Contents Benefits Booklet.pdf · Mount Sinai Medical Center will continue to promote a healthy...

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ContentsWelcome …………………………………………………………………………………… 2

Wellness Offerings ………………………………………………………………………… 4

Medical …………………………………………………………………………………… 5

EPO Plan …………………………………………………………………………………… 6

HMO Low & HMO High Plan …………………………………………………………… 11

Pharmacy ……………………………………………………………………………… 16

Dental …………………………………………………………………………………… 17

Vision …………………………………………………………………………………… 20

2015 Contribution Rates ……………………………………………………………… 21

Long Term Disability Plan ……………………………………………………………… 23

Basic Life Insurance Plan ……………………………………………………………… 24

Flexible Spending Accounts: …………………………………………………………… 25

Healthcare Spending Account …………………………………………………… 25

Dependent Care Spending Account ……………………………………………… 25

Retirement Plan ………………………………………………………………………… 25

Colonial Life Plans ……………………………………………………………………… 26

Voluntary Short Term Disability Plan ……………………………………………… 26

Employee Assistance Program ………………………………………………………… 27

Additional Value-Added Benefits ……………………………………………………… 28

Important Notice About Prescription Drug Coverage ………………………………… 30

The information contained in this booklet is only a summary of coverage and is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Should there be differences between the information in the booklet and the contract, the contract will govern.

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Welcome to Your Benefits ProgramIt is time to enroll in your Mount Sinai Medical Center (MSMC) employee benefits for 2015. These benefits are for all eligible employees. This booklet has been provided to inform you of all the benefit options available to you. Please take the time to review the various plan designs and coverages when deciding which option(s) best fit your needs for the 2015 plan year.

What’s new for 2015?l No increase in Employee Premiums

We are pleased to announce that in 2015 the Medical (Non-Tobacco), Dental, Vision, Life and Long Term Disability bi-weekly premiums will not be increasing. In addition, the Medical plan co-pays, deductibles and co-insurance (if applicable) for services received from Mount Sinai and Miami Children’s Hospital (Tier 1) providers will remain the same.

l Annual Deductible increase for EPO, HMO Low and HMO High plans for Tier 2 (Non-MSMC or Non-MCH) providersPreventive services and prescriptions drugs will continue to be excluded from the annual deductible. The annual deductible for services provided by a Tier 2 provider will increase as follows:

o EPO – $1,200 per year for Individual and $2,400 per year for Familyo HMO Low and HMO High – $800 per year for Individual and $1,600 per year for Family

l Physician Office Co-pays increase for Tier 2 (Non-MSMC or Non-MCH) providersThe office co-pay for physicians who are in United Healthcare’s network, but not employed by Mount Sinai Medical Center or Miami Children’s Hospital will increase to $35 for primary care and $60 for specialist care.

l Prescription Drug PlanMount Sinai Medical Center is introducing an out-of-pocket (OOP) maximum for the prescription drug plan which is limited to:

o Individual – $3,600 out-of-pocket maximum o Family – $7,200 out-of-pocket maximum

Co-pays for generic prescription drugs will continue to be $15. Co-pays for specialty drugs will continue to be 10% up to $250. Co-pays for brand name preferred and brand name non-preferred will increase to $40 and $60 respectively. You will continue to be able to purchase a 90 day supply for the cost of a 60 day supply through mail order.

l Mandatory Tobacco Testing for Spouses/Domestic Partners Enrolled in Medical PlanIn continued support of our efforts to promote health and well-being, mandatory tobacco testing will be required of all employees and employees’ spouses/domestic partners participating in Mount Sinai Medical Centers’ Employee Medical Insurance plan. The tobacco test will be administered within the Occupational Health office as part of the wellness screening process. To schedule an appointment for you and for your spouse/domestic partner, please contact the Occupational Health Office at (305) 674-2312.

Employees and/or their spouses/domestic partners testing positive for tobacco use will result in the employee being charged a bi-weekly tobacco premium in addition to their medical premium. Also, employees and/or their spouses/domestic partners enrolled in the Medical Insurance Plan that do not complete a tobacco test will result in the employee being charged a bi-weekly tobacco premium in addition to their medical premium.

Employees and/or their spouses/domestic partners, who test positive for tobacco use are encouraged to participate in Mount Sinai’s on-site Smoking Cessation program. Successful completion of the program could result in a premium reduction. For information on the Smoking Cessation program, please contact Cathy Torres at (305) 674-7629.

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l Enhanced Wellness Program (Biometric Screening)Mount Sinai Medical Center will continue to promote a healthy workforce through our Healthy for Life Medical Insurance Discount Program. To qualify for the Healthy for Life discount, employees need to complete the biometric screening and meet or show improvement in four (4) of the six (6) outlined biometric measures.

There are six (6) biometric measures: Body Mass Index, Systolic Blood Pressure, Diastolic Blood Pressure, LDL Cholesterol, HDL Cholesterol and Diabetes Screening.*

Additionally, the employee must log onto www.myuhc.com to complete an online Health Risk Assessment (only if one was not completed in the past).

Please contact the Occupational Health Office at (305) 674-2312 to schedule your appointment.

Remindersl Primary Care Center

Employees are encouraged to use Mount Sinai primary care physicians as their health care provider. Co-payments will be waived after deductible is met for employees who use Mount Sinai Medical Center primary care physicians for their healthcare needs.

l Flu ShotAs required by the Centers for Medicare and Medicaid, summary vaccination data about our healthcare personnel, including all employees that receive a paycheck, medical staff, students and volunteers that provide care, treatment or service at the medical center, will be reported to the National Health Safety Network (CDC). Please note, individual vaccination data will not be reported.

To promote vaccination among Mount Sinai Medical Center employees, the influenza vaccination will be included in the Healthy for Life Wellness Program. Employees are encouraged to call the Occupational Health Office to schedule their annual flu vaccination.

During your enrollment, you will be meeting with a benefits professional who can answer questions about the benefit plans available to you.

What Do You Need To EnrollWhen it is time for you to enroll, you will need to have the following items on hand:

l This booklet as a reference.

l Your employee identification number.

l The names, Social Security numbers, dates of birth and addresses of any/all dependents you may wish to enroll in one or more of the plans.

l Life Insurance beneficiary information.

l If you are adding a new dependent to the Medical, Vision or Dental Insurance plans, proof of dependent status (i.e. copies of marriage license, birth certificate, court order, Domestic Partner Registration or Certificate).

*Your health plan is committed to helping you achieve your best health status. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact your Benefits & Wellness Department 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.

