BENEFITS HANDBOOK — SUMMARY PLAN DESCRIPTION

A

Booklet A

Using Your Handbook and

Benefits Program

For questions and assistance with your benefits

or information in this booklet, contact the

HR Business Center at:

www.HR4Uonline.org

(650) 723-HR4U (3-4748)

October 2012

Understanding Your Benefits Program

Stanford Hospital & Clinics (SHC) wants you to understand how your benefit program works. This booklet

provides you with information about how to use your Handbook, a summary of your benefits, eligibility

information, when benefits begin and end and when you may enroll or make changes.

Welcome to Your Benefits Handbook ............................................................................... 1

Intent of Handbook .............................................................................................................. 2

How Your Benefits Program Was Developed ................................................................... 2

Choice ................................................................................................................................... 2

Flexibility ................................................................................................................................ 2

Value ..................................................................................................................................... 2

Competitiveness .................................................................................................................... 2

Who is Eligible ..................................................................................................................... 3

Eligible Dependents — A Definition of Dependents ........................................................ 3

Coverage if Both You and Your Spouse/Eligible Domestic Partner Work at SHC ......................................................................................................................... 4

Working Spouse/Eligible Domestic Partner Access Fee: ..................................................... 4

Summary of Your Benefits ................................................................................................. 5

Your Benefits ......................................................................................................................... 5

Enrollment ............................................................................................................................ 8

Other Benefits ...................................................................................................................... 9

Default Coverage ................................................................................................................. 10

Supporting Documentation Needed .................................................................................. 10

Special Enrollment Period .................................................................................................. 11

Cost of Coverage ................................................................................................................. 11

Paying for Eligible Domestic Partner Coverage............................................................... 11

When Coverage Begins ...................................................................................................... 12

Changing Your Benefits ..................................................................................................... 13

Changing Your Health Coverage and Flexible Spending Accounts...................................... 13

Making Changes to Health Plans Due to Mid-Year Qualifying Life Events .................................................................................................................................... 13

Changing Your Other Benefits ........................................................................................... 15

Life and AD&D Insurance ...................................................................................................... 15

Annual Open Enrollment Period ........................................................................................ 15

When Coverage Ends ......................................................................................................... 15

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For Your Covered Dependents .......................................................................................... 16

Options When Coverage Ends ........................................................................................... 16

Other Important Provisions ................................................................................................ 17

Coverage During an Approved Leave of Absence (LOA) ..................................................... 18

Certificate of Creditable Coverage .................................................................................... 20

Notes ..................................................................................................................................... 21

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Welcome to Your Benefits Handbook

Within this folder are 10 booklets which constitute your Benefits Handbook. These booklets are as follows:

A. Using Your Handbook and Benefits Program

B. Health Benefits

C. Income Protection Benefits – in case you become ill or disabled

D. Survivor Protection Benefits – if you or a family member dies

E. Tax Advantage Savings Accounts – an account to save tax-free money and incentive dollars to pay for

eligible health care and dependent care expenses

F. Additional Benefits – additional benefits provided to you by SHC

G. Retirement and Tax Deferred Annuity Plans – to help you build your retirement income

H. Retiree Medical Insurance – when you leave SHC on or after age 55

I. Administrative Information – contains information and resources to help you

The booklets are designed to help you learn about your benefits so you can use them effectively. Because

benefits are a major part of your total compensation, it is important to Stanford Hospital & Clinics (SHC) that you

understand and get the most from your benefits program.

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Intent of Handbook

This Handbook and the SHC benefits program apply to all eligible employees.

The information in this Handbook and in the Health Booklets from the medical plans and DeltaCare is intended

to provide a Summary Plan Description of the Stanford Hospital and Clinics benefit plans. It is your responsibility

to read this Handbook and the Health Booklets, and to ask questions if you need more information. It is also

your responsibility to visit the BenefitsConnect website via www.healthysteps4u.org to download your plan’s

Health Booklet. If you do not have access to a computer please contact the HR Business Center to have a

paper copy mailed to you. The website address and phone number is found in Booklet I.

The summary provided in this Handbook and in the Health Booklets is intended to provide an accurate

explanation of how your benefit plans work. It is not intended to serve as any form of contract or plan document.

If there is a discrepancy between the descriptions in this Handbook and the insurance contracts and plan

documents, the contracts and plan documents will always govern.

This Handbook does not serve as a guarantee of continued employment or benefits. SHC may change, modify

or terminate the benefits and policies described in this Handbook at any time.

How Your Benefits Program Was Developed

Before we begin, we would like to share our strategy in the development of this competitive benefits program.

First, we considered the organization’s missions and values to care, educate, and discover. This commitment

includes providing a comprehensive benefits program to SHC employees, and their families, that is flexible

enough to meet their changing needs. Next, we considered the competitive marketplace in which SHC operates.

In addition, the program also recognizes our shared responsibility of keeping the costs of benefits moderate and

manageable for all.

In summary, your benefits program offers you:

Choice

The opportunity to design your package of benefits – a package that reflects personal choices and individual

needs for coverage.

Flexibility

The freedom to adjust your benefit selections as your lifestyle changes.

Value

A carefully considered approach so that SHC can give you the best value for the money we spend.

Competitiveness

The chance for SHC to reward you with a package of benefits that is progressive and competitive in Northern

California.

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Who is Eligible

Employees who work at least 40 hours per pay period are eligible for the benefits described in this Handbook

with the following exceptions:

Fixed Term employees are not eligible for the Severance Pay Plan.

