Employee Benefits Guide - Mitsubishi Hitachi Power Systems · 2019-01-28 · MHPSA Employee Benefits 3 What’s New For 2019 In 2019, we’re introducing new benefits and resources

2019 Employee Benefits Guide

2 MHPSA Employee Benefits

TABLE OF CONTENTS

WHAT’S NEW FOR 2019 ............................................................................................................................................................................................................................3

ENROLLMENT AND LIFE EVENTS .........................................................................................................................................................................................................4

DEPENDENTS AND BENEFICIARIES ....................................................................................................................................................................................................5

MEDICAL BENEFITS ......................................................................................................................................................................................................................................6

PRESCRIPTION DRUG BENEFITS ...........................................................................................................................................................................................................9

2019 MEDICAL AND PRESCRIPTION DRUG BENEFITS AT A GLANCE .........................................................................................................................10

WELLNESS ......................................................................................................................................................................................................................................................12

DENTAL BENEFITS ......................................................................................................................................................................................................................................13

VISION BENEFITS .........................................................................................................................................................................................................................................15

FLEXIBLE SPENDING ACCOUNTS (FSAs) ......................................................................................................................................................................................16

LIFE INSURANCE .........................................................................................................................................................................................................................................17

SHORT/LONG TERM DISABILITY ........................................................................................................................................................................................................19

VALUABLE ADDITIONAL BENEFITS ..................................................................................................................................................................................................20

FAMILY MEDICAL LEAVE ACT .............................................................................................................................................................................................................22

COBRA CONTINUATION .........................................................................................................................................................................................................................23

RETIREMENT ..................................................................................................................................................................................................................................................24

HIPAA NOTICE ..............................................................................................................................................................................................................................................25

ADDITIONAL NOTICES ..........................................................................................................................................................................................................................29

FREQUENTLY ASKED QUESTIONS ....................................................................................................................................................................................................32

DEFINITIONS .................................................................................................................................................................................................................................................35

BENEFITS SUMMARY ..............................................................................................................................................................................................................................37

HR/PAYROLL AND BENEFITS INFORMATION/LINKS ..........................................................................................................................................................38

CONTACT INFORMATION/LINKS .......................................................................................................................................................................................................39

This booklet describes the principal features of the benefit plans sponsored by MHPSA and all third-party carriers. If there are variations between the information in this booklet and the provisions of the policies and plan document, the policies and plan document will prevail.

This booklet contains important information and should be kept in a safe place known to you and your family.

MHPSA Employee Benefits 3

What’s New For 2019In 2019, we’re introducing new benefits and resources and making a few changes to your current benefits.

Introducing the HSA PlanDuring 2019 Open Enrollment, you will have the option to choose a new medical plan: the HSA Plan. The HSA Plan provides similar coverage to the PPO and offers you the triple-tax advantage of a Health Savings Account (HSA), as well as employer funding to your account. In addition, you’ll pay less per paycheck for the HSA Plan. Furthermore, if you are enrolled in the Employee coverage tier, you will automatically receive Accident Insurance to protect you from high medical expenses should you experience an accident such as a fracture, burn, or concussion. Learn more about how you can better manage your healthcare spending by enrolling in the HSA Plan on page 7.

Flexible Spending Accounts (FSAs)We’re introducing the Limited Purpose FSA for employees who enroll in the HSA Plan. You may use the Limited Purpose FSA for dental and vision expenses only. The 2019 IRS maximum contribution limit is $2,650.

For 2019, the Health Care FSA maximum contribution amount limit is $2,650 as well. You may contribute to a Health Care FSA if you enroll in the EPO or PPO medical plan.

Meet Vitality, Your New Wellness AdministratorAt Mitsubishi, we’re committed to helping you reach your wellness goals. That’s why we offer you unique wellness programs in which you can earn financial rewards for taking steps to improve your health!

In 2019, your wellness program will be better than ever before, with Vitality as your wellness vendor. Through Vitality, you can gain insight into your health status, set goals, access health resources, and earn rewards, including gift cards and an Apple Watch! See page 12 to learn more.

An Enhanced Employee Benefits Service Center and SoftwareThe Employee Benefits website, administered by Empyrean, has a new look and new features!

Use the enhanced website to:

• Select your 2019 benefits

• View your benefits and coverage details

• Compare your plan options

• Designate or update your beneficiaries

• Make mid-year changes when you experience a qualified change in employment or family status

• Web chat with call center representatives who can assist you with your benefits inquiries in real time

• And much more!

Visit www.MSSAbenefits.US. For questions about the Benefits Service Center, call 1.833.251.9456.


Web EnrollmentYou will have the opportunity to enroll in your benefits through an online enrollment system. Visit www.MSSAbenefits.US to select your benefits for 2019. Log on using your employee ID. If you need to reset your password, email [email protected].

New HireTo enroll as a new hire, you will need your employee profile set up in the Employee Self-Service Portal. Your earliest access will depend on the timing of your hire and submittal of required documentation.

Once your employee profile is established, an email will be sent to you. Then you must sign in and complete your online enrollment no earlier than your date of hire and no later than 30 days after your date of hire.

Annual EnrollmentAnnual Enrollment is your once-a-year opportunity to select or update the employee health benefits that matter to you and your family. The employee benefits available to you are determined by various factors such as your employee status, full/part time status, benefit code, life event(s), and effective date(s). Based on these factors, certain benefits and/or election options may or may not be available to you.

In certain cases, you may also have a special enrollment opportunity, outside of Annual Enrollment, because of a qualifying life event. Please see the Life Events Enrollment section for examples of qualifying life events and how to change your benefits when one occurs.

Life Event(s) EnrollmentLife events are events that may affect your health benefit needs and include any of the following:• Marriage• Childbirth/adoption• Death of a spouse• Job loss• Retirement• Divorce• Loss/gain of eligibility for coverage under another

plan (including but not limited to Medicare/Medicaid eligibility)

• Court orders

When a life event occurs, it is your responsibility to report the event within 30 days AND add/remove coverage for your dependents on www.MSSAbenefits.US. Reporting the event does NOT automatically add or remove coverage for your dependent. Once recorded, each event will create an enrollment opportunity when you will have 24 hours to make any necessary changes to your benefits. Any changes MUST be confirmed or they will not be processed. You are encouraged to print a confirmation of your changes to verify that you have changed the intended benefits. Required life event and/or proof of relationship documentation will be required. Documentation can be uploaded through the online enrollment system at www.MSSAbenefits.US.

Enrollment and Life Events

When do my benefits become effective?Your medical, dental, and vision benefits become effective the first day of the month following your date of hire.

DAYS

You have 30 days from the qualifying life event to report the event on the Employee Self-Service Portal. Qualifying life events will require documentation.


Dependents and Beneficiaries Dependent Verification You must provide documentation for qualifying life events and proof of relationship for dependents.

DependentsWithin the Benefits section of the Employee Self-Service Portal, you will be able to update your dependents by adding, removing, or correcting any of the following information:

• Names

• Addresses

• Dates of birth

• Gender

• Relationship (to you)

• Full-time student status

• Disabled status

• Medicare disabled status

You are responsible for making sure your covered dependents are eligible. MHPSA benefits may cover your spouse, and your children until the end of the month in which their 26th birthday occurs. If at any time your covered dependents’ status has changed, you are responsible for notifying Human Resources and most importantly, reporting any coverage changes on the Employee Self-Service Portal within 30 days of the event. If you do not report coverage changes on the Employee Self-Service Portal, you risk:

• Not being able to make election changes (adding/removing dependents)

• Being back-charged for claims or not having claims covered by the provider

• Being back-charged for deductions from the employer

• Being locked into your elections until the next Annual Enrollment period or qualifying life event

If you change the relationship status of your dependent, please keep in mind that this may or may not create a qualifying life event and/or opportunity to enroll. Please notify your local Human Resources Department of any relationship status changes.

The Benefits Department may require additional documentation (e.g., proof of relationship, Social Security numbers, Evidence of Insurability). If additional documentation is required, the Benefits Department reserves the right to reverse/not approve elections until the requisite documentation is received.

BeneficiariesWithin the Benefits section of the Employee Self-Service Portal, you will be able to manage/designate your beneficiaries. This is where you can add, remove, and update/correct your beneficiary information for your:

• Basic Life/AD&D

• Optional Life/AD&D

• Business Travel Accident insurance coverages

• 401(k) plan (www.401k.com)

You have the option to select one of three types of beneficiaries: person, organization, or other (e.g., trust). You will be required to provide information about your beneficiary based on the type you select.

You can have different beneficiaries for different coverages. It is highly recommended that you add a contingent or secondary beneficiary.

If you would like to manage/designate beneficiaries for your 401(k) or deferred compensation plan, you must do so on the Fidelity website at www.401k.com.

You must upload documentation to www.MSSAbenefits.US by the effective date.


Medical Benefits

Medical plan participants have access to UnitedHealthcare Choice-Plus network. When you visit www.umr.com, look for “Choice-Plus” to ensure you find a provider in your network. Remember: If you’re enrolled in the EPO plan, you’ll only be covered if you choose an in-network provider.

MHPSA medical plans are designed to cover a portion of the expenses you incur for the vast majority of medical services. Medical elections will become effective on the first day of the month after your date of hire. You will be able to choose from three plans: HSA Plan, EPO, and PPO. You should evaluate your health care needs and those of your family members when selecting your medical plan option. You and MHPSA share the cost of medical coverage. MHPSA pays the greater portion of the cost, and your contribution, which is deducted from your pay, depends on the medical option and coverage level you choose. Your 2019 medical plan contributions are shown in the table on page 11.

HSA Plan – A High Deductible Health PlanThe HSA Plan is a high deductible health plan that is paired with a Health Savings Account (HSA). With the HSA Plan, you pay less per-paycheck and more out of pocket if and when you need care. It provides the flexibility to not only see in- and out-of-network providers, but also to save your HSA balance for future expenses.

EPO – Exclusive Provider OrganizationThis plan does not require that you obtain all medical care or treatment through a primary doctor. You choose your doctor from a network of UMR participating physicians. Since you use the national network, a referral isn’t required. This plan has a 90% in-network coinsurance level. If you obtain medical care outside of this network, there is no coverage.

PPO – Preferred Provider OrganizationThis plan is similar to a standard preferred provider option (PPO) plan with a lower deductible requirement, lower out-of-pocket costs, and a 90% in-network coinsurance. It does not require that you obtain care or treatment through a primary doctor. Physicians are also chosen from a network of UMR participating physicians. When you use the national network, a referral isn’t required. If you obtain medical care outside of this network, there is still coverage through UMR but at a lesser percentage — typically 60%, depending on the care provided.


Get to Know the HSA PlanThe HSA Plan provides the same comprehensive medical coverage as the OAP. But it has two key advantages: Your per-paycheck contributions are less, and it comes with a Health Savings Account (HSA) that you can use to pay for healthcare expenses today and tomorrow—tax-free!

You Pay You and Plan Pay (Shared Medical Expenses)

Plan Pays (100% Coverage for You)

Plan Deductible

You pay out-of-pocket for expenses until you reach the annual deductible or use up your HSA funds.

Coinsurance

After you reach your annual deductible, you and UMR share the cost of your medical expenses through coinsurance.

