17-Exhibit 7. Fort Bend ISD Choice HSA Plan SPD 2025.pdf

Fort Bend Independent School District Choice HSA Plan

Effective: January 1, 2025 Plan Year: January 1 – December 31

Group Number: 902915

Summary Plan Description

FORT BEND INDEPENDENT SCHOOL DISTRICT MEDICAL CHOICE HSA PLAN

i TABLE OF CONTENTS

TABLE OF CONTENTS

SECTION 1 – WELCOME

SECTION 2 - INTRODUCTION

Eligibility

Cost of Coverage

How to Enroll

When Coverage Begins

Changing Your Coverage

SECTION 3 - HOW THE PLAN WORKS

Accessing Benefits

Health Services from Non-Network Providers

Eligible Expenses

Annual Deductible

Coinsurance

Out-of-Pocket Maximum

SECTION 4 - PERSONAL HEALTH SUPPORT AND PRIOR AUTHORIZATION

Care Management

Prior Authorization

Special Note Regarding Medicare

SECTION 5 - PLAN HIGHLIGHTS

SECTION 6 - ADDITIONAL COVERAGE DETAILS

Ambulance Services

Cellular and Gene Therapy

Clinical Trials

Congenital Heart Disease (CHD) Surgeries

Dental Services - Accident Only

Diabetes Services

Durable Medical Equipment (DME)

Emergency Health Services - Outpatient

Enteral Nutrition

Hearing Aids

Home Health Care ii TABLE OF CONTENTS

Hospice Care

Hospital - Inpatient Stay

Lab, X-Ray and Diagnostics - Outpatient

Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine

- Outpatient

Mental Health Services

Neurobiological Disorders - Autism Spectrum Disorder Services

Nutritional Counseling

Ostomy Supplies

Pharmaceutical Products - Outpatient

Physician Fees for Surgical and Medical Services

Physician's Office Services - Sickness and Injury

Pregnancy - Maternity Services

Preventive Care Services

Prosthetic Devices

Reconstructive Procedures

Rehabilitation Services - Outpatient Therapy and Manipulative Treatment

Scopic Procedures - Outpatient Diagnostic and Therapeutic

Skilled Nursing Facility/Inpatient Rehabilitation Facility Services

Substance-Related and Addictive Disorders Services

Surgery - Outpatient

Temporomandibular Joint (TMJ) Services

Therapeutic Treatments - Outpatient

Transplantation Services

Urgent Care Center Services

Urinary Catheters

Virtual Visits

Vision Care

Wigs

SECTION 7 – CLINICAL PROGRAMS AND RESOURCES

Consumer Solutions and Self-Service Tools

Disease Management Services

Complex Medical Conditions Programs and Services iii TABLE OF CONTENTS

SECTION 8 - EXCLUSIONS: WHAT THE MEDICAL PLAN WILL NOT COVER

Alternative Treatments

Dental

Devices, Appliances and Prosthetics

Drugs

Experimental or Investigational or Unproven Services

Foot Care

Medical Supplies

Mental Health, Neurobiological Disorders - Autism Spectrum Disorder and Substance- Related and Addictive Disorders Services

Nutrition

Personal Care, Comfort or Convenience

Physical Appearance

Procedures and Treatments

Providers

Reproduction

Services Provided under Another Plan

Transplants

Travel

Types of Care

Vision and Hearing

All Other Exclusions

SECTION 9 - CLAIMS PROCEDURES

Network Benefits

Non-Network Benefits

If Your Provider Does Not File Your Claim

Health Statements

Explanation of Benefits (EOB)

Claim Denials and Appeals

External Review Program

Limitation of Action

SECTION 10 - COORDINATION OF BENEFITS (COB)

SECTION 11 - SUBROGATION AND REIMBURSEMENT

iv TABLE OF CONTENTS

Right of Recovery

SECTION 12 - WHEN COVERAGE ENDS

Coverage for a Disabled Child

Continuing Coverage Through COBRA

When COBRA Ends

Uniformed Services Employment and Reemployment Rights Act

SECTION 13 - OTHER IMPORTANT INFORMATION

Amendments to the Plan

Qualified Medical Child Support Orders (QMCSOs)

Your Relationship with UnitedHealthcare and Fort Bend Independent School District

Relationship with Providers

Your Relationship with Providers

Interpretation of Benefits

Information and Records

Incentives to Providers

Incentives to You

Rebates and Other Payments

Workers' Compensation Not Affected

Future of the Plan

Plan Document

Medicare Eligibility

SECTION 14 - GLOSSARY

SECTION 15 - IMPORTANT ADMINISTRATIVE INFORMATION

ATTACHMENT I - HEALTH CARE REFORM NOTICES

Patient Protection and Affordable Care Act ("PPACA")

ATTACHMENT II - LEGAL NOTICES

Women's Health and Cancer Rights Act of 1998

Statement of Rights under the Newborns' and Mothers' Health Protection Act

A note regarding UHC’s position on Genetic Information Nondiscrimination Act

(GINA):

ATTACHMENT III– HEALTH SAVINGS ACCOUNT

Introduction v TABLE OF CONTENTS

About Health Savings Accounts

Who Is Eligible And How To Enroll

Contributions

Reimbursable Expenses

Additional Medical Expense Coverage Available with Your Health Savings Account . 133

Using the HSA for Non-Qualified Expenses

Rollover Feature

Additional Information About the HSA

ATTACHMENT IV – NONDISCRIMINATION AND ACCESSIBILITY REQUIREMENTS

ATTACHMENT V – GETTING HELP IN OTHER LANGUAGES OR FORMATS

ADDENDUM I – REAL APPEAL

ADDENDUM II – FBISD SPONSORED PROGRAM

CCS Medical Diabetes Wellness Program

ADDENDUM III – FBISD SPONSORED PROGRAM

Maternity Support Program

ADDENDUM IV – FBISD SPONSORED PROGRAM

Rally Well-being Rewards Program

What does this mean for Fort Bend ISD employees?