Represented employees should consult their collective bargaining agreement for information about

Education Assistance and Severance Pay benefits.

Temporary and Relief employees are covered under a separate program described in a separate

Handbook.

– Commitment B Relief Nurses who are members of CRONA are eligible for all benefits described in this

Handbook except the Retirement Plan, and must pay the full cost for any benefits elected.

– Commitment C and D Relief Nurses who are members of CRONA are eligible for all benefits described

in this Handbook, however, must meet the criteria outlined in Booklet G to be eligible for the Basic

Contribution.

Temporary agency, contract, or other workers who are not on SHC’s payroll are not eligible for any benefits.

Eligible Dependents — A Definition of Dependents

The following dependents are eligible for benefits

Legally married spouse

Eligible Domestic Partners who meets the following criteria:

– Is at least 18 years of age, and

– Is capable of consenting to the domestic partnership, and

– Shares a common residence with you, and

– Is not legally married to you, or anyone else, and does not have another domestic partner, and

– Is not related to you by blood or any other family relationship that would bar marriage in your state of

residence, and

– Is the same gender provided you and your partner are under age 62, or opposite gender if you or your

partner is over the age of 62 and meets the eligibility criteria under Title II of the Social Security Act as

defined in 42 U.S.C. Section 402(a) for old-age insurance benefits, or Title XVI of the Social Security Act

as defined in 42 U.S.C Section 1381 for aged individuals, and

– Consents to the jurisdiction of the Superior Courts of California for the purpose of a proceeding to obtain

a judgment of dissolution or nullity of domestic partnership or for legal separation of partners in the

domestic partnership, or for any other proceeding related to the partners’ rights and obligations, even if

one or both partners ceases to be a resident of, or maintain a domicile in, this state.

Eligible Children:

– Your children (including natural children, adopted children or children for whom you have initiated legal

adoption proceedings prior to age 18, stepchildren, children for whom you are the legal guardian up to

age 18, and children for whom you are required to provide health coverage resulting from a Qualified

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Medical Child Support Order [QMCSO]) up to age 26 (age 21 for dependent life insurance). Please note

children ages 19-26 are not eligible if they are eligible for coverage under another employer-sponsored

plan.

– Unmarried children, of any age, who are incapable of self-support and principally dependent on you or

your spouse/eligible domestic partner, as a result of physical or mental disabilities which began before

age 19.

Coverage if Both You and Your Spouse/Eligible Domestic Partner Work at SHC

You cannot be covered both as a dependent and an employee. If you have a dependent who is also eligible for

benefits as an employee, you can:

Both select coverage as employees. In this case, only one of you can cover your eligible children as

dependents, or

Decline coverage for one of you and enroll that person, along with eligible children, as dependents of the

one who elects coverage.

Exception: If you and your eligible spouse/eligible domestic partner both work at SHC and you both enroll in

benefits separately, you can both enroll your eligible children in dental plan coverage.

With regard to retiree medical benefits, when both spouses work for SHC and are eligible under different

categories, please consult with an HR Generalist to determine the appropriate classification at least five years

prior to retiring. Special rules apply for retiree medical coverage. See Booklet H for additional information.

Working Spouse/Eligible Domestic Partner Access Fee:

If your spouse or eligible domestic partner has access to other coverage but decides not elect that coverage,

and elects to join an SHC sponsored plan instead, your family will be required to contribute a monthly access

fee of $50 on a pre-tax basis. The fee applies if you meet all the following criteria:

Your spouse/eligible domestic partner is employed

Your spouse/eligible domestic partner is offered health coverage from his/her employer as a part of their

benefits package

Your spouse/eligible domestic partner declines that coverage

You enroll your spouse/eligible domestic partner in a SHC plan

You earn $27.51 or more per hour as of August 31, 2011, or your date of hire, whichever is later.

Please Note: If you claim your eligible domestic partner on your Federal Income Taxes, then the $50 access fee

for your eligible domestic partner is paid on a pre-tax basis. If you do not claim your domestic partner on your

Federal Income Taxes, the access fee is paid on an after-tax basis.

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Summary of Your Benefits

The following chart serves as a brief illustration of the components of your benefits program. Certain limitations may apply. Read this Handbook and your health plan’s Health Booklet for complete information about your

benefits.

Your Benefits

Your Choices Cost Sharing

Health Insurance

Medical UMR EPO

UMR PPO with HSA

Kaiser Permanente HMO

Waive coverage*

You share the cost depending on which plan you pick and who you cover.

Prescription For UMR members: Express-Scripts

For Kaiser Members: Kaiser Permanente

Included with Medical Coverage

Included with Medical Coverage

Working Spouse/Eligible Domestic Partner Access Fee

All SHC sponsored Medical Plans Employee Paid*

Dental DeltaPreferred Option DPO/PPO

DeltaCare HMO

Waive Coverage**

You share the cost depending on which plan you pick and who you cover.

Vision VSP Included with Medical Coverage

Mental Health/

Substance Abuse Insurance

For UMR members: United Behavioral Health, operating under the brand Optum

For Kaiser Permanente members: Kaiser Permanente plan

Included with Medical Coverage

Included with Medical Coverage

Survivor Protection

Employee Basic Life Insurance Your annual base salary or $50,000, whichever is lower.

Employer Provided

Employee Supplemental Life Insurance

You choose one to six times salary up to $3 million (combined with Basic Life).