Out-of-Pocket Maximum

When you reach your out-of-pocket maximum, UMR pays 100% of additional covered medical expenses.

Health Savings Account (HSA)

MHPSA will and you can contribute to your HSA. Unused HSA dollars can be saved for future eligible expenses, such as during retirement.

Preventive Care In-network preventive care is covered at 100%


Considering the HSA Plan but have a Health Care FSA? If you currently have a Health Care FSA but plan to enroll in the HSA Plan, you must use all of your FSA funds by December 31, 2018. If you have a balance in your FSA as of January 1, 2019, you will not be able to open and use your HSA until April 1, 2019. Keep in mind that you can use your FSA dollars for items such as prescription glasses, so be sure to stock up on your medical, dental, and vision necessities by the end of December!

Important HSA Eligibility RulesTo open and contribute to an HSA, you must be enrolled in the HSA Plan. In addition:

• You can’t have other health coverage that pays for out-of-pocket health care expenses before you meet your plan deductible (another high deductible health plan is allowed).

• You or your spouse can’t have a general purpose Health Care FSA or Health Reimbursement Account (HRA) in the same year you open an HSA.

• If you’re enrolled in Medicare, you are not eligible to contribute to the HSA and the company cannot either.

• You can’t be enrolled in TRICARE or have received Veterans Administration (VA) health benefits in the previous three months.

• You can’t be claimed as a dependent by someone else.

A Closer Look at the HSAWhen you enroll in the HSA Plan, you gain access to an HSA. Learn more about this unique savings account below.

Key HSA AdvantagesThere are three key advantages of an HSA:

Triple-Tax Advantage No “Use It or Lose It” Rule The Account is Yours Forever

Money goes into your account tax free, grows tax free, and can be withdrawn tax-free as long as you use the funds for eligible health care expenses.

Unlike the FSA, the HSA is designed as a savings account, allowing you to spend and/or save dollars as you see fit.

Unused money in your account will roll over to the next year. Your account balance will earn interest tax-free. Once your account balance reaches $1,000, you can invest it.

Your HSA is always yours even if you retire from or leave the company. That means you can take your HSA dollars all the way through retirement and pay for health care with them then.

Did You Know? Investing your HSA dollars is a great way to grow your savings for future health care expenses. Once your HSA balance reaches $1,000, you can invest your account in investment options available through HSA Bank.

Contributions to Your HSAFor 2019, you may contribute the following amounts depending upon which coverage level you elect. Keep in mind that the company contributes to your account, too.

Coverage Level You Elect IRS Maximum Contribution

Company Contribution

Your Maximum Contribution

Employee Only $3,500 $1,000 $2,500

Employee & Spouse/Child(ren) $7,000 $1,500 $5,500

Family $7,000 $2,000 $5,000

If you are age 55 or older in 2019, you may contribute a “catch-up” contribution of up to $1,000, as well.


Prescription Drug Benefits

Certain retailers, such as Target, Walmart, and grocery stores offer $4, $10, and free antibiotics. Please consult your local pharmacy for more information.

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All MHPSA medical plans include prescription drug benefits. These benefits include prescribed medications and related supplies provided either by a retail pharmacy (30-day supply) or by mail order (90-day supply). There are three levels of coverage, each with different copays:

Generic drugs (different inactive ingredient)

Brand name drugs (preferred and with no generic equivalent)

Any brand name drugs (non-preferred and with a generic equivalent)

These levels can be seen in the coverage table on page 10 and are listed in the prescription drug section on www.umr.com. UMR also offers a home delivery pharmacy program to help you to control the cost of prescriptions.


2019 Medical and Prescription Drug Benefits at a Glance

HSA Plan EPO PPO

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

Annual Deductible

Individual $2,000 $4,000 $350 $150 $500

Family $4,000 $8,000 $700 $300 $1,000

Coinsurance 80% 60% 90% 90% 60%

Out-of-Pocket

Individual $4,000 $12,500 $1,750 $1,500 $3,000

Family $8,000 $25,000 $3,500 $3,000 $6,000

Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited

Office Visit (Non-Preventive Care)

Primary 80% after deductible

60% after deductible

$35 copay $30 copay 70% after deductible

Specialist 80% after deductible


$40 copay $30 copay 70% after deductible

Emergency Room 80%, not subject to deductible$100 copay,

waived if admitted

$100 copay, then at 90% not subject to deductible

Hospitalization 80% after deductible


90% after $150 copay

& deductible

90% after $150 copay &

deductible

60% after $150 copay &

deductible

Rx Copay Retail (30-day Supply)

Generic 80% after deductible

Not covered

$15 copay $15 copay

60% not subject to deductible

Brand 80% after deductible

$45 copay $45 copay

Any Brand 80% after deductible

$60 copay $60 copay

Rx Copay Mail Order (Up to 90-day Supply)

Generic 80% after deductible of the cost of a

60-day supply (to receive a

90-day supply)

Not covered

$30 copay $30 copay

Not coveredBrand $90 copay $90 copay

Any Brand $120 copay $120 copay

Note: Out-of-network costs are based on reasonable and customary rates. Employees may be responsible to cover costs that exceed what is considered reasonable and customary as determined by UMR.

This is a high-level summary of the benefit plans. Detailed specifics may be obtained from the individual SPDs. If discrepancies exist, the SPD will be the ruling document.


2019 Medical Rates

Coverage Levels

HSA Plan EPO PPO

Employee Biweekly Contribution



Employee $46.00 $65.68 $118.27

Employee & Spouse $73.11 $95.63 $223.22

Employee & Child(ren) $62.76 $85.64 $178.26

Family $85.90 $105.57 $262.28

Compare Your PlansReview the table below to understand the similarities and differences among the HSA Plan, EPO, and PPO. Copayments, deductibles, and benefit percentages for covered expenses vary by each plan.

HSA Plan EPO PPO

Deductible High Middle Low

Paycheck Contributions Low Middle High

In-Network Preventive Care Covered at 100% Covered at 100% Covered at 100%

Coverage In-network and out-of-network

In-network onlyIn-network and out-of-network

Spousal Surcharge (for Medical Only)The spousal surcharge is designed to encourage your spouse to elect coverage under his/her employer’s plan. If you elect to cover your spouse who has employer medical coverage available to him or her, a bi-weekly $57.69 ($125 monthly) spousal surcharge will be applied. This means even if your spouse has elected not to enroll in coverage with his/her employer, you must elect the “Working Spouse Coverage Available” option.

You are responsible for making sure your covered dependents are eligible. MHPSA benefits may cover your spouse and your children until the end of the month in which their 26th birthday occurs. If at any time the status of your dependent(s) has changed, you are responsible for notifying Human Resources and, most importantly, reporting any coverage changes on the Employee Self-Service Portal within 30 days of the event. If you do not report coverage changes on the portal, you risk:

• Not being able to make election changes (adding/removing dependents)

• Being back-charged for claims or not having claims covered by the provider

• Being back-charged for deductions by the employer

• Being locked into your elections until the next Annual Enrollment period or qualifying life event


WellnessWith Vitality, our new wellness administrator, you can live well and get rewarded! Vitality helps you gain insight into your health status, set goals, access health resources, and more.

• Vitality Points and Rewards: When you complete health activities, you’ll earn points that can be used to redeem rewards at the Vitality Mall. Using your points, you can purchase rewards such as gift cards from leading retailers and popular fitness devices.

• Vitality Check: Learn more about your health by getting a confidential blood screening and biometric assessment, at no additional cost to you.

• Vitality Goals: Create personal wellness goals, establish a timeline for achieving them, and then earn points when you make progress!

• Vitality Active Rewards with Apple Watch: Order Apple Watch Series 1 or Apple Watch Series 3 through Vitality and pay based on your level of physical activity. The more points you earn each month through your workouts, the less you pay!

Visit www.powerofvitality.com or call1.877.224.7117 to learn more.


2019 Dental Benefits at a Glance Review the chart below to learn more about the differences between the DPPO and DHMO plans.

DPPO DHMO

In-Network Out-of-Network In-Network Benefits Only

Annual Deductible (Deductible Applies to Basic and Major Services Only)

Individual $50 $50 $50

Family $100 $100 $100

Type A – Preventive 100% 100%* 100%

Type B – Basic 80% 80%* 65%

Type C – Major 50% 50%* 50%

Calendar Year Maximum (In- and Out-of-Network Benefit Combined)

$2,000 $2,000 $1,500

Orthodontia 50% 50%* 50%

Lifetime Orthodontic Maximum $1,500 (In- and Out-of-Network Benefit Combined) $1,500

*Out-of-network costs are based on reasonable and customary rates. Employees may be responsible to cover costs that exceed what is considered reasonable and customary as determined by UMR.

Dental BenefitsMHPSA dental benefits provide two options — the Dental PPO (DPPO) and the Dental DHMO — for you and your family. These plans are designed to cover a portion of your dental expenses after you meet an annual deductible, if applicable. Both provide coverage for four classes of services: Preventive (Class I), such as X-rays or cleanings; Basic Restorative (Class II), such as fillings; Major Restorative (Class III), such as crowns or casts; and Orthodontia (Class IV), such as braces. Dental elections will become effective on the first of the month after your date of hire.

2019 Dental RatesCoverage Levels DPPO DHMO

Employee $5.74 $1.26

Employee & Spouse $14.27 $3.14

Employee & Child(ren) $11.43 $2.51

Employee & Family $17.12 $3.77


DPPO – Dental Preferred Provider OptionThe Dental Preferred Provider Option (DPPO) plan provides a variety of benefits under which you and your family have the freedom to use any dentist or specialist anywhere. If you choose to use an in-network dentist, you will pay your deductible, when applicable, and the coinsurance that corresponds to your procedure. If you choose an out-of-network provider, in addition to your deductible and applicable coinsurance, you may be billed by the dentist for costs over the reasonable and customary amount as determined by UMR.

If you choose to use an out-of-network provider, the cost of your claims will generally be higher because UMR has not negotiated discounts on your behalf with that provider. You may be required, as the plan participant, to file claims for out-of-network services manually using a paper claim form. This will be determined based on the provider’s claim processing procedures. You can find claims forms online at www.myuhc.com or in the Document Library in the Benefit portion of the Employee Self-Service Portal.

DHMO – Dental Maintenance CareThe Dental Maintenance Care (DHMO) plan provides a wide variety of benefits through participating in-network providers. Throughout the plan year you may change your dentist; however, all services must be performed by an in-network provider.

The DHMO is available in all areas, and employees are responsible for working with in-network providers as there is no out-of-network coverage.


EyeMed The EyeMed plan offers comprehensive vision coverage with minimal premiums for employees. With this plan, you have the option of using both in-network and out-of-network providers. You can only obtain eyeglasses or contact lenses within a 12-month period; you cannot obtain both.

2019 Vision Benefits at a GlancePlease see the chart below for a more in-depth description of coverage with EyeMed. Employees are encouraged to register online at www.eyemedvisioncare.com and create their accounts to view claims and obtain ID cards.

