HSU Orientation - Benefits by Humboldt State University

NKW EMPLOYEE ORIENTATION -BENEFITS Health Benefits;

Benefits Website: http://www.humboldt.edu/hsuhr/employee/benefits/ Premium Rates in Benefits Packet and on website

Blue Shield Access+ HMO or Blue Shield Net Value HMO - Blue Shield web site: https://www.blueshieldca.com/bsc/calpers/calpers welcome. jhtml . No deductibles; $15 co-payment for doctor's visits; $50 for ER visits (waived if hospitalized); no charge for liospitalizations. Must select Primary Care Physician (PCP); PCP providers and specialists at Blue Shield web site. No lifetime maximum. Medical ID cards issued.

PERS Choice/PEHS Sclect/PEHS Care PPO - Blue Crnss web site: www.bluecrnssca.com o $500 dcdudible/$1,000 per family -- 80/20 ratio. Use prnvideirs in the nehvol'IL Some Prnventive Care procedures not subject fo deductible/pays 100% of costs (see Evidence of Coverage). Annual out-ofpocket costs per person-$3,000; $6,000 maximum per family. No lifetime maximum. o Medical ID rnrds issued, must request for dependents. o

Delta Enhanced and Delta Car" are the tivo dental plans available. CSlU Delta Dental web site: http: Ilvvww. d eltad entaka. org/csu/ Delta Enhanced is a PPO plan which allows choice of dental provider; Delta Care is an HMO plan which limits employees to seek scJ:'Vices from one local dentist that is designated to provide HMO dental services. Employees in Delta Care may not obtain services from any other dentist. NOTE: Currently there is not a Delta Care provider accepting new patients in Hmuboldt County.

Vision Insurance (covers all dependents)- Vision Service Provider (VSP)- Group# 12292796. No ID cards issued for Dental/Vision Insurance Benefits.

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Life Insurance for most bargaining units; MED EX travel insurance included

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Any life (permitting) events-e.g., marriage, divorce, adding a newborn or adopted child, or child turns age 26-will affect eligibility for health benefits. Some life events require the dependent to be added/removed the first of the month following the event; other events permit the new dependent to be added once the enrollment forms are received within 60 days of the event. Please see Human Resources for specific details when a life event occurs. Employees do not need to wait for Open Enrollment for changes in healthbenefits due to life event occurrence.

Health Care/Dependent Care Reimbursement Accounts (HCRA/DCRA)- Must enroll each year during Open Enrollment. If enrolling within first 60 days of employment for 2012 must submit another enrollment form for 2013 during the Open Enrollment period in September- October of this year. For comprehensive list of eligible expenses, see ASI website; http;//www.asiflex.com/

Open Enrollment - Each fall--allows employees to change health, dental plans, add or delete dependents without a permitting event to occur. Must enroll/re-enroll for the Flexible Spending Accounts-Health Care and De1iendentCare Pre-Tax Savings Accounts--for the following calendar year,

CaIPERS Retirement System; 2%@62, lifetime medical & dental, if receiving at time of retirement. Vesting- S years, retire at 52+. Employee contribution is calculated at: Gross salary is calculated at 0% contribution by the employee. Unit08, Public Safety members are not subject to Social Security and will contribute 9% of total gross salary.

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Example: Gross Salary: $4,000 per month Employee retirement contribution:

$4,000.00 x 6% $ 240.00

Current match of PERS retirement by employer is 24.198%

Retirement contribution will stop for employer/employee, when annual salary reaches $113, 700..

PST Retirement Plan - pre-PERS. 7.5% of gross montlily salary-no employer match. Allfull-time employees are enrolled directly into PERS. If you are less tliau full time, yon will be enrolled in PST until yon meet tlie guidelines for PERS membership.

Volunta1y Insurances- MAIL COMPLETED APPLICATIONS DIRECTLY TO COMPANY catastrophic illness insurance, travel, AID&D, disability. Voluntary Life Insurance may be pnnhased within the first 60 days from hire date, with 110 medical certification required.

TSA and DefeATed Compensation Plans - 403(b); 401(k) and 457 plans available to employees. Detailed information is on Benefits website and in the Human Resources office. Please see website and/or contact Human Resources for information.

Leaves of Absences/Workers' Compensation -Seveml leave of absence programs: o Non-Industrial Disability Leave o Industrial Disability Leave o Parental Leave o Catastrophic Leave o Family .Medical Leave Please see linlcs on website for information and contact Cindy Darnall Stevens directly for more information on leave programs.

Workers' Compensation Immediately report all injuries to supervisor or call Cindy Darnall Stevens directly at extension 5171. Pre-Designation of Physician-must be on file before injury-allows employee to see own physician first in the event of industrial injury. First line of contact for medical treatment for industrial injury is Student Health Center if injury occurs during semester, or Mad River Occupational Health Services or Mad River Emergency Room; or, St. .Joseph Occupational Services or St. Joseph Emergency Room, if necessary. Other Benefit Programs - Homeowners Insurance and Auto Insurance programs, Credit Union membership, Cal-Ore Life Flight Program. All information regarding benefits on HR web site-http://www.humboldt.edu/hsuhr/ - click on "Benefits"; or "Forms" for various enrollment forms (scroll down to Benefit Forms). Benefit Bulletins - First section of the Benefits website. Current information and changes that relate to employee benefits. University Notices are sent each week to campus email address-benefit information is distributed to employees through this venue with links to appropriate web sites and documents. Please contrtct Ciiidy Darnall Stevens at extension 5171 or Kristina Bamum at extensio115172for ([dditional injornwtion.

Human Resources 826-3626

HSU Employment & Benefit Fact Sheet The following outline summarizes Humboldt State University employee benefits. Please contact Human Resources for further details. The provisions of Collective Bargaining Agreements may modify employee benefits. Check respective agreements for specific information. PAYDAY is once each month. Payroll warrants are normally released at 4:00 P.M. on the last day of the pay period at the Cashier's Window. Automatic bank deposit forms are available from either Human Resources or the Payroll Office. Payroll warrants will not be mailed to homes. Please refer to the Humboldt State University Calendar for further information. (Extra calendars are available from Human Resources.) HOLIDAYS are normally observed as follows: Labor Day Martin Luther King's Birthday Admission Day* Lincoln's Birthday* Columbus Day* Washington's Birthday* Veterans Day Memorial Day Thanksgiving Day Independence Day Christmas Day Personal Holiday New Year's Day Cesar Chavezâ&#x20AC;&#x2122; Birthday *These holidays are moved to Thanksgiving and Christmas.

HEALTH INSURANCE: HSU employees have four health plans from which to choose. Each plan varies in coverage and premium cost, therefore, it is essential that employees compare each plan against personal and family needs prior to making a selection. The State pays a portion of the premium and the balance is deducted from enrolled employee's payroll warrants. Eligibility for health coverage: Half-time or more in an appointment that exceeds six months in duration for all employees except part-time lecturers. Effective Fall 2002, part-time lecturers and coaches appointed for one semester for at least 6 WTUâ&#x20AC;&#x2122;s (.4 time base) also qualify for health coverage. Employees must enroll in a health plan within the first 60 days of eligible employment, or serve a 90-day waiting period after enrollment before coverage begins, or wait for the next open enrollment period.

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DENTAL INSURANCE is available to all eligible employees. Delta Dental and DeltaCare (formerly PMI) are the only dental plans available at this time. Currently the State pays the entire premium for the employee and dependents. The Delta Dental Plan allows a choice of dentists while the DeltaCare plan restricts you to one. Please check with Human Resources for the name of the dentist currently contracting with DeltaCare services. Eligibility for dental plan: Half-time or more in an appointment that exceeds six months in duration. NOTE: Effective Fall 2002, part-time lecturers and coaches appointed for one semester for at least 6 WTUâ&#x20AC;&#x2122;s (.4 time base) also qualify for dental coverage. Employees must enroll in a dental plan within the first 60 days of eligible employment, or serve a 90day waiting period after enrollment before coverage begins, or wait for the next Open Enrollment period. It is important that employees not seek dental plan services until after the deduction code is reflected on the payroll warrant stub. VISION INSURANCE is available to all eligible employees. Vision Service Plan (VSP) is the only vision plan available at this time. Currently the State pays the entire premium for employees and their dependents. If eligible, enrollment will be automatic and no action is necessary. Eligibility for the vision plan is identical to the requirements for the health and dental plan information listed above. It is important that employees not seek vision plan services until after the deduction code is reflected on the payroll warrant stub. LIFE INSURANCE is available to certain bargaining unit employees and is currently paid in full by the employer. If eligible, enrollment will be automatic and no action is required. The amount of coverage varies between bargaining units. You may view your Certificate of Insurance on the web at: http://www.calstate.edu/Benefits/carrier.materials/BasicLife_Cert_10_2002.pdf AUTO/HOMEOWNERS INSURANCE is available by payroll deduction through A+ Auto & Home Insurance Plus (formerly California Casualty). The representative visits the campus monthly and can usually be reached once each month in Human Resources during regular office hours. Employees may contact the agent assigned to HSU directly at her toll free number (1-800-448-1317). LONG TERM DISABILITY INSURANCE is available to certain bargaining unit employees and is currently paid in full by the employer. If eligible, enrollment will be automatic and no action is required. Brochures are available from Human Resources. DEPENDENT CARE ACCOUNT is available for all eligible employees. It provides for the payment of certain dependent care expenses from pre-tax income. Each month, the amount pre-selected is deducted from the gross salary before income and social security taxes are withheld. These funds are held in a personal Dependent Care Account until eligible expenses are incurred and a claim is filed for reimbursement. Employees must enroll within the first 60 days of eligible employment, or wait until the annual Open Enrollment period each fall. Brochures are available from Human Resources. TAX ADVANTAGE PREMIUM PLAN (TAPP) is available to all employees who are enrolled in a health plan. The Tax Advantage Premium Plan provides for the employee contribution made toward health plan premiums to be deducted from the gross salary before income 09/08