Employee Paid based on employee’s age

Spouse/Eligible Domestic Partner Life Insurance

Available in $1,000 increments up to $200,000.

Waive coverage

Employee Paid based on employee’s age

Dependent Child Life Insurance $10,000 per child. You must purchase supplemental coverage for yourself.

Waive coverage

Employee Paid

Employee or Family Accidental Death & Dismemberment (AD&D) Insurance

You choose one to10 times your annual salary (increments of $10,000), from $10,000 up to $1 million.

Waive coverage

Employee Paid

Business Travel Accident Five times annual salary up to $500,000 maximum

Employer Provided

*Does not apply to employees who earn $27.50 or less per hour as of August 31, 2011, or your date of hire, whichever is later. Note, hourly rates do change on a yearly basis.

**If you waive your health coverage because you have coverage elsewhere, please read the Special Enrollment section.

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Your Choices Cost Sharing

Income Protection Benefits For Your Own Disability

First 12 months Insurance (SDI) California State Disability Insurance (SDI)

Automatic Payroll Deduction

Supplemental Short Term

Disability (STD) up to 6 months

Employee Paid (age-based)

Paid Family Leave (PFL)

After 6 months

Basic Long Term Disability (LTD) – 50%

Supplemental Long Term Disability – 66

2/3%

Automatic Payroll Deduction

Employer Paid

Employee Paid

House Staff Income Protection Benefits

Short Term Disability – after seven consecutive days of disability, and up to six months of consecutive disability

After 90 days

California State Disability Insurance*

Basic Long Term Disability (LTD) – 60%

Supplemental Long Term Disability – up to an additional $1500/month

Automatic Payroll Deduction + State Compensation

Compensation is based on past quarterly earning up to six weeks.

Employer Paid

Employee Paid. Purchase directly from the insurance company.

Paid Family Leave (PFL) California State Disability Insurance (SDI)

Automatic Payroll Deduction

Retirement Benefits

Retirement Plan* The Retirement Plan allows you to invest a portion of your pay

* on a tax-

deferred basis. You are eligible for this plan after you complete one year of service.

Note: Staff Pension Plan participants refer to the Staff Pension Plan Summary Plan Document.

After one year of service, SHC automatically deposits into your Retirement Plan account an amount equal to 5% of your eligible pay each pay period. You can contribute up to 4% of pay.

** SHC also matches your

contribution. So, you can save as much as 13% of your pay.

**

Tax Deferred Annuity

(TDA) Plan

A voluntary savings plan. You may contribute up to the IRS limits.

Retiree Medical

You may be eligible for retiree medical benefits if you are age 55 or older and meet the service requirements when you leave SHC.

Please reference Booklet I for more information on your Retiree Medical Plan options

*Benefits for House Staff employees may vary. Please See Booklet C for more information and eligibility requirements.

**You may be eligible for an enhanced contribution and match. For more information, see Your Contributions and the Special Provisions for Certain Employees in Booklet G

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Benefit Options Your Choices Cost Sharing

Tax Advantage Savings Accounts

Heath Savings Account (HSA)

Offered only with the PPO plan. SHC makes nontaxable contributions to this account four times a year. Employees can contribute to this account on a pre-tax basis and can use the funds to help pay for health care expenses now and in the future.

**You cannot enroll in both the HIA and the

HSA**

SHC may contribute up to $400 for one employee

SHC may contribute up to $800 for one employee + 1 or more dependents

For Employee only coverage, you may contribute up to $2,700 (including $100 for completing the SHALA)

For Employee plus one or more dependents, you may contribute up to $5,450 (including $100 for completing the SHALA)

Health Incentive Account (HIA)

Offered only with EPO or Kaiser HMO, the HIA will be set up to receive your wellness incentive dollars. Use this account to pay for eligible health care expenses. Any funds remaining in this account at the end of the calendar year will be lost.

Employer Contribution

Flexible Spending Account (FSA)

Offered with EPO, Kaiser HMO, or if you waive coverage. You may make contributions to this account on a pre-tax basis. Use this account to pay for eligible health care expenses. Any funds remaining in this account at the end of the calendar year will be lost.

You may contribute up to $3,000 in 2012; $2,500 in 2013

Dependent Daycare Reimbursement Account

Allows you to pay certain expenses on a pre-tax basis.

You may contribute up to $5,000 each calendar year.

Education Assistance Plan For approved courses, you will generally be reimbursed up to $1,000 each fiscal year (Sept 1-Aug 31).

Employer Provided

Liability & Malpractice Insurance

Protects you while working at SHC. Employer Provided

Employee Assistance Program (EAP)

Range of services: counseling, workshops, peer support groups.

Employer Provided

Severance Pay Plan If your job is eliminated and a comparable position is not available, the Severance Pay Plan continues your salary for a period of time based on service.

Employer Provided

Voluntary Benefits administered by Marsh U.S. Consumer

Auto Insurance Offers rates that may be lower than individual rates and provides a convenient payroll deduction of your premiums. Choose from a list of trusted insurance companies.

Employee Paid

Homeowners/Renters Insurance

This program offers: liability protection, living expenses should you be forced to live away from your home due to insured damage or disaster, coverage of your personal belongings if stolen or destroyed by insured disaster, coverage for the structure of your home should it need to be rebuilt or repaired due to damage by an insured disaster.

Employee Paid

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Benefit Options Your Choices Cost Sharing

Identity Theft Protect your identity: continuous monitoring of credit with email alerts, credit restoration and protection consultation services.

