ອຮັກສາໄວ              ້ ການຄ   ້ ມຄອງສຂະພາບຂອງທ          ີ່ ານ
thông báo này. Quý vị có thể phải thực hiện theo thông báo đúng
trong thời hạn để duy trì bảo hiểm sức khỏe hoặc được trợ trúp             ຫ
                                                                           ຼື ຊ  ີ່ ວຍເຫ   ຼື ອດ    ້ ານຄ    ີ່ າໃຊ  ້ ຈ     ີ່ າຍ.ທ      ີ່ ານມ
                                                                                                                                               ີ ິສດທ  ີີ່ ຈະໄດ      ໍ້ ມ
                                                                                                                                                                ້ ຮັບຂ   ູ ນນີ ້ ແລະ
thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ   ຄວາມຊ                              ີ່ໍ ເສຍຄ
                                                                             ີ່ ວຍເຫ
                                                                                   ຼື ອໃນພາສາຂອງທ ີ່ ານໂດຍບ      ີ່ າ. ໂທຫາເບ
                                                                                                                            ີ (800)
giúp bằng ngôn ngữ của mình miễn phí. Xin gọi số (800) 362-3310.
TTY / TDD: 711 / (800) 877-8973.                                       362 3310. TTY / TDD: 711 / (800) 877 8973.
MY BENEFITS | 16 |