and social security taxes are calculated and withheld. Employees who do not wish to participate in the TAPP program, must notify Human Resources in writing. Brochures are available from Human Resources. HEALTH CARE REIMBURSEMENT ACCOUNT (HCRA) is available to eligible CSU employees. It provides the ability to pay for eligible out-of-pocket health care expenses with pre-tax dollars. Employees must enroll within the first 60 days of eligible employment, or wait until the annual Open Enrollment period each fall. Brochures are available from Human Resources. FLEXCASH is an optional benefit plan that allows eligible employees to waive CSU medical and/or dental insurance in exchange for cash if they have other non-CSU coverage. Employees participating in this program will receive additional taxable income each month up to a maximum of $140. This benefit is offered to all bargaining units. Employees who are covered as dependents of employees of the CSU system are not eligible to participate in the Flex Cash Plan. Employees must enroll during the first 60 days of eligible employment or wait for the next Open Enrollment period, unless a change of status event occurs as defined by the Flex Cash brochure available in Human Resources NON-INDUSTRIAL DISABILITY INSURANCE (NDI) is a wage continuation program for non-work injuries and illnesses. It is completely paid by the State. The program may provide a benefit of $125 - $250 per week, depending upon the bargaining unit. Benefits are payable once a month (for a maximum of 26 weeks) during any one continuous period of disability. Contact Human Resources for further details. See also the Catastrophic Leave Donation program below that may supplement wages with the NDI program. CATASTROPHIC LEAVE DONATION is available to supplement the NDI, IDL and Temporary Disability Programs, and is also available for employees who are required to care for family members who meet the definition of incapacitation (according to each bargaining contract). It allows employees to donate vacation and sick leave credits to other employees who have exhausted all accrued sick leave, vacation and CTO due to catastrophic illness or injury that has totally incapacitated them from work. Eligible employees must apply for IDL, NDI, or Temporary Disability, if appropriate. Please contact Human Resources for further details. PUBLIC EMPLOYEES' RETIREMENT SYSTEM (PERS) is the retirement system in which eligible employees of Humboldt State University participate. It is coordinated with Federal Social Security. Membership is mandatory for those employed full-time for a period that exceeds six months or part-time (50% or more) for a period of employment that exceeds one year. Effective Fall Semester 2003, part-time lecturers and coaches may become eligible to the PERS retirement system at the beginning of a third consecutive semester at .4 or more time base. The monthly employeeâ&#x20AC;&#x2122;s contribution is 5% of the gross in excess of the first $513 before Federal and State Income Taxes. GROUP TERM LIFE INSURANCE: A $5,000 term life insurance benefit plus six months pay is provided through the Public Employees Retirement System (PERS) to assist the beneficiary if death occurs before eligibility to retire. Membership in PERS is required. 09/08

PST RETIREMENT PLAN is a mandatory retirement plan for part-time seasonal and temporary/intermittent employees in Bargaining Units 3, 4, & 8 who are not eligible for membership in the UC or Public Employees' Retirement System. The plan is administered by the Department of Personnel Administration, Savings Plus Program (457). The employee's contribution is 7.5% of the gross monthly salary. Employees may request a detailed brochure from Human Resources. SOCIAL SECURITY (OASDI) deductions are coordinated with Public Employees' Retirement System deductions at a rate of 6.2%. All employees in one or more positions which total 50% or more are required to contribute to both Social Security and the retirement system unless specifically exempted by the retirement law. MEDICARE TAX is deducted from employee's wages at a rate of 1.45% of the gross monthly salary. PRE-RETIREMENT REDUCTION IN TIME BASE PROGRAM (PRRTB): This program allows academic employees, including Student Services Professionals, Academic-Related; Counselors and Librarians, to phase into actual retirement through reduction in time base to an average of two-thirds, one-half or one-third of full-time while maintaining full retirement and other benefits for a maximum period of five years. Contact the Office of Faculty Personnel Services for specific information. FACULTY EARLY RETIREMENT PROGRAM (FERP) allows tenured faculty members who are eligible for service retirement under the Public Employees' Retirement System (PERS) to elect service retirement and teach one semester each succeeding academic year for a maximum of (5) consecutive academic or fiscal years or through the academic year in which they reach age 70, whichever occurs first. Please contact Faculty Personnel Services for specific information. SICK LEAVE is accumulated for full-time employees at the rate of 8 hours per month. Part-time employees accumulate sick leave on a prorated basis. VACATION accrual rate for the majority of non-academic and administrative classifications is determined by years of service and applicable collective bargaining agreements. For information concerning specific accrual rates, please contact the Payroll Department. Employees in academic year appointments are not eligible for vacation. WORKERS' COMPENSATION/INDUSTRIAL DISABILITY LEAVE: Employees are fully insured under Worker's Compensation law against any injury/illness arising out of or in the course of employment. It is the employee's responsibility to report all job-related injuries or illnesses immediately to his/her supervisor by use of the "Employee's Claim for Worker' Compensation Benefits form. Use of this form is mandatory if the employee loses time from work or must seek medical services for a work incurred injury or illness. IDL provides full pay for the first 22 days of disability, subject to a 3-day waiting period, and drops to 2/3 thereafter. PERS membership is required to be eligible for IDL benefits. Certain bargaining units may choose IDL Supplementation. Please contact Human Resources for additional information. 09/08

CSU SPONSORED GROUP INSURANCE PLANS are voluntary insurance plans available through payroll deduction, including disability income, supplemental income protection, personal accident insurance, supplemental family hospital income, cancer medical reimbursement, and travel assistance international. The plans are administered by Sanders & Associates and brochures may be obtained from Human Resources. TAX-SHELTERED ANNUITY/DEFERRED COMPENSATION PROGRAM: These programs permit an employee to contribute, through payroll deduction, to a tax-sheltered annuity account. The tax-sheltered portion of gross income is not included as part of the gross earnings for State and Federal tax purposes. Income taxes are paid at the time funds are withdrawn. Please view the tax sheltered annuity program guide on the web at: http://www.calstate.edu/Benefits/carrier.materials/2002_TSA_Brochure.pdf There are numerous tax sheltered annuity (403b) plans available in addition to the state Deferred Compensation (457) and (401k) plans. Please contact Human Resources for a list of participating companies. FEE WAIVER/CAREER DEVELOPMENT PROGRAM: Under this voluntary program, admission fees are waived or reduced for approved HSU courses. Full-time employees and tenured part-time employees are eligible. Effective Fall 2002, certain bargaining units are now eligible for dependent fee waiver. Please contact Human Resources for more information. CREDIT UNION: The California State & Federal Employees Credit Union #20 and the Coast Central Credit Union are available to all University employees. Contact each credit union directly for more information. UNEMPLOYMENT INSURANCE may provide a weekly income when employment terminates. Contact the nearest Employment Development Department (EDD) for eligibility and claim filing instructions. COBRA CONTINUATION OF BENEFITS: As a result of federal legislation enacted in 1986, employees or family members who lose medical, dental or vision coverage through the University as a result of a qualifying event have the right to participate in a group benefits continuation plan. A group continuation plan is a health, dental, or vision insurance plan with identical coverage to the current group plans. The cost of this coverage may not exceed 102% of the applicable group premium rate. Upon termination of employment, notification of the right to continue benefits will automatically be sent to the last known home mailing address by Human Resources. It is important that employees maintain a current mailing address. Please contact Human Resources if additional information is required. VOLUNTARY CHILD SUPPORT PROGRAM (VCS) provides for voluntary payroll deduction for the payment of support, maintenance, or care of the employee's children, or family for whom the employee has duty of support. Please contact Human Resources for information. VOLUNTARY SPOUSAL SUPPORT PROGRAM (VSS) provides for voluntary payroll deduction for the payment of support, maintenance or care of the employee's former 09/08

spouse for whom the employee has a duty of support. Please contact Human Resources for information. SAVINGS BONDS are available by payroll deduction. Please contact Human Resources for the appropriate payroll deduction authorization form. ($100 minimum denomination at $50/mo.) SEPARATING EMPLOYEE CHECK OUT/CLEARANCE FORM is required upon termination of employment. This process requires the completion of the Separating Employee Check Out/Clearance form (provided by the hiring department). The last payroll warrant and retirement contributions, if any, will be held pending completion of this form. For more information please contact Human Resources. Rev 09/08

09/08

TECHNICAL LETTER HR/Benefits 2014-07 ATTACHMENT C

2015 CalPERS Health Benefits Program Basic Plan Rates

HEALTH PLAN

ANTHEM BLUE CROSS TRADITIONAL HMO CALIFORNIA

BLUE SHIELD ACCESS+ HMO CALIFORNIA

PERSCARE

PERS CHOICE

PERS SELECT CALIFORNIA PEACE OFFICERS RESEARCH ASSOCIATION OF CALIFORNIA (PORAC)*

Enrolled Employee & Eligible Dependents

Employee Only Employee + 1 Employee + 2 or more Employee Only Employee + 1 Employee + 2 or more Employee Only Employee + 1 Employee + 2 or more Employee Only Employee + 1 Employee + 2 or more Employee Only Employee + 1 Employee + 2 or more Employee Only Employee + 1 Employee + 2 or more

Total Monthly Premium

All Employee Groups (except Unit 6) Amount Paid by CSU

Amount Paid by Employee

Unit 6 Amount Paid by CSU

Amount Paid by Employee

$727.34 $1,454.68 $1,891.08

$655.00 $1,246.00 $1,605.00

$72.34 $208.68 $286.08

$660.00 $1,256.00 $1,625.00

$67.34 $198.68 $266.08

$718.16 $1,436.32 $1,867.22 $718.93 $1,437.86 $1,869.22 $640.45 $1,280.90 $1,665.17 $618.22 $1,236.44 $1,607.37 $675.00 $1,292.00 $1,642.00

$655.00 $1,246.00 $1,605.00 $655.00 $1,246.00 $1,605.00 $640.45 $1,246.00 $1,605.00 $618.22 $1,236.44 $1,605.00 $655.00 $1,246.00 $1,605.00

$63.16 $190.32 $262.22 $63.93 $191.86 $264.22 $0.00 $34.90 $60.17 $0.00 $0.00 $2.37 $20.00 $46.00 $37.00

$660.00 $1,256.00 $1,625.00 $660.00 $1,256.00 $1,625.00 $640.45 $1,256.00 $1,625.00 $618.22 $1,236.44 $1,607.37

$58.16 $180.32 $242.22 $58.93 $181.86 $244.22 $0.00 $24.90 $40.17 $0.00 $0.00 $0.00

*This plan is restricted to employees in Unit 8, State University Police Association (SUPA) and requires membership.