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Wellness O�eringsMount Sinai Medical Center promotes a healthy workforce through our comprehensive

Healthy for Life Wellness Program:

l Free Biometric Screenings and Flu Vaccine: MSMC o�ers free annual biometric screenings, including blood pressure, BMI, cholesterol and HgA1C. In addition, the �u vaccine is available free of cost to all employees.

l Health Risk Assessment: An online resource used to help the employee identify and track health risk factors as well as the progress made toward improving any risks.

l Onsite Wellness Coaching: Available free of cost to all employees who want to make positive changes to improve any aspect of their wellbeing. The Health Coach will help each individual explore their personal goals and options, identify potential barriers to success and create a plan of action to address barriers.

l Health and Wellness Education: Mount Sinai Medical Center provides continued employee education to support our wellness culture through Lunch & Learn workshops, the Healthy for Life corner in our Employee Bulletin, a monthly Health Education Table in front of our cafeteria and Onsite Health Coach participation in Departmental Sta� meetings.

l Nutrition and Weight Management Programs: Onsite Weight Watchers at Work®, Healthy for Life menu at the cafeteria, healthier food options at Medical Center sponsored events, healthier vending machines and an onsite pick-up location for the Endlessly Organic® produce buying club.

l Physical Activity Programs: MSMC acknowledges that promoting increased physical activity is the most e�ective way to improve overall health. We o�er onsite Zumba and CrossFit classes on our Main Campus. We also promote a Walking Club, encouraging employees to enjoy the beautiful scenery while keeping active at work.

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Group Medical Insurance Mount Sinai Medical Center offers a choice of three (3) Medical Plan optionsadministered by United Healthcare:

l EPO

l HMO Low

l HMO High

All three medical plans have open access to a comprehensive network of physicians and hospitals. Your contribution for the Medical Plan is deducted on a pre-tax basis*.

You may provide coverage to an eligible dependent child up to the end of the month in which they turn age 26.


United Healthcare Member ServicesPhone: 800-842-4194Website: www.myuhc.comGroup No. 701799

*Taking Advantage of Pre-Tax BenefitsMount Sinai Medical Center has put into place a Section 125 Pre-Tax Plan. Certain coverages you contribute to are deducted from your paycheck on a pre-tax basis. The IRS stipulates that when you elect to have your deductions taken out with pre-tax dollars, you also agree to remain in the benefit plan of your selection for one full year, unless you experience a change in family status. Examples of changes in family status may include the following:

l Marriage l Birth/adoption of a child l Spouse loses his/her jobl Divorce l Death of a spouse/child l Loss of other Coverage

You must meet with a Benefits Representative at Human Resources within 30 days of the family status change and provide appropriate documentation. For Medicare-Eligible Employees:Contained in this enrollment guide is the Certificate of Creditable Coverage for Plan Members who will be in the following plan: 1) United Healthcare High Plan. Also enclosed is the certificate of Non-Creditable Coverage for Plan Members who will be enrolled in the following two plans: 1) United Healthcare EPO Plan; 2) United Healthcare HMO Low Plan. These Certificates of Coverage apply to the new Medicare Part D coverage that became available to Medicare-Eligible Individuals starting on 1/1/2006. The information contained in this booklet is only a summary of coverage and is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Should there be differences between the information in the booklet and the contract, the contract will govern.

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This is a summary of bene�ts. Refer to your Summary Plan Description for covered services and exclusions. Bene�ts are determined in accordance with the terms of the Summary Plan Description.

Calendar Year Deductible$500 Individual / $1,000 Family

$1,200 Individual / $2,400 Family


Lifetime Maximum Unlimited Unlimited Unlimited

Out-of-Pocket Maximum (Per calendar year)OOP includes co-payments, deductible and coinsurance




Co-insurance 20% after calendar year deductible is met

40% after calendar year deductible is met

50% of eligible expenses, after calendar year deductible is met

Preventive Care

• Physical Exam• Immunizations• Well-Baby Care• Well Woman Exam• Mammogram Screening• Colonoscopy

(Deductible does not apply)

No ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo Charge



50% of eligible expenses, after deductible is met

Physician Office Visits*

• Primary Care

• Specialist Care

* Applies to physicians who are in United Healthcare’s network and employed by MSMC or Miami Children’s Hospital

$25 co-pay per visit, after deductible is met(Co-pay waived after deductible is met if employees use Mount Sinai Primary Care Center physicians located in the Lowenstein Building)

$50 co-pay per visit, after deductible is met

* Applies to physicians who are in United Healthcare’s network, but not employed by MSMC or Miami Children’s Hospital

$35 co-pay per visit, after lower deductible is met Co-Insurance does not apply


Applies to physicians who are not in United Healthcare’s network



EPO PlanCovered Benefits

Your Cost

In-NetworkTier 1

MSMC/Miami Children’s

In-NetworkTier 2

Non-MSMC/Non-Miami Children’s

Out-of-Network

Services received from participating providers covered by

Insurance Company


Insurance Company

Services received from non-participating providers

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Maternity Care - Pre and Post Natal Exams

Same as Specialty Care Services in a Physician’s Office; Professional Fees for Surgical and Medical Services; Inpatient Hospital and Related Services; and Outpatient Surgery, Diagnostic and therapeutic Services. (Deductible and co-insurance applies for initial visit).



Allergy Testing and Treatment

$30 co-pay per visit, after deductible is met (co-insurance applies)

$30 co-pay per visit, after deductible is met (co-insurance applies)


Family Planning

• Tests, counseling, surgical sterilization procedures (vasectomy, tubal ligation, etc)

• Inpatient facility charge

• Outpatient facility charge

• Surgery in physician’s office

Infertility Services - Subject to exclusions.

Office Visit

20% after deductible is met




Not covered





Not covered





Not covered

This is a summary of benefits. Refer to your Summary Plan Description for covered services and exclusions. Benefits are determined in accordance with the terms of the Summary Plan Description.


Your Cost

In-NetworkTier 1


In-NetworkTier 2


Out-of-Network


Insurance Company


Insurance Company


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Emergency Room 20% after deductible is met (waived if admitted for reasons other than patient observation)

40% after lower deductible is met (waived if admitted for reasons other than patient observation)

50% after lower deductible is met (waived if admitted for reasons other than patient observation)

Urgent Care 20% after deductible is met 40% after lower deductible is met


Ambulance 20% after deductible is met 40% after lower deductible

is met50% after lower deductible is met

Hospital Inpatient Services

• Semi-private room and board • Physician Services

• Surgical Services

• Diagnostic x-ray and lab services

No charge after deductible is met (If Miami Children’s is used, reimbursement must be submitted)

No additional charge















Your Cost

In-NetworkTier 1


In-NetworkTier 2


Out-of-Network


Insurance Company


Insurance Company



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Outpatient Services

• Surgical Care

• Scopic Procedure (Diagnostic)

• X-rays, laboratory and diagnostics (e.g. blood test)

• MRI, CT, PET, Ultra- sound, Nuclear Medicine









50% of eligible expenses, after deductible is met50% of eligible expenses, after deductible is met



Mental Health and Substance Abuse * Requires prior authorization

Inpatient*

Outpatient*


$25 co-pay Group$25 co-pay Individual





Home Health Care 20% after deductible is met. Limited to 60 visits for Skilled Service per calendar year. One visit equals four hours of Skilled Care Services.