When and how do I receive the incentive?

What incentives are employees eligible for?

Benefits Offered

ADDENDUM V – FBISD SPONSORED PROGRAM

Surgery Plus Benefit

SECTION 1 - WELCOME

SECTION 1 – WELCOME

Quick Reference Box

■ Member services, claim inquiries, Personal Health Support and Mental Health/Substance-Related and Addictive Disorder Administrator: 1-888-651-7319.

■ Claims submittal address: UnitedHealthcare - Claims, P.O. Box 30555, Salt Lake City, UT 84130-0555.

Online assistance: www.myuhc.com.

Fort Bend Independent School District is pleased to provide you with this Summary Plan Description (SPD), which describes the health Benefits available to you and your covered family members. It includes summaries of:

■ who is eligible;

■ services that are covered, called Covered Health Services;

■ services that are not covered, called Exclusions;

■ how Benefits are paid; and

■ your rights and responsibilities under the Plan.

This SPD is designed to meet your information needs. It supersedes any previous printed or electronic SPD for this Plan.

IMPORTANT

The healthcare service, supply or Pharmaceutical Product is only a Covered Health Service if it is Medically Necessary. (See definitions of Medically Necessary and Covered Health Service in Section 14, Glossary.) The fact that a Physician or other provider has performed or prescribed a procedure or treatment, or the fact that it may be the only available treatment for a Sickness, Injury, Mental Illness, substance-related and addictive disorders, disease or its symptoms does not mean that the procedure or treatment is a Covered Health Service under the Plan.

Fort Bend Independent School District intends to continue this Plan, but reserves the right, in its sole discretion, to modify, change, revise, amend or terminate the Plan at any time, for any reason, and without prior notice subject to any collective bargaining agreements between the Employer and various unions, if applicable. This SPD is not to be construed as a contract of or for employment. If there should be an inconsistency between the contents of this summary and the contents of the Plan, your rights shall be determined under the Plan and not under this summary.

UnitedHealthcare is a private healthcare claims administrator. UnitedHealthcare's goal is to give you the tools you need to make wise healthcare decisions. UnitedHealthcare also helps your employer to administer claims. Although UnitedHealthcare will assist you in many ways, it does not guarantee any Benefits. Fort Bend Independent School District is solely responsible for paying Benefits described in this SPD.

SECTION 1 - WELCOME

Please read this SPD thoroughly to learn how the Fort Bend Independent School District Choice HSA Plan works. If you have questions contact the Fort Bend ISD Benefits Department or call the number on your ID card.

How To Use This SPD

■ Read the entire SPD, and share it with your family. Then keep it in a safe place for future reference.

■ Many of the sections of this SPD are related to other sections. You may not have all the information you need by reading just one section.

■ You can find copies of your SPD and any future amendments or request printed copies by contacting the Fort Bend ISD Benefits Department.

■ Capitalized words in the SPD have special meanings and are defined in Section 14, Glossary.

■ If eligible for coverage, the words "you" and "your" refer to Covered Persons as defined in Section 14, Glossary.

■ Fort Bend Independent School District is also referred to as Company.

■ If there is a conflict between this SPD and any benefit summaries (other than Summaries of Material Modifications) provided to you, this SPD will control.

3 SECTION 2 - INTRODUCTION

SECTION 2 - INTRODUCTION

What this section includes:

■ Who's eligible for coverage under the Plan.

■ The factors that impact your cost for coverage.

■ Instructions and timeframes for enrolling yourself and your eligible Dependents.

■ When coverage begins.

■ When you can make coverage changes under the Plan.

Eligibility

You are eligible to enroll in the Plan if you are a regular full-time employee or some part-time employees who is scheduled to work at least 22.5 hours per week.

Your eligible Dependents may also participate in the Plan. An eligible Dependent is considered to be:

■ your Spouse, as defined in Section 14, Glossary;

■ your or your Spouse's child who is under age 26, including a natural child, stepchild, a legally adopted child, a child placed for adoption or a child for whom you or your Spouse are the legal guardian; or

■ an unmarried child age 26 or over who is or becomes disabled and dependent upon you.

Note: Your Dependents may not enroll in the Plan unless you are also enrolled. In addition, if you and your Spouse are both covered under the Plan, you may each be enrolled as a Participant or be covered as a Dependent of the other person, but not both. In addition, if you and your Spouse are both covered under the Plan, only one parent may enroll your child as a Dependent.

A Dependent also includes a child for whom health care coverage is required through a Qualified Medical Child Support Order or other court or administrative order, as described in Section 13, Other Important Information.