N/A

CalPERS Health Plan Benefit Comparison – 2015 BENEFITS

HMO

PPO

Anthem Blue Cross Traditional HMO

Blue Shield Access+ HMO

PERS Select PPO

PPO

Non-PPO

PPO PERS Care

PERS Choice PPO

Non-PPO

PPO

Non-PPO

Calendar Year Deductible Individual

Family

N/A

$500

(not transferable

between plans)

$1,000

(not transferable

between plans)

N/A

Maximum Calendar Year Co-pay (excluding pharmacy) Individual Family

$1,500 $3,000

$1,500

$3,000

N/A

$3,000

N/A

$2,000

N/A

$3,000

$6,000

N/A

$6,000

N/A

$4,000

N/A

Hospital (including Mental Health and Substance Abuse) Deductible (per admission)

N/A

Inpatient

No Charge

N/A 20–30%

N/A

$250

40%

20%

40%

10%

40%

20%

40%

10%

40%

(hospital tiers)

Outpatient

No Charge

Facility/Surgery Services

20–30% (hospital tiers)

Emergency Services Emergency Room Deductible Emergency (co-pay

N/A

$50

N/A

$50

waived if admitted as an

$50 (applies to

hospital emergency

room charges only)

20% (applies to other

10% (applies to other

services such as physician, services such as physician, services such as physician, x-ray, lab, etc)

inpatient or for

x-ray, lab, etc)

observation as an outpatient) Non-emergency (Co-pay waived if admitted as an

$50

20%

40%

20%

40%

10%

40%

inpatient or for observation as an outpatient) (payment for physician

(payment for physician

charges only; emergency

room facility charge is not

covered)

BENEFITS

HMO

PPO

Anthem Blue Cross Traditional HMO

Blue Shield Access+ HMO

PERS Select

PPO PERS Care

PERS Choice

PPO

Non-PPO

PPO

Non-PPO

PPO

Non-PPO

Physician Services (including Mental Health and Substance Abuse) Office Visits (co-

$15

$20

40%

$20

40%

$20

40%

Inpatient Visits

No Charge

20%

40%

20%

40%

10%

40%

Outpatient Visits

$15

$20

40%

$20

40%

$20

40%

Urgent Care

$15

$20

40%

$20

40%

$20

40%

No Charge

20%

40%

20%

40%

10%

40%

No Charge

20%

40%

20%

40%

10%

40%

pay for each service provided)

Visits Vision

Not Covered

Exam/Screening Surgery/Anesth esia

Diagnostic X-Ray/Lab

Occupational / Physical / Speech Therapy Inpatient (hospital or

No Charge

$15

No Charge

skilled nursing facility) Outpatient (office and

20%

home visits)

40%;

20%

40%;

Occupational

Therapy:

20%

(pre-certification required

for more than 24 visits)

20%

Diabetes Services Glucose Monitors, test strips

No Charge

Self-management training

$15

Coverage Varies

$20

Coverage Varies

$20

Acupuncture $15/visit

$15/visit

(acupuncture/chiroprac

tic; combined 20 visits

tic; combined 15 visits

tic; combined 20 visits

per calendar year)

$15/visit

(acupuncture/chiroprac

tic; combined 20 visits

tic; combined 15 visits

tic; combined 20 visits

per calendar year)

50% of Covered

Not Covered

Charges

20%

40%

20%

40%

10%

40%

Chiropractic 20%

40%

20%

40%

10%

40%

Infertility Testing/Treatment

comprehensive enefit summary for the Access+ HMO plan - 2015 Calendar-year deductible Member

None

Family

None

Physician services Preventive health exam

No charge

Gynecological/well-woman exam

No charge

Pregnancy and maternity care; prenatal/postnatal office visits

No charge

Well-baby care

No charge

Immunization/inoculation

No charge

Allergy jesting/treatment

No charge

Office/home visits

$15/visit 路

Teladoc video or phone consultation

$15/call

Urgent care

$15/visit

Infertility testing and treatment

503 of allowable amount

Physician inpatient hospital visits

No charge

Surgery/anesthesia

No charge

Chiropractic and acupuncture services (Combined maximum of 20 visits per year)

$15/visit

Access+ Specialist' - self-referral to specialists

$30/visit

Hospital services Inpatient

No charge

Outpatient

No charge

Ambulatory surgery centers

No charge

Transgender surgical services

No charge

Ambulance services

No charge

Emergency care - no copayment if hospitalized or kept for observation

$50/visit

路oiagnostic X-ray/lab

No charge

Skilled nursing facility- up to JOO days per calendar year

No charge

Hospice

No charge

Mental health/substance abuse Inpatient

No charge

Outpatient

$15/visit

Prescriptions' Prescriptions for non-maintenance drugs and for the first three fills of maintenance drugs from a retail pharmacy (up to a 30-day supply)

$5 generic $20 formulary brand-name $50 non-formulary brand-name

Prescriptions for maintenance drugs after the first three fills from a retail pharmacy (up to a 30-day supply)

$10 generic $40 formulary brand-name $100 non-formulary brand-name

Prescriptions for maintenance drugs by mail order (up to a 90-day supply)

$l0generic $40 formulary brand-name $100 non-formulary brand-name

Prescriptions for specialty drugs (up to a 30-day supply)

$30

Prescription drugs to treat sexual dysfunction

503 of the cost of the drug

Maximum annual out-of-pocket payments for mail~service formulary prescription drugs'

$1000

Flu vaccine from network refoil pharmacies

No charge

Vision care

Eye refraction to determine need for corrective lenses (This service is limited to one visit per calendar year for members age l 8 and older; no limit on number of visits for members under age 18.)

No charge

Eyeglasses - not covered, except for those that are necessary after cataract surgery

203 discount available' (See page 12.)

Hearing-aid services Evaluation

No charge

Hearing aid - up to a maximum of $1.000 per member, every 36 months for both ears for the hearing-aid instrument and ancillary equipment

Charges in excess of $1.000

Durable medical equipment, including orthoses and prostheses

No charge

Physical/occupational/speech therapy Inpatient visits at a hospital or skilled nursing facility

No charge

Outpatient and home visits

$15/visit

Member Calendar Year Out-of-Pocket Maximum Member

$6,600 - Medical - $1.500 maximum - Pharmacy - $5, 100 maximum*

Family

$13,200 - Medical - $3,000 maximum - Pharmacy- $10,'.\00 maximum*

*-Includes the $1,000 maximum annual out-of-pocket payments for mail-service formulory prescription drugs per member This chart is a summary of the Access+ and NetVolue plan benefit coverage. It is not a contract. for complete details, please visit our website, blueshieldca.com/calpers, where you can find in-depth information about the plan, as well as download the Access+ HMO or NetValue HMO Evidence of Coverage and Disclosure Form. Or you can contact Member Services at (800) 334-5847 if you prefer a printed copy. 路

PERS Choice

PER~

The PERS Choice and PERSCare Preferred Provider Organization (PPO) plans are designed for individuals who va lue the freedom to choose health care providers and pharmacies. We've. developed this brochure to answer some commonly asl<ed questions about PERS Choice and PERSCare. How do I decide which plan meets my needs? PERSCare and PERS Choice provide a networl< of high-quality providers that you can access without a referra l. You ca n receive ca re from any networl< provider and have your health care costs covered at the maximum plan coverage amount. PERSCare pays a higher percentage of your medical bills, but with PERS Choice you have a lower monthly premium. Tal<e a minute to consult th e chart in th is broch ure, and th en co nsider your medica l and financial needs. If you'd lil<e to cut down on you r monthly premium wh ile maintaining quality coverage, PERS Choice is the plan for you. It offers most of the benefits of PERSCare for a lower premium. Wit h PERSCare, you pay a l1igher monthly premium, but have lower out-of-pocl<et expenses when you receive services. So, if your annua l medical bills tend to be high, you may save mon ey with PERSCare. Cal PERS has a third option called PERS Select. The highefficiency networl< gives members access to high-quality, costeffective providers at a lower premium. Although PERS Select benefits can match benefits available under PERS Choice by using Select networl<physicians and Tier One hospitals, the premium is lower than PERS Choice. PERS Select provides access to a subset (approximately half) of the Anthem Blue Cross PPO physician networl< that the PERS Choice plan uses. Please refer to the Freedom to Select brochure for more information about PERS Select. How does a PPO health plan work? Anthem Blue Cross contracts with ove r 59,000 physicians and approximately 390 hospitals t hroughout the st ate (our "p referred providers") who have agreed to accept payment amou nts set by Anthem Blue Cross for their services. These "a ll owable amou nts" are usu ally lower t han what other physicians and hospita ls charge for their services. Your portio n of t he charges wil l also be lower whe n you use a preferred provider. It's health ca re teamwork that saves you money. Once yo u've met yo ur deductible, your health plan will cover your hea lth care costs at a high percentage (depending on you r plan, usually 80 or 90 percent) when you use Anthem Blue Cross PERS Cho ice/PERSCare preferred providers. Once you have met your maximum ca lendar year responsibility ($3,000 for PERS Choice and $2,000 for PERSCare), per member and $6,000 fo r PERS Choice and $4,000 for PERS Care for fam ilies, most of your health care costs are paid 100 percent when you use a preferred provider. If you don't use prefe rred providers, yo u will pay substantially more. The chart in th is brochure shows how you r choice of physician affects your out-of-pocl<et respo nsibility.

What is Value Based Site of Care?