Employee Paid

Legal Insurance This provides you and your family access to legal advice and professional representation at an affordable price; plan fully covers telephone advice and office consultations.

Employee Paid

Online Discount Marketplace

This is a members only discount marketplace that brings hundreds of brand name retails and merchants right to you.

Employee Paid

Pet Insurance Helps pay for your pet’s treatments, surgeries, lab fees, x-rays and more.

Employee Paid

Purchasing Program Instead of using cash or credit card to make a purchase, this program lets you make payments directly out of your pay check in equal installments over 12 months.

Employee Paid

For more information visit: www.healthysteps4u.org

Enrollment

If you are a new hire* and meet the benefits eligibility requirements or a current employee transferring to a

benefit eligible position, you must enroll in your benefits through www.healthysteps4u.org within 31 days of the

date you became eligible or you will be assigned a “default” coverage. This default coverage is effective the first

day of the second month after your hire date. If you waived your health coverage because you had coverage

elsewhere and you lose that coverage, you may have the opportunity to enroll in a SHC health care option

pursuant to a Special Enrollment Period as described in Booklet B.

Each fall during annual open enrollment, you will be able to change your benefits elections under medical,

dental, Flexible Spending Accounts and legal plan. If you do not make changes during annual open enrollment,

you will receive the same coverage you had the previous year, but you will not be able to contribute to the

Flexible Spending Accounts. You must actively enroll in the Flexible Spending Accounts during annual open

enrollment each year in order to participate for the following year. If you waived your health coverage because

you had coverage elsewhere and you lose that coverage, you may have the opportunity to enroll in a SHC

health care option pursuant to a Special Enrollment Period as described in Booklet B.

*Default coverage for House Staff is effective the first of the month following the Date of Hire.

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Other Benefits

When you become eligible*, you are automatically enrolled in the Basic Life, Basic Long Term Disability (LTD),

and Liability and Malpractice insurance plans.

For other benefits, you must enroll yourself and any eligible dependents, as well as authorize any applicable

payroll deductions. You can enroll through, www.healthysteps4u.org within 31 days of the date you become an

eligible employee or are permitted to make a change in your enrollment.

If you do not need medical insurance, select the “waive coverage” option when you enroll through

www.healthysteps4u.org.

To enroll your eligible dependents, the HR Business Center must verify their relationship to you. Within 60 days

of the date you are first eligible for benefits, marry, start a new eligible domestic partnership, or acquire a new

dependent you must submit the following documents to HR Business Center to verify your dependents’

relationship to you:

To enroll your spouse: a marriage certificate and either: (1) a copy of page 1 of your most recently filed

federal tax return listing your spouse (please black out all financial information), or (2) a recurring monthly or

quarterly household bill or account statement listing your spouse’s name at your address and dated within

the past 60 days.

To enroll your eligible domestic partner: a copy of your State of California Declaration of Domestic

Partnership form AND a recurring monthly or quarterly household bill or account statement listing your

partner’s name at your address and dated within the past 60 days.

To enroll eligible children, one of the following:

– A birth certificate, or

– A copy of the Qualified Medical Child Support Order (QMCSO), or

– A copy of certificate of adoption or legal guardianship from a U.S. court or immigration office.

To enroll eligible children over the maximum age: proof of their physical or mental incapacity. Proof must be

submitted directly to the medical plan carriers. Recertification will occur every 2-3 years depending on the

medical plans requirements.

Please Note: If you are covering a stepchild and your spouse/eligible domestic partner is not a covered

dependent, you must also provide documentation for your spouse/eligible domestic partner as requested above.

*Important: House Staff are auto-enrolled in the Basic Long Term Disability plan.

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Default Coverage

As a new hire or if you transfer to a benefit eligible position, you must complete your enrollment process through

www.healthysteps4u.org within 31 days of becoming benefit eligible or you will be assigned default coverage*.

You may only change your default coverage during annual open enrollment unless you experience a mid-year

qualifying life event during the year.

Default coverage is for you only and will be effective on the first day of the second month after you became

benefit eligible. Default coverage consists of the following benefits:

Medical – UMR PPO (employee only). Medical includes Health Savings Account (HSA), prescription drug,

vision, mental health and substance abuse benefits.

Dental – Delta Dental PPO (employee only)

*Important: Medical default coverage for House Staff is the EPO plan, which includes the prescription, vision and mental health coverage.

Coverage begins the first of the month following your date of hire.

Supporting Documentation Needed

When you are adding or removing a dependent from your benefits, you must provide the supporting

documentation to prove your relationship with this dependent within 60 days from the date of the event. Here is

a list of a few of them:

When you want to You need to provide

Add a new spouse A marriage certificate and either: (1) a copy of page 1 of your most recently filed federal tax return listing your spouse(please black out all financial information), or (2) a recurring monthly or quarterly household bill or account statement listing your spouse’s name at your address and dated within the past 60 days.

Add a spouse/eligible domestic partner or adult child who lost health coverage

COBRA/HIPAA notice or a letter of certification indicating loss of health coverage. Please note the notice or letter indicating the spouse/eligible domestic partner or adult child’s loss of health coverage must come from the source providing health care – i.e. their employer.

Add a child A copy of the birth certificate, adoption certificate or court order of legal guardianship.

Add an eligible domestic partner Declaration of Domestic Partnership filed with the State of California AND a

recurring monthly or quarterly household bill or account statement listing your partner’s name at your address and dated within the past 60 days.