40% after lower deductible is met. Limited to 60 visits for Skilled Service per calendar year. One visit equals four hours of Skilled Care Services.




Your Cost

In-NetworkTier 1


In-NetworkTier 2


Out-of-Network


Insurance Company


Insurance Company


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Skilled Nursing 20% after deductible is met. Limited to 60 days per calendar year

40% after deductible is met. Limited to 60 days per calendar year


Prosthetics 20% after deductible is met. Initial purchase only. Limited to $10,000 per calendar year.

40% after deductible is met. Initial purchase only. Limited to $10,000 per calendar year.


Durable Medical Equipment




Outpatient Rehabilitation Services


Limited to:

• 20 visits of physical therapy per calendar year

• 20 visits of occupational therapy per calendar year

• 20 visits of speech therapy per calendar year

• 36 visits of cardiac rehabilitation per calendar year

• 36 visits of pulmonary rehabilitation per calendar year

40% after lower deductible is met

Limited to:







Limited to:






Hospice Care 20% after deductible is met. Limited to 180 days during the entire period of time a covered person is under contract.

40% after lower deductible is met. Limited to 180 days during the entire period of time a covered person is under contract.

50% of eligible expenses, after deductible is met. Limited to 180 days during the entire period of time a covered person is under contract.



Your Cost

In-NetworkTier 1


In-NetworkTier 2


Out-of-Network


Insurance Company


Insurance Company


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Calendar Year Deductible $300 Individual / $600 Family $800 Individual / $1,600 Family$5,000 Individual / $10,000 Family

Lifetime Maximum Unlimited Unlimited Unlimited

Out-of-Pocket Maximum (Per calendar year)OOP includes co-payments, deductible and coinsurance

Not Applicable $3,000 Individual / $6,000 Family


Co-insurance None 20% after calendar year deductible is met; for inpatient admissions, outpatient surgeries and procedures, x-rays, labs, diagnostics and other facility charges


Preventive Care

• Physical Exam• Immunizations• Well-Baby Care• Well Woman Exam• Mammogram Screening• Colonoscopy






Physician Office Visits*

• Primary Care

• Specialist Care

* Applies to physicians who are in United Healthcare’s network and employed by MSMC or Miami Children’s Hospital

$25 co-pay per visit, after deductible is met(Co-pay waived after deductible is met if employees use Mount Sinai Primary Care Center physicians located in the Lowenstein Building) $50 co-pay per visit, after deductible is met

* Applies to physicians who are in United Healthcare’s network, but not employed by MSMC or Miami Children’s Hospital



Applies to physicians who are not in United Healthcare’s network



HMO Low & HMO High

Covered Benefits

Your Cost

In-NetworkTier 1


In-NetworkTier 2


Out-of-Network


Insurance Company


Insurance Company


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Maternity Care - Pre and Post Natal Exams

Same as Specialty Care Services in a Physician’s Office; Professional Fees for Surgical and Medical Services; Inpatient Hospital and Related Services; and Outpatient Surgery, Diagnostic and therapeutic Services. (Deductible applies for initial visit).



Allergy Testing and Treatment

$40 co-pay per visit, after deductible is met

$40 co-pay per visit, after lower deductible is met (Co-insurance applies)


Family Planning

• Tests, counseling, surgical sterilization procedures (vasectomy, tubal ligation, etc)

• Inpatient facility charge

• Outpatient facility charge

• Surgery in physician,s office

Infertility Services - Subject to exclusions.

Office Visit

No charge after deductible is met


$100 co-pay after deductible is met


$40 co-pay per visitLimited to $2,000 per calendar year after deductible is met


$400 co-pay per day / Max $1,600 plus 20% after deductible is met

$500 co-pay plus 20% after deductible is met


$40 co-pay per visitLimited to $2,000 per calendar year after lower deductible is met






HMO Low & HMO High

Covered Benefits

Your Cost

In-NetworkTier 1


In-NetworkTier 2


Out-of-Network


Insurance Company


Insurance Company


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Emergency Room(co-insurance and higher deductible will not apply)

$100 co-pay per visit after deductible is met (waived if admitted for reasons other than patient observation)

$200 co-pay per visit after lower deductible is met (waived if admitted for reasons other than patient observation)

$200 co-pay per visit after lower deductible is met (waived if admitted for reasons other than patient observation)

Urgent Care $75 co-pay per visit after deductible is met

$75 co-pay per visit plus 20% after lower deductible is met


Ambulance $100 co-pay after deductible is met

$100 co-pay after lower deductible is met

Same as In-Network Benefit

Hospital Inpatient Services

• Semi-private room and board

• Physician Services

• Surgical Services

• Diagnostic x-ray and lab services
















HMO Low & HMO High

Covered Benefits

Your Cost

In-NetworkTier 1


In-NetworkTier 2


Out-of-Network


Insurance Company


Insurance Company


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Outpatient Services

• Surgical Care

• Scopic Procedure (Diagnostic)

• X-rays, laboratory and diagnostics (e.g. blood test)

• MRI, CT, PET, Ultra- sound, Nuclear Medicine

$100 co-pay after deductible is met, if Mount Sinai or Miami Children’s is used


No charge after deductible is met, if Mount Sinai or Miami Children’s is used




20% after calendar year deductible is met






Mental Health and Substance Abuse*Requires prior authorization

Inpatient*

Outpatient*

No charge after deductible is met (If Miami Children’s is used, reimbursement must be submitted






Home Health Care No charge after deductible is met. Limited to 60 visits for Skilled Service per calendar year. One visit equals four hours of Skilled Care Services.

No charge after lower deductible is met. Limited to 60 visits for Skilled Service per calendar year. One visit equals four hours of Skilled Care Services.


HMO Low & HMO High

Covered Benefits

Your Cost

In-NetworkTier 1


In-NetworkTier 2


Out-of-Network


Insurance Company


Insurance Company


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Skilled Nursing (Limited to 60 days per calendar year)


$400 co-pay per day / Max $1,600 plus 20% after deductible is met. (No co-payment applies when transferred to a skilled nursing or inpatient rehabilitation facility directly from an acute facility).


Prosthetics $100 co-pay per item after deductible is met. Initial purchase only. Limited to $10,000 per calendar year.