Programs designed to l<eep you informed about the variances in cost of medical care to l<eep your overall out-of-pocl<et cost down. Hip and Knee Joint Replacement: Hospital charges for these procedures vary throughout the state with no clinical evidence of better quality or outcomes. Ca lPERS and Anthem Blue Cross have designated 54 facilities throughout California where hip and l<nee joint replacement surgeries can be rendered and <Sal PERS I members wi ll have little to no out of-pocl<et costs above the plan's deductible and coinsurance. As a PPO plan member you continue to have the option to choose any facility, but may have lower out-of-pocl<et cost if you see I< services from one of the 54 facilities in this program. Site of Care: The Value Based program is utilized for three frequently used, routine outpatient hospital procedures. Wide geographic and treatment cost variations exist in California for routine outpatient.procedures. Services can be 2.5 to 3 times more costly in an outpatient hospital setting than in an Ambulatory Surgical Center. Value Based Site of Care establishes a payment threshold for 3.targeted routine procedures when the service is received at an outpatient hospital. Site of Care will apply to colonoscopy ($1,500 threshold), cataract surgery ($2,000 threshold) and arthroscopy ($6,000 threshold). There will be no benefit change when a participating Ambulatory Surgical Center is useq. Please refer to you r Evidence of Coverqge bool<let for further details. Please contact Customer Service to verify that your provider is a Value Based Site of Care. May I choose my own doctor? You have the freedom to access any licensed physician in the Anthem Blue Cross PPO networl<. Physicians who do not participate in the Anthem Blue Cross PPO networl< may choose to charge a fee that exceeds the "allowable amount." You are responsible for th e difference between their fees and Anthem Blue Cross' payment. You will pay more if you go to a physician that is outside of the Anthem Blue Cross PPO networl<. It's easy to l<eep your costs to a minimum; simply choose a provider within the Anthem Blue Cross PPO networl<. Can I get health information around the clock? Yes! The PERS Choice and PERSCare plans offer a 24-h our service called 24/7 Nurse line that connects you to a registered nurse with a toll-free phone cal l. This number is printed on your member ID card. This service provides you with a med ical professional's insight and guidance to help you mal<e decisions about your health care. Members can also tal<e adva ntage of t he audio libra ry, which contains hundreds of audiot apes that provide informat ic;in on self and preventive care, as well as other health-related issues. The telephone number is 800-700-9185.

2014 PERS Choice and PERSCare Basic Plan Comparison PERS Choice

PERSCare

$500 $1,000

DEDUCTIBLES:

CALENDAR YEAR DEDUCTIBLE/ AND MAXIMUM COPAYMENT/COINSURANCE Individual Family

-=========:::===..;:==========:======:

HOSPITAL ADMISSION DEDUCTIBLE Per admission

PPO None

non·PPO None

PPO $250

non·PPO $250

EMERGENCY ROOM DEDUCTIBLE Per visit

PPO $50

non·PPO $50

PPO $50

non·PPO $50

PPO $3,000 $6,000

non-PPO None None

PPO $2,000 $4,000

non·PPO None None

MAXIMUM CALENDAR YEAR COPAYMENT/COINSURANCE Member Family

--~

MEDICAL BENEFITS

Non-PPO

20%

40%

10%t

20%

40%

10%

$20 copay*

40%

$20 copay*

20%

40%

10%

No charge

40%

No charge

Diagnostic X-ray and Laboratory

20%

40%

10%

40%

Hearing Aid Services (One device In 36-month period for hearing aids)

20%

40%

10%

40%

Ambulance Services

20%

Emergency Services ($50 deductible er visit for covered ER char es)

20%

10%

20% (15 visits per calendar ear)

40% (15 visits per calendar earl

10% (20 visits per calendar ear)

40% (20 visits per calendar year)

Speech Therapy

20%*

40%

10%*

40%

Durable Medical Equipment (Precertlflcation required)

20%

40%

10%

40%

Hos Ice Care

20%

10%

Physical Therapy

20%

40%

10%

40%

20%

Physician Office Visits & Urgent Care Visits Other Physician Services Preventive Care (e.g., Immunizations and eriodlc health exams)

Chiropractic/Acupuncture Services (Combined benefit)

t Services received are not subject to the calendar year deductible, but are subject to the $250 hospital admission deductible. :f: Services received from a preferred provider are not subject to the calendar year deductible. * PPO and out-of-area providers. **A $250 hospital admission deductible applies for PERSCare. ***Hip and knee joint replacement su rgery provided by a designated Value Based Purchasing Center, benefits would be limited to $30,00,0 per procedure.

2014 PERS Choice and PERSCare Basic Plan Comparison PERS Choice MEDICAL BENEFITS (Continued)

PERSCare

non-PPO

MENTAL HEALTH (Includes mental health parity provisions) Inpatient (precertlflcatlon required)

20%

40%

10%**

40%"*

Outpatient (precertlflcatlon required at first visit - for facllity-based care>

20%

40%

10%

40%

Inpatient (precertlflcation required)

20%

40%

10%"*

40%**

Outpatient (precertiflcatlon required at first visit - for facility-based care)

20%

40%

10%

40%

SUBSTANCE ABUSE

HOME HEALTH CARE (precertiflcatlon required)

40% 10% 40% 20% (up to 45 visits per (up to 45 visits per (up to 100 visits !up to 100 visits calendar year) per calendar year) per calendar year) calendar year)

SKILLED NURSING FACILITY (precertlflcatlon required) First 10 Days

Hip and knee olnt re lacement PRESCRIPTION DRUG BENEFITS

2D%* 30%* (next 90 days>

40% 40% !next 90 da~s)

20%***

40%

Generic

Preferred Brand

RETAIL PHARMACY (short-term use)

10%* 20%* !next 170 days)

40% 40% (next 170 days) 40%

Non-preferred Brand

$50

PERS Choice (up to 30-day supply)

($40 If partial copay waiver Is approved)

PERSCare (UJI to 34-da

($40 If artlal co a waiver Is approved)

RETAIL PHARMACY MAINTENANCE MEDICATIONS after second fill at non-Maintenance Choice® Retall (a maintenance medication taken longer than 60 da s for chronic conditions not Including specialty medications) CVS Caremark Pharmacy™ mall-order service I Maintenance Choice• Retall Pharmacy (up to 90-day supply) A$1,000 maximum copayment per person per calendar year applies (excludes copayments made for Non-preferred brand drugs and erectile or sexual dysfunction drugs) "Member Pays the Difference" Brand name medications that have enerlc e ulvalents

$10

$40

$100

$10

$40

$100 ($70 If partial copay waiver is approved)

Difference In cost of the brand named drug and enerlc dru + enerlc copa ment

50% coinsurance for erectile or sexual dysfunction drugs applies to both retail and mail order (refer to EOC for details) Note: In addition to the amounts shown above, if you receive services from a Non-preferred Provider, you will be responsible for all of the charges In excess of the Allowable Amount, plus all charges for non-covered services. Th e Allowable Amount for covered services provided by Non-preferred Providers is usually lower thari, what the providers customarily charge. Therefore, you may have substantial out-of-pocl<et responsibility if you visit a Non-preferred Provider.

Anthem Blue Cross helps you put that out of pocket back In your pocket. Anthem Care Comparison Is our Industry-leading cost disclosure tool and It Is just a few clicks away. An on line-based resource, Anthem Care Comparison allows you to evaluate the cost of 120+ common medical procedures between providers and locations In order to facllltate health care decision making. Different health care facilities can charge different prices for the same service. That's a big deal If you're sharing the cost. Anthem Care Comparison clearly lists what those price ranges are - right down to the procedure and facility. Will I have to flll out complicated clalm forms? You do not have to fill out a claim form when you receive services from preferred providers participating In the Anthem Blue Cross PPO network. What are the prescription drug benefits? With PERS Choice and PERSCare, you pay $5 for up to a one-month supply of generic drugs, $20 for preferred brand-name drugs, and $50 for Non-preferred brand-name drugs when using a CVS Caremark participating retail pharmacy. When you use the CVS Caremark mall service pharmacy, you can receive up to a 90-day supply of maintenance medications and pay $10 for generic drugs, $40 for preferred brand-name drugs, and $100 for Non-preferred brand-name drugs. Maintenance medications are drugs that your doctor prescribes to treat a long-term condition or a chronic condition, such as asthma, diabetes, or high blood pressure, and that do not require frequent dosage adjustments. Drugs classified as specialty, even If taken long term, are not considered maintenance. Why should I use CVS Caremark mall-order service for maintenance medications? CVS Caremark mail-order service Is safe, convenient and ensures privacy. Every prescription Is Inspected for safety by a registered pharmacist and delivered to your home or a location of your choice in confidential, tamper-proof, and, when applicab.,le, temperature-sensitive packaging. Pharmacists are available for consult 24 hours a day 7 days a week to answer questions about your medication. They are familiar with your plan, so they suggest options that could save you money. If you need more information regarding mail service for maintenance medications, please call CVS Caremark toll free at 877-542-0284, or visit caremark.com/calpers.

Wiii i have access to health care services nationwide? Yes. PEijS Choice a.net PERSCare have the Bluecard速 program, which glves you the freedom to choose Anthem Blue Cross and Blue Stile1d ~a provider$ nationwide. With Bluecard, no matter where you travelJyou are covered by the largest health care network In the country. You will save money and have no claim forms to complete when yon use BlueCard PPO net work providers. These provider.s represent 74 percent of all doctors and hospitals In the United States. What's more, Bluecard Worldwide速 provides benefits at participating hospitals In certain countries around the world. How can I be sure I'll have coverage when I need It? PERS Choice and PERSCare help pay for a wide range of benefits, Including periodic health exams, emergency care, well-baby care, ch iropractic services and home health care. This coverage follows you statewide, nationwide and worldwide. Please refer to the plan's Evidence of Coverage booklet for exact benefits. Where can I get more Information about my coverage? The Anthem Blue Cross/CalPERS website, located at anthem.com/ca/calpers, offers Interactive member services. Once you're enrolled and Issued a personal Identification card, you can verify family enrollment, review your benefits, check your clalms, request ID cards, find a PERS Choice and PERSCare provider and electronically communicate with the CalPERS dedicated Anthem Blue Cross Customer Service staff. You may also call us toll free at 877-PERSPPO (877-737-7776). For Information about your pharmacy benefits call CVS Caremark toll free at 877-542-0284 or log on to ca remark.com/calpers.