EyeMed Vision Care

Services In-Network Out-of-Network

Exam w/ Dilation (Every 12 Months) $10 copay Up to $39

Contact Lens Fit & Follow-Up (Every 12 Months)

Standard Contact Fit Up to $55 N/A

Premium Contact Fit 10% off retail N/A

Frames (Every 12 Months) $0 copay; $150 allowance, plus 80% of balance over $150

Up to $75

Contact Options

Conventional$0 copay; $150 allowance,

plus 85% of balance over $150Up to $120

Disposable$0 copay; $150 allowance,

plus balance over $150Up to $120

Medically Necessary $0 copay; paid in full Up to $210

Laser Vision Correction (Lasik or PRK from US Laser Network)

15% off retail price or 5% off promotional price

N/A

2019 Vision Rates

Biweekly Employee ContributionEmployee - $2.79 Employee & Spouse - $5.58

Employee & Child(ren) - $5.96 Employee & Family - $9.12

Vision Benefits


FSAs can help you pay for eligible expenses with pre-tax dollars. We offer two types of FSAs: Health Care and Dependent Care.

Flexible Spending Accounts (FSAs)

Health Care FSAThis benefit can be used for any of your taxable dependents even if they are not covered by MHPSA. This account is for eligible health care expenses not covered by your insurance. You can be reimbursed throughout the plan year or claim period as you incur these expenses.

Examples of eligible Health Care FSA expenses include items such as copays and deductibles for medical and dental care, prescription drugs, and eyeglasses/contact lenses for you and your eligible dependents and/or adult children.

Eligible medical expenses must not be reimbursed by any other source, and you cannot seek reimbursement for expenses from any other source.

You are strongly encouraged to consult your personal tax advisor or the IRS for further guidance as to what is or is not an eligible FSA expense if you have any doubts.

The maximum you can contribute to your Health Care FSA in 2019 is $2,650. Note: This limit is subject to change.

Limited Purpose FSAIf you enroll in the HSA Plan with the HSA, you also have the option to set aside pre-tax money in a Limited Purpose FSA. This account is for eligible dental and vision expenses only not covered by your insurance. You can be reimbursed throughout the plan year or claim period as you incur these expenses.

Examples of eligible dental and vision expenses include dental cleanings and fillings, orthodontia, eye exams, prescription eyeglasses and sunglasses, prescription contact lenses, laser surgery for you and your eligible dependents and/or adult children.

The maximum you can contribute to your Limited Purpose FSA in 2019 is $2,650. Note: This limit is subject to change.

Dependent Care FSAThis account is for eligible work-related dependent day care expenses you (and your spouse, if applicable) may incur. You can be reimbursed throughout the plan year or claim period as you incur these expenses. Please note that funds in the Dependent Care FSA cannot be used to pay for your dependents’ health care expenses. In addition, funds are only available once they have been deposited into your account. You may not use funds ahead of time.

An eligible work-related dependent day care expense is an expense incurred to enable you (and your spouse, if applicable) to be gainfully employed or look for work as the custodial parent(s) or custodial provider(s) of an eligible dependent. Expenses for overnight stays or overnight camps are not eligible. Tuition expenses for kindergarten (or above) do not qualify as custodial care. However, summer day camps are considered to be for custodial care even if they provide primarily educational activities.

If you have any doubts, you are strongly encouraged to consult your personal tax advisor for further guidance as to what is or is not an eligible Dependent Care FSA expense.

A qualifying individual is:

• An individual age 12 or under who is a “qualifying child” of the employee as defined in IRS Code Section 152(a)(1). Generally speaking, a “qualifying child” is a child (including a brother, sister, or stepsibling) of the employee or a descendant of such child (e.g., a niece, nephew, or grandchild), who shares the same principal place of residence with you for more than half the year and does not provide more than half of his/her support;

or

• A spouse or other tax dependent (as defined in IRS Code Section 152) who is physically or mentally incapable of caring for himself/herself and who has the same principal place of residence as you for more than half the year.

Note: There are special rules for children of divorced parents. This child is a qualifying individual of the “custodial parent,” as defined in Code Section 152(e).

The maximum you can contribute to your Dependent Care FSA in 2019 depends on your federal tax filing status:

• $2,500 per married couple filing single head of household, or

• $5,000 per married couple filing jointly.

Two FSA Rules Not to Forget1. The FSAs are subject to the “use it or lose it” rule.

For 2019, if you don’t use the funds in your account for eligible services provided by December 31, 2019, you’ll lose them. You’ll have until March 31, 2020, to submit 2019 FSA expenses.

2. Funds in your Dependent Care FSA cannot be used to pay for your dependent’s medical expenses. For more information about eligible expenses, see IRS Publication 503, “Child and Dependent Care Expenses,” on www.irs.gov.


Life InsuranceTo help with the task of planning for your family’s security, MHPSA provides all eligible employees with basic group life insurance and accidental death and dismemberment (AD&D) coverage through Cigna at no cost to you. In the event you die or have an accident resulting in dismemberment while covered, this plan may pay a benefit to your designated beneficiary.

Basic Life Coverage is valued at 2x your annual salary, up to a maximum of $500,000. Please note: The group life insurance over $50,000 is defined as taxable income by the Internal Revenue Service (IRS). This means that the IRS requires MHPSA to tax premiums for company paid term life for amounts exceeding $50,000. You will see these taxes indicated on your paycheck (GTL) and W-2.

Basic AD&D Coverage is valued at 2x your annual salary, up to a maximum of $500,000.

If your employment with MHPSA terminates, you will have the opportunity to purchase an individual life insurance and an AD&D policy from Cigna through the conversion privilege.

Business Travel Accident To help manage the risks involved with business travel, MHPSA provides all eligible employees with Business Travel Accident insurance. Coverage is valued at $100,000.

Optional Life InsuranceMHPSA also offers optional life insurance plans. You may elect additional life insurance coverage up to plan maximums. You may also elect coverage for your spouse and/or children, subject to the plan provisions. Optional life insurance amounts may require approval from the insurance carrier based upon medical evidence of insurability (EOI). EOIs are required for any amount over the guaranteed amount (newly hired employees), or for any requests past the first 30 days of hire (year-round enrollment), unless otherwise specified by the insurance company. Premiums are based on age-rated tables and paid by the employee every pay period through a payroll deduction. These premiums are post-tax benefits.

Evidence of Insurability (EOI)If you elect optional life coverage, and are required to complete an EOI, it is your responsibility to obtain the EOI, fill out the information, and submit it online within 30 days of your election.


Optional Employee LifeCoverage is based on multiples of your base annual salary, with a minimum of 1x and a maximum of 5x, not to exceed $1,000,000. You are able to enroll at any time of the year, but the insurance company will require additional documentation if enrollment is not within the initial 30 days of hire. Additional documentation may also be required if you are electing over the guaranteed issue amount. The guaranteed issue amount is defined as the lesser of 2x your base salary or $150,000. Enrollment in the optional employee life plan is the prerequisite for enrollment in any of the other optional life/AD&D plans.

Optional Employee AD&DMuch like optional employee life, optional employee AD&D is based on multiples of your base annual salary, and the same plan provisions apply. In order to enroll in the optional AD&D plan, you must be enrolled in the optional life plan. If optional AD&D is elected, the amount of coverage must match the coverage of optional life.

Optional Spouse LifeIn order to enroll in the optional spouse coverage, you must be enrolled in the optional life plan. The guaranteed issue amount is $20,000. The amount requested must be in increments of $10,000 and cannot exceed half of your optional life amount or $100,000. If half of your optional life amount is not an increment of $10,000, the optional spouse amount will default to the nearest $10,000 without going over.

Optional Spouse AD&DIn order to enroll in optional spouse AD&D, you must also be enrolled in the other optional plans: optional employee life, optional employee AD&D, and optional spouse life. The amount enrolled in must match the amount of optional spouse life.

Optional Child LifeEnrollment for optional child life is also based on your enrollment in the optional employee life plan. The amounts are in $1,000 increments with a maximum of $4,000. Per-child elections are not available.

Please see the age-rated tables below for determining contribution amounts:

Optional Life Insurance Step Rates Per $1,000

Age Employee Spouse Child

<20 $0.05 $0.05 $0.20

20–24 $0.05 $0.05 N/A

25–29 $0.06 $0.06 N/A

30–34 $0.08 $0.08 N/A

35–39 $0.12 $0.12 N/A

40–44 $0.18 $0.18 N/A

45–49 $0.29 $0.29 N/A

50–54 $0.48 $0.48 N/A

55–59 $0.80 $0.80 N/A

60–64 $0.99 $0.99 N/A

65–69 $1.71 $1.71 N/A

70–74 $2.78 N/A N/A

75+ $2.78 N/A N/A

Optional AD&D Insurance Rate Per $1,000

Employee $0.023

Spouse $0.025

Child $0.028

Please note the life insurance benefits for an employee have an age-based reduction starting at age 65 or older. The age reduction coverage is as follows:

Optional Employee Life/AD&D Age-Based Reduction

Age Payable Benefit

70+ 50% of Life Insurance Benefits


The Short Term Disability (STD) insurance plan provides a stable income source to carry you and your family through a temporary disability. In the event of a non-work related accident or any non-work related debilitating event, a portion of your salary will be continued for a period of time. This benefit is provided at no cost to all eligible employees. There is a seven-day waiting period from the date of the disability for STD benefits to begin. The Cigna Claims Department will determine eligibility, and your earnings will determine the maximum you are allowed for coverage.

STD will provide you the lesser of 70% of your weekly salary or $3,000 per week for up to 26 weeks.

If the disability lasts longer than 26 weeks, you may be eligible for Long Term Disability (LTD), which provides you 60% of your monthly salary not to exceed $11,000 per month, for a period of time. This benefit will be based on your age at onset of disability as defined in the Certificate of Insurance that will be provided to you.

A board-certified physician and Cigna’s Claims Department must approve the disability for benefits to be paid. You must also apply for any state or government related benefits for which you qualify because these may affect your disability benefit. FMLA and medical leave provisions will also apply.

Please see the chart below for sample benefit payments.

Annual Salary

STD

Weekly Salary

Potential Weekly Benefit Max. Benefit

$30,000.00 $403.85 $403.85

$60,000.00 $807.69 $807.69

$74,285.00 $1,000.00 $1,000.00

$120,000 .00 $1,615.38 $1,615.38

$150,000 .00 $2,019.23 $2,019.23

$200,000.00 $2,692.31 $2,692.31

$250,000.00 $3,365.38 $3,000.00

Annual Salary

LTD

Monthly Salary

Potential Monthly Benefit

Max. Benefit

$30,000.00 $1,500.00 $1,500.00

$60,000.00 $3,000.00 $3,000.00

$120,000.00 $6,000.00 $6,000.00

$150,000.00 $7,500.00 $7,500.00

$200,000.00 $10,000.00 $10,000.00

$250,000.00 $12,500.00 $11,000.00

Short/Long Term Disability


Valuable Additional BenefitsRethinkRethink provides a focus on behavioral therapy resources for children and individuals with developmental disabilities, such as:

• Autism spectrum disorders

• Developmental delays

• Intellectual disabilities

• Learning disabilities

• Speech/language problems

• ADD/ADHD

• Down syndrome

• Problem behaviors

The Rethink program provides employees and their families with clinical best practice training tools and an integrated support system. It also provides access to online tools, personalized plans, video-based training, and coordinated care, and allows employees to track individual progress and find resources for support. Contact [email protected] for additional information.