Remove a spouse Divorce decree, court documentation for Legal Separation or proof of spouse benefits coverage elsewhere.

Remove a domestic partner Notice of Termination of Domestic Partnership filed with the State of California.

Remove an adult child who gained health coverage from another employer

Proof of health care coverage with new employer.

Retain a child over age 26 Proof of physical or mental incapacity must be submitted to medical carrier every two to three years based on their requirement.

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Special Enrollment Period

If you decline enrollment for yourself or your dependents (including your spouse or registered domestic partner)

because either you or your dependent had health insurance coverage under another group health plan or other

health insurance, you may be able to enroll yourself or your dependent in one of the health care options offered

through SHC in the future if you enroll within 31 days of the event. For a list of mid-year qualifying events,

please see page A-13.

Cost of Coverage

Your share of the cost of your benefits depends on which plans you choose and which family members you

cover. For some benefits, such as life and disability insurance, the cost may also depend on your age and/or

covered salary.

Contributions to the Retirement Plan and the Tax Deferred Annuity Plan are taken from each paycheck.

Deductions for other benefits are taken over 24 pay periods*.

Payroll deductions for your health insurance are taken on a pretax basis. This election remains in effect until

you revoke it. There are special rules for covering eligible domestic partners discussed below.

Contributions to the Retirement Plan can be taken on either a pretax or post-tax basis. You may change

your contributions to a post-tax basis (or vice versa) at any time. However, pretax contributions to the Plan

will automatically change to post-tax if you reach the IRS maximum in any year. (In this case, contributions

will revert back to pretax on January 1 – unless indicated otherwise.)

Deductions for life, AD&D, disability or any of the Voluntary Benefits plans must be taken on a post-tax

basis.

Deductions for the Tax-Deferred Annuity Plan and the Tax Advantage Savings Accounts are always taken

on a pretax basis.

*With the exception of Voluntary Benefits deductions, which are taken over 26 pay periods.

Paying for Eligible Domestic Partner Coverage

The IRS generally does not recognize eligible domestic partners (or their children) as legal dependents for

income tax reporting. If you elect health coverage for your eligible domestic partner or their children, your share

of the cost for their coverage will be deducted from your pay after taxes are taken.

Your payroll deductions for providing medical and dental coverage for your domestic partner are the same as

that charged for a legal spouse. However, federal law requires that the value of your domestic partner's benefits

be treated as ordinary taxable income to you unless the domestic partner qualifies as a tax dependent under the

Internal Revenue Code. This is called imputed*(taxable) income. You will be taxed on this imputed income,

unless you certify that your domestic partner is your tax dependent. You will also be taxed on the amount that

SHC pays to provide medical and dental benefits to your Partner's child(ren) unless you are enrolling at least

one child who is your dependent. You must certify that the child is your dependent.

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In order to qualify as a tax dependent, a Domestic Partner or your partner’s child must:

Receive over 50% of his or her support from you for the year; and

Have your home as his or her principal abode for the entire year, and

Be a member of your household.

When you initially enroll your eligible domestic partner and/or your eligible domestic partner’s children, you will

fill out the Imputed Income Certification Form as part of your enrollment process, found on the BenefitsConnect

website via www.healthysteps4u.org. This form will help determine whether imputed income will be applied to

your situation or not. If the tax status of your eligible domestic partner or eligible domestic partner’s children

changes during the year, you are responsible for contacting the HR Business Center to have the eligibility status

changed.

*Imputed Income – additional compensation employees receive as cash or as benefits that is considered taxable.

When Coverage Begins

Benefit Type When it Becomes Effective:

Health, Short Term Disability, Supplemental Life and Supplemental LTD Insurance, and Dependent Daycare FSA and Health Care FSA Contributions:

If you enroll on time, coverage begins:

The first day of the month after you are hired*,

The first day of the month after you become eligible for benefits, or

The first day of the month after a mid-year qualifying life event described in this booklet.

New Children

If you enroll on time, coverage for new children is effective as of the date of their birth, adoption, placement for adoption or the date you are legally obligated to provide support.

Basic Life and Basic LTD Insurance: The first day of the month after you are hired or become eligible for benefits, whichever is later. You must be actively at work on the date your coverage begins.

TDA Plan: Deductions are effective the first day of the month following the date in which you made your online elections.

Legal Insurance: First of the month following the date in which you made your online election. If your election is made during annual open enrollment your benefit will be effective January 1st of the following year.

Retirement Plan:

SHC’s basic contribution begins the first pay period after you complete one year of service. Your contributions and SHC’s matching contributions begin the first pay period after you complete the waiting period or the HR Business Center processes your enrollment form, whichever is later. See Booklet G for more information about who is eligible for the Retirement Plan and when you begin participating in the Plan.

Liability and Malpractice Insurance: Your first day at work.

BTA Insurance: Your first day at work. *Important: Medical, Prescription and Mental Health & Substance Abuse coverage for House Staff is effective as of the date of hire if

enrolled in on time.

If a Statement of Health (SOH) is required, coverage begins the first day of the month after the insurance company approves

your application. See Booklets C and D for information about when a Statement of Health (SOH) is required for the life and

disability insurance plans.

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Changing Your Benefits

Each year SHC gives you the opportunity to change your medical/vision/dental plans, enroll in or change your

FSA, add or delete family members from your coverage or enroll if you had previously waived coverage. You

may not change your election during the year unless certain events occur. A list of these events and the types of

changes you can make are discussed below. These change “rules” are regulated by the federal government.