PERS Choice and PERSCare offer a combination that's hard to beat - the freedom to choose your own doctor and coverage that w/11 be there when you need It. To find out more, please call our toll-free number, 877-PERSPPO (877-737-7776). For Information about your pharmacy benefits, call CVS Caremark toll free at 877-542-0284.

For more information, please call us at: 877-PERSPPO (877-737-7776) Improve your health and earn a reward. You have access to tools and resources that can help you live a healthier llfestyle - at no extra cost. Any CalPERS member enrolled in the PERS Choice or PERSCare program on January l , 2014, who completes the onllne Health Risk Assessment will be enrolled In a quarterly raffle for a $500 debit card (limit one per family). The debit card spends llke cash and can be used at any location that accepts debit cards.

Or reach us at: anthem.com/ca/calpers · Superior customer service · Hassle-free access to specialists · Quality providers · Nationwide coverage · Online services For more information about your CVS Caremark pharmacy benefits, please call CVS Caremark toll free at 877-542-0284, or visit caremark.com/calpers.

PERS Choice SC7014 Rev. 08/13

PER~

Ca/PERS 2014 Health Premiums - State Only Single

2-Party

Family

PERS Select

$594.95

$1,189.90

$1,546.87

PERS Choice

$643.53

$1,287.06

$1,673.18

PERSCare

$698.73

$1,397.46

$1,816.70

Basic Premium Rf)tes

Ca/PERS 2014 Health Premiums - Regional Contracting Agencies Only Basic Premium Rates

2-Party

Single

Family

Bay Area Alameda, Amador, Contra Costa, Marin, Napa, Nevada, San Francisco, Sa n Joaq uin, San Mateo, Santa Clara, Santa Cruz, Solano, Sonoma, Sutter, Yolo, Yuba PERS Select

$661.52

$1,323.04

$1,719.95

PERS Choice

$690.77

$1,381.54

$1,796.00

PERSCare

$720.04

$1,440.08

$1,872h0

Sacramento El Dorado, Placer, Sacramento PERS Select

$637.85

$1~75.70

PERS Choice

$665.99

$1,331.98

$1,731.57

PERSCare

$694.26

$1,338.52

$1,805.08

$1,658.41

Los Angeles Area Los Angeles, San Bernardino, Ventura PERS Select

$5?3.83

$1,147.66

$1,491.96

PERS Choice

$599.19

$1,198.38

$1,557.89

PERSCare

$624.59

$1,249.18

$1,623.93

Other Southern California Fresno, Imperial, Inyo, l<ern, l<ings, Madera, Riverside, Orange, San Diego, San Luis Obispo, Santa Barbara, Tulare PERS Select

$586.32

$1,172.64

$1,524.43

PERS Choice

$612.25

$1,224.50

$1,591.85

PERSCare

$638.22

$1,276.44

$1,659.37

Other Northern California Alpine, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Lal<e, Lassen, Mariposa, Mendocino, Merced, Modoc, Mono, Monterey, Plumas, San Benito, Shasta, Sierra, Sisl<iyou, Stanislaus, Tehama, Trinity, Tuolumne PERS Select

$613.99

PERS Choice

$641.08

$1,282.16

$1,666.81

$668.27

$1,336.54

$1,737.50

PERSCare

$1,227.98

$1,596.37

Out of State

PERS Select

NOT AVAILABLE

PERS Choice

$706.40

$1,412.80

$1,836.64

PERSCare

$736.32

$1,427.64

$1,914.43

For more information, please call us at: 877-PERSPPO (737-7776) SCI0361 Rev. 08/13

DeltaCare USA Basic and Delta Dental PPO Level I Enhanced Benefits Comparisons For eligible employees in the following categories: Unit 11 (Teaching Associate) and Unit 13

Plan Benefit

DeltaCare USA Basic Plan Charges:

Delta Dental PPO of California Enhanced Level I Plan Pays:

PREVENTIVE AND DIAGNOSTIC DENTISTRY Prophylaxis (cleaning)

No Deductible* No charge – limit 2 per calendar year

No Deductible* 100% – limit 2 per calendar year+

Fluoride Application

No charge – only to age 19

100%

Oral Exams Space Maintainers Emergency Office Visits

No charge $10 No charge

100% – limit 2 per calendar year 100% 100%

X-rays

No charge (Full mouth X-rays: 1 set per 24 consecutive months. Bitewings: 1 set (4 films) per every 6-month period.)

100% (Full mouth X-rays: 1 set in a 3-year period. Bitewings: 1 set per calendar year for age 18 and over**)

BASIC DENTISTRY

No Deductible*

Deductible*

Fillings

No charge for amalgam

80%

Anesthesia

Local – no charge; General – not covered

80% -limited to oral surgery and select endodontic and periodontic procedures.

Injection of Antibiotics

Not covered

80%

Extractions

Uncomplicated – no charge; $15-$25 for bony impactions (not covered for orthodontia)

80%

Oral Surgery

No charge

80%

Endodontics

Root canal – $20 anterior, $40 bicuspid, $60 molars

80%

Periodontics

$10 for scaling/root planning per quadrant $20 for gingivectomy per quadrant $80 for osseous surgery per quadrant

80%

Denture Relining

Office – no charge; Lab – $15

80%

PROSTHETIC DENTISTRY

No Deductible* $35-$50 per unit; plus additional cost for precious metals and porcelain on molars

Deductible*

Prosthetic Appliance Repair

Up to $15

50%

Dentures

Full – $60 each; Partials – $70 each

50%

Implants

Not covered

50%

ORTHODONTICS

No Deductible* $1,400 maximum co-payment plus $350 start-up costs for 24-month treatment plan (only for covered children up to age 26). Orthodontics extractions are not covered.

No Deductible*

Work in progress when you join

Not covered. (Examples: in-progress root canals, teeth prepped for crowns, etc.)

Pre-determination of benefits

Not required

Alternative to treatment provision

May be additional cost.

Only covers charges for services the member receives on and after effective date of coverage. Not required; however, suggested for services proposed over $300. If dentist determines alternative treatment is necessary, approval is subject to Delta review.

Crowns and Bridges

Orthodontics

50%

50% - $1,000 maximum per patient per case (for employees, spouse and dependent children).

SPECIAL PROVISIONS, LIMITATIONS, EXCLUSIONS

Referral to specialist

Approval is subject to review by dental consultant.

N/A

Missing teeth

No exclusion against replacing missing teeth.

Out-of-area emergency

Maximum of $50

PPO dentists available nationwide. Submit non-network dentist’s billing statement to Delta Dental of California for reimbursement.

Deductible

No deductible

$50/person up to maximum of $150/family deductible per calendar year for basic and prosthetic dentistry. Any part of deductible satisfied during last 3 months of calendar year is credited toward the next calendar year deductible.

Prosthetic replacements

Limited to one each 5 years.

No maximum*

$2,000 per calendar year per person

MAXIMUM BENEFIT FOR PREVENTIVE, BASIC AND

*Refer to the Evidence of Coverage (EOC) booklet. **Children under 18 are eligible for 2 sets of bitewing x-rays per calendar year. There is a $500 maximum, per year, per child for pedodontic procedures only when performed by a specialist (applies to DeltaCare USA only).

+Under certain guidelines Delta Dental participants who are pregnant are eligible to receive an additional cleaning and/or periodontal examination in a calendar year.

DeltaCare USA Enhanced and Delta Dental PPO Level II Enhanced Plans Benefits Comparison

For eligible employees in the following categories: Units 1, 2, 3, 4, 5, 6, 7, 9, 10, and C99, M98, M80 and FERP Annuitants

Plan Benefit

DeltaCare USA Enhanced Plan Charges:

Delta Dental PPO of California Enhanced Level II Plan Pays:

PREVENTIVE AND DIAGNOSTIC DENTISTRY Prophylaxis (cleaning)

No Deductible* No charge – limit 2 per calendar year

No Deductible* 100% – limit 2 per calendar year+

Fluoride Application

No charge – only to age 19

100%

Oral Exams

No charge

100% – limit 2 per calendar year

Space Maintainers

No charge

100%

Emergency Office Visits

No charge

100%

X-rays

No charge (Full mouth X-rays: 1 set per 24 consecutive months. Bitewings: 1 set (4 films) per every 6-month period.)

100% (Full mouth X-rays: 1 set in a 3-year period. Bitewings: 1 set per calendar year for age 18 and over**)

BASIC DENTISTRY

No Deductible*

Deductible*

Fillings

No charge for amalgam

80%

Injection of Antibiotics

Local – no charge; General – covered for extractions only and only when medically necessary Not covered

80% – limited to oral surgery and select endodontic and periodontic procedures. 80%

Extractions

No charge

80%

Oral Surgery

No charge

80%

Endodontics

No charge

80%

Periodontics Denture Relining

No charge No charge

80% 80%

PROSTHETIC DENTISTRY

Deductible*

Prosthetic Appliance Repair

No Deductible* No charge; however, additional cost for precious metals and porcelain on molars is applicable No charge

Dentures

No charge

80%

Implants

Not covered

80%

ORTHODONTICS

No Deductible*

Orthodontics

$1,400 maximum co-payment (only for covered children up to age 26) $1,600 maximum co-payment for adults. Plus $350 start-up costs for 24-month treatment plan. Orthodontic extractions are not covered.

50% - $1,000 maximum per patient per case (for employees, spouse and dependent children).

Anesthesia

Crowns and Bridges

80% 80%

SPECIAL PROVISIONS, LIMITATIONS, EXCLUSIONS Work in progress when you join

Not covered. (Examples: in-progress root canals, teeth prepped for crowns, etc.)

Pre-determination of benefits

Not required

Not required; however, suggested for services proposed over $300.

May be additional cost.

If dentist determines alternative treatment is necessary, approval is subject to Delta review.

Referral to specialist

Approval is subject to review by dental consultant.

N/A

Missing teeth

No exclusion against replacing missing teeth.

Out-of-area emergency

Maximum of $100

PPO dentists available nationwide. Submit non-network dentist’s billing statement to Delta Dental of California for reimbursement.

Deductible

No deductible

Prosthetic replacements

Limited to one each 5 years.