German – Diese Benachrichtigung enthält wichtige Informationen.              Pennsylvanian Dutch – Die Bekanntmaching gebt wichdichi
Diese Benachrichtigung enthält wichtige Informationen bezüglich              Auskunft. Die Bekanntmaching gebt wichdichi Auskunft baut dei
Ihres Antrags auf Krankenversicherungsschutz durch Quartz. Suchen            Application oder Coverage mit Quartz. Geb Acht fer wichdiche
Sie nach wichtigen Terminen in dieser Benachrichtigung. Sie                  Daadem in die Bekanntmachung. Es iss meeglich, ass du ebbes
könnten bis zu bestimmten Stichtagen handeln müssen, um Ihren                duh muscht, an beschtimmde Deadlines, so ass du dei Health
Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten.            Coverage bhalde kannscht, odder bezaahle helfe kannscht. Du
Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer             hoscht es Recht fer die Information un Hilf in deinre eegne Schprooch
Sprache zu erhalten. Rufen Sie an unter (800) 362-3310. TTY / TDD:           griege, un die Hilf koschtet nix. Kannscht du (800) 362-3310 uffrufe.
711 / (800) 877-8973.                                                        TTY / TDD: 711 / (800) 877-8973.
         Arabic – ‫ يتضمن هذا‬.‫يحتوي هذا اإلشعار على معلومات مهمة‬              Polish – To ogłoszenie zawiera ważne informacje. To ogłoszenie zawiera
                                                                             ważne informacje odnośnie Państwa wniosku lub zakresu świadczeń
         ‫ ابحث‬.Quartz ‫اإلشعار معلومات هامة حول طلبك أو تغطيتك عبر‬            poprzez Quartz.Prosimy zwrócic uwagę na kluczowe daty zawarte w tym
          ‫ قد تحتاج إلى إجراء تدابير‬.‫عن التواريخ الرئيسية في هذا اإلشعار‬     ogłoszeniu aby nie przekroczyć terminów w przypadku utrzymania polisy
          ‫معيّنة وفقا ً لمواعيد معيّنة من أجل الحفاظ على تغطيتك الصحية أو‬    ubezpieczeniowej lub pomocy związanej z kosztami. Macie Państwo
         ‫ ليدك الحق في الحصول على هذه المعلومات‬.‫المساعدة في التكاليف‬         prawo do bezpłatnej informacji we własnym języku. Zadzwońcie pod
                                                                             (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
          ‫ اتصل على‬.‫وعلى المساعدة في لغتك دون أي تكلفة‬TTY / TDD:
                       711 / (800) 877-8973 / (800) 362-3310.                Hindi – इस सच              ू ण जानकारी शाममल है। इस सच
                                                                                         ू ना में महत्वपर्                        ू ना में
                                                                             Quartz से जड़
                                                                                        ु े आपके आवेदन या कवरे ज के बारे में महत्वपर्
                                                                                                                                   ू ण जानकारी
French – Cet avis a d’importantes informations. Cet avis a d’importantes
informations sur votre demande ou la couverture par l’intermédiaire de       शाममल है। इस सूचना में महत्वपर्
                                                                                                          ू ण तारीखों को दे खना न भूलें। स्वास््य
Quartz. Rechercher les dates clés dans le présent avis. Vous devrez          कवरे ज जारी रखने या खचे में मदद के मलए आपको कुछ तय तारीखों तक
peut-être prendre des mesures par certains délais pour maintenir
votre couverture de santé ou d’aide avec les coûts. Vous avez le droit       कारणवाई करनी ज़रूरी है। आपके पास अपनी भाषा में , बबना ककसी शुल्क के
d’obtenir cette information et de l’aide dans votre langue à aucun coût.     इस जानकारी और सहायता को पाने का अधिकार है। (800) 362‑3310.
Appelez (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
                                                                             TTY / TDD: 711 / (800) 877‑8973 पर कॉल करें ।
Korean – 본 통지서에는 중요한 정보가 들어 있습니다. 즉 이 통지서는
                                                                             Albanian – Ky njoftim përmban informacion të rëndësishëm. Ky njoftim
귀하의 신청에 관하여 그리고 Quartz을 통한 커버리지 에 관한 정보를                                     përmban informacion të rëndësishëm për aplikimin ose mbulimin tuaj
포함하고 있습니다.본 통지서에서 핵심이 되는 날짜들을 찾으십시오. 귀하는                                     nëpërmjet Quartz. Kontrolloni për data të rëndësishme në këtë njoftim.
귀하의 건강 커버리지를 계속유지하거나 비용을 절감하기 위해서 일정한                                        Mund t’ju duhet të ndërmerrni veprim brenda afatave të caktuara për të
마감일까지 조치를 취해야 할 필요가 있을 수있습니다. 귀하는 이러한                                        mbajtur mbulimin tuaj shëndetësor ose për ndihmën me koston. Keni
                                                                             të drejtë ta merrni këtë informacion dhe ndihmë falas në gjuhën tuaj.
정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가있습니다.
                                                                             Telefononi numrin (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
(800) 362-3310로 전화하십시오. TTY / TDD: 711 / (800) 877-8973.
                                                                             Somali – FIIRO GAAR AH: Haddii aad ku hadashid af Soomaali,
Tagalog – Ang Paunawa na ito ay naglalaman ng mahalagang
                                                                             adeegyada caawimada luuqada, ayaa waxaa laguugu siinayaa
impormasyon. Ang paunawa na ito ay naglalaman ng mahalagang
impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan            bilaash, waa laguu heli karaa. 1-800-362-3310
ng Quartz. Tingnan ang mga mahalagang petsa dito sa paunawa.                 (TTY: 1-800-877-8973) bilbilaa.
Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga
itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan
o tulong na walang gastos. May karapatan ka na makakuha ng ganitong
impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa
(800) 362-3310. TTY / TDD: 711 / (800) 877-8973.

Cushite – Oroomiffa XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa
(800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
Amharic –

Karen –
Mon-Khmer, Cambodian –

Serbocroatian – OBAVJEŠTENJE: Ako govorite srpskohrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite
(800) 362‑3310 TTY‑ Telefon za osobe sa oštećenim govorom ili sluhom: 711 / (800) 877‑8973.
Thai – เรียน: ถา้ คุณพดู ภาษาไทยคุณสามารถใชบ้ ริการช่วยเหลือทางภาษาไดฟ้ รี โทร (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
Gujarati –

Urdu –

Italian – ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero
(800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
Greek – ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται
δωρεάν. Καλέστε (800) 362-3310. TTY / TDD: 711 / (800) 877-8973.
MY BENEFITS | 17 |