Note: Additional eligibility information is located on the Fort Bend Independent School District website: http://www.fortbendisd.com/Domain/143

Family and Medical Leave Act (FMLA)

If you are granted a leave of absence by the employer as required by the Federal Family and Medical Leave Act (leave), you may continue to be covered under the Plan for the duration of the leave under the same conditions as other employees who are in active status and covered by the Plan. If you choose to terminate coverage during the leave, or if coverage terminates as a result of nonpayment of any required contribution, coverage may be reinstated on the date you return to active status immediately following the end of the leave.

If you do not wish to change your benefit election due to the birth of a newborn, the automatic coverage for the newborn will terminate immediately following day 31 after birth.

4 SECTION 2 - INTRODUCTION

You will need to wait until the next annual Open Enrollment to change your election if coverage has not been selected within 31 days.

Cost of Coverage

You and Fort Bend Independent School District share in the cost of the Plan. Your contribution amount depends on the Plan you select and the family members you choose to enroll.

Your contributions are deducted from your paychecks on a before-tax basis. Before-tax dollars come out of your pay before federal income and Social Security taxes are withheld⎯and in most states, before state and local taxes are withheld. This gives your contributions a special tax advantage and lowers the actual cost to you.

Your contributions are subject to review and Fort Bend Independent School District reserves the right to change your contribution amount from time to time.

You can obtain current contribution rates by calling the Fort Bend ISD Benefits Department.

How to Enroll

To enroll, call the Fort Bend ISD Benefits Department within 30 days of the date you first become eligible for medical Plan coverage. If you do not enroll within 30 days, you will need to wait until the next annual Open Enrollment to make your benefit elections.

Each year during annual Open Enrollment, you have the opportunity to review and change your medical election. Any changes you make during Open Enrollment will become effective the following January 1.

Important If you wish to change your benefit elections following your marriage, birth, adoption of a child, placement for adoption of a child or other family status change, you must contact the Fort Bend ISD Benefits Department within 30 days of the event. Otherwise, you will need to wait until the next annual Open Enrollment to change your elections.

When Coverage Begins

Once the Fort Bend ISD Benefits Department receives your properly completed enrollment, coverage will begin on the first day of the month following your start date. Coverage for your Dependents will start on the date your coverage begins, provided you have enrolled them in a timely manner. Proper enrollment or enrollment forms must be returned to the Fort Bend ISD Benefits Department within 30 days of your start date.

Coverage for a Spouse or Dependent stepchild that you acquire via marriage becomes effective the first of the month following the date of the event, provided you notify the Fort Bend ISD Benefits Department within 30 days of your marriage. Coverage for Dependent children acquired through birth, adoption, or placement for adoption is effective the date of

5 SECTION 2 - INTRODUCTION

the family status change, provided you notify the Fort Bend ISD Benefits Department within 30 days of the birth, adoption, or placement.

If you do not wish to change your benefit election due to the birth of a newborn, the automatic coverage for the newborn will terminate immediately following day 31 after birth.

You will need to wait until the next annual Open Enrollment to change your election if coverage has not been selected within 31 days.

Late Enrollees

A late enrollee is an Eligible Person or Dependent who does not enroll for coverage under the Plan when he or she is first eligible, and who does not enroll during the initial enrollment period, Open Enrollment period or a special enrollment period. Coverage begins on the date identified by the Plan Administrator after the Plan Administrator receives the completed enrollment form and any required contribution for coverage.

If You Are Hospitalized When Your Coverage Begins

If you are an inpatient in a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility on the day your coverage begins, the Plan will pay Benefits for Covered Health Services related to that Inpatient Stay as long as you receive Covered Health Services in accordance with the terms of the Plan.

You should notify UnitedHealthcare within 48 hours of the day your coverage begins, or as soon as is reasonably possible. Network Benefits are available only if you receive Covered Health Services from Network providers.

Changing Your Coverage

You may make coverage changes during the year only if you experience a change in family status. The change in coverage must be consistent with the change in status (e.g., you cover your Spouse following your marriage, your child following an adoption, etc.). The following are considered family status changes for purposes of the Plan:

■ your marriage, divorce, legal separation or annulment;

■ the birth, adoption, placement for adoption or legal guardianship of a child;

■ a change in your Spouse's employment or involuntary loss of health coverage (other than coverage under the Medicare or Medicaid programs) under another employer's plan;

■ loss of coverage due to the exhaustion of another employer's COBRA benefits, provided you were paying for premiums on a timely basis;

■ the death of a Dependent;

■ your Dependent child no longer qualifying as an eligible Dependent;

■ a change in your or your Spouse's position or work schedule that impacts eligibility for health coverage;

■ contributions were no longer paid by the employer (this is true even if you or your eligible Dependent continues to receive coverage under the prior plan and to pay the amounts previously paid by the employer);

6 SECTION 2 - INTRODUCTION

■ you or your eligible Dependent who were enrolled in an HMO no longer live or work in that HMO's service area and no other benefit option is available to you or your eligible Dependent;

■ benefits are no longer offered by the Plan to a class of individuals that include you or your eligible Dependent;

■ termination of your or your Dependent's Medicaid or Children's Health Insurance Program (CHIP) coverage as a result of loss of eligibility (you must contact the Fort Bend ISD Benefits Department within 60 days of termination);

■ you or your Dependent become eligible for a premium assistance subsidy under Medicaid or CHIP (you must contact the Fort Bend ISD Benefits Department within 60 days of determination of subsidy eligibility);

■ after gaining/losing exchange coverage;

■ a strike or lockout involving you or your Spouse; or

■ a court or administrative order.