MAXIMUM BENEFIT FOR PREVENTIVE, BASIC AND PROSTHETIC DENTISTRY

No maximum*

$2,000 per calendar year per person

Alternative to treatment provision

Only covers charges for services the member receives on and after effective date of coverage.

California State University and VSP provide you an affordable eyecare plan. Coverage from a VSP Select Network Doctor Exam .................................................... every calendar year • Covered in full with a $10 copay Prescription Glasses 1 Lenses covered in full ......... every other calendar year • Single vision, lined bifocal and lined trifocal lenses. • Polycarbonate lenses for dependent children. Frame ..................................... every other calendar year • Frame of your choice covered up to $95 Retail. ~OR~ Contact Lens Care .................... every other calendar year When you choose contacts instead of glasses, your $120 allowance applies to the cost of your contacts and the contact lens exam (fitting and evaluation). This exam is in addition to your vision exam to ensure proper fit of contacts. ~AND~ VDT Supplemental Benefit for Eligible Employees Exam .......................................... every other calendar year • Covered in full with a $10 copay 1 Lenses covered in full ............. every other calendar year • Single vision, lined bifocal and lined trifocal lenses. Frame ......................................... every other calendar year • Frame of your choice covered up to $95 Retail. 1

New lenses will be approved and replaced every calendar year if at least one of the following criteria is met: • The new prescription differs from the original by at least a .50 diopter sphere or cylinder • There is a change in the axis of 15 degrees or more • A difference in vertical prism greater than on prism Extra Discounts and Savings

Laser Vision Correction • Savings averaging 15% off laser vision correction surgery (PRK, LASIK, and custom LASIK) through VSP contracted centers Contacts* • 15% off cost of contact lens exam (fitting and evaluation) Dollar for dollar you get the best value from your VSP benefit when you visit a VSP network doctor. If you decide not to see a VSP doctor, copays still apply. You'll also receive a lesser benefit and typically pay more out-of-pocket. You are required to pay the provider in full at the time of your appointment and submit a claim to VSP for partial reimbursement. If you decide to see a provider not in the VSP network, call us first at 800-877-7195. Out-of-Network Reimbursement Amounts: Exam: Routine and VDT ......................................... Up to $50 Lenses: Single Vision: Routine and VDT ............................. Up to $45 Lined Bifocal: Routine and VDT.............................. Up to $65 Lined Trifocal: Routine and VDT............................. Up to $85 Polycarbonate for dependent children .................... Up to $65 Lenticular and Aphakic ......................................... Up to $125 Frame: Routine and VDT ........................................ Up to $60 Elective Contacts .................................................. Up to $110 Necessary Contacts.............................................. Up to $250 VSP guarantees service from VSP network doctors only. In the event of a conflict between this information and the CSU contract with VSP, the terms of the contract will prevail.

SAVING MADE EASY One Step At A Time

WHAT IS A TSA PROGRAM?

HOW MUCH?

WHY PARTICIPATE?

WHAT ARE MY OPTIONS?

The sooner you start saving

The TSA Program features

up to $17,000 of your annual

That depends on you. The IRS allows you to invest

toward your retirement the

five Fund Sponsors, each

The CSU TSA Program is a

salary per year, but you can

better. The earlier you start,

offering quality investment

voluntary 403(b) plan that

decide to invest as little as

the more you benefit from

options. They are:

allows eligible employees

$15 per month. Plus, if you

“compounding.”

• Fidelity

to save for retirement by

are or will be age 50 or older

Compounding happens

• ING Life & Annuity

investing monthly, pre-tax

this year, you can invest up

over time as your money

• MetLife

contributions in tax-

to $5,500 more per year.

generates earnings, which

• TIAA-CREF

deferred accounts, under

And, if you have been

are re-invested to generate

• VALIC

Internal Revenue Code

employed by the CSU for

MORE earnings.

You can choose to invest

Section 403(b). A TSA

at least 15 years and didn’t

in one or split your monthly

can help you save money

take full advantage of

contribution between two

on taxes now AND invest

TSA contribution maximums

(2) or more Fund Sponsors.

over the course of your

in your future at the same time!

employment, you may be able to “catch-up” and invest even more.

www.calstate.edu/hr/benefitsportal

Take A Step Toward Your Future with the California State University Tax Sheltered Annuity (TSA) Program.

SAVING MADE EASY One Step At A Time

STEP 9: STEP 5:

CONFIRM YOUR CONTRIBUTIONS ON YOUR PAY WARRANT.

STEP 6:

If you don’t see the changes you made in Retirement Manager, please see your Benefits Office for assistance.

CHOOSE YOUR FUND SPONSOR(S).

STEP 1:

EXPLORE YOUR OPTIONS. There are five (5) Fund Sponsors to choose from, and each Fund Sponsor has a number of retirement savings plans and investment vehicles with your goals in mind.

STEP 2:

GET ADDITIONAL INFORMATION. You should feel comfortable with your decision to enroll in a TSA. If you need additional information, contact your Benefits Office to obtain the contact information of the TSA representatives assigned to your campus. Each of the Fund Sponsors has campus representatives available.

STEP 3:

DETERMINE THE MAXIMUM YOU CAN INVEST. You can defer up to $17,000 per year toward your TSA, and if you will be age 50 or older this year, you can defer another $5,500. In addition, if you have 15 years of CSU full-time employment and under-contributed over the course of your CSU employment, you may be able to defer an additional $3,000 per year for up to $15,000. Not sure if you qualify? Complete the online Maximum Contribution Worksheet available on the Benefits Portal (www.calstate.edu/hr/

benefitsportal).

STEP 4:

DETERMINE HOW MUCH YOU WANT TO INVEST EACH MONTH. Enter your figures into the SCO paycheck calculator (www.sco.ca.gov/ppsd_se_ paycheck_calc.html) to see how much you can afford to invest. You can invest as little as $15 per month for each Fund Sponsor you choose, and you can choose to invest in all five. The choice is yours! HR12504

ENROLL (SET UP) YOUR TSA ACCOUNT. Each Fund Sponsor (with one exception) has a CSU-dedicated website for you to enroll in its TSA plan. This is an important step—don’t overlook this. Here are their websites and toll-free customer service numbers:

STEP 10:

REVIEW YOUR SAVINGS STRATEGY EACH YEAR TO ENSURE YOU ARE REACHING YOUR RETIREMENT GOALS.

• Fidelity (800-343-0860):

http://enrollonline.fidelity.com

• ING (800-525-4225):

www.ingretirementplans.com/custom/csu403b

• MetLife (866-294-0807):

www.metlife.com/csu

• TIAA-CREF (800-842-2888):

www.tiaa-cref.org/csu

• VALIC (888-569-7055):

www.valic.com/calstate

STEP 7:

CHOOSE YOUR INVESTMENT OPTIONS. Each Fund Sponsor has a unique platform of investment choices, and they all offer Target Year Lifestyle Funds where the Fund Sponsor selects a suite of investment products based on the year you plan to retire.

STEP 8:

SET UP YOUR PAYROLL DEDUCTIONS VIA RETIREMENT MANAGER. This is very important because the Fund Sponsors can only set up your TSA account and your investment options. Deductions, however, are set up online via Retirement Manager at www.myretirementmanager.com. You can make changes every month if you choose to, and changes made by the 5th of each month are effective on your pay warrant the following month.

A WORD ABOUT LOANS AND HARDSHIP WITHDRAWALS All five of the current Fund Sponsors offer hardship withdrawals and four fund sponsors offer loans. If you want a loan or hardship withdrawal, you can request it from the Fund Sponsor and then download the appropriate transaction certificate from Retirement Manager. If you have investments contributed to a TSA company prior to January 1, 2009, you may be able to obtain a loan and/or hardship withdrawal if the TSA company has been certified as a Legacy Vendor by the CSU. To access these funds, you would follow the same steps as above. For more information on the CSU TSA Program, please visit the systemwide Benefits Portal at www.calstate.edu/hr/benefitsportal.

Revised 2012

Health Care Reimbursement Account Are You Missing an OPPORTUNITY to Put More Money in Your Pocket?

Find out how a Health Care Reimbursement Account (HCRA) can help you save! When you’re first hired, and each year during Open Enrollment, you can enroll in a HCRA. A HCRA is a great way to save money on taxes when you pay for eligible health care expenses.

How Does the HCRA Work? You decide how much money you want to contribute to the account for the year, then money is deducted in equal amounts from each paycheck, before taxes are taken out, lowering your taxable income. When you have an eligible expense, you submit a claim and get reimbursed (up to three times per month) with tax-free money from your account. Turn the page to find out more.

What’s an Eligible Expense? Use your HCRA funds for health care expenses not covered by your health plans, like: • Medical and dental plan deductibles and copays • Prescription and certain over-the counter drug costs • Eyeglasses, contact lenses and lens solution • Expenses that are partially covered by your health care plans, such as acupuncture, orthodontia, and laser vision correction

Don’t Forget the DCRA You can save additional money by enrolling in the Dependent Care Reimbursement Account (DCRA). A DCRA can be used to reimburse expenses for the care of an eligible dependent while you and your spouse work. An eligible dependent is someone you claim as a dependent on your federal income tax return and is either under age 13 or is mentally or physically unable to take care of him or herself. You can enroll for the DCRA at the same time that you enroll for the HCRA.