$100 co-pay per item after lower deductible is met. Initial purchase only. Limited to $10,000 per calendar year.


Durable Medical Equipment (Higher Deductible does not Apply)

$100 co-pay per item after deductible is met. Initial purchase only. Limited to $10,000 per calendar year.

$100 co-pay per item after lower deductible is met. Initial purchase only. Limited to $10,000 per calendar year.


Outpatient Rehabilitation Services

$10 co-pay per visit after deductible is met

Limited to:






$25 co-pay per visit plus 20% after lower deductible is met

Limited to:






$50 of eligible expenses, after deductible is met

Limited to:






Hospice Care

$10 co-pay per visit after deductible is met. Limited to 180 days during the entire period of time a covered person is under contract.

$25 co-pay per visit plus 20% after lower deductible is met. Limited to 180 days during the entire period of time a covered person is under contract.

50% of eligible expenses, after deductible is met.Limited to 180 days during the entire period of time a covered person is under contract.


HMO Low & HMO High

Covered Benefits

Your Cost

In-NetworkTier 1


In-NetworkTier 2


Out-of-Network


Insurance Company


Insurance Company


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Pharmacy Benefits provided by Express Scripts All employees that participate in the HMO High Medical Plan are automatically enrolled in the Pharmacy Benefits plan under Express Scripts.

Express Scripts is Mount Sinai Medical Center’s provider for the prescription benefits. If you are enrolled in the HMO High Medical Plan, you will continue to have an Express Scripts prescription drug ID card that is separate from your United Healthcare medical ID card.

In 2015 Express Scripts will continue to offer home-delivery requirement for maintenance medication, as well as pre-authorization requirements for brand name and specialty drugs.*Express Scripts Member Services Phone: 877-860-0983Website: www.express-scripts.comRx Grp: MSMCRX1; Rx BIN: 610014; Rx PCN: Express Scripts

Your Prescription Benefits under the HMO High are:

HMO HighPharmacy Benefit

Your CostIn-Network

Services received from participating providers and covered by Insurance

Company

Deductible Individual/Family Not Applicable

Lifetime Maximum Unlimited

Out-of-Pocket Maximum $3,600 Individual / $7,200 Family

Co-insurance None

Retail Pharmacy

• Generic

• Brand name- preferred

• Brand name- non-preferred

• Specialty Drugs

$15

$40

$60

10% up to $250 co-pay

Mail Order Drugs

• Generic

• Brand name- preferred

• Brand name- non-preferred

• Specialty Drugs

$30

$80

$120

N/A

* Please contact Express Scripts for information on particular drug exclusions, drugs dispense limitations, preferred drug alternatives and switching of maintenance drugs from retail pharmacy to home delivery.

This is a summary of benefits. Mount Sinai Medical Center complies with the Affordable Care Act. Refer to your Summary Plan Description for covered services and exclusions. Benefits are determined in accordance with the terms of the Summary Plan Description.

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Group Dental InsuranceDelta Dental’s website – www.deltadentalins.com is user-friendly and provides self-service capabilities to employees in real-time. You can view the status of claims, print ID cards, request materials or make inquiries. A complete benefit guide and the network of participating dental providers is also available.

Delta Dental Member Services – Phone: 800-521-2651– Group #: 03463-01001 (PPO Low) 03463-02001 (PPO High)Website: www.deltadentalins.com

Group Dental InsuranceDelta Dental is offering a choice of two PPO dental plans.

l PPO Low Planl PPO High Plan

The PPO plans offer a variety of benefits with set reimbursement amounts. You pay the provider for services at the time of your appointment. Claim payments are then made to you or your provider. The plans feature:

l Freedom to choose any dentistl Orthodontics for children and adultsl Periodonticsl Quick claims turnaroundl National coverage

Keep in mind, by using one of the PPO Providers, you have the benefit of reduced out-of-pocket expenses. You also get the additional peace of mind knowing that their providers go through an extensive credentialing process.

You may provide coverage to an eligible dependent child up to the end of the month in which they turn age 26.

The following charts contain the plan highlights for the two (2) Dental Plans to assist you in selecting the best Dental Plan for you and your family.

During your first year of dental coverage, you will be covered only for Type A and Type B Services for both plans. After being enrolled in the plan for one year (12 consecutive months), you will be covered for all services. This incudes Type C and Type D services.


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Dental PPO Low Plan

This is a summary. Refer to your Certificate of Coverage for covered services and exclusions. Benefits are determined in accordance with the terms of the Certificate of Coverage.

*Services for type C and D have a one year waiting period to be covered.

PLAN DESIGNIn-Network Out-of-Network

Reimbursement forReasonable & Customary Fees

Type A – Preventative 100% 90%

Type B – Basic 80% 60%Type C – Major 50% 40%Type D – Orthodontics - Child & Adult(Annual maximum of $500)

50% 50%

Plan LimitsIndividual Deductible (Annual)Family Deductible (Annual)Deductible Applies ToCalendar Year MaximumLifetime Orthodontia Maximum - Child & Adult

NoneNoneN/A

$1,500$1,000

$100$300

B, C & D$1,000$1,000

ALLOCATION OF SERVICES - LOW PLANType APreventive & Diagnostic

Type BRestorative

Type C Prosthodontics/ Major Restorative*

Type D Orthodontics*- Child & Adult

Oral Exams (once every 6 months)Full mouth X-raysBitewings X-raysPeriapicals and other X-raysProphylaxis/Cleaning (once every 6 months)Fluoride TreatmentsSealantsSpace Maintainers

FillingsLabs and Other TestPeriodontal maintenancePeriodonticsSimple ExtractionsConsultationsEndodontics/Root Canal TherapyGeneral AnesthesiaOral SurgeryPalliative Care

Inlays/OnlaysCrownsRebases/RelinesDenturesBridgesRepairs

Orthodontic DiagnosticsOrthodontic Treatment

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PLAN DESIGNIn-Network Out-of-Network

Reimbursement forReasonable & Customary Fees

Type A – Preventative 100% 100%

Type B – Basic 80% 80%Type C – Major 50% 50%Type D – Orthodontics – Child & Adult (Annual maximum of $500)

50% 50%

Plan Limits

Individual Deductible (Annual) None $100Family Deductible (Annual) None $300Deductible Applies To N/A B, C & DCalendar Year Maximum $1,500 $1,500Lifetime Orthodontia Maximum - Child & Adult $1,000 $1,000

ALLOCATION OF SERVICES - HIGH PLANType APreventive & Diagnostic

Type BRestorative

Type C Prosthodontics/ Major Restorative*

Type D Orthodontics* - Child & Adult

Oral Exams (once every 6 months)Full Mouth X-raysBitewings X-raysPeriapicals and Other X-raysProphylaxis/Cleaning (once every 6 months)Fluoride TreatmentsSealantsSpace Maintainers

FillingsLabs and Other TestPeriodontal MaintenancePeriodonticsSimple ExtractionsConsultationsEndodontics/Root Canal TherapyGeneral AnesthesiaOral SurgeryPalliative Care

Inlays/OnlaysAll Other CrownsRebases/RelinesDenturesBridgesRepairs

Orthodontic DiagnosticsOrthodontic Treatment

Dental PPO High Plan

This is a summary. Refer to your Certificate of Coverage for covered services and exclusions. Benefits are determined in accordance with the terms of the Certificate of Coverage.