Unless otherwise noted above, if you wish to change your elections, you must contact the Fort Bend ISD Benefits Department within 30 days of the change in family status.

Otherwise, you will need to wait until the next annual Open Enrollment.

While some of these changes in status are similar to qualifying events under COBRA, you, or your eligible Dependent, do not need to elect COBRA continuation coverage to take advantage of the special enrollment rights listed above. These will also be available to you or your eligible Dependent if COBRA is elected.

Note: Any child under age 26 who is placed with you for adoption will be eligible for coverage on the date the child is placed with you, even if the legal adoption is not yet final. If you do not legally adopt the child, all medical Plan coverage for the child will end when the placement ends. No provision will be made for continuing coverage (such as COBRA coverage) for the child.

Change in Family Status - Example Jane is married and has two children who qualify as Dependents. At annual Open Enrollment, she elects not to participate in Fort Bend Independent School District's medical plan, because her husband, Tom, has family coverage under his employer's medical plan. In June, Tom loses his job as part of a downsizing. As a result, Tom loses his eligibility for medical coverage. Due to this family status change, Jane can elect family medical coverage under Fort Bend Independent School District's medical plan outside of annual Open Enrollment.

7 SECTION 3 - HOW THE PLAN WORKS

SECTION 3 - HOW THE PLAN WORKS

What this section includes:

■ Accessing Benefits.

■ Eligible Expenses.

■ Annual Deductible.

■ Coinsurance.

■ Out-of-Pocket Maximum.

Accessing Benefits

As a participant in this Plan, you have the freedom to choose the Network Physician or health care professional you prefer each time you need to receive Covered Health Services.

The choices you make affect the amounts you pay, as well as the level of Benefits you receive and any benefit limitations that may apply.

You are eligible for Benefits under this Plan when you receive Covered Health Services from Physicians and other health care professionals who have contracted with UnitedHealthcare to provide those services. You must see a Physician as described above in order to obtain Benefits. Except as specifically described within the SPD, Benefits are not available for services provided by a non-Network provider. This Plan does not provide a non-Network level of Benefits.

Benefits apply to Covered Health Services that are provided by a Network Physician or other Network provider. You are not required to select a Primary Physician in order to obtain Benefits. In general health care terminology, a Primary Physician may also be referred to as a Primary Care Physician or PCP.

Emergency Health Services provided by a non-Network provider will be reimbursed as set forth under Eligible Expenses as described at the end of this section.

Covered Health Services provided at certain Network facilities by a non-Network Physician, when not Emergency Health Services, will be reimbursed as set forth under Eligible Expenses as described at the end of this section. For these Covered Health Services, "certain Network facility" is limited to a hospital (as defined in 1861(e) of the Social Security Act), a hospital outpatient department, a critical access hospital (as defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center as described in section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the Secretary.

Air Ambulance transport provided by a non-Network provider will be reimbursed as set forth under Eligible Expenses as described at the end of this section.

Ground Ambulance transport provided by a non-Network provider will be reimbursed as set forth under Eligible Expenses as described at the end of this section.

Designated Network Benefits apply to Covered Health Services that are provided by a Network Physician or other provider that has been identified as a Designated Provider. Only

8 SECTION 3 - HOW THE PLAN WORKS

certain Physicians and providers have been identified as a Designated Provider. Designated Network Benefits are available only for specific Covered Health Services as identified in Section 5, Plan Highlights. When Designated Network Benefits apply, they are included in and subject to the same Annual Deductible, and Out-of-Pocket Maximum and requirements as all other Covered Health Services provided by Network providers

Network Providers

UnitedHealthcare or its affiliates arrange for health care providers to participate in a Network. At your request, UnitedHealthcare will send you a directory of network providers free of charge. Keep in mind, a provider's Network status may change. To verify a provider's status or request a provider directory, you can call UnitedHealthcare at the number on your ID card or log onto www.myuhc.com.

Network providers are independent practitioners and are not employees of Fort Bend Independent School District or UnitedHealthcare. It is your responsibility to select your provider.

UnitedHealthcare's credentialing process confirms public information about the providers' licenses and other credentials, but does not assure the quality of the services provided.

Before obtaining services you should always verify the Network status of a provider. A provider's status may change. You can verify the provider's status by calling UnitedHealthcare. A directory of providers is available online at www.myuhc.com or by calling the number on your ID card to request a copy. If you receive a Covered Health Service from a non-Network provider and were informed incorrectly prior to receipt of the Covered Health Service that the provider was a Network provider, either through a database, provider directory, or in a response to your request for such information (via telephone, electronic, web-based or internet-based means), you may be eligible for Network Benefits.

It is possible that you might not be able to obtain services from a particular Network provider. The network of providers is subject to change. Or you might find that a particular Network provider may not be accepting new patients. If a provider leaves the Network or is otherwise not available to you, you must choose another Network provider to get Benefits.