Saving With an HCRA — Three Examples Let’s meet three fictional CSU employees, with different health care situations this year:

Kevin, who expects to have minimal eligible expenses for himself Carol, who expects to have around $600 in eligible expenses for herself and her husband Dan, who expects to have significant eligible expenses for himself and his family

Meet Kevin… Kevin is enrolled in an HMO medical plan. His overall health is good, so he expects only to need limited health care this year. He normally gets one prescription during the year and plans to get new glasses. Kevin decides to set aside $20 per month into his HCRA, which will add up to $240 for the year — the minimum amount allowed. With this tax-free money, Kevin can pay for: • A copay for one eye exam

• The copay for three non-preventive doctor visits

• A new pair of prescription glasses

• One non-formulary prescription

Meet Carol… Carol and her husband are enrolled in a PPO medical plan. They expect to visit their doctor and dentist a few times this year, especially because Sally’s been having some tooth pain. They’re also both expecting to need new glasses, and to use some over-the-counter medications. Carol decides to put $600 into her HCRA for the year — $50 per month. With her tax-free money, Carol can pay for: • Two copays for eye exams

• Two porcelain dental fillings

• Two new pairs of prescription glasses

• $50 worth of over-the-counter medications

• The copay or coinsurance for three doctor’s office visits

Meet Dan… Dan and his family are enrolled in an HMO medical plan and have some big health care expenses this year. Their son will start orthodontia treatment, and one of their daughters needs new glasses. Dan’s wife also needs new glasses and has been seeing a chiropractor recently. Additionally, Dan requires a year’s supply of contact lenses. They also expect the whole family will need dental care and have several prescriptions to fill. Dan decides to contribute the maximum allowable amount to his HCRA — $5,000, or about $415 per month. With this tax-free money, Dan can pay for: • Seven non-preventive care doctor appointments • Two pairs of prescription glasses

• A year’s supply of contact lenses • The employee percentage of the cost for orthodontia treatment

Remember, these are examples only — your health care needs and geographic location will affect what your HCRA contributions will cover.

It All Adds Up! So just how much money can you save with a HCRA? Well, if Dan sets aside $5,000 in his HCRA, he lowers his taxable income by that amount. If he’s in the 33% tax bracket, that means he can save $1,650 on his taxes (33% of $5,000) — that’s an extra $1,650 in his pocket this year!

W i l l Yo u M i s s Yo u r O P P O R T U N I T Y t o S a v e ? 15,000 – 09/07

2015 INTERNAL REVENUE CODE (IRC) LIMITS AND COMPARISON CHART

TAX SHELTERED ANNUITY (403[b]), STATE DEFERRED COMPENSATION (457[b]) AND STATE THRIFT (401[k]) PLANS Eligibility: Generally, all employees are eligible to participate in the 403(b) program with the exception of certain student classifications and Special Consultants. Seasonal or temporary employees required to be enrolled in the Part-time, Seasonal and Temporary Employees Retirement Program (PST Program) are not eligible to enroll in the 457(b) and 401(k) plans. TSA PLAN (403[b])

DEFERRED COMP (457[b])

THRIFT PLAN (401[k])

Deferred tax on investment; variety of investment choices. $15 minimum monthly contribution. Maximum annual contribution is $18,000. Additional $6,000 age based catch-up deferral available to participants who will reach age 50 by the end of the calendar year. 15-year “Catch-up” provision may be available for up to $3,000 per year, for a lifetime maximum of $15,000. Participants must prove eligibility by submission of completed Maximum Contribution Calculation Worksheet.

Deferred tax on investment; variety of investment choices. Roth also available. $50 minimum monthly contribution. Maximum annual contribution is $18,000. Additional $6,000 age based catch-up deferral available to participants who will reach age 50 by the end of calendar year. Traditional 457 “Catch-up” provision up to $36,000 is available. Participants in this plan cannot utilize both the age-based, and special 457 catch-up provisions in the same calendar year. Contact Savings Plus for details.

Eligible rollover in from another employer’s 403(b), 401(k) or governmental 457(b) plan.

Eligible rollover in from another employer’s 403(b), 401(k) or governmental 457(b) plan. Or from a Traditional IRA.

Eligible rollover distribution to an IRA (Traditional or Roth), another employer’s governmental 457(b), or 401(k), or 401(a), or 403(b) plan.

Eligible rollover distribution to an IRA (Traditional or Roth), or to another employer’s 401(k), or 457(b) governmental plan, or 401(a), or 403(b) plan.

Eligible rollover to another employer’s 403(b), 401(k), or governmental 457(b) plan (exceptions apply), or to a 401(a) (service credit purchase) plan (exceptions apply) or to an IRA (must be at least age 59 ½ or separated from CSU employment). In-service 403(b) contract exchanges to any of the selected five fund sponsors. Loans Available; restrictions apply. Hardship withdrawal for severe financial hardship. Contributions suspended for 6 months. Surviving spouse of participant may roll over distributions. Non-spousal beneficiary may rollover distributions to an inherited IRA. At least age 55 and retired, or 59 ½ (regardless of employment status) - receive plan payout without tax penalty.

Loans Available; restrictions apply. Hardship withdrawal for unforeseeable financial emergency. Contributions suspended for 6 months. Surviving spouse of participant may roll over distributions. Non-spousal beneficiary may rollover distributions to an inherited IRA. Plan payout upon retirement or separation from State service without tax penalty (no age requirement). At age 70 ½, IRS requires mandatory At age 70 ½, IRS requires mandatory distributions, unless participant is still distributions, unless participant is still employed. employed. Employees can manage contributions online Employees can manage contributions online at: at: myretirementmanager.com savingsplusnow.com

Deferred tax on investment; variety of investment choices. Roth also available. $50 minimum monthly contribution. Maximum annual contribution is $18,000. Additional $6,000 age based catch-up deferral available to participants who will reach age 50 by the end of the calendar year. The 15-year “Catch-up” provision and Traditional 457 “Catch-up” is not available.

Loans Available; restrictions apply. Hardship withdrawal for severe financial hardship. Contributions suspended for 6 months. Surviving spouse of participant may roll over distributions. Non-spousal beneficiary may roll over distributions to an inherited IRA. At least age 55 and retired, or 59 ½ (regardless of employment status) - receive plan payout without tax penalty. At age 70 ½, IRS requires mandatory distributions, unless participant is still employed. Employees can manage contributions online at: savingsplusnow.com

For more information about these plans please visit CSYou at: https://csyou.calstate.edu/Pages/default.aspx or the CSU Systemwide Benefits Portal at: www.calstate.edu/hr/benefitsportal. NOTES: 1. Maximum contribution limits for these plans are all interrelated. Please note: Participants may contribute to both a 403(b) and a 401(k) plan in the same tax year, however, combined contributions across both plans cannot exceed $18,000. 401(k) and 403(b) deferrals do not count against the 457(b) dollar limit and 457(b) deferrals do not count against the 401(k) and 403(b) dollar limit. 2. These statements are general comparisons only. For specific information refer to your tax advisor. For the Deferred Compensation and Thrift Plans, additional information is available from the CalHR Savings Plus Program (SPP) Office at (855) 616-4SPN(4776) or savingsplusnow.com.

Revised: 10/23/2014

Humboldt State University

WHEN YOU CHANGE RETIREMENT SYSTEMS ............................................. CalPERS has an agreement with many California public retirement systems that allows you to move from one retirement system路 to the other without loss of benefits. This is called "reciprocity," These reciprocal agreements can allow you to coordinate your benefits between the retirement systems when you retire. Currently, you must leave and.enter into employment with a reciprocal public agency within six months to be eligible. With reciprocity, there is no transfer of your retirement contributio.ns or service credit between retirement systems. You would be 路a member of both systems and are subject to the membership, benefits and rights of each system. At retirement, you must apply to retire from both systems using the same retirement date, unless you meet retirement eligibility requirements in the other system before m'eeting our age requirement. The highest final compensation from either system can be used to calculate your retirement benefit, but you'll receive separate retirement payments from each system. Yciu can review a listing of Reciprocal Retirement Systems路 that have reciprocity agreements with CalPERS and find out more in our When You Change Retirement Systems booklet, both of which are located on the CalPERS website: www.calpers.ca.gov

CalPERS SPECIAL POWER OF ATTORNEY FORM

It has come to our attention that CalPERS is recommending that members complete the Special Power of Attorney from {PERS-OSS-138) that is specifically designed to assist in conducting your retirement affairs in the event you become incapacitated. The authority of this document is limited to CalPERS only. This affects both active and retired members. If you currently have any other power of attorney in place for your family, in most cases, it cannot be used for your CalPERS retirement. (Please see publication at link below for specific guidelines.) The following excerpt from the CalPERS publication explains in detail why this form is necessary and we have included a link to the informational booklet and form. Upon completion of the members' portion of the Durable Power of Attorney form, you may provide signatures of two witnesses as an alternative to providing a notarized signature. CalPERS recommends that you consult an attorney before signing the document. For additional information please call CalPERS at 888-225-7377. Link to publication and form at: https: //www .ca Ipe rs. ca .gov /mss-p ublicatio n/pdf/xj NBS27qbO1 l<z pub-30-booklet. pdf or, available in the campus Human Resources office. A CalPERS Special Power of Attorney allows you to designate a representative or agent, known as your attorney-in-fact, to conduct your retirement affairs. Having a CalPERS Special Power of Attorney on file with us ensures that your designated attorney-in-fact will be able to perform important duties concerning your CalPERS business such as address changes, federal or state tax withholding elections, lost or stolen retirement checks, beneficiary designation, or retirement benefit elections should you become unable to act on your own behalf. You must complete a power of attorney form while you are able to understand the powers you are granting. If you become unable to handle your affairs before completing a power of attorney, CalPERS may find it necessary to withhold your retirement allowance until a court appoints a conservator to handle your affairs. Since appointment of a conservator can be both expensive and time consuming, you may wish to safeguard against this possibility by completing the Cal PERS Special Power of Attorney form. Again, any questions should be directed to Cal PERS.

B!J The California State University (

CSU VOLUNTARY BENEFITS PLANS Providing Employees with Income Protection

RETIREMENT SAVINGS PLANS

HEALTH CARE REIMBURSEMENT ACCOUNT PLAN

As a CSU employee, you have three voluntary retirement savings plans available to you, which allow you to invest pre-tax dollars. The three plans are listed below:

A Health Care Reimbursement Account (HCRA) allows you to set aside a portion of your pay on a pre-tax ba'sis to reimburse yourself for eligible health, dental and vision care expenses for you, your spouse/domestic partner, and eligible dependent(s). you may contribute up to $5,000 each plan year through payroll deduction. New employees may enroll in the plan within 60 .days of e.mployment or during open enrollment. AS!Flex is the claims administrator forth is plan. Additional information aboutthis plan can be obtained at. www.asillex.com, or by contacting ASIF!ex at (800) 659-3035.