*Services for type C and D have a one year waiting period to be covered.

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PLAN DESIGN

Plan Provisions In-Network Out-of-Network

Co-PayExam 100% after $15 co-pay Up to $40

Lenses:Single Vision 100% after $25 co-pay Up to $40

Bifocal 100% after $25 co-pay Up to $60Trifocal 100% after $25 co-pay Up to $80

Lenticular 100% after $25 co-pay Up to $80Frames Covered in full selection 100% after $25

co-pay (applies to all frames with a $50 wholesale cost or less at private practice providers.) For any frame with a wholesale cost greater than $50 at private practice providers, the member pays the difference between the wholesale cost and the $50 allowance. Plan participants receive a $130 retail frame allowance for frames pur-chased at retail chain providers, and for any frame above $130, the member pays only the difference.

Up to $45

Contact Lenses:Elective If in lieu of lenses and frames:

Covered in full elective – 100% after $25 co-pay for fitting/evaluation fees, and up

to two follow-up visits All other elective – up to $125 allowance

(also applies to fitting/evaluation fees)Up to $125

Medically Necessary 100% after $25 co-pay Up to $210

LimitsExam Once every 12 months

Lenses or Contact Lenses Once every 12 monthsFrames Once every 24 months

Vision PlanOur voluntary vision plan is provided by Spectera, a subsidiary of United Healthcare. Through the Spectera website – www.myspectera.com – you have access to a variety of online services: view your benefits, check your claim status, find a provider, print ID card and more.

Spectera Member Services – Phone: 800-638-3120 Website: www.myspectera.comGroup No. 701799

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Mount Sinai Medical Center 2015 Contribution RatesThe following chart lists the full-time and part-time employee bi-weekly contribution rates for 2015:

EPO 80 Medical Plan

Tier

Non-Tobacco User

Wellness Discount Rate Standard Rate

Full-Time Employee Part-Time Employee Full-Time Employee Part-Time Employee

Employee Only $ 19.34 $ 35.32 $ 20.90 $ 38.18

Employee + One $ 44.31 $ 60.29 $ 47.89 $ 65.60

Employee + Family $ 70.39 $ 86.38 $ 76.08 $ 93.37

*Domestic Partner $ 24.97 $ 24.97 $ 26.99 $ 27.42

*DP + Child(ren) $ 51.05 $ 51.06 $ 55.18 $ 55.19

A bi-weekly tobacco premium of $36.61 will be applied in addition to your premium if you OR your spouse/domestic partner did not complete and pass the tobacco test.

A bi-weekly tobacco premium of $73.22 will be applied in addition to your premium if you AND your spouse/domestic partner did not complete and pass the tobacco test.

HMO Low Medical Plan

Tier

Non-Tobacco User



Employee Only $ 42.07 $ 58.95 $ 45.48 $ 63.72

Employee + One $ 96.43 $ 113.27 $ 104.23 $ 122.44

Employee + Family $ 153.21 $ 170.08 $ 165.60 $ 183.81


*DP + Child(ren) $ 111.14 $ 111.13 $ 120.12 $ 120.09


A bi-weekly tobacco premium of $90.08 will be applied in addition to your premium if you AND your spouse/domestic partner did not complete and pass the tobacco test.

HMO High Medical Plan

Tier

Non-Tobacco User



Employee Only $ 63.87 $ 80.75 $ 69.04 $ 87.27

Employee + One $ 146.34 $ 163.21 $ 158.17 $ 176.42

Employee + Family $ 232.58 $ 249.45 $ 251.40 $ 269.62


*DP + Child(ren) $ 168.71 $ 168.70 $ 182.36 $ 182.35


A bi-weekly tobacco premium of $179.14 will be applied in addition to your premium if you AND your spouse/domestic partner did not complete and pass the tobacco test

*The employee contribution for the domestic partner coverage will be post-tax as required by federal regulations. The domestic partner must be enrolled under the same plan as the employee.

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DentalTier PPO Low Plan PPO High Plan

Employee Only $ 10.72 $ 17.64Employee + One $ 17.78 $ 30.92

Employee +Family $ 24.08 $ 39.51*Domestic Partner $ 7.06 $ 13.28*DP + Child(ren) $ 13.36 $ 21.76

VisionTier Employee Contribution

Employee Only $ 2.26 Employee + One $ 4.18

Employee +Family $ 7.15*Domestic Partner $ 1.92*DP + Child(ren) $ 4.89

Mount Sinai Medical Center 2015 Contribution RatesThe following chart lists the full-time and part-time employee bi-weekly contribution rates for 2015:

*The employee contribution for the domestic partner coverage will be post-tax as required by federal regulations. The domestic partner must be enrolled under the same plan as the employee.

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Long Term Disability*Mount Sinai Medical Center offers Long Term Disability benefits through Lincoln Financial Group. These benefits provide a portion of your income while you are disabled because of a non-work-related illness or injury. You are eligible for this benefit the first day of the month following one year of full-time employment.

Lincoln Financial Group: 800-423-2765

Basic Long Term Disability Basic Long Term Disability is provided to all full-time employees by Mount Sinai Medical Center at no cost. You are automatically enrolled once you complete the eligibility period.

l Benefits begin after you are disabled for 6 months.l You will receive 40% of your monthly pre-disability

basic income, up to a specified maximum benefit, which is a taxable benefit.

l You will receive benefits as long as you qualify as disabled, to a maximum of 3 years. However, certain types of disabilities may be covered for a shorter period of time.

l Benefit is integrated with payment received from Social Security.

Long Term Disability Buy-Up Coverage*Mount Sinai Medical Center also offers a Long Term Disability Buy-Up Plan, which serves to enhance the Basic Long Term Disability Plan (see above) by reducing the waiting period, increasing the benefit amount, and extending the benefit period. You must elect to participate in this program.

l Benefits begin after you are disabled for 3 months. l If you elect this coverage, you will receive an additional 20% of your monthly pre-disability

base income, subject to a specified maximum benefit. Benefits are partially taxed.l Basic and buy-up plan combined equals 60% income replacement up to a specified maximum

benefit.l You will receive benefits as long as you qualify as disabled, to a specified maximum of your

Social Security normal retirement age. However, certain types of disabilities may be covered for a shorter period of time.

l After-tax deduction.l Benefit is integrated with payment received from Social Security.