Changing Your Health Coverage and Flexible Spending Accounts

Once enrolled in your health plans, the Health Care FSA and/or the Dependent Daycare FSA, you can only

make changes to your benefit elections within 31 days of a mid- year qualifying life event* (see table below for

general rules for making changes to your health plan elections during the year) or during annual open

enrollment each fall. Annual open enrollment changes are effective on January 1st of the following year.

Election changes made during the year due to a birth or adoption of a child are effective on the date of the

event, provided the change was made within 31 days of the life event. To request a change, you must log on to

BenefitsConnect via www.healthysteps4u.org and click on the “Work & Life Events”. Election changes made

during the year for all other qualifying events are effective on the first day of the month following the date of the

event. You must provide proof of the event.

If one of your dependents is no longer eligible for coverage, you must log on to BenefitsConnect via

www.healthysteps4u.org and click on the “Work & Life Events”, even if you continue to cover your other

dependents. Failure to timely notify SHC of your dependent’s loss of eligibility will result in your dependent’s

claims being denied and loss of COBRA rights.

*Changes to health plans must be made within 60 days of a CHIRPA event.

Making Changes to Health Plans Due to Mid-Year Qualifying Life Events

When One of These Events Occurs During the Calendar Year...

You May Make the Following Changes to Your Health Plan Elections (subject to the general rules outlined above)

Acquire new dependents through marriage/eligible domestic partnership, birth, adoption (placement for adoption) or legal guardianship.

Add dependent coverage.*

Add new spouse/eligible domestic partner and any eligible children.

If you are not enrolled, you can enroll yourself, your spouse/eligible domestic partner and any eligible children.

If you will be covered under your new spouse/eligible domestic partner’s plan, you can stop SHC coverage.

Change in dependent’s status, e.g. child reaches maximum age, death of a dependent, divorce/annulment/end eligible domestic partnership. You may also make a change if you obtain a legal separation – although you are not required to make a change until divorce/annulment.

Stop coverage for spouse/eligible domestic partner or child who is no longer eligible.

If divorce or death cause you or your eligible children to lose other coverage, you and your eligible children may enroll in SHC’s plans.

**

Change in Your or Dependent’s Employment Status which affects eligibility for health coverage, such as termination or commencement of employment, the commencement or return from an approved unpaid leave of absence, a change from part-time to full-time status (or vice versa), a change in hours or a strike or lockout.

Drop dependent coverage.*

Add spouse/eligible domestic partner and children to your SHC plans if they are losing other coverage.

**

If you are losing other coverage and you are not enrolled in SHC’s plans, you can enroll yourself, spouse/eligible domestic partner and children.

**

If the event is the commencement or return from a leave of absence (LOA), you may cancel coverage and re-enroll when you return to work (see page A-18 and your LOA information package).

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When One of These Events Occurs During the Calendar Year...

You May Make the Following Changes to Your Health Plan Elections (subject to the general rules outlined above)

Medicare or Medicaid Eligibility***

You may cancel medical coverage for the individual who becomes eligible for Medicare or Medicaid.

You may enroll the individual who loses Medicare or Medicaid coverage.

Judgment, Decree or Order, including a qualified medical child support order (QMSCO), which requires you (or your former spouse/eligible domestic partner) to provide health coverage for a child. The order may be the result of a divorce, legal separation, annulment or change in legal custody.

You may add your child to your coverage.

If you are not enrolled, you and your child may enroll in one of SHC’s medial/vision and dental plans.

You may cancel coverage for the child if the order requires your former spouse or other individual to provide coverage for the child.

Change of Residence or Worksite You may change your medical/vision and/or dental plan if you move out of your current plan’s service area.

Change in SHC Health Coverage, e.g. SHC adds or eliminates a plan option or significantly limits coverage under an option

If you are already enrolled in a plan, you may change plans.

If you are not currently enrolled, you may enroll only if a new plan is being offered.

Significant Increase or Decrease in Cost of SHC Health Coverage

If cost increases, you may change to a less expensive plan. If you are not currently enrolled and cost decreases, you may enroll in the plan with the cost decrease.

(Note: Changes are not allowed for insignificant cost changes. Also, insignificant cost changes for SHC coverage may result in an automatic change in your payroll deduction.)

Health Plan Election Change Under Spouse/Eligible Domestic Partner’s Employer Plan, if the other employer’s open enrollment period is different from SHC’s open enrollment period.

If your dependent cancels coverage under his/her employer’s plan, you may:

– Add the dependent to your plan, or

– Enroll yourself and dependent in a SHC plan.

If your spouse/eligible domestic partner had previously declined his/her employer’s coverage and now enrolls, you may cancel their SHC coverage.

If you enroll in your spouse/eligible domestic partner’s employer plan, you may cancel SHC coverage.

You or Your Dependent Lose Other Coverage for Any Reason Not Mentioned Above

**

You may enroll the dependent who is losing the other coverage.**

If you are not enrolled, you may enroll yourself and the dependents losing the other coverage.

**

*You and you dependent are entitled to a 30-day HIPAA Special Enrollment Period to reelect benefits. Special enrollment rights must

mirror the enrollment rights typically available for similarly situated Individuals at initial enrollment. **These special enrollment rights are available if you meet both of these conditions:

1. You declined SHC coverage when you were hired or at the last open enrollment , and

2. You (or your spouse/eligible domestic partner or your dependent) lose other coverage because you exhaust your rights to COBRA

coverage, employer contributions to the other coverage stop, or you are no longer eligible under that other coverage. ***

Under the Children’s Health Insurance Program Reauthorization Act (CHIPRA), if you or your eligible dependents lose eligibility for

coverage under a state Medicaid or CHIP program, or become eligible for state premium assistance under Medicaid or CHIP, you or your

dependents can enroll in the SHC/LPCH medical plan as long as you request coverage within 60 days of being terminated from Medicaid

or CHIP coverage, or within 60 days of being determined to be eligible for premium assistance.