However, if you are currently receiving treatment for Covered Health Services from a provider whose network status changes from Network to non-Network during such treatment due to expiration or nonrenewal of the provider's contract, you may be eligible to request continued care from your current provider at the Network Benefit level for specified conditions and timeframes. This provision does not apply to provider contract terminations for failure to meet applicable quality standards or for fraud. If you would like help to find out if you are eligible for continuity of care Benefits, please call the telephone number on your ID card.

If you are currently undergoing a course of treatment utilizing a non-Network Physician or health care facility, you may be eligible to receive transition of care Benefits. This transition period is available for specific medical services and for limited periods of time. If you have questions regarding this transition of care reimbursement policy or would like help determining whether you are eligible for transition of care Benefits, please contact the telephone number on your ID card.

9 SECTION 3 - HOW THE PLAN WORKS

Do not assume that a Network provider's agreement includes all Covered Health Services.

Some Network providers contract with UnitedHealthcare to provide only certain Covered Health Services, but not all Covered Health Services. Some Network providers choose to be a Network provider for only some of UnitedHealthcare's products. Refer to your provider directory or contact UnitedHealthcare for assistance.

Health Services from Non-Network Providers

If specific Covered Health Services are not available from a Network provider, you may be eligible for Benefits when Covered Health Services are received from a non-Network provider. In this situation, your Physician will notify the UnitedHealthcare, and if UnitedHealthcare confirms that care is not available from a Network provider, the UnitedHealthcare will work with you and your Network Physician to coordinate care through a non-Network provider.

When you receive Covered Health Services through a Network Physician, the Plan will pay Network Benefits for those Covered Health Services, even if one or more of those Covered Health Services is received from a non-Network provider.

Looking for a Network Provider?

In addition to other helpful information, www.myuhc.com, UnitedHealthcare's consumer website, contains a directory of health care professionals and facilities in UnitedHealthcare's Network. While Network status may change from time to time, www.myuhc.com has the most current source of Network information. Use www.myuhc.com to search for Physicians available in your Plan.

Possible Limitations on Provider Use

If UnitedHealthcare determines that you are using health care services in a harmful or abusive manner, you may be required to select a Network Physician to provide and coordinate all of your future Covered Health Services.

If you don't make a selection within 31 days of the date you are notified, UnitedHealthcare will select a single Network Physician for you.

In the event that you do not use the selected Network Physician, Benefits will not be paid.

Designated Providers

If you have a medical condition that UnitedHealthcare believes needs special services, UnitedHealthcare may direct you to a Designated Provider chosen by UnitedHealthcare. If you require certain complex Covered Health Services for which expertise is limited, UnitedHealthcare may direct you to a Network facility or provider that is outside your local geographic area. If you are required to travel to obtain such Covered Health Services from a Designated Provider, UnitedHealthcare may reimburse certain travel expenses at UnitedHealthcare's discretion.

In both cases, Benefits will only be paid if your Covered Health Services for that condition are provided by or arranged by the Designated Provider or other provider chosen by UnitedHealthcare.

10 SECTION 3 - HOW THE PLAN WORKS

Eligible Expenses

Fort Bend Independent School District has delegated to UnitedHealthcare the discretion and authority to decide whether a treatment or supply is a Covered Health Service and how the Eligible Expenses will be determined and otherwise covered under the Plan.

Eligible Expenses are the amount UnitedHealthcare determines that the Plan will pay for Benefits.

■ For Designated Network and Network Benefits for Covered Health Services provided by a Network provider, you are not responsible for any difference between Eligible Expenses and the amount the provider bills.

- For Covered Health Services that are Ancillary Services received at certain Network facilities on a non-Emergency basis from non-Network Physicians, you are not responsible, and the non-Network provider may not bill you, for amounts in excess of your Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in this SPD.

- For Covered Health Services that are non-Ancillary Services received at certain Network facilities on a non-Emergency basis from non-Network Physicians who have not satisfied the notice and consent criteria or for unforeseen or urgent medical needs that arise at the time a non-Ancillary Service is provided for which notice and consent has been satisfied as described below, you are not responsible, and the Non-Network provider may not bill you, for amounts in excess of your Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in the SPD.

- For Covered Health Services that are Emergency Health Services provided by a Non-Network provider, you are not responsible, and the Non-Network provider may not bill you, for amounts in excess of your applicable Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in this SPD.

- For Covered Health Services that are Air Ambulance services provided by a Non-Network provider, you are not responsible, and the Non-Network provider may not bill you, for amounts in excess of your applicable Copayment, Coinsurance or deductible which is based on the rates that would apply if the service was provided by a Network provider which is based on the Recognized Amount as defined in the SPD.

Eligible Expenses are determined in accordance with the Claims Administrator's reimbursement policy guidelines or as required by law, as described in the SPD.

For Designated Network and Network Benefits, Eligible Expenses are based on the following:

■ When Covered Health Services are received from a Designated Network and Network provider, Eligible Expenses are UnitedHealthcare's contracted fee(s) with that provider.

■ When Covered Health Services are received from a non-Network provider as arranged by us, including when there is no Network provider who is reasonably accessible or available to provide Covered Health Services, Eligible Expenses are an amount

11 SECTION 3 - HOW THE PLAN WORKS

negotiated by UnitedHealthcare or an amount permitted by law. Please contact us if you are billed for amounts in excess of your applicable Coinsurance, Copayment or any deductible. The Plan will not pay excessive charges or amounts you are not legally obligated to pay.