* If employees did not elect LTD Buy-Up when they first became eligible for coverage, they will be required to show proof of good health and complete an evidence of insurability form and submit it to the insurance carrier for approval.

Employees must be actively at work in an eligible class on the date an increase in their insurance is to take effect.

If not, such increase will take effect on the day they resume such work. The date the increase is to take effect might not be on a scheduled workday. If so, employees will be considered actively at work on such date if they were actively at work on their last scheduled workday.

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Life InsuranceMount Sinai Medical Center offers several Group Life Insurance plans through Lincoln Financial Group, which provide benefits based on the amount of coverage you purchase. You are eligible for this benefit following 90 days of employment.

Lincoln Financial Group: 800-423-2765

Basic Life InsuranceMount Sinai Medical Center provides Basic Life Insurance with Accidental Death and Dismemberment (AD&D) at no cost to you. Basic Life Insurance with AD&D is one (1) times your base annual salary, to a maximum of $200,000 and a minimum of $10,000.

AD&D Insurance provides additional benefits based on your pay if you should die or suffer the loss of an eye or limb as the result of an accident.

Supplemental Life Insurance*Mount Sinai Medical Center offers Supplemental Life Insurance, which allows you to purchase additional Life Insurance coverage of one-to-five times your base annual salary rounded to the next higher $1,000. The maximum amount of supplemental coverage you may have is $500,000.

Supplemental Accidental Death & Dismemberment InsuranceMount Sinai Medical Center offers Supplemental AD&D Insurance, which allows you to purchase additional AD&D insurance coverage of one-to-five times your base annual salary rounded to the next higher $1,000. The maximum amount of supplemental coverage you may have is $500,000. Employees must enroll in Supplemental Life to elect Supplemental AD&D.

Combined total maximum benefit for Basic & Supplemental Life coverage is $700,000.

Dependent Life Insurance*Dependent Life coverage is available for your eligible spouse and children in the following coverage amounts. In order to elect Dependent Life coverage, employees must elect Supplemental Life coverage.

SPOUSE/DEPENDENTS$5,000/$2,500 $10,000/$5,000 $15,000/$7,500 $20,000/$10,000 $25,000/$12,500

l Spouse coverage cannot exceed 50% of your own life insurance coverage.l Child coverage begins at the 14th day from birth and ends at age 19 (age 25 if full time student).l After-tax deduction.

*If employees did not elect Supplemental and/or Dependent Life when they first became eligible for coverage, they will be required to show proof of good health and complete an evidence of insurability (EOI) form and submit it to the insurance carrier for approval.

Employees and dependents currently enrolled for supplemental and/or dependent life may elect an additional one level increase during the open enrollment period and will not be required to give evidence of insurability. However, if they elect more than one level increase, an evidence of insurability form must be completed for the employees and their dependents and submitted to the insurance carrier for approval.

Employees must be actively at work in an eligible class on the date an increase in the insurance is to take effect. If not, such increase will take effect on the day they resume such work. The date the increase is to take effect might not be on a scheduled workday. If so, they will be considered actively at work on such date if they were actively at work on their last scheduled workday. Spouses of employees might be hospitalized on the date an increase in their insurance is to take effect. If so, such increase will take effect on the day after they are discharged.


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Flexible Spending AccountsWageWorks Phone: 855-774-7441 Website: www.wageworks.com

A Flexible Spending Account (FSA) allows you to set aside pre-tax dollars from your paycheck and put them into a special account. By using a FSA, you pay for eligible expenses with pre-tax dollars. Mount Sinai Medical Center offers a Healthcare Spending Account and a Dependent Care Spending Account. You may contribute a minimum annual election amount of $260 up to a maximum annual election amount of $2,500 for the Healthcare FSA. The Dependent Care FSA will continue to have a maximun annual election amount of $5,000.A complete list of eligible expenses that are reimbursable under the flexible spending account is available on the WageWorks website.

Healthcare Spending AccountThe Healthcare FSA is a great way to save money while keeping you and your family healthy. You can use tax free funds to pay for out-of-pocket medical, dental and vision care expenses. Remember that over the counter (OTC) drugs will not be eligible for reimbursement unless ordered by a physcian.

Eligible health care expenses may include:l Medical and dental care plan deductibles.l Medical and dental plan co-payments.l Amounts over the maximum your medical and dental plan pays (e.g. orthodontics over the

dental plan maximum).l Other expenses not covered by your medical and dental plan.

Dependent Care Spending AccountThe Dependent Care FSA helps you pay for childcare services, care of elderly parents, or care of a disabled spouse or dependent.

You must meet one of the following eligibility criteria:l You are a single parent or guardian.l You have a working spouse or a spouse looking for work.l Your spouse is physically or mentally unable to provide for his/her own care.l You are divorced or legally separated and have custody of your child even though your former spouse may

claim the child for income tax purposes.

An eligible dependent is a qualifying individual who spends at least 8 hours a day in your home and is one of the following:l Your dependent under age 13 for whom you can claim an exemption.l A child under the age of 13 for whom you have custody if you are divorced or legally separated.l Your spouse who is physically or mentally incapable of self-care.l Your dependent who is physically or mentally incapable of self-care, even if you cannot claim an exemption

for the person for income tax purposes.

Retirement PlanVALIC Phone: 1-800-448-2542 or 305-535-7980Website: www.valic.com/mtsinai

Mount Sinai Medical Center provides a retirement plan to all employees (full-time, part-time and per diem if you work 1,000 hours within the calendar year). The employer match for all eligible participating employees is:l 50% for up to a maximum of 6% of your annual pay.l Employees with more than 15 years of service are eligible to receive 75% for up to a maximum of 4% of their

annual pay.A VALIC Retirement representative is available on the Mount Sinai campus to discuss the retirement plan and assist you in enrolling.The information contained in this booklet is only a summary of coverage and is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Should there be differences between the information in the booklet and the contract, the contract will govern.

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The Advantage of ChoiceColonial Life products will be available to all benefit-eligible employees of Mount Sinai Medical Center to apply for during this year’s annual enrollment. A Colonial Life benefits counselor will explain these voluntary products in greater detail during the Benefits Fair and your 1-to-1 personal benefits consultation.

With most Colonial Life insurance products:l Benefits are paid directly to you, unless you specify otherwise.l You can continue coverage with no increase in premium when you retire or change jobs.l You’re paid regardless of any other insurance you may have with other insurance companies.l Coverage is available for your spouse and dependent children.