Health AdvocateHealth Advocate is designed to help employees handle health care and insurance related issues by cutting through the red tape and barriers that often create frustration and problems. With Health Advocate, you will have your own Personal Health Advocate, a registered nurse, supported by a team of medical doctors and administrative experts. Below is a sample of the many services you will now have readily available to you.

Help with insurance claims and billing issues

• Coordination of care

• Help finding the best doctors and hospitals and getting to see them

• Help obtaining services for your elderly parents

• Rx Advocate

• Help when faced with serious illness or injury

• Health Cost Estimator

• Help with Medicare/Medicaid

• Multilingual translators available

Health Advocate can also cover your spouse, your children,your parents, and the parents of your spouse. To find outmore about Health Advocate, call 1.866.695.8622, or visittheir website at www.healthadvocate.com.

Employee Assistance Program (EAP)Living a productive and fulfilling life requires a healthy mind and a healthy body. The Employee Assistance Program by Magellan, a confidential, third-party administrator, is available for you and your dependents should you need assistance with managing the daily stresses of work, home, and family.

Magellan can assist with health and wellness topics such as stress, alcohol and drug dependencies, adjusting to change, child and elder care, grief, family or parenting issues, marital or relationship issues, self-improvement, pre- and postnatal concerns, work/life balance, and much more. Magellan provides up to three free consultations per issue and help with referrals, if necessary.

This program is available to you at no cost. It offers online screening tools, self-assessments, and personalized improvement plans to help you better understand and cope with your everyday and not-so-everyday concerns.

Magellan also provides legal and financial consultation services.

You can contact Magellan at 1.800.523.5668 or online at www.magellanhealth.com/member.

MBA®: Medical Benefits AbroadCigna’s MBA Program is designed to give you the peace of mind that your health needs will be covered while traveling abroad for business. During your international assignment, you will have access to toll-free, telephonic global service centers (available 24/7/365), and Cigna’s in-house team of international doctors and nurses. Cigna’s multilingual customer service representatives can verify your coverage and benefits to doctors and hospitals worldwide. Anytime you call Cigna’s International Service Center, the following Global Health Solution services are available to you:

• Access to medical advice and consultation from your location via telephone

• Medical appointment and hospital admission assistance (outside the U.S.)

• Medical monitoring (outside the U.S.)

• Case management (inside the U.S.)

• Communication of patient condition and treatment plans to family members

• Coordination of treatment plans, if necessary


Accident Protection PlanThrough the UnitedHealthcare Accident Protection Plan, you can receive a benefit if you have a covered injury and need care. The amount you receive is based on the covered expenses, which may include emergency room services, surgeries, recovery care and more. You can use the benefit to pay for medical and non-medical expenses, such as your mortgage or even groceries.

Tuition ReimbursementMHPSA recognizes the importance of supporting the continual educational growth of our employees. The Tuition Reimbursement Program is designed to assist employees with increasing their knowledge, skills, and abilities as they relate to employees’ individual career paths.

Tuition reimbursement can be used to pay for course(s) toward the completion of a qualified curriculum. If the requested courses do not apply toward the completion of a qualified curriculum, then they may be considered training and development.

The Tuition Reimbursement form is located online in your Document Library under Benefits in the Employee Self-Service Portal.

Adoption AssistanceMHPSA offers the Adoption Assistance Program to assist full-time employees with the cost of adoption through a licensed agency. The program will reimburse 100% of certain costs that may be incurred up to $4,000 per adoption. If you and your spouse are both employed by MHPSA, you will only receive the maximum of $4,000 as assistance. You are eligible for a maximum of two adoptions over the course of your employment with MHPSA.

You may be reimbursed for the following expenses:

• Legal fees and court costs

• Agency or placement fees

• Medical expenses of birth mother and child that are not covered by insurance

• Travel or lodging expenses for parents and child

• Temporary foster care prior to placement

• Immunization fees required to enter the U.S.

• Immigration fees

Reimbursements are subject to FICA and Medicare taxes only.

Will Preparation ProgramCigna makes it easy for you to take charge of those difficult life and health legal decisions. With www.CignaWillCenter.com, you can create and maintain your personalized legal documents (e.g., last will and testament, living will, health care power of attorney, financial power of attorney) by using its intuitive, interactive question-and-answer process to create state-specific legal documents tailored to your situation. You will be able to preview, edit, download, and print your legal documents for execution.

InfoArmorInfoArmor is one of the leading identity theft and security vendors with a comprehensive roster of services including the following benefits:

• Monitors your credit

• Uncovers unauthorized activity, including exploits of your name, fraudulent affiliated addresses, and usage of your Social Security number

• Alerts you in real time to credit, banking, employment, and other security events and transactions

• Tracks web presence of personally identifying information from breaches

• Identifies and remedies previous issues at no additional cost

• Helps to restore your name and good standing

Visit www.InfoArmor.com/Mitsubishi to enroll.

FSA StoreYou have access to the FSA Store where you can purchase FSA-eligible products without a prescription. Use your FSA payment card to purchase a multitude of items, ranging from first aid kits to contact lens solution. You can also use your credit card and submit your receipt for reimbursement later. Visit https://fsastore.com to start shopping.


The Family and Medical Leave Act (FMLA) of 1993 was designed to provide eligible employees with up to 12 workweeks per year of job-protected leave to address critical personal and family matters. It is the policy of MHPSA and its U.S. subsidiaries (collectively, the “Company” or “employer”) to provide eligible employees with a leave of absence in accordance with the provisions of FMLA.

You are eligible for an FMLA leave of absence under this policy if you meet the following requirements:

• You have completed at least 12 months of employment (need not be consecutive, but employment prior to a continuous break in service of seven or more years may not be counted).

• You have worked at least 1,250 hours during the 12-month period immediately preceding the commencement of the requested leave.

• You are employed at a work site where 50 or more employees are employed by the Company within 75 miles of that work site (“eligible employees”).

To the extent permitted by law, leave taken pursuant to FMLA will run concurrently with Workers’ Compensation, Short Term Disability, and all other Company leave policies.

The “break in service cap” doesn’t apply if it:- is attributable to fulfillment of National Guard or Reserve military service

obligations or- is addressed in a written agreement, including a collective bargaining

agreement, that expresses the employer’s intent to rehire the employee after

the break in service, such as a break to pursue education or raise children.

Procedure for Applying for FMLA LeaveIf you desire and require an FMLA leave of absence under this policy, you must notify your manager and your local Human Resources Department and call Cigna’s FMLA Administration at 1.800.36.CIGNA at least 30 calendar days in advance of the start of the leave when the need for such leave is reasonably foreseeable (as in the case of a birth, the placement for adoption of a son or daughter, or a planned medical treatment for a serious health condition). However, if the date of the birth, placement, or planned medical treatment requires leave to begin in less than 30 calendar days, you must provide such notice to the aforementioned parties as soon as it is both possible and practicable. Failure to provide timely notice may result in a delay or denial of FMLA leave.

When FMLA leave is taken due to a “Qualifying Exigency” and such leave is foreseeable, whether because your spouse, son, daughter, or parent is on active duty or because of a notification of deployment under a call or order to active duty, you must provide such advance notice to the Company as is both reasonable and practicable under the circumstances. When requesting such leave, you must also provide the Company with a copy of the covered military member’s active duty orders and must also provide the Company with a completed Certification of Qualifying Exigency form within 15 calendar days, unless unusual circumstances exist to justify providing the form at a later date.

Upon notification of the request for FMLA leave, Cigna will send an FMLA Rights Package to you. Cigna will require you to provide certification of the leave from your own or the family member’s (spouse’s, son’s, daughter’s, parent’s) health care provider. For Military Caregiver Leave, an invitational travel order or invitational travel authorization may be submitted in lieu of a Certification of Health Care Provider form. This information must be submitted to Cigna within 15 calendar days from the date the FMLA Rights Package is sent to you. At the Company’s expense, the Company may also require a second or third medical opinion regarding your own serious health condition. You are expected to cooperate with the Company in obtaining additional medical opinions that the Company may require.

If you are granted a leave under the FMLA, you may be required to furnish periodic reports every 30 calendar days to Human Resources. Additionally, if the circumstances surrounding your leave change and you are able to return to work earlier than expected, you must inform your local Human Resources Department as soon as possible. It is strongly recommended your local Human Resources Department be informed either way if the circumstances of leave change: if you need to extend your leave or have a different pattern of intermittent leave.

Failure to provide the Company with requested information within the time frames prescribed herein may result in a delay in approving your leave or in the denial of your leave. Employees who are approved for intermittent FMLA through Cigna must fill out the FMLA Intermittent Leave Monthly Update Sheet with appropriate manager signature and submit this form to Cigna each month whether or not intermittent leave was taken.

Other RequirementsIn the case of a serious health condition of your family member (spouse, son, daughter, parent) or you, you must make a reasonable effort to schedule medical treatment so as not to unduly disrupt the Company’s operations.

Family Medical Leave Act


Family Medical Leave ActFederal law requires MHPSA to offer employees and their families the opportunity for a temporary extension of health coverage (called “continuation coverage”) at group rates in certain instances where coverage under the plan would otherwise end.

To Qualify for COBRA Coverage Employees – As an employee of MHPSA covered by UMR, you have the right to elect this continuation coverage if you lose your group health coverage because of a reduction in your hours of employment or the termination of your employment (for reasons other than gross misconduct on your part).

Spouses – As the spouse of an employee covered by UMR, you have the right to choose continuation coverage for yourself if you lose group health coverage under UMR for any of the following reasons:

• The death of your spouse who was an MHPSA employee

• A termination of your spouse’s employment (for reasons other than gross misconduct)

• A reduction in your spouse’s hours of employment

• Divorce or legal separation from your spouse

• Your spouse becomes entitled to Medicare

Dependent Children – Dependent children of MHPSA employees covered by UMR have the right to continuation coverage if group health coverage under UMR is lost for any of the following reasons:

• The death of a parent who was an MHPSA employee

• The termination of a parent’s employment (for reasons other than gross misconduct) or reduction in a parent’s hours of employment with MHPSA

• Parents’ divorce or legal separation

• A parent who is an employee of MHPSA becomes entitled to Medicare

• The dependent ceases to be a “dependent child” under the terms of the UMR plan

- Please note that it is the employee’s responsibility to notify the Human Resources/Benefits Department of any communication regarding loss of coverage and communication regarding such between the employee and the insurance carrier.

• Please note that employees must also provide notice of other events (e.g., divorce) to the Human Resources Department.

COBRA Continuation


Account OptionsMHPSA has established a traditional 401(k) and a Roth 401(k) to help provide retirement savings for you. MHPSA’s company-matching contribution is 125% of the first 4%, and 100% of the following 2% that you contribute to the plan each pay period. Company-matching contributions cumulatively apply to the traditional 401(k) and the Roth 401(k), and any contributions made by you are immediately vested.

Traditional 401(k)Every new full-time employee eligible for the 401(k) is enrolled automatically in the MHPSA Group Retirement Plan. You will be eligible to contribute to this plan after completing one month of service with MHPSA.