When Covered Health Services are received from a non-Network provider as described below, Eligible Expenses are determined as follows:

■ For non-Emergency Covered Health Services received at certain Network facilities from non-Network Physicians when such services are either Ancillary Services, or non-Ancillary Services that have not satisfied the notice and consent criteria of section 2799B-2(d) of the Public Health Service Act with respect to a visit as defined by the Secretary (including non-Ancillary Services that have satisfied the notice and consent criteria but unforeseen urgent medical needs arise at the time the services are provided), the Eligible Expense is based on one of the following in the order listed below as applicable:

- The reimbursement rate as determined by a state law All Payer Model Agreement.

- The reimbursement rate as determined by state law.

- The initial payment made by the Claims Administrator, or the amount subsequently agreed to by the non-Network provider and the Claims Administrator.

- The amount determined by Independent Dispute Resolution (IDR).

For the purpose of this provision, "certain Network facilities" are limited to a hospital (as defined in 1861(e) of the Social Security Act), a hospital outpatient department, a critical access hospital (as defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center as described in section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the Secretary.

IMPORTANT NOTICE: For Ancillary Services, non-Ancillary Services provided without notice and consent, and non-Ancillary Services for unforeseen or urgent medical needs that arise at the time a service is provided for which notice and consent has been satisfied, you are not responsible, and a non-Network Physician may not bill you, for amounts in excess of your applicable Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in the SPD..

■ For Emergency Health Services provided by a non-Network provider, the Eligible Expense is based on one of the following in the order listed below as applicable:

- The reimbursement rate as determined by a state All Payer Model Agreement.

- The reimbursement rate as determined by state law.

- The initial payment made by the Claims Administrator, or the amount subsequently agreed to by the non-Network provider and the Claims Administrator.

- The amount determined by Independent Dispute Resolution (IDR).

IMPORTANT NOTICE: You are not responsible, and a non-Network provider may not bill you, for amounts in excess of your applicable Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in the SPD.

12 SECTION 3 - HOW THE PLAN WORKS

■ For Air Ambulance transportation provided by a non-Network provider, the Eligible Expense is based on one of the following in the order listed below as applicable:

- The reimbursement rate as determined by a state All Payer Model Agreement.

- The reimbursement rate as determined by state law.

- The initial payment made by the Claims Administrator, or the amount subsequently agreed to by the non-Network provider and the Claims Administrator.

- The amount determined by Independent Dispute Resolution (IDR).

IMPORTANT NOTICE: You are not responsible, and a non-Network provider may not bill you, for amounts in excess of your Copayment, Coinsurance or deductible which is based on the rates that would apply if the service was provided by a Network provider

■ For Emergency ground ambulance transportation provided by a non-Network provider, the Eligible Expense, which includes mileage, is a rate agreed upon by the non-Network provider or, unless a different amount is required by applicable law, determined based upon the median amount negotiated with Network providers for the same or similar service.

IMPORTANT NOTICE: Non-Network providers may bill you for any difference between the provider’s billed charges and the Eligible Expense described here.

When Covered Health Services are received from a non-Network provider, except as described above, Eligible Expenses are determined as follows: (i) an amount negotiated by the Claims Administrator, (ii) a specific amount required by law (when required by law), or (iii) an amount the Claims Administrator has determined is typically accepted by a healthcare provider for the same or similar service or an amount that is greater than such rate when elected or directed by the Plan. The Plan will not pay excessive charges.

You are responsible for paying, directly to the non-Network provider, the applicable Coinsurance, Copayment or any deductible. Please contact the Claims Administrator if you are billed for amounts in excess of your applicable Coinsurance, Copayment or any deductible to access the Advocacy Services as described below. Following the conclusion of the Advocacy Services described below, any responsibility to pay more than the Eligible Expense (which includes your Coinsurance, Copayment, and deductible) is yours.

Advocacy Services

The Plan has contracted with the Claims Administrator to provide advocacy services on your behalf with respect to non-network providers that have questions about the Eligible Expenses and how the Claims Administrator determined those amounts. Please call the Claims Administrator at the number on your ID card to access these advocacy services, or if you are billed for amounts in excess of your applicable coinsurance or copayment. In addition, if the Claims Administrator, or its designee, reasonably concludes that the particular facts and circumstances related to a claim provide justification for reimbursement greater than that which would result from the application of the Eligible Expense, and the Claims Administrator, or its designee, determines that it would serve the best interests of the Plan and its Employees (including interests in avoiding costs and expenses of disputes over payment of claims), the Claims Administrator, or its designee, may use its sole discretion to increase the Eligible Expense for that particular claim.

13 SECTION 3 - HOW THE PLAN WORKS

Annual Deductible

The Annual Deductible is the amount of Eligible Expenses, or the Recognized Amount when applicable, you must pay each calendar year for Covered Health Services before you are eligible to begin receiving Benefits.. The amounts you pay toward your Annual Deductibles accumulate over the course of the calendar year.