Health Savings Account
To Receive and Make Contributions:
•	You will need to open an account with Fidelity (Instructions below.)
   This will allow your payroll contributions and the UnityPoint Health
   contribution to be deposited at Fidelity.                                                       GENERAL NEED-TO-KNOW

•	In order to make pre-tax contributions to your HSA, you will need to                            •	If you enroll in the Health
   elect those contributions within the Fidelity website. This will be the                            Savings Medical Plan for
   only method of making and changing your contributions throughout                                   2021 but do not open
                                                                                                      your account with Fidelity
   the year.
                                                                                                      between October 27, 2020
•	Beginning October 27th, login to your Fidelity account to make your                                and December 31, 2020,
   2021 HSA pre-tax contribution election. Elections made by December                                 you will forfeit the UnityPoint
   15th, will be applied beginning the first pay period of 2021.                                      Health HSA contributions for
                                                                                                      the 2021 calendar year.
•	Team members currently enrolled in an HSA, will have their 2020 HSA
   pre-tax contribution election roll over into 2021, if no action is taken.                       •	Your 2021 payroll
                                                                                                      and UnityPoint Health
Opening an account with Fidelity                                                                      contributions will be applied
When you’re ready, opening and managing your HSA with Fidelity is                                     to your new Fidelity HSA
fast and easy. You’ll get information on investment choices, payment                                  account beginning the first
options, and ongoing support to help you build and manage your                                        pay period of 2021.
savings. For convenience, you can open a Fidelity HSA online.
Here’s how it works:
•	Log into NetBenefits® at NetBenefits.com/UnityPoint.
•	From the home page, click “Open” next to Health Savings Account.
•	If you do not have access to NetBenefits, contact a Fidelity Representative at 1-800-544-3716.

2021 Annual HSA Contribution Limits

  Individual health care coverage                                           $3,600*
  Family health care coverage                                               $7,200*
  Additional catch-up contribution (if age 55 or older)                     $1,000
*The maximum amount you may contribute to your HSA, assuming you enroll at the start of 2021. These amounts include UnityPoint Health
  contributions. If you enroll into an HSA after the first of the year, this amount will change based on the prorated UnityPoint contribution.
MY BENEFITS | 18 |

Dental Coverage
You will have the choice to elect dental coverage from two plans:

01          Premier Plan
                                02          Basic Plan

About the Dental Plans
Both dental plans provide coverage for preventive and basic care services. When you enroll in the Premier Plan,
orthodontia and major services will be covered for you and your eligible dependents. The Basic Plan will have
significantly lower premiums as a result of not covering major services and orthodontia. If you and your eligible
dependents don’t have orthodontia (under age 19) or major dental service needs, the Basic Plan offers you a
way to save money while still getting coverage for your diagnostic, preventive and routine restorative services.
Delta Dental contracts with dentists and other dental care providers in all of the communities where UnityPoint
Health affiliates are located. When you see a dental provider who is in the Delta Dental PPO network, you will
commonly pay less than when you see a dental provider who is in the Delta Dental Premier network or an out-
of-network provider. You can review the coverage levels and premium information for each dental plan below
to help you determine which plan is best for you. The percentages in the following table are the percentages
you pay.

        If you and your eligible dependents
        don’t have orthodontia or major
        dental service needs, the Basic Plan
        offers you a way to save money
        while still getting coverage for your
        diagnostic, preventive and routine
        restorative services.
Dental Coverage continued                                                                            MY BENEFITS | 19 |