Available through payroll deduction:Premium payment for these products will be made through payroll deduction.

Voluntary Short Term DisabilityMount Sinai Medical Center offers an individual Voluntary Short Term Disability benefit through Colonial Life & Accident Insurance Company, which provides income replacement in the event of a non-work-related illness or injury.

l Elimination period (waiting period) is 14 days for accidents/14 days for sickness.l You can choose a benefit amount of up to 60% of monthly base income up to a maximum of $5,000/month.l Pays you up to a maximum of 90 days.l Age-rated premiums.l Premium rates do not increase as you enter a new age band.l After-tax deduction.

If you are interested in applying for Colonial Life products, please call our authorized agent, Craig Sottile at: 954-873-9889.

Critical illness insurance supplements your major medical coverage by providing a lump-sum benefit that you can use to pay the direct and indirect costs related to a covered critical illness, such as heart attack (myocardial infarction), end-stage renal failure, coronary artery bypass surgery, stroke or major organ transplant.

Cancer insurance helps offset the out-of-pocket medical and indirect, non-medical expenses related to cancer that most plans don’t cover. This coverage also provides a benefit for specified cancer-screening tests.

Universal life insurance provides death benefit coverage that you can increase or decrease as your needs change. The policy builds cash value on a tax-deferred basis at current interest rates, and premium payments are flexible.

Take steps now to help protect your way of life.Coverage is subject to policy exclusions and limitations that may affect benefits payable.Contact your Colonial Life benefits counselor toll free for more information at 866.995.1967.

Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. Colonial Life, 1200 Colonial Life Boulevard, Columbia, SC 29210

Colonial Life Policyholder Services: Phone: 800-325-4368; Website: www.coloniallife.com

The information contained in this booklet is only a summary of coverage and is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Should there be differences between the information in the booklet and the con-tract, the contract will govern.

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Employee Assistance ProgramMount Sinai Medical Center is offering you an Employee Assistance Program (EAP) that responds to those increasing pressures. With a range of programs, resources, and tools, the EAP can help with a myriad of issues that can mean greater peace of mind.

You are eligible to receive benefits related to the EAP as early as your first day of employment. Through this program you are eligible to receive up to four sessions of confidential counseling, per issue of need or concern each year. Counseling and support services are offered at no cost in a private and supportive environment.

You have unlimited telephone and online access to legal, financial and work-life services, 24 hours a day, 7 days a week.

Services Incude:l Confidential Counseling - This services helps you address

stress, grief and loss, relationship problems, psychological disorders, substance abuse and other personal issues you and your family may face.

l Financial Counseling - Speak by phone with certified public accountants and certified financial planners on a wide range of financial issues, including getting out of debt, planning for retirement, saving for college and more.

l Legal Support and Resources - Speak to EAP attorneys by phone, and if you require representation, they will refer you to a local attorney for a free 30-minute consultation, with a 25 percent reduction in customary legals fees thereafter.

l Work-Life Assistance - Delegate your “to-do” list to EAP specialists, who will provide qualified referrals and customized resources for child and elder care, planning for college, pet care, home repairs and more.

How Do I Access These Services?l Call Toll-Free: 888-628-4824l Visit: www.lincoln4benefits.com/

or www.guidanceresources.com/ Username: LFGsupport Password: LFGsupport1

The information contained in this section of this book is only a summary. Please refer to Mount Sinai Medical Center’s Policy and Procedure Manual for further clarification.

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Additional Value-Added BenefitsTuition ReimbursementAfter six months of service, you are eligible for financial assistance in your pursuit of higher education that benefits you and Mount Sinai Medical Center. Our Tuition Reimbursement program offers reimbursement of your tuition costs up to specified limits depending on course of study and full-time/part-time status.

On-Site Child CareOur Young Presidents’ Club Child Care Center, now in its third decade of service to children, provides a progressive educational program in a nurturing setting for children of employees. This was one of the first corporate child care facilities in the nation. The center, located on our Mount Sinai campus, is committed to offering work-life solutions to all employees. The program is designed to challenge children ages 6 weeks to 5 years. There is state-funded financial assistance for employees who qualify.

Mater AcademyMater Academy at Mount Sinai Medical Center offers a high quality public charter school on campus. The vision of Mater Academy is to provide a nurturing and supporting educational environment where the whole child is developed and a philosophy of respect and high expectations is instilled for all students, parents, teachers and staff. The school’s mission is to provide an innovative and challenging curriculum, preparing students to have a global edge, strive to create a thirst for knowledge in all disciplines of the curriculum and enrich every student with a sense of purpose and commitment to the common good. Mater Academy at Mount Sinai Medical Center serves students in grades K-5.

Paid Time Off BankEligible employees, including full-time and part-time employees who are regularly scheduled to work at least 20 hours per week, accrue paid time off (PTO) to provide for holidays, vacation, personal illness and other personal matters.

Extended Leave BankEmployees accrue Extended Leave Bank (ELB) time and are eligible for this time when they are unable to work because of their own illness or disability.

Jury DutyYou will be provided full salary while serving jury duty.

Bereavement LeaveYou will be provided up to three consecutive bereavement leave days for the death of an immediate family member.

Service Awards Recognition ProgramMount Sinai’s Board of Trustees and Senior Leadership honor employees with a special celebration when they reach a certain number of service years (5-year increments). Service pins and other gifts are presented to the honorees at a gala hosted by members of the Board and Senior Leadership team.

Retiree Recognition Program Mount Sinai offers a Retiree Recognition Program. When you retire from employment with 10 or more years of service with Mount Sinai, you will be presented with a lovely personalized retirement presentation plaque and retirement check in recognition of your years of service and dedication toward making Mount Sinai Medical Center a great place to work.


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Transportation OptionsMonthly county-wide transportation MetroPasses, for unlimited use on buses and trains, are available at an employee discount. These passes are on a pre-tax basis and via convenient payroll deduction. Free parking is provided for those employees who choose to drive to work.

On-Site ConveniencesWe offer convenient payroll deduction for our on-site pharmacy, gift shop and food court:

l Pharmacy—Easy access to a centrally located pharmacy. Prescription drugs are available at employee discounts.

l Credit Union—Full-service credit union. l Food Courts—Serve many selections of hot and cold meals, all at employee discounts.l Gift Shop—Offers a wide array of gift items and many other products. l ATMs—On-site ATM machines are conveniently located on both campuses.l Primary Care Center— All office visit co-payments are waived after deductible is met. Walk-ins

are accepted.

Prescription Savings CardIf you don’t have health insurance, or need medicine not covered by your insurance plan, Mount Sinai Medical Center invites you to take advantage of our free, easy to use Prescription Savings Card.