Amounts paid toward the Annual Deductible for Covered Health Services that are subject to a visit or day limit will also be calculated against that maximum benefit limit. As a result, the limited benefit will be reduced by the number of days or visits you used toward meeting the Annual Deductible.

When a Covered Person was previously covered under a benefit plan that was replaced by the Plan, any amount already applied to that annual deductible provision of the prior plan will apply to the Annual Deductible provision under this Plan.

Coinsurance

Coinsurance is the percentage of Eligible Expenses that you are responsible for paying.

Coinsurance is a fixed percentage that applies to certain Covered Health Services after you meet the Annual Deductible.

Coinsurance - Example Let's assume that you receive Plan Benefits for outpatient surgery from a Network provider. Since the Plan pays 100% after you meet the Annual Deductible, you are responsible for paying the other 0%. This 0% is your Coinsurance.

Out-of-Pocket Maximum

The annual Out-of-Pocket Maximum is the most you pay each calendar year for Covered Health Services. If your eligible out-of-pocket expenses in a calendar year exceed the annual maximum, the Plan pays 100% of Eligible Expenses for Covered Health Services through the end of the calendar year.

The Out-of-Pocket Maximum applies to all Covered Health Services under the Plan, including Covered Health Services provided in Section 15, Outpatient Prescription Drugs.

The following table identifies what does and does not apply toward your Out-of-Pocket Maximums:

Plan Features Applies to the Out-of-Pocket Maximum?

Payments toward the Annual Deductible Yes

Coinsurance Payments Yes

Charges for non-Covered Health Services No

14 SECTION 3 - HOW THE PLAN WORKS

Plan Features Applies to the Out-of-Pocket Maximum?

Charges that exceed Eligible Expenses, or the Recognized Amount when applicable.

No

15 SECTION 4 - PERSONAL HEALTH SUPPORT AND PRIOR AUTHORIZATION

SECTION 4 - PERSONAL HEALTH SUPPORT AND PRIOR AUTHORIZATION

What this section includes:

■ An overview of the Personal Health Support program.

■ Covered Health Services which Require Prior Authorization.

Care Management

When you seek prior authorization as required, the Claims Administrator will work with you to implement the care management process and to provide you with information about additional services that are available to you, such as disease management programs, health education, and patient advocacy.

UnitedHealthcare provides a program called Personal Health Support designed to encourage personalized, efficient care for you and your covered Dependents.

Personal Health Support Nurses center their efforts on prevention, education, and closing any gaps in your care. The goal of the program is to ensure you receive the most appropriate and cost-effective services available.

If you are living with a chronic condition or dealing with complex health care needs, UnitedHealthcare may assign to you a primary nurse, referred to as a Personal Health Support Nurse to guide you through your treatment. This assigned nurse will answer questions, explain options, identify your needs, and may refer you to specialized care programs. The Personal Health Support Nurse will provide you with their telephone number so you can call them with questions about your conditions, or your overall health and well-being.

Personal Health Support Nurses will provide a variety of different services to help you and your covered family members receive appropriate medical care. Program components are subject to change without notice. As of the publication of this SPD, the Personal Health Support program includes:

■ Admission counseling - Personal Health Support Nurses are available to help you prepare for a successful surgical admission and recovery. Call the number on your ID card for support.

■ Inpatient care management - If you are hospitalized, a Personal Health Support Nurse will work with your Physician to make sure you are getting the care you need and that your Physician's treatment plan is being carried out effectively.

■ Readmission Management - This program serves as a bridge between the Hospital and your home if you are at high risk of being readmitted. After leaving the Hospital, if you have a certain chronic or complex condition, you may receive a phone call from a Personal Health Support Nurse to confirm that medications, needed equipment, or follow-up services are in place. The nurse will also share important health care information, reiterate and reinforce discharge instructions, and support a safe transition home.

16 SECTION 4 - PERSONAL HEALTH SUPPORT AND PRIOR AUTHORIZATION

■ Risk Management - Designed for participants with certain chronic or complex conditions, this program addresses such health care needs as access to medical specialists, medication information, and coordination of equipment and supplies.

Participants may receive a phone call from a Personal Health Support Nurse to discuss and share important health care information related to the participant's specific chronic or complex condition.

■ Cancer Management - You have the opportunity to engage with a nurse that specializes in cancer, education and guidance throughout your care path.

■ Kidney Management - You have the opportunity to engage with a nurse that specializes in kidney disease, education and guidance with CKD stage 4/5 or ESRD throughout your care path.

If you do not receive a call from a Personal Health Support Nurse but feel you could benefit from any of these programs, please call the number on your ID card.

Prior Authorization

UnitedHealthcare requires prior authorization for certain Covered Health Services. Physicians and other health care professionals who participate in a Network are responsible for obtaining prior authorization

It is recommended that you confirm with the Claims Administrator that all Covered Health Services listed below have been prior authorized as required. Before receiving these services from a Network provider, you may want to contact the Claims Administrator to verify that the Hospital, Physician and other providers are Network providers and that they have obtained the required prior authorization. Network facilities and Network providers cannot bill you for services they fail to prior authorize as required. You can contact the Claims Administrator by calling the number on your ID card.

To obtain prior authorization, call the number on your ID card. This call starts the utilization review process. Once you have obtained the authorization, please review it carefully so that you understand what services have been authorized and what providers are authorized to deliver the services that are subject to the authorization.