All benefit-eligible new hires will be automatically enrolled into the 401(k) plan at a 4% contribution rate after one month of service. If you do not want to contribute to the 401(k) plan, you must opt out of the automatic enrollment election directly through Fidelity’s website (www.401k.com). First-time deductions are transmitted by Fidelity to Payroll just prior to the first pay date of eligibility. You must opt out of the automatic enrollment election or change your contribution percentage well before the first pay period in which you become eligible. If elections are not initiated before the first deduction, they will not be transmitted by Fidelity to Payroll until after the next-available payroll. This applies to all initial elections. You may elect to defer from 1% to 60% of your annual salary on a pre-tax basis (subject to regulatory limits). This election will be taken through payroll deductions each pay period.

Immediate VestingParticipants are 100% vested in their 401(k) contributions, after-tax contributions, Rollover contributions, catch-up contributions, and Safe Harbor Employer Matching contributions.

Any changes to contribution percentages and/or fund allocation need to be made directly online at www.401k.com or by calling Fidelity at 1.800.835.5097.

Beneficiary information for your 401(k) must be established online with Fidelity.

Roth 401(k)The Roth 401(k) allows you to contribute post-tax dollars into your retirement account. Unlike your traditional, pre-tax 401(k), the Roth 401(k) allows you to withdraw your money tax-free when you retire.

The Roth 401(k) contributions are under the same IRS limits as pre-tax contributions to our plan; each dollar of the Roth contribution reduces the amount that can be contributed pre-tax and vice versa.

Taxes: Pay Now or Pay Later

Traditional Pre-tax 401(k)

Post-tax Roth 401(k)

Employee Contributions

Pre-tax dollars Post-tax dollars

Employee Withdrawals

Taxable upon withdrawal

Tax-free upon withdrawal

EXAMPLEThis example has been designed to help you understand the traditional 401(k) and the Roth 401(k) plans. This is intended as an illustration only.

Sally earns $40,000 annually and has elected to put 6% in her traditional pre-tax 401(k) and 6% in her Roth 401(k) each pay period.

Sally’s Story Traditional Pre-tax 401(k)

Post-tax Roth 401(k)

Sally’s pay period contribution

$200 $200

Sally’s reduction in take-home pay

$150 $200

Investment Help from ProfessionalsFidelity® Portfolio Advisory Service at Work allows you to delegate your day-to-day 401(k) account management to experienced professional investment managers. Fidelity’s professionals evaluate your investment options and identify and invest in those that are best for your specific situation. Portfolio Advisory Service at Work also helps to manage your account through market volatility, advises on your investments, and makes recommendations based upon any life changes you may experience. To learn more, log on to NetBenefits® at https://netbenefits.fidelity.com/pas or contact the Fidelity Retirement Benefits Line at 1.800.890.4015.

Retirement


Retirement HIPAA NoticeTo: Employees (both active and inactive), retirees, dependents, and COBRA beneficiaries who are

eligible to participate in any of the health plans offered by Mitsubishi Hitachi Power Systems Americas, Inc. (MHPSA).

Effective Date of Notice: January 1, 2019

From: Human Resources Department

Subject: HIPAA Notice of Privacy Practices

The privacy regulations of the Health Insurance Portability and Accountability Act (HIPAA) became effective April 14, 2003. These federal regulations require covered entities, such as health plans, to provide plan participants with a notice of privacy practices describing the health-related information that is collected, how it is used, and the ways in which the regulations permit it to be disclosed. These privacy notices also provide information on a participant’s right to access, review and, if necessary, to have this information amended.

The following HIPAA Notice of Privacy Practices for the health plans sponsored by MHPSA details the uses and disclosure that the plan may make of your health information along with your rights and the plan’s obligations with respect to that information.

We’d like to take this opportunity to assure you that MHPSA and its health plans strive to take all appropriate measures to protect the privacy of your health information. We take this responsibility very seriously and consider it our obligation to you and to your family, not simply a legal requirement that we must fulfill. Not only do the MHPSA health plans place limits on disclosing your health information to outside parties, but also take precautions regarding who can access that information internally. Your health information is not disclosed to outside parties for the purpose of marketing products and services.

If you have questions, please contact the Human Resources Department.

MHPSA Notice of Health Information Privacy PracticesTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice describes the medical information practices of MHPSA’s health benefit plans and programs, and of any third party (called a “business associate”) that assists in the administration of those plans and programs.

“We,” “us”, and “Plan” refer to all the health benefit plans and programs presented herein. “Plan Sponsor” refers to MHPSA. ‘’You” or “yours” refers to individual participants in the Plans.

If you participate in one of the insured health plans sponsored by MHPSA, you will receive a notice from the appropriate insurance plan regarding the policies and procedures they will follow related to the use and disclosure of your Protected Health Information (PHI).

PHI is information that may identify you and that relates to past, present, or future health care services provided to you, payment for health care services provided to you, or your physical or mental health or condition. This Notice of Privacy Practices describes how regulations permit us to use and disclose your PHI. It also describes your rights to access and control your PHI.


We are required by the Health Insurance Portability and Accountability Act (HIPAA) to:

• Maintain the privacy of your PHI

• Provide you with certain rights with respect to your PHI

• Provide you with this Notice of our legal duties and privacy practices regarding your PHI

• Abide by the terms of this Notice as it may be updated from time to time

We protect your PHI from inappropriate use or disclosure. Our employees and those of our Business Associates are required to protect the confidentiality of PHI. They may look at your PHI only when there is an appropriate reason to do so, such as to determine coordination of benefits or services.

We will not disclose your PHI to anyone for marketing purposes.

Uses and Disclosures of PHIPrimary Uses and Disclosures of PHIThe main reasons for which we may use and may disclose your PHI are in order to administer our health benefit programs effectively and to evaluate and process requests for coverage and claims for benefits. The following describe these and other uses and disclosures together with some examples.

• Treatment, Payment, and Health Care Operations Purposes*

For Treatment: Treatment refers to the provision and coordination of health care by a doctor, hospital or other health care provider. We may disclose your PHI to health care providers to provide you with treatment. For example, we might respond to an inquiry from a hospital about your eligibility for a particular surgical procedure.

For Payment: Payment refers to our activities in collecting premiums and paying claims for health care services you receive. We may use your PHI or disclose it to others for these purposes. For example, if you had insurance coverage from a spouse’s employer, we might disclose your PHI to the other insurer to determine coordination of benefits or services. Payment also refers to the activities of a health care provider in obtaining reimbursement for services. We may disclose your PHI to a provider for this purpose.

* The amount of health information used, disclosed, or requested will be limited and, when needed, restricted to the minimum necessary to accomplish the intended purpose, as defined under the HIPAA rules.

For Health Care Operations Purposes: Health care operations purposes refer to the following:

(1) We may use your PHI or disclose it to others for quality assessment and improvement activities.

(2) We may use your PHI or disclose it to others for activities relating to improving health or reducing health care costs, development of health care procedures, case management, and care coordination.

(3) We may use your PHI or disclose it to others for the purpose of informing you or a health care provider about treatment alternatives.

(4) We may use your PHI or disclose it to others for the purpose of reviewing the competence, qualifications, or performance of health care providers, or conducting training programs.

(5) We may use your PHI or disclose it to others for accreditation, certification, licensing, or credentialing activities.

(6) We may use your PHI or disclose it to others in the process of contracting for health benefits or insurance covering health care costs.

(7) We may use your PHI or disclose it to others for purposes of reviewing your medical treatment, obtaining legal services, performing audits or obtaining auditing services, and detecting fraud and abuse.

(8) We may use your PHI or disclose it to others in our business management, planning, and administrative activities. As an example, we might use your PHI in the process of analyzing data about treatment of certain conditions to develop a list of preferred medications.

• Business Associates: We contract with various individuals and entities (Business Associates) to perform functions on behalf of the Plans or to provide certain services. To perform these functions, our Business Associates may receive, create, maintain, use, or disclose PHI, but only after we require the Business Associates to agree in writing to contract terms designed to safeguard your PHI.

• Plan Sponsor: We and our Business Associates may also disclose PHI to the Plan Sponsor without your written authorization in connection with payment, treatment, or health care operations purposes or pursuant to a written request signed by you. Such disclosures may only be made to the individuals authorized to receive such information. If PHI is disclosed to the Plan Sponsor for these purposes, the Plan Sponsor agrees not to use or disclose your health information other than as permitted or required by the Plan documents and by law.

• Other Covered Entities: MHPSA Plans (including the insured plans) together are called an “organized health care arrangement.” The Plans may share PHI with each other for the health care operations purposes of the organized health care arrangement.


Other Possible Uses and Disclosures of PHIIn addition to using and disclosing your PHI for treatment, payment, and health care operations purposes, we may (and are permitted to) use or disclose it in the following circumstances:

• To Persons Involved in Care and for Notification Purposes: We may disclose PHI to a family member, relative, close personal friend, or any other person identified by you, provided that the PHI is directly relevant to that person’s involvement with your care or payment related to your care. In addition, we may use or disclose PHI to notify a member of your family, your personal representative, or another person responsible for your care of your location, your general condition, or your death.

• In Regard to Abuse, Neglect, or Domestic Violence: In certain circumstances, we may disclose your PHI to a government authority that is authorized to receive reports of cases of abuse, neglect, or domestic violence.

• To Coroners, Medical Examiners, and Funeral Directors: We may disclose PHI to coroners and medical examiners for the purpose of identifying a deceased person, determining a cause of death, or other purposes authorized by law. We may disclose PHI to funeral directors to enable them to carry out their duties.

• For Public Health Activities: We may disclose PHI to public authorities for the purpose of preventing or controlling disease, injury, or disability. Under some circumstances, when authorized by law, we may disclose PHI to an individual who is at risk of contracting or spreading a contagious disease or condition. We also may disclose PHI to appropriate parties for the purpose of activities related to the quality, safety, or the effectiveness of products regulated by the U.S. Food and Drug Administration.

• To Avert a Threat to Health or Safety: We may, under certain circumstances, disclose PHI to avert a serious threat to the health or safety of a person or the general public.

• Organ and Tissue Donations: We may, under certain circumstances, disclose PHI for purposes of organ, eye, or other medical transplants or tissue donation purposes.

• To Comply with Workers’ Compensation Laws: We may disclose your PHI to the extent necessary to comply with laws relating to Workers’ Compensation or other similar programs.

• For Law Enforcement and National Security Purposes: In certain circumstances, we may disclose PHI to appropriate officials for law enforcement purposes; for example, if it is required by law or legal process. In addition, we may disclose your PHI if you are or were armed forces personnel or to authorized federal officials for conducting national security and intelligence activities.

• In Connection with Legal Proceedings: In certain cases, we may disclose PHI in connection with the legal proceedings of courts or governmental agencies. For example, we may disclose your PHI in response to a subpoena for such information but only after certain conditions required by HIPAA are met.

• For Health Oversight Activities: We may disclose PHI to a governmental agency authorized by law to oversee the health care system, compliance with civil rights laws, or government benefit. Health oversight activities include audits, inspections, investigations, or legal proceedings.