Benefits of a Mount Sinai Medical Center Prescription Savings Card:

l No applications, no fees l You can start saving today l Covers everyone without health insurance or prescription coverage l Available even to those with insurance who may need medications not covered under their plan l No age, income or citizenship restrictions l Up to 70% savings on many generic medicationsl Discounts available on brand-name medicationsl More than 55,000 pharmacies in the network

Mount Sinai’s Prescription Savings Card is the one you can trust. With thousands of participating pharmacies nationwide, you’ll get the best possible savings and our commitment to your health and well being.

The network includes pharmacy chains, such as CVS, Rite Aid, Medicine Shoppe, Walgreens, Wal-Mart and more, as well as thousands of independent pharmacies throughout the country. For a directory of participating pharmacies in your area, visit www.emsmed.com/vendors/pharmacy.aspx.

For a directory of covered prescription drugs and prices, visit www.emsmed.com/vendors/rxpricing.aspx.

For your convenience, some medications are available via mail-order for home delivery. Check the drug pricing schedule for these costs. To use the convenient mail order option, please call 1-866-909-5170.

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MODEL INDIVIDUAL NON-CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE OMB 0938-0990

FOR USE ON OR AFTER APRIL 1, 2011

Important Notice From Mount Sinai Medical Center AboutYour Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Mount Sinai Medical Center and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are three important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. Mount Sinai Medical Center has determined that the prescription drug coverage offered by the Mount Sinai Medical Center is, on average for all plan participants, NOT expected to pay out as much as standard Medicare prescription drug coverage pays. Therefore, your coverage is considered Non-Creditable Coverage. This is important because, most likely, you will get more help with your drug costs if you join a Medicare drug plan, than if you only have prescription drug coverage from the Mount Sinai Medical Center. This also is important because it may mean that you may pay a higher premium (a penalty) if you do not join a Medicare drug plan when you first become eligible.

3. You can keep your current coverage from Mount Sinai Medical Center. However, because your coverage is non-creditable, you have decisions to make about Medicare prescription drug coverage that may affect how much you pay for that coverage, depending on if and when you join a drug plan. When you make your decision, you should compare your current coverage, including what drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. Read this notice carefully - it explains your options.

When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

However, if you decide to drop your current coverage with Mount Sinai Medical Center since it is an employer sponsored group coverage, you will be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan; however you also may pay a higher premium (a penalty) because you did not have creditable coverage under Mount Sinai Medical Center.

MODEL INDIVIDUAL NON-CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE OMB 0938-0990

FOR USE ON OR AFTER APRIL 1, 2011

CMS Form 10182-NC Updated April 1, 2011 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?Since the coverage under Mount Sinai Medical Center, is not creditable, depending on how long you go without creditable prescription drug coverage you may pay a penalty to join a Medicare drug plan. Starting with the end of the last month that you were first eligible to join a Medicare drug plan but didn’t join, if you go 63 continuous days or longer without prescription drug coverage that’s creditable, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?If you decide to join a Medicare drug plan, your current Mount Sinai Medical Center coverage will not be affected. If you do decide to join a Medicare drug plan and drop your current Mount Sinai Medical coverage, be aware that you and your dependents will be able to get this coverage back.

For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information at 305-674-2630 NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan and if this coverage through Mount Sinai Medical Center changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:

l Visit www.medicare.gov l Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the

“Medicare & You” handbook for their telephone number) for personalized help l Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available.

For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Date: 09/30/2011

Name of Entity/Sender: Mount Sinai Medical Center

Contact--Position/Office: Human Resources Director

Address: 4300 Alton Road, Miami Beach FL, 33140

Phone Number: 305-674-2630

CMS Form 10182-NC Updated April 1, 2011 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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Important Notice About Your Prescription Drug Coverage and Medicare You are being sent this notice because you may be Medicare eligible. This notice has information about your current prescription drug coverage with Mount Sinai Medical Center, and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. Information about where you can request help to make decisions about your prescription drug coverage is at the end of this notice.

Note: While you are in active employment and either you or your spouse is covered by Medicare by reason of reaching age 65, as required by law the Mount Sinai Medical Center medical plan is the primary plan for you and your covered family members. If neither you nor any of your covered family members are eligible for or have Medicare, this notice does not apply to you or your family members, as the case may be. However, you should keep a copy of this notice in the event you or your family members should qualify for coverage under Medicare in the future.

Background on Medicare Prescription Drug Coverage and Mount Sinai Medical Center Prescription Drug Coverage

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can obtain this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. Mount Sinai Medical Center has determined that the prescription drug coverage offered by the Mount Sinai Medical Center Medical Plan (“Plan”) is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered “creditable” prescription drug coverage. Because your coverage under the Mount Sinai Medical Center Plan is creditable coverage, you will not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

When Can You Join a Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescription drug coverage through no fault of your own, you will also be eligible for a two-month special enrollment period to join a Medicare drug plan without penalty. This special enrollment periods runs for the two months after the month in which your current creditable coverage ends.

What Happens to Your Current Coverage if You Decide to Join a Medicare Drug Plan?

If you decide to join a Medicare drug plan while covered under the Mount Sinai Medical Center Plan, your coverage under the Mount Sinai Medical Center Plan will not be affected.

If you do decide to join a Medicare drug plan and drop your Mount Sinai Medical Center Plan, be aware that you and your family members may not be able to get this coverage back. To regain coverage, you would have to re-enroll in the Plan, pursuant to the Plan’s eligibility and enrollment rules. You should review the Plan’s summary plan description to determine if and when you are allowed to add coverage.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with Mount Sinai Medical Center and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

The following Notice is required by law if you or a family member is Medicare eligible.For Use On or After April 1, 2011

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If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go 19 months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage…

Contact the Human Resources Department. NOTE: You will be sent this notice each year before the next period you can join a Medicare drug plan, and if this coverage through Mount Sinai Medical Center changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You will be sent a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:l Visit www.medicare.gov l Call your State Health Insurance Assistance Program (see the inside back cover of your copy of

the “Medicare & You” handbook for their telephone number) for personalized help,l Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and whether or not you are required to pay a higher premium (a penalty).

Date: 09/30/2011

Name of Entity/Sender: Mount Sinai Medical Center

Contact--Position/Office: Human Resources Director

Address: 4300 Alton Road, Miami Beach FL, 33140

Phone Number: 305-674-2630

Nothing in this notice gives you or your family members a right to coverage under the Plan. Your (or your family members’) right to coverage under the Plan is determined solely under the terms of the Plan.

The following Notice is required by law if you or a family member is Medicare eligible.For Use On or After April 1, 2011

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Notes:

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Notes:

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Notes:

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