The utilization review process is a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or settings. Such techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, retrospective review or similar programs.

Contacting UnitedHealthcare or Personal Health Support is easy.

Simply call the number on your ID card.

Services for which you are required to obtain prior authorization are identified in Section 6, Additional Coverage Details within each Covered Health Service Benefit description. Please note that prior authorization timelines apply. Refer to the applicable Benefit description to determine how far in advance you must obtain prior authorization and any applicable reductions in Benefits.

17 SECTION 4 - PERSONAL HEALTH SUPPORT AND PRIOR AUTHORIZATION

Please note that prior authorization is required even if you have a referral from your Primary Physician to seek care from another Network Physician.

Special Note Regarding Medicare

If you are enrolled in Medicare on a primary basis (Medicare pays before the Plan pays Benefits) the prior authorization requirements do not apply to you. Since Medicare is the primary payer, the Plan will pay as secondary payer as described in Section 10, Coordination of Benefits (COB). You are not required to obtain authorization before receiving Covered Health Services.

18 SECTION 5 -PLAN HIGHLIGHTS

SECTION 5 - PLAN HIGHLIGHTS

What this section includes:

■ Payment Terms and Features.

■ Schedule of Benefits.

Payment Terms and Features

The table below provides an overview of the Plan's Annual Deductible and Out-of-Pocket Maximum.

Plan Features Network Amounts

Annual Deductible

■ Individual. $4,000

■ Family (not to exceed the applicable Individual amount per Covered Person)

$6,000

Coupons: The Plan Sponsor may not permit certain coupons or offers from pharmaceutical manufacturers or an affiliate to apply to your Annual Deductible.

Annual Out-of-Pocket Maximum

■ Individual. $6,000

■ Family (not to exceed the applicable Individual amount per Covered Person)

$12,000

The Annual Deductible applies toward the Out-of-Pocket Maximum for all Covered Health Services.

Coupons: The Plan Sponsor may not permit certain coupons or offers from pharmaceutical manufacturers or an affiliate to apply to your Annual Out-of- Pocket Maximum.

Lifetime Maximum Benefit

There is no dollar limit to the amount the Plan will pay for essential Benefits during the entire period you are enrolled in this Plan.

Unlimited

19 SECTION 5 -PLAN HIGHLIGHTS

Plan Features Network Amounts

Generally the following are considered to be essential benefits under the Patient Protection and Affordable Care Act:

Ambulatory patient services; emergency services, hospitalization; maternity and newborn care, mental health and substance-Related and Addictive Disorders services (including behavioral health treatment); prescription drug products;

rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

20 SECTION 5 -PLAN HIGHLIGHTS

Schedule of Benefits

This table provides an overview of the Plan's coverage levels. For detailed descriptions of your Benefits, refer to Section 6, Additional Coverage Details.

Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Eligible Expenses or, for specific Covered Health Services as described in the definition of Recognized Amount in Section 14, Glossary.

Covered Health Services

Benefit

(The Amount Payable by the Plan based on Eligible Expenses)

Network

Ambulance Services

Ground Ambulance

■ Emergency Ambulance. 80% after you meet the Annual Deductible

Air Ambulance

80% after you meet the Annual Deductible

Eligible Expenses for ground and Air Ambulance transport provided by a non- Network provider will be determined as described in Section 3, How the Plan Works.

■ Non-Emergency Ambulance. Ground Ambulance

Air Ambulance

80% after you meet the Annual Deductible

Ground or Air Ambulance, as the Claims Administrator determines appropriate.

Eligible Expenses for ground and Air Ambulance transport provided by a non- Network provider will be determined as described in Section 3, How the Plan Works.

Cellular and Gene Therapy

Services must be received at a Designated Provider.

Depending upon where the Covered Health Service is provided, Benefits will be the

21 SECTION 5 -PLAN HIGHLIGHTS

Covered Health Services

Benefit

(The Amount Payable by the Plan based on Eligible Expenses)

Network same as those stated under each Covered Health Service category in this section

Clinical Trials

Benefits are available when the Covered Health Services are provided by either Network or non-Network providers.

Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this section.

Congenital Heart Disease (CHD) Surgeries

80% after you meet the Annual Deductible

Dental Services - Accident Only

See Section 6, Additional Coverage Details, for limits.

80% after you meet the Annual Deductible

Diabetes Services

Diabetes Self-Management and Training/ Diabetic Eye Examinations/Foot Care

Depending upon where the Covered Health Service is provided, Benefits for diabetes self-management and training/diabetic eye examinations/foot care will be paid the same as those stated under each Covered Health Service category in this section.

Diabetes Self-Management Items Depending upon where the Covered Health Service is provided, Benefits for diabetes self-management items will be the same as those stated under Durable Medical Equipment in this section.

See Durable Medical Equipment in Section 6, Additional Coverage Details, for limits.

Durable Medical Equipment (DME)

See Section 6, Additional Coverage Details, for limits.

22 SECTION 5 -PLAN HIGHLIGHTS

Covered Health Services

Benefit

(The Amount Payable by the Plan based on Eligible Expenses)

Network

Emergency Health Services - Outpatient

Emergency services received at a non- Network Hospital are covered at the Network level.

80% after you meet…