Changes to benefits, including removing dependents who are no longer eligible for benefits, may be made by

visiting www.healthysteps4u.org. Failure to notify SHC of your dependent’s loss of eligibility will result in claims

being denied and loss of COBRA rights.

For information about when you can make changes to Flexible Spending Accounts, please refer to Booklet E.

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Changing Your Other Benefits

Life and AD&D Insurance

When you experience a mid-year qualifying life event, you may keep your coverage at the same level or make

any one of the following changes in coverage, subject to any Statement of Health (SOH) requirements:

Decrease your coverage;

Increase your coverage including enrolling for the first time.

You must apply for the change in coverage within 31 days of the date of the mid-year qualifying life event. Such

changes in coverage must be due to or consistent with the reason that the change in coverage was permitted.

Changes to your life and disability benefits are effective the first day of the month after the later of:

The date you elect the additional coverage through www.healthysteps4u.org, or

The date the insurance company approves your change request, if a Statement of Health (SOH) is required.

Annual Open Enrollment Period

During the annual open enrollment period you may:

Enroll in or change medical and dental plans.

Add/delete dependents to your medical and dental plans.

Enroll or re-enroll in the Flexible Spending Accounts and Health Care Spending Account*.

Add, change or drop legal care coverage.

Re-elect your annual contribution to your HSA. If you miss your opportunity during Open Enrollment, you

can make changes any time after the new year begins.

Changes made during the annual open enrollment period are effective the following January 1.

Unless you make changes through www.healthysteps4u.org, your health plan elections will automatically

continue in the next calendar year.

*Participation in the Flexible Spending Accounts and the Health Care Spending Accounts does not automatically renew. The election you

made for the current calendar will reset on the first day of the new calendar year. You must re-enroll each year to continue participation in

these tax advantaged savings accounts. You may, however, change your HSA elections at any time during the year.

When Coverage Ends

This section defines when the benefits coverage will end for you and your covered dependents. It also describes

how to continue coverage through the Consolidated Omnibus Budget Reconciliation Act (COBRA) and

individual policy conversion options.

Your coverage as an active employee ends on the last day of the month in which the first one of the following

events occurs:

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You stop working;

Your employment terminates;

Your pay ends;

You are no longer an eligible employee;

You stop making required contributions; or

The plan terminates.

For Your Covered Dependents

Coverage for your dependents (see definition of “covered dependent” for more information) under SHC benefit

plans (as applicable) ends on the earliest of the following:

The date your coverage ends for any reason.

The date you elect to stop dependent coverage either during annual open enrollment or within 31 days of a

qualifying life event.

The date in which your dependent ceases to be a dependent as defined by the plan for any reason,

including age, marriage, divorce, legal separation or termination of a domestic partnership arrangement.

The date the dependent enters active duty in the armed services of any state, country or international

authority.

The date SHC terminates the dependent's coverage for nonpayment of the required contributions.

The date SHC terminates any of its benefit plans, to the extent the plan termination would affect your

benefits.

Options When Coverage Ends

When your coverage as an active employee ends, you may be able to continue certain insurance plans as

follows:

You, or your covered dependents, may be able to continue health insurance and Health Care FSA

contributions under COBRA. See Booklet B for information on COBRA.

You, or your covered dependents, may be able to convert your medical insurance to an individual policy.

See Booklet B for information about converting your medical insurance to an individual policy.

You may be able to continue your Basic Life and Supplemental Life insurance under the insurance

company’s conversion and portability options. See Booklet D for information about options when your Life

insurance coverage ends.

You may be able to convert and become insured under MetLife’s group disability conversion policy without

submitting Statement of Health (SOH) when, as a Covered Person, you terminate employment with a

Sponsor and are no longer insured under the policy. See Booklet C for information regarding MetLife’s

disability coverage.

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Other Important Provisions

While you are on an approved leave of absence, your benefits continue as long as you continue to pay the

required premium. See the chart on page A-18 for information about continuing your benefits during an

approved leave of absence.

Disability insurance ends on the date a terminating event occurs. If you are receiving disability benefits, your

disability benefits continue until you are no longer disabled or until you reach the maximum benefit period,

whichever occurs first.

Coverage under the Health Care FSA ends on the date of termination. Any eligible medical expenses

incurred on or prior to the date of termination may be submitted for reimbursement. Reimbursement will be

made based on annual election and account balance.

If you leave regular employment on or after age 55, and meet certain age and service requirements, you

may be eligible for retiree medical benefits. See Booklet H for information about retiree medical insurance.

CRONA C and D Commitment Relief Nurses who are off call one month or more may continue benefits at

full cost for up to 12 weeks.

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Coverage During an Approved Leave of Absence (LOA)

Medical/Vision, Dental, Life, Disability, AD&D, Legal Care

Tax Advantage Saving Accounts, Retirement

and TDA Plans

Who pays for your coverage during an approved leave of absence

You pay a subsidized cost (the same as if you were still an

active employee) during the first six months (consecutive or in combination of months) of:

Medical, pregnancy disability, family and military leaves; and

All paid personal and educational leaves.