   Dental Benefit Coverage            Basic                                Premier Plan
                                                          Delta Premier/                      Delta Premier/
                                        Delta PPO                            Delta PPO
                                                          Out of Network                      Out of Network
   Deductible/Individual                       $25              $50             $15                  $25
   Annual Maximum                             $750             $750            $1,500               $1,500
   Diagnostic & Preventive
   Exams, cleanings, fluoride,
   space maintainers
                                       100% covered       100% covered      100% covered      100% covered
   Sealants
   X-rays
   Routine Restorative Services
   Simple extractions, surgical
   services                              10% after           20% after        10% after             20% after
   Emergency Treatment                  deductible          deductible       deductible            deductible
   Routine Oral Surgery
   Posterior Composites                        50% after deductible              50% after deductible
   Major Services
   Endodontics - root canal therapy
                                                                              20% after             20% after
   Periodontics -conservative and       Not covered        Not covered
                                                                             deductible            deductible
   maintenance therapies
   Periodontics - complex
   procedures
   Crowns, inlays, onlays                                                     50% after             50% after
                                        Not covered        Not covered
                                                                             deductible            deductible
   Bridges and dentures
   Repairs and adjustments
   Orthodontics (Dependent Children Under 19)
   Appliances, treatment & related
                                                                                           50%
   services
                                        Not covered        Not covered
   Lifetime Maximum per
                                                                                          $2,000
   dependent child
   Dental Premium Cost
                                                              Annual                                Annual
                                       Per Pay Period      (Based on 26     Per Pay Period       (Based on 26
                                                            Pay Periods)                          Pay Periods)
   Employee Only                              $5.11          $132.86            $8.28               $215.28
   Employee + Spouse/DP                   $10.05             $261.30           $16.54               $430.04
   Employee + Child(ren)                  $11.47             $298.22           $18.78               $488.28
   Family                                 $15.20             $395.20           $25.06               $651.56
MY BENEFITS | 20 |

Vision Coverage
Under the vision plan, you may purchase your eyeglasses and contacts at the eye care provider of your choice.
However, when you use an Avesis network provider, you receive the highest level of plan benefits and have the
lowest out-of-pocket costs.
For routine eye exams, you can see any Optometry provider; in or out-of-network. However, for non-routine eye
care, you’ll need to visit an in-network provider.

Vision Care Services          In-Network                                  Out-of-Network Reimbursement
Routine Annual Eye Exam                      $10 copay                                Up To $35
Materials                                    $10 copay*                               See Below
Glasses Frames                  $10 copay then covered 100% up to                     Up to $45
                                 $150 retail / $50 wholesale value

Glasses Lenses
Single Vision                      Covered in full after $10 copay                       $25
Bifocal                            Covered in full after $10 copay                       $40
Trifocal                           Covered in full after $10 copay                       $50
Lenticular                         Covered in full after $10 copay                       $80
Standard Progressives         Covered up to $140, plus 20% discount                   Up to $48

Lens Package Details
Polycarbonate
(Single Vision/Multi-Focal)                   $40/$44                                    N/A

Youth Polycarbonate
                                           Covered in full                            Up to $10
(Up to age 19)
Standard Scratch-Resistant
                                                $17                                      N/A
Coating
Ultra-Violet Screening                          $15                                      N/A
Solid or Gradient Tint                          $17                                      N/A
Standard Anti-Reflective
Coating                                         $45                                      N/A

Level 1 Progressives                       Covered in full                            Up to $40
Level 2 Progressives                       Covered in full                            Up to $48
Transitions
(Single Vision/Multi-Focal)                   $70/$80                                    N/A

Polarized                                       $75                                      N/A
PGX/PBX                                         $40                                      N/A
Other Lens Options                      Up to 20% discount                               N/A
Vision Coverage continued                                                                                                   MY BENEFITS | 21 |

   Contact Lenses (in lieu of glasses)
   Elective                                               Up to $150                                        Up to $130
   Medically Necessary**                               Covered in full                                      Up to $250

   Surgery
   Refractive Laser Surgery              $150 lifetime allowance, plus provider                     $150 lifetime allowance
                                                   discount up to 25%

   Frequency
   Exam                                           Once every 12 months                               Once every 12 months
   Glasses Lenses or                              Once every 12 months                               Once every 12 months
   Contact Lenses
   Glasses Frames                                 Once every 24 months                               Once every 24 months
                                                                    Employee +                  Employee +
   Vision Premium Cost                  Employee Only                                                                      Family
                                                                     Child(ren)                 Spouse/DP
   Full & Part Time Rates                     $3.29                     $7.16                       $6.32                  $9.38
  * Applies to eyeglasses frames up to $150 retail value ($50 wholesale value) and standard lenses (excluding progressive lenses)
  ** Prior authorization required
You can also read