• Military Personnel: If you are in the armed forces, we may disclose your PHI for activities that military authorities consider necessary to the accomplishment of a mission.

• Inmates: If you are incarcerated, we may disclose your PHI to appropriate authorities who tell us they need it for your health care, your safety, the health or safety of other persons, or general administrative purposes.

• Research: Under certain circumstances, we may disclose PHI for research purposes.

• Health Information: We may contact you with information about treatment alternatives and other health-related benefits and services.

• As Required by Law: We may disclose your PHI when required to do so by federal, state, or local law.

Required Disclosures of PHIThe following is a description of disclosures we are required by law to make:

• Disclosures to the Secretary of the U.S. Department of Health and Human Services: We are required to disclose your PHI to the Secretary of the U.S. Department of Health and Human Services when the Secretary is investigating or determining compliance with HIPAA.

• Disclosure to You: We are required to disclose to you most of your PHI. We will also disclose your PHI to an individual whom you have designated as your personal representative. However, before we can disclose your PHI to such person, you must submit a written notice of his/her designation along with documents supporting his/her qualification (such as a power of attorney). In limited situations HIPAA permits us to elect not to treat the person as your personal representative if we have reasonable belief that it could endanger you.


Other Uses and Disclosures of Your PHI with AuthorizationOther uses and disclosures of your PHI that are not described above will be made only with your written authorization. You may revoke an authorization at any time by providing written notice to us. We will honor a request to revoke as of the day it is received and to the extent that we have not already used or disclosed your PHI in reliance on the authorization. To obtain an Authorization for Release of Information, call the Human Resources Department. You may revoke an authorization by contacting the Health Information Privacy Officer identified at the end of this Notice.

Your RightsRight to Request Restrictions on Uses and Disclosure

You may ask us to restrict uses and disclosures of your PHI for treatment, payment, or health care operations purposes, or to restrict disclosures to family members, relatives, friends, or other persons identified by you who are involved in your care or payment for your care, or to restrict disclosures for notification purposes. However, we are not generally required to comply with your request for restrictions except in those situations where the requested restriction relates to the disclosure to the Plan for purposes of carrying out payment or health care operations (and not for treatment), and the PHI pertains solely to a health care item or service that was paid out of pocket in full. You may exercise this right by contacting the Health Information Privacy Officer identified at the end of this Notice who will provide you with additional information including what information is required to make a restriction request.

Right to Inspect, Copy, and Amend Your PHIAs long as we maintain records containing your PHI, you have a right to inspect and copy such information. These rights are subject to certain limitations and exceptions. For example, if the requested information contains psychotherapy notes or may endanger someone, it may not be available. You may request a review of any denial to access. If the Plan keeps your records in an electronic format, you may request an electronic copy of your health information in a form and format readily producible by the Plan. If you believe your PHI held and created by us is incorrect or incomplete, you may request that we amend your PHI. You will be required to provide the reason the amendment is necessary. Requests for access to your PHI or amendment of your records should be in writing and directed to the Health Information Privacy Officer identified at the end of this Notice.

Right to a List of DisclosuresYou have a right to an accounting of certain disclosures of your PHI by us. The accounting will not include those items which are not required to be provided such as disclosures made at your request or disclosures made for treatment,

payment, or health care operations. A request for a list of disclosures should be directed to the Health Information Privacy Officer identified at the end of this Notice.

Right to Request Confidential CommunicationsWe will accommodate a reasonable request by you to receive communications from us by alternative means or at an alternative location if you believe that disclosure of your PHI could pose a danger to you. For example, you may request that we only contact you by mail or at work. Requests for confidential communications should be in writing and directed to the Health Information Privacy Officer identified at the end of this Notice.

Right to be Notified of a BreachYou have the right to be notified in the event that we (or a Business Associate) discover a breach of unsecured PHI.

Right to Receive Paper CopyYou have the right to receive a paper copy of this Notice from the Plan upon request even if you have previously agreed to receive copies of this Notice electronically. Requests for a paper copy should be in writing and directed to the Health Information Privacy Officer identified at the end of this Notice.

Changes to This NoticeWe reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all PHI we maintain. If we change this Notice, you will receive a new Notice. Active employees will receive the Notice by distribution in the workplace; inactive employees (including retirees) will receive the Notice by mail.

ComplaintsIf you believe that your privacy rights have been violated, you may complain to us in writing at the location described below under “Health Information Privacy Officer’’ or with the office for Civil Rights of the Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington, DC 20201. You will not be retaliated against for filing a complaint.

Health Information Privacy OfficerYou may exercise the rights described in this Notice by contacting the office identified below, which will provide you with additional information.

MHI Shared ServicesAttn: Benefits DepartmentHealth Information Privacy Officer400 Colonial Center Pkwy, Suite 350Lake Mary, FL 32746


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

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.

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

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

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2018. Contact your State for more information on eligibility.

ALABAMA – Medicaid FLORIDA – MedicaidWebsite: http://myalhipp.com/Phone: 1-855-692-5447

Website: http://flmedicaidtplrecovery.com/hipp/Phone: 1-877-357-3268

ALASKA – Medicaid GEORGIA – Medicaid

The AK Health Insurance Premium Payment ProgramWebsite: http://myakhipp.com/ Phone: 1-866-251-4861Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: http://dch.georgia.gov/medicaid- Click on Health Insurance Premium Payment (HIPP)Phone: 404-656-4507

ARKANSAS – Medicaid INDIANA – Medicaid Website: http://myarhipp.com/Phone: 1-855-MyARHIPP (855-692-7447)

Healthy Indiana Plan for low-income adults 19-64Website: http://www.in.gov/fssa/hip/Phone: 1-877-438-4479All other MedicaidWebsite: http://www.indianamedicaid.comPhone 1-800-403-0864

COLORADO – Health First Colorado (Colorado’s Medicaid Program) &

Child Health Plan Plus (CHP+)IOWA – Medicaid

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/State Relay 711CHP+: Colorado.gov/HCPF/Child-Health-Plan-PlusCHP+ Customer Service: 1-800-359-1991/State Relay 711

Website: http://dhs.iowa.gov/hawk-iPhone: 1-800-257-8563

KANSAS – Medicaid NEW HAMPSHIRE – MedicaidWebsite: http://www.kdheks.gov/hcf/Phone: 1-785-296-3512

Website: https://www.dhhs.nh.gov/ombp/nhhpp/Phone: 603-271-5218Hotline: NH Medicaid Service Center at 1-888-901-4999

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIPWebsite: https://chfs.ky.govPhone: 1-800-635-2570

Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/Medicaid Phone: 609-631-2392CHIP Website: http://www.njfamilycare.org/index.htmlCHIP Phone: 1-800-701-0710

LOUISIANA – Medicaid NEW YORK – MedicaidWebsite: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331Phone: 1-888-695-2447

Website: https://www.health.ny.gov/health_care/medicaid/Phone: 1-800-541-2831

Additional Notices


MAINE – Medicaid NORTH CAROLINA – MedicaidWebsite: http://www.maine.gov/dhhs/ofi/public-assistance/index.htmlPhone: 1-800-442-6003TTY: Maine relay 711

Website: https://dma.ncdhhs.gov/ Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – MedicaidWebsite: http://www.mass.gov/eohhs/gov/departments/masshealth/Phone: 1-800-862-4840

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/Phone: 1-844-854-4825

MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIPWebsite: https://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/other-insurance.jspPhone: 1-800-657-3739

Website: http://www.insureoklahoma.orgPhone: 1-888-365-3742

MISSOURI – Medicaid OREGON – MedicaidWebsite: http://www.dss.mo.gov/mhd/participants/pages/hipp.htmPhone: 573-751-2005

Website: http://healthcare.oregon.gov/Pages/index.aspxhttp://www.oregonhealthcare.gov/index-es.htmlPhone: 1-800-699-9075

MONTANA – Medicaid PENNSYLVANIA – MedicaidWebsite: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPPPhone: 1-800-694-3084

Website: http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htmPhone: 1-800-692-7462

NEBRASKA – Medicaid RHODE ISLAND – MedicaidWebsite: http://www.ACCESSNebraska.ne.govPhone: (855) 632-7633Lincoln: (402) 473-7000Omaha: (402) 595-1178

Website: http://www.eohhs.ri.gov/Phone: 855-697-4347

NEVADA – Medicaid SOUTH CAROLINA – MedicaidMedicaid Website: http://dhcfp.nv.govMedicaid Phone: 1-800-992-0900

Website: https://www.scdhhs.govPhone: 1-888-549-0820

SOUTH DAKOTA – Medicaid WASHINGTON – MedicaidWebsite: http://dss.sd.govPhone: 1-888-828-0059

Website: http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-programPhone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid WEST VIRGINIA – MedicaidWebsite: http://gethipptexas.com/Phone: 1-800-440-0493

Website: http://mywvhipp.com/Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIPMedicaid Website: https://medicaid.utah.gov/CHIP Website: http://health.utah.gov/chipPhone: 1-877-543-7669

Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdfPhone: 1-800-362-3002

VERMONT– Medicaid WYOMING – MedicaidWebsite: http://www.greenmountaincare.org/Phone: 1-800-250-8427

Website: https://wyequalitycare.acs-inc.com/Phone: 307-777-7531

VIRGINIA – Medicaid and CHIPMedicaid Website: http://www.coverva.org/programs_premium_assistance.cfmMedicaid Phone: 1-800-432-5924CHIP Website: http://www.coverva.org/programs_premium_assistance.cfmCHIP Phone: 1-855-242-8282

To see if any other states have added a premium assistance program since July 31, 2018, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Serviceswww.dol.gov/agencies/ebsa www.cms.hhs.gov1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

OMB Control Number 1210-0137 (expires 12/31/2019)


Wellness Program NoticeYour health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet the tobacco free standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact the Benefits Department at 1.407.688.6800 and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status.

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

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

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

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

• Prostheses; and

• Treatment of physical complications of the mastectomy including lymphedema.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under the group medical plan you choose for coverage.

If you would like more information on WHRCA benefits, please call the Benefits Department (see the telephone numbers located in the back of your Benefits Guide) or you can contact UMR Member Services at the toll-free number listed on your ID card.

Michelle’s Law Notice The health plan may extend medical coverage for dependent children if they lose eligibility for coverage because of a medically necessary leave of absence from school. Coverage may continue for up to a year, unless your child’s eligibility would end earlier for another reason.

Extended coverage is available if a child’s leave of absence from school — or change in school enrollment status (for example, switching from full-time to part-time status) — starts while the child has a serious illness or injury, is medically necessary, and otherwise causes eligibility for student coverage under the plan to end. Written certification from the child’s physician stating that the child suffers from a serious illness or injury and the leave of absence is medically necessary may be required.

If your child will lose eligibility for coverage because of a medically necessary leave of absence from school and you want his or her coverage to be extended, contact MHPSA’s Benefits Department as soon as the need for the leave is recognized. In addition, contact your child’s health plan to see if any state laws requiring extended coverage may apply to his or her benefits.