You pay the full cost during:

Unpaid personal leaves, educational leaves or any medical leave over six months (consecutive or in combination of months).

All contributions to the Retirement and TDA Plans stop when pay/PTO ends and automatically resume when you return to work. See Booklet G for information about loan payments to your TDA Plan account while you are on an approved leave of absence.

You may continue to participate in the Reimbursement Accounts by prepaying your contributions or by sending checks during your leave. In this case, payroll deductions automatically resume when you return to work. Or, you may stop your participation in the Accounts. In this case, you must re-enroll within 31 days of the date you return to work. See Booklet E for information about submitting claims to your Tax Advantage Savings Accounts during an approved leave of absence.

Changing benefits during a leave of absence

You may change your benefits under the same conditions that active employees are allowed to make changes.

If you have a planned Leave of Absence (ex: pregnancy, scheduled surgery, etc.), you may prepay your share of the cost to continue coverage during your leave of absence.

If you discontinue your contributions or drop your coverage during your leave, please refer to “Resuming your benefits when you return to work” on how to re-enroll.

Medical/Vision or Dental Plans

You may enroll yourself, your spouse/eligible domestic partner and/or any eligible children within 31 days of the birth or adoption of a child. You must enroll, if you have not already enrolled in order to cover dependents. If you are adding an eligible Domestic Partner, Imputed Income may apply.

If you are enrolled, you may change your medical plan option. See the chart on page A16-A17 for more details. You may also drop your coverage (or dependent coverage) if you will be covered under your spouse/eligible domestic partner’s plan.

Employee Supplemental Life Insurance

You may enroll in the amount of 1x your base annual salary without Statement of Health (SOH) within 31 days of the birth or adoption. You may purchase coverage levels up to 6x your base annual salary within 31 days of the birth or adoption; however, a SOH is required.

If you are already enrolled, you may increase your coverage level in the amount of 1x your base annual salary within 31 days of the birth or adoption, without a SOH.

Coverage starts the first day of the month after you become eligible, or if evidence of good health is required, coverage starts the first day of the month after approval by the insurance company, whichever is later.

Dependent Child Life Insurance

You may enroll your dependent children within 31 days of the birth or adoptions of your child.

Coverage starts the first day of the month after you become eligible, or if evidence of good health is required, coverage starts the first day of the month after approval by the insurance company, whichever is later.

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Medical/Vision, Dental, Life, Disability, AD&D, Legal Care

Tax Advantage Saving Accounts, Retirement

and TDA Plans

AD&D Plan If you are currently enrolled in employee only coverage, you may change to Family Coverage or you can increase your current coverage amount within 31 days of the date of birth/adoption.

If you are currently not enrolled in the plan, you may enroll in employee only coverage or Family Coverage within 31 days of the birth/adoption. Your Beneficiary designations may be reviewed or changed at any time.

Supplemental STD & Supplemental LTD Plans

You may stop your Supplemental STD or Supplemental LTD coverage (or elect to enroll in one of these plans) at any time, by submitting a change request form to the HR Business Center. If you elect to stop coverage, your change request form will be processed as soon as administratively possible.

For new coverage, a SOH is required. Your coverage will be effective the first day of the month after the insurance company approved your application. If you are absent from work on the date your coverage begins, your coverage becomes effective when you return to work.

When benefits end

House Staff: Refer to the House Staff Policies & Procedures Handbook

Earliest of:

Leave ends and you do not return to work.

Plan is terminated.

You stop paying your share of the premium.

When you or your dependent are no longer eligible.

Six, consecutive or in combination, months (seven months if you take a combination of pregnancy disability and family leaves, CRONA with over 15 years of service, or you take a military leave).

Options when benefits end

See page A-16

Resuming your benefits when you return to work

You continue benefits during your leave by paying your share of the portion, if applicable, up to six months (consecutive or in combination of months).

Insurance you discontinue, or which terminates during your leave is effective the first day of the month after you return to work – if you re-enroll within 31 days of your return. You may re-enroll in the same benefits you had before your leave.

However, a Statement of Health (SOH) is required for the life and disability plans.

You may be eligible to make up contributions to the Retirement Plan and TDA Plan when you return to work following a military leave that qualifies under the Uniformed Services Employment and Reemployment Rights Act (USERRA).

Refer to the LOA policy for more information about when your benefits resume when you return to work.

Changing your benefits when you return to work

You may change your benefits when you return to work under the same conditions active employees are allowed to make changes.

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Certificate of Creditable Coverage

When your coverage under the health plans ends, you will need to obtain a "Certificate of Creditable Coverage"

from VITA, our COBRA administrator. This document states how long you were continuously covered under the

health care plans. SHC is mandated to provide this certificate by HIPAA, a federal law that requires employers

to reduce their coverage exclusions for pre-existing health care conditions by the amount of time an employee

was previously covered continuously under another health care plan.

You will need this certificate even if you elect to continue your coverage through COBRA. When your COBRA

coverage ends, you must obtain another certificate from VITA stating how long you were continuously covered

by COBRA.

Your Certificate of Creditable Coverage can help reduce the amount of time you are subject to any exclusions

for pre-existing health conditions under a future health care plan. Your Certificate of Coverage can help you

prove how long you were previously covered.

For more information or to request a Certificate of Coverage, contact VITA:

VITA Administration Company

900 N Shoreline Blvd

Mountain View, CA 94043

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Notes