Special Enrollment NoticeAs you know, if you have declined enrollment in MHPSA’s health plan for you or your dependents (including your spouse) because of other health insurance coverage, you or your dependents may be able to enroll in some coverages under this plan without waiting for the next open enrollment period provided that you request enrollment within 30 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your eligible dependents provided that you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

MHPSA will also allow a special enrollment opportunity if you or your eligible dependents either:

• Lose Medicaid or Children’s Health Insurance Program (CHIP) coverage because you are no longer eligible, or

• Become eligible for a state’s premium assistance program under Medicaid or CHIP.

For these enrollment opportunities, you will have 60 days instead of 30 from the date of the Medicaid/CHIP eligibility change to request enrollment in the MHPSA group health plan. Note that this new 60-day extension doesn’t apply to enrollment opportunities other than due to the Medicaid/CHIP eligibility change.


Medical/DentalWhat should I do if I have not received my ID card(s) from UMR or need additional/replacement card(s)?Log into your www.myumr.com account and request the card(s) needed. You can print out temporary ID card(s) until your new card(s) arrive/s. You may also contact Cigna directly at 1.800.826.9781.

I elected the Dental PPO and did not receive a dental card. Why?UMR does not distribute dental cards to participants who have elected the Dental PPO. Your medical ID card is sufficient.

My child(ren)’s address is different than mine and I elected medical coverage. What should I do?Update your child(ren)’s address in the Employee Self-Service Portal and notify the Benefits Department at [email protected] that your child(ren) has/have a different address. This way we will manually update the address with UMR directly so that you may call UMR to have a guest network assigned.

VisionHow do I submit an out-of-network vision claim with EyeMed?You are responsible for submitting claims only when using benefits at an out-of-network provider because it is the responsibility of the provider to verify eligibility and submit the claim for in-network services.

If you visit an out-of-network provider, you will be responsible for paying the provider in full at the time of service and then submitting the claim and receipts to EyeMed for reimbursement. Claim forms can be located online in your Document Library in the Employee Self-Service Portal, Health & Welfare or on the EyeMed website.

To ensure timely payment, contact the Customer Care Center or visit the EyeMed website to request an out-of-network claim form prior to seeing the doctor. Mail, fax, or email the completed form along with the itemized paid receipts for services and materials.

How do I access my vision benefits with EyeMed?1. Locate the EyeMed provider most convenient for you

by calling the Customer Care Center or by visiting the EyeMed website.

2. Schedule an appointment and be sure to tell the office that you are an EyeMed member, and provide your name, the name of your organization or plan, and your Member ID or Social Security number.

3. When you arrive, identify yourself as an EyeMed member and present your ID (if you have it with you, otherwise they will look up your benefits with your Social Security number).

I forgot to use my EyeMed insurance during my office visit. What do I do?If you forget to use your EyeMed insurance during an in-network visit to the doctor, just contact the doctor’s office and ask them to submit/resubmit the claim to EyeMed. The doctor’s office is responsible for reimbursing you for the claim.

If you have any problems receiving your reimbursement, you can utilize Health Advocate for assistance. See the Health Advocate section for more details on their services.

Flexible Spending Accounts (FSAs)Can I cancel my Health Care FSA or Dependent Care FSA? If so, how and for what reasons? Your life event and type of FSA coverage will determine what options you have for canceling your coverage. In most cases for the Health Care FSA, you will be able to change the annual contribution but not cancel your coverage. In most cases for the Dependent Care FSA, you will be able to change the annual contribution or cancel your coverage.

How quickly will I receive my FSA debit card once I’ve made my elections?You could receive your FSA card within 10 business days from the date your account was set up. You will also receive a welcome email directly from American Benefits Group (ABG) if there is an email address on file for you.

What should I do if I have not received my FSA debit card or need an additional/replacement card?Send an email to [email protected] informing them of your name, account number, and company name and that you have not received your debit card. If you would like an additional or replacement card, please follow the above instructions and indicate you would like to order an additional debit card. You will need to let them know the name of the cardholder. Age restrictions may apply to cardholders.

My child’s day care provider does not accept debit cards. How can I get reimbursed?You will need to complete a claim form and submit it with requested proof directly to ABG. You have two form options:

1. Standard Claim Form: You’ll need to itemize your dependent care expenses and provide a copy of a receipt with each expense listed.

2. Automatic Dependent Care Request Form: You can use this form if you have recurring dependent care with a particular provider. You will use this form if you are receiving dependent care for an extended time period with one provider. You do not need to submit a receipt; you just need to have your provider fill out a portion of the form.

Frequently Asked Questions


When is the last day I can use my FSA card for the current year?The last day you can use your FSA card for services that occurred during the year is on December 31 of that year. For example, if on December 31, 2018, you went to the doctor and were prescribed medication that you filled that same day and your dependent child went to day care, you could use your FSA card for all three expenses on that day. If you are unable to use your card, you can submit a reimbursement claim directly to ABG.

When is the last day I can submit reimbursement claims for the current year?You can submit reimbursement claims directly to ABG for services that occurred during the year up to March 31 of the next plan year. Claims must be postmarked no later than March 31.

Can I still get reimbursed even if I don’t/can’t use my FSA debit card?You can still get reimbursed for claims even if you were unable to use your FSA debit card during the date of service. You will need to complete a standard claim form and submit it with the requested proof directly to ABG.

Will I receive a new card every plan year, or can I keep my same card if I sign up for the FSA again next year? You will not be issued a new FSA card each year that you sign up for the plan. Your FSA card will be replaced once the expiration date is reached or if you request a replacement card due to it being lost or stolen.

Life/AD&D When will I receive my proof of life insurance? How often will I receive proof? The Certificate of Insurance for the group coverage (basic life/AD&D) is located online in your Document Library in the Employee Self-Service Portal Health & Welfare. You can retrieve this at any time as a copy for your records.

For your optional life/AD&D and optional spouse life/AD&D elections, once your request for amounts over the guaranteed issue is approved, you will receive a letter directly from Cigna. This letter is your proof of coverage.

Please remember that an EOI is required for amounts that exceed the guaranteed issued amount.

Can I elect optional life/AD&D, optional spouse life/AD&D, and/or optional child life/AD&D insurance any time during the year? Yes, these elections can be made any time during the year. The life event to report on the Employee Self-Service Portal is “Change in After-Tax Benefits.”

Please remember that an EOI is required for amounts that exceed the guaranteed issued amount.

FMLA/STD/LTDHow do I report my Family Medical Leave request? 1. Call Cigna at 1.888.84.CIGNA (24462)

(Spanish – 1.866.562.8421).2. Cigna’s intake specialist will walk you through the process.

or

1. Access your account on www.mycigna.com.

2. Request a new leave by following the request instructions.

How do I report my STD/LTD claim?

Follow the same instructions as reporting a Family Medical Leave request above.

401(k) How do I set up my 401(k) online account access?You can either go online to www.401k.com (see recommended links) or contact Fidelity directly at 1.866.612.4573 to set up your account and enroll.

If you choose to go online, you will need to set up a new account if you haven’t done so already.

1. Go to www.401k.com.

2. Under “New User?” click “Register Now.”

3. Complete the remaining registration steps by providing the requested information including your Social Security number.

If you already have an account with Fidelity (i.e., personal or through a prior employer), you can use your current customer ID/SSN and PIN information; Fidelity’s website will automatically link your online accounts.

How do I enroll in/opt out of the 401(k) plan? You will be auto enrolled at 4% once you have become eligible. To change your elections or opt out, you will need to log into your 401(k) account online at www.401k.com (see recommended links) or contact Fidelity directly at 1.800.835.5097 for phone assistance.

How do I change my contribution amounts and/or investment options to my 401(k) account?You can log into your 401(k) account online at www.401k.com (see recommended links) or contact Fidelity directly at 1.800.835.5097 for phone assistance.

How often can I change my contribution amounts to my 401(k) account?You can change your contribution amounts as often as you wish. Due to the timing in which the election file is uploaded and payroll is processed, it may take up to two pay periods before changes are reflected on your paycheck.


How do I transfer my 401(k) from my previous employer to MHPSA’s 401(k) plan?

1. You must first contact your prior employer for instructions on requesting a distribution.

• Make distribution checks payable to FIIOC or FMTC (personal checks are not acceptable).

2. Complete the Fidelity Incoming Rollover Form from Fidelity.

3. Send the distribution check and completed form to Fidelity.

Fidelity Investment Client Services Operations PO Box 770003

Cincinnati, OH 45277-0065

4. Make checks payable to FMTC or FIOC FBO your name.

How do I know if I can apply for a 401(k) loan? You can determine if you can apply for a loan by accessing your account at Fidelity’s website at www.401k.com, or you can contact them by phone at 1.800.835.5097.

Unless you are applying for a loan to purchase your primary residence, no additional documentation will be required. If the loan is to purchase your primary residence, you may be required to provide proof, which would be a copy of closing cost documents, purchase agreement, etc., showing the cost/purchase price.

How do I pay off my 401(k) loan early?1. Determine your loan payoff balance by accessing your

account information online at www.401k.com or by contacting Fidelity directly at 1.800.835.5097.

2. Send payment in the form of a cashier’s check or money order to Benefits Department Plan Administrator. (Personal checks are not acceptable.)

MHI Shared ServicesAttn: Benefits Department400 Colonial Center Pkwy., Suite 350Lake Mary, FL 32746

3. The Plan Administrator will complete a Letter of Instruction and forward your loan payoff to Fidelity.

I applied for a 401(k) hardship. What type of documentation do I need to provide?You must submit documentation that supports your qualified hardship request. For example:

• Purchase of Primary Residence – Copy of closing cost documents, purchase agreement, etc., showing the cost/purchase price

• To Prevent Eviction – Eviction notice showing the amount owed

• To Pay for Medical Bills – Copy of invoice(s) from the provider (hospital, doctor’s office, etc.)

• To Pay for Secondary Education – Copies of the tuition invoice from the school’s administrative office (e.g., student accounts, registrar)

Please submit the supporting documentation to the Benefits Department. You may do so by sending a scanned copy to [email protected] or via mail directly to the Lake Mary, FL office, or by giving the completed form to one of your local HR representatives to forward to the Benefits Department.

MiscellaneousWhom do I contact if I have a benefit-related question?

You have three options:

1. You can contact your local Human Resources Department.

2. You can send an email directly to [email protected].

3. You can contact one of the Benefits Department team members listed at the back of this booklet.

When do my benefits become effective?

Health Coverage – 1st of the month after your hire date

401(k) – Following one month of service

What proof of documentation is required to add or remove a dependent to/from my benefits?You must provide one or all of the following to DVS to show that your dependent is a qualified tax dependent for purposes of medical/dental/vision insurance coverage:

• Spouse – Marriage certificate or current-year 1040 tax filing*, divorce decree, or proof of other coverage

• Child – Birth certificate, adoption agreement, or current-year 1040 tax filing*, divorce decree, proof of other coverage, or guardianship documents

*If you provide the current-year 1040 tax filing, please black out the dollar amounts. We only need to see the dependents listed and your signature.

When are the carriers (UMR, ABG, Fidelity, Cigna Life, etc.) provided updated election information? How often? All carriers including Fidelity are provided an updated file (additions/changes) on Thursday morning of every week. These files are processed automatically. Any changes that you wish to have shown on the next file feed will need to be entered through the Employee Self-Service Portal prior to 5:00 pm ET each Wednesday.


DefinitionsDependent Verification Services (DVS) – Service used to verify dependent proof of relationship when adding dependents to benefit plans

Employee Self-Service (ESS) Portal – The portal employees use to access their personal information for review, changes, pay statements, etc.

Health & Welfare Service Engine (HWSE) – Benefits information system (enrollment, life events, dependents, beneficiaries, etc.)

Kronos – Time and attendance system (e.g., time sheets, vacation, STA)

Beneficiary – A person designated by you, the participant of a benefit plan, to receive the benefits of the plan in the event of the participant’s death

• Primary Beneficiary – A person who is designated to receive the benefits of a benefit plan in the event of the participant’s death

• Contingent Beneficiary – A person who is designated to receive the benefits of a benefit plan in the event of the Primary Beneficiary’s death

Charges – The term “charges” means the actual billed charges. It also means an amount negotiated by a provider, directly or indirectly, if that amount is different from the actual billed charges.

Coinsurance – The percentage of charges for covered expenses that an insured person is required to pay under the plan (separate from copayments)

Deductible – This is an amount that is required to be paid by a subscriber before health plan benefits will begin to reimburse for services.

Dependents – Dependents are your:

• Lawful spouse through a marriage that is lawfully recognized.

• Dependent child (married or unmarried) under the age of 26 including stepchildren and legally adopted children.

Proof of relationship documentation will be required in order to add dependents to your plan(s). Employees will receive request for documentation directly from DVS.

Emergency Services – Medical, psychiatric, surgical, hospital, and related health care services and testing, including ambulance service, that are required to treat a sudden, unexpected onset of a bodily injury or serious sickness that could reasonably be expected by a prudent layperson to result in serious medical complications, loss of life, or permanent impairment to bodily functions in the absence of immediate medical attention. Examples of emergency situations include uncontrolled bleeding, seizures or loss of consciousness, shortness of breath, chest pains or severe squeezing sensations in the chest, suspected overdose of medication or poisoning, sudden paralysis or slurred speech, burns, cuts, and broken bones. The symptoms that led you to believe you needed emergency care, as coded by the provider and recorded by the hospital, or the final diagnosis – whichever reasonably indicated an emergency medical condition – will be the basis for the determination of coverage provided such symptoms reasonably indicate an emergency.

Evidence of Insurability (EOI) – Proof that you are insurable based on the requirements of the insurance carrier. For example, the results of a blood test or a doctor’s signature on a form may be required for you to be covered by/for Optional Life insurance.

Health Savings Account (HSA) – A tax-advantaged savings account that is only available to participants in a qualified high-deductible health plan. You contribute to your HSA through pre-tax payroll contributions and can use the money to pay for eligible medical expenses, including deductibles, coinsurance, and copays for medical, dental, and vision care. All of the money in your HSA rolls over from year to year and is always yours to keep. For example, you may use the money in your HSA to pay for eligible health expenses in retirement.

In-Network/Out-of-Network – The term “in-network” refers to health care services or items provided by your Primary Care Physician (PCP) or services/items provided by another participating provider and authorized by your PCP or the review organization. Authorization by your PCP or the review organization is not required in the case of mental health and substance abuse treatment other than hospital confinement solely for detoxification.

The term “out-of-network” refers to care that does not qualify as in-network.

Emergency care that meets the definition of “emergency services” and is authorized as such by either the PCP or the review organization is considered in-network.


Medically Necessary/Medical Necessity – Required to diagnose or treat an illness, injury, disease, or its symptoms; in accordance with generally accepted standards of medical practice; clinically appropriate in terms of type, frequency, extent, site, and duration; not primarily for the convenience of the patient, physician, or other health care provider; and rendered in the least intensive setting that is appropriate for the delivery of the services and supplies.

Participating Provider – A hospital, physician, or any other health care practitioner or entity that has a direct or indirect contractual arrangement with UMR to provide covered services with regard to a particular plan under which the participant is covered.

Post-Tax – An option to have the payment to your benefits deducted from your gross pay after your taxes have been withheld. Therefore, your tax contributions will be calculated based on a higher amount. Your statutory deductions (federal income tax, Social Security, Medicare) will be calculated based on a higher amount.

Pre-Tax – An option to have the payment to your benefits deducted from your gross pay before your taxes have been withheld. Therefore, your tax contributions will be calculated based on a lesser amount. Your statutory deductions (federal income tax, Social Security, Medicare) will be calculated based on a lesser amount.

Primary Care Dentist (PCD) – The term “Primary Care Dentist” means a dentist who (a) qualifies as a participating provider in general practice, referrals, or specialized care; and (b) has been selected by you, as authorized by the provider organization, to provide or arrange for dental care for you or any of your insured dependents.

Primary Care Physician (PCP) – The term “Primary Care Physician” means a physician who (a) qualifies as a participating provider in general practice, obstetrics/gynecology, internal medicine, family practice, or pediatrics; and (b) has been selected by you, as authorized by the provider organization, to provide or arrange for medical care for you or any of your insured dependents.

Proof of Relationship Documentation – Documents that show a dependent is lawfully your dependent. Documents can include marriage certificates, birth certificates, adoption agreements, previous years’ tax returns, court orders, and/or divorce decrees showing your or your spouse’s responsibility for the dependent.


Benefits SummaryThe chart below provides an overview of MHPSA’s benefits offerings.

2019 Choices

Medical HSA Plan – High deductible health plan that is paired with a tax-advantaged Health Savings Account (HSA), which includes Accident Insurance for Employee coverage only

EPO – Use the national network for referral-free access to specialists; pay moderate rates

PPO – Pay the highest rates of the three plans, lower out-of-pocket costs, and a lower deductible

Wellness Take advantage of Vitality’s many offerings and even get an Apple Watch

Dental DHMO – Use in-network care

DPPO – Use any in- or out-of-network dentist for care

Vision Pay minimal rates for comprehensive vision coverage and use both in-network and out-of-network providers

Obtain either one pair of eyeglasses or contact lenses within a 12-month period with EyeMed

Receive discounts on other vision care such as Lasik Vision Correction

Flexible Spending Accounts

Health Care FSA – Contribute pre-tax dollars to this account to pay for eligible health care expenses

Dependent Care FSA – Contribute pre-tax dollars to this account to pay for eligible work-related dependent day care expenses

Company-Provided Life Insurance

Basic Life – Receive coverage valued at two times your annual salary up to a maximum of $500,000

Basic Accidental Death & Dismemberment (AD&D) – Receive coverage valued at two times your annual salary up to a maximum of $500,000

Business Travel Accident – Receive coverage valued at $100,000

Optional Life Insurance Employee Life – Receive coverage based on multiples of your base annual salary with a minimum of one time and a maximum of five times

Employee AD&D – Receive coverage based on multiples of your base annual salary with a minimum of one time and a maximum of five times

Spouse Life – Receive the guaranteed issued amount of $20,000

Spouse AD&D – Enroll in other optional plans in order to receive this

Child Life – Enroll in optional employee life plan and receive coverage in amounts of $1,000 increments with a $4,000 per child maximum

Short and Long Term Disability

Both benefits are provided at no cost to you

Short Term Disability will provide the lesser of 70% of your weekly salary or $3,000 per week for up to 26 weeks

Long Term Disability will provide 60% of your monthly salary not to exceed $11,000 per month

Valuable Additional Benefits

Health Advocate – Navigate health care and insurance by using this service

Employee Assistance Program – Manage everyday challenges by using this third-party, confidential service

Medical Benefits Abroad – Maintain peace of mind while traveling abroad for business with this offering

UMR NurseLine – Find answers you need about health information 24/7

Will Preparation Program – Create and maintain a will with Cigna’s program

InfoArmor – Monitor your credit and protect your identity with this service

Rethink – Behavioral health support for employees and their families

Adoption Assistance – Earn up to $4,000 toward eligible adoption-related costs

Tuition Reimbursement – Continue your education and receive reimbursement for courses

FSA Store – Purchase FSA-eligible items online

Retirement Traditional 401(k) – Contribute pre-tax dollars to this retirement account

Roth 401(k) – Contribute post-tax dollars to this retirement account

Fidelity® Portfolio Advisory Service at Work – Get help from professionals to manage your investment portfolio


HR/Payroll and Benefits Information/LinksUse the following HR systems/portals.

1. Employee Central (EC): For employee personal information updates and MHPSA employee directory access

Example: Home address and emergency contact changes; direct deposit enrollments and changesWebsite: https://performancemanager5.successfactors.eu/login?company=mitsubisP1

2. iPay: For pay statement

Website: https://my.adp.com

3. Health and Welfare Service Engine: For health insurance family coverage changes

Website: www.MSSAbenefits.US

4. Kronos: For time and attendance management

Example: Request paid time off (vacation, sick and personal); check paid time off balancesWebsite: https://mss.kronos.net/wfc/logon

Please contact [email protected] for login assistance for any of the above noted systems.

Should you have further questions regarding these benefits, please contact the Benefits Department at the Lake Mary Corporate office. Multilingual translation services may be available with some providers.

Phone Number Website/Email

Benefits Service Center 1.833.251.9456 www.MSSAbenefits.US

Benefits Department: [email protected]

Brenda Kercado – Benefits Specialist 1.407.915.8204 [email protected]

Liz Jordan – Senior Benefits Analyst 1.407.915.8199 [email protected]

Scott Hultgren – Senior Benefits Manager 1.346.308.8836 [email protected]

Vendor information:

American Benefits Group (ABG) Group Name: Mitsubishi Location: MHPSAEmployer/Registration ID: ABGMITPS

1.800.499.3539 www.amben.com [email protected] (Login Issues/Plan Questions)[email protected] (Card Requests)[email protected] (Claim Questions)

Cigna FMLA/STD/LTDPolicy #FML752253/LK752253/LK965528

1.888.842.4462 or1.800.362.4462

www.mycigna.com

Cigna Group Life/AD&D InsurancePolicy #FLX968139/OK969620

1.800.362.4462 www.mycigna.com

UMR Medical and Dental ServicesGroup #76-413133

Customer Service: 1.800.826.9781

NurseLine: 1.877.950.5083

Teladoc: 1.800.835.2362

www.umr.com

EyeMed VisionGroup #9769738 Plan: Insight

Customer Care Center: 1.866.939.3633 By Fax:

1.866.293.7373

www.eyemedvisioncare.comwww.eyemed.comFax/email out-of-network claims to: EyeMed Vision [email protected]

FidelityGroup #50450

1.800.835.5097 orFor Login Assistance: 1.866.612.4573

www.401k.com

Health AdvocateGroup Name: MHPSA

1.866.695.8622 [email protected]

HSA Bank 1.800.357.6246 myaccounts.hsabank.com/Login

InfoArmor 1.800.789.2720 [email protected]

MagellanOrganization Name: MHPSA

1.800.523.5668 www.magellanhealth.com/member

Medical Benefits Abroad (MBA®) 1.800.243.1348 www.CIGNAenvoy.com

PowerUP to Wellness 1.855.864.0721 https://[email protected] (General Support)[email protected] (Coaching Questions)

Rethink 1.877.988.8871 http://mitsubishi.rethinkbenefits.com

Contact Information/Links✁