1. The CSU 403(b) Tax Sheltered Annuity (TSA) Plan

2. The Savings Plus 401(k) Thrift Plan 路 3. The Savings Plus 457 Deferred Compensation Plan You may participate in any or all of these plans. The CSU 403(b) PLAN allows employees to allocate deductions 路 among the following five fund sponsors: Fidelity, ING, MetLife, TIAA-Cref, and Valic. To learn more about the CSU 403(b) plan, go to www.calstate.edu/hr/benefitsportal/tsa. TSA enrollments and deferral changes路are designated by employees via Retirement Manager at www.myretire.me.ntmanager.com.' ,,,e SAVINGS PLUS 401(k) and 457 PLANS are administered by the Department of Personnel Administration. To learn more about these plans, go to www.sppforu.com, or call (866) 566-4777.

DEPENDENT CARE REIMBURSEMENT ACCOUNT PLAN A Dependent Care Reimburse.men! Account (DCRA) Account allows you to set aside a portion of your pay on a pre-tax basis to reimburse yourself for chlld-care expenses for your eligible dependent child(ren) under the age of 13.. Additionally, if you have an older dependentthat lives with you and requires assistance with day-to-day living, you can路 claim these expenses through your DCRA. You may contribuie

up to $5,000 each plan year ($2;500 ii married, filing a separate tax return) through payroll deduction. Neither contributions nor reimbursements are taxed. New employees may enroll in the plan within 60 days of employment or during open enrollment. AS IFlex is the claims administrator for this plan. Additional information about this plan can be obtained at www.asiflex.com, or by contacting ASIFlex at (800) 659-3035.

VOLUNTARY LIFE INSURANCE

This plan allows you to pay for parking in CSU-qualified parking facilities With pre-tax dollars. The premiums are deducted from your paycheck. You may cancel your election at any time. Check with campus HR/Payroll department, as eligibility varies.

The Standard offers you the opportunityto purchase group life insurance for you and your eligible dependents. New employees are eligible to receive Guaranteed Issue coverage up to $150,000 for themselves, $50,000 for their spouse/ domestic partner, and $20,000 for their eligible dependent child(ren)-no health questions asked. For Guaranteed Issue, coverage must be elected within 60 days of employment. Coverage elected outside of this time period, or above the Guaranteed Issue amount, will be subjectto evidence of insurability. To learn more about this benefit and/or to enroll, go to www.standard.com/mybenefits/csu, or call (800) 378-5745.

LEGAL PLAN

VOLUNTARY LONG-TERM DISABILITY (LTD)

The group legal plan, called MetLaw庐, is provided by Hyatt Legal Plans, a MetLife company. This plan provides representation for many personal legal services for you and your eligible depenaents. Covered legal services performed by a network attorney are fully paid for by the plan. New employees may enroll in the plan within 60 days of employmenror during open enrollment. To learn more about this plan or to enroll, go to www.metlife.coni/mybene!its, or call (800) GE_T-MET-8.

The Standard offers you the opportunity to purchase a level of group disability insurance that fits your needs, with either a 30-day or 90-day waiting period. New employees are eligible to enroll in this plan with Guaranteed Issue (no health questions asked), within BO days of employment. Coverage elected outside of this time period will be subject to evidence of insurability. To learn more about this benefit. and/or to enroll, go to www.standard.com/mybenefits/csu,. or call (800) 378-5745.

PRE-TAX PARKING

CRITICAL ILLNESS INSURANCE Group Critical Illness insurance, offered by Aflac, provides a lump-sum payment to cover out-of-pocket medical expenses and costs associated with life changes following the diagnosis of a covered critical illness. In addition, Aflac provides a cash benefit for specified health screenings. You and/or your spouse/domestic partner must be between the age of 18-64, and enrolled in a health insurance plan in order to enroll in this plan. New employees are eligible to receive Guaranteed Issue coverage up to $20,000 for themselves and $10,000 for their spouse/domestic partner-no health questions asked. For Guaranteed Issue, coverage must be elected within 60 days of employment. Coverage elected o路utside of this time period or above the Guaranteed Issue amount will be subject to evidence of insurability. To learn more about this plan or to enroll, visit www.aflac.com/csu, or call (877) 801-7931.

AUTO AND. HOME INSURANCE California Casualty provides CSU employees with group auto and home insurance at a disco路unted rate. Policy rates are guaranteed for 12 months-even if you have a claim. In addition California Casualty offers policyholders enhanced ID Defense ' services. CSU employees are eligible to enroll in the plan at anytime. To learn more aboutthis program, or to enroll, go to wwvv.calca.s.com/csu, or call (866) 680-5142.

(

VOLUNTARY ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE The Standard offers group Accidental Death and Dismemberment (AD&D) insurance that covers you and your beneficiaries, in the event of death or dismemberment as a result of a covered accident. You may electup to $1 million in coverage. Spouse/Domestic Partner and dependent child(ren) coverage is also available. As a CSU employee, you can enroll in this plan at anytime-no health questions asked. To learn more about this benefit and/orto enroll, go to www.standard,com/myhenefits/csu, or call (800) 378-5745.

Learn more aboutthese CSU benefits online at the Systemwide Benefits Portal: www_calstate.edu/hr/benefitsportal

Membership Terms and Conditions A Cal-Ore Life Flight LLC (“Company”) membership ensures the patient will have no out-of-pocket flight expenses if flown by the Company or another AirMedCare Network participating provider (together with the Company, each an “AMCN Provider”) by providing prepaid protection against AMCN Provider emergent air ambulance costs that are not covered by a member’s insurance or other benefits or third party responsibility, subject to the following terms and conditions: 1.

Patient transport will be to the closest appropriate medical facility for medical conditions that are deemed by AMCN Provider attending medical professionals to be life- or limb-threatening, or that could lead to permanent disability, and which require emergency air ambulance transport. A patient’s medical condition, not membership status, will dictate whether or not air transportation is appropriate and required. Under all circumstances, an AMCN Provider retains the sole right and responsibility to determine whether or not a patient is flown. AMCN Provider air ambulance services may not be available when requested due to factors beyond its control, such as use of the appropriate aircraft by another patient or other circumstances governed by operational requirements or restrictions including, but not limited to, equipment manufacturer limitations, governmental regulations, maintenance requirements, patient condition, age or size, or weather conditions. FAA restrictions prohibit most AMCN Provider aircraft from flying in inclement weather conditions. The primary determinant of whether to accept a flight is always the safety of the patient and medical flight crews. Emergent ground ambulance transport of a member by an AMCN Provider will be covered under the same terms and conditions. Members who have insurance or other benefits, or third party responsibility claims, that cover the cost of ambulance services are financially liable for the cost of AMCN Provider services up to the limit of any such available coverage. In return for payment of the membership fee, the AMCN Provider will consider its air ambulance costs that are not covered by any insurance, benefits or third party responsibility available to the member to have been fully prepaid. The AMCN Provider reserves the right to bill directly any appropriate insurance, benefits provider or third party for services rendered, and members authorize their insurers, benefits providers and responsible third parties to pay any covered amounts directly to the AMCN Provider. Members agree to remit to the AMCN Provider any payment received from insurance or benefit providers or any third party for air medical services provided by the AMCN Provider, not to exceed regular charges. Neither the Company nor AirMedCare Network is an insurance company. Membership is not an insurance policy and cannot be considered as a secondary insurance coverage or a supplement to any insurance coverage. Neither the Company nor AirMedCare Network will be responsible for payment for services provided by another ambulance service. Membership starts 15 days after the Company receives a complete application with full payment; however, the waiting period will be waived for unforeseen events occurring during such time. Members must be natural persons. Memberships are non-refundable and nontransferable. Some state laws prohibit Medicaid beneficiaries from being offered membership or being accepted into membership programs. By applying, members certify to the Company that they are not Medicaid beneficiaries. These terms and conditions supersede all previous terms and conditions between a member and the Company or AirMedCare Network, including any other writings, or verbal representations, relating to the terms and conditions of membership.

Questions? Call Membership Sales Manager

Jennifer Hart ● 530-510-2915 or visit www.airmedcarenetwork.com GET CODE

TRACK CODE

12952

PLAN CODE

6805

Membership Application— Humboldt State University

Quick STEP 1

Member Contact Information By applying for membership, I agree to Cal-Ore’s terms and conditions.

Initials: X

Today's Date:

month

day

year

Last Name:

First Name: Physical Address: Mailing Address: City:

State:

Home Phone:

Cell Phone:

E-Mail Address:

County:

Zip:

Affiliation: Humboldt State University Date of Birth:

month

day

Quick STEP 2

( M / F )

year

Do you live within the City Limits? Yes

List Other Persons In Household and Date of Birth

/ First Name

month

Last Name

2 First Name

Last Name

month

First Name

Last Name

month

(M / F)

day

year

day

/ day

year

(M / F)

(M / F) year

If more space is needed please attach an additional sheet and detail the full name and date of birth for each member.

Quick STEP 3

Membership and Payment Options

1-Year Membership

$55

Household



Check or money order made payable to: AirMedCare Network PO Box 948 West Plains, MO 65775



One Time transfer from credit card.

Credit Card Number

Signature

(select one)



# Check or Money Order Number



3 digit code on back of

Expires

Date:

month

day

year

BEFORE YOU PURCHASE: If you are currently enrolled in a health maintenance organization (HMO) or other health insurance, the benefits provided by REACH may duplicate the benefits provided by your HMO or other health insurance. If you have a questions regarding whether your HMO or other health insurance offers benefits for ambulance services, you should contact that other company directly. WARNING: REACH is not an insurance program. It will not compensate or reimburse another ambulance company that provides emergency transportation to you or your family. This may occur when 911 Emergency System has independently determined that another company could provide more expeditious service or is next in the rotation to receive a call. This might also occur when REACH is unable to perform within a medically appropriate timeframe due to a mechanical or maintenance problem or being called on another flight. Initial or sign here________________ COMPLAINTS: For complaints regarding REACH, first attempt to call the plan at 1 800 793 0010. If REACH fails to resolve the complaint to your satisfaction, contact the Department of Managed Health Care at 1 800 400 0815. The Department’s website is http://www.dmhc.ca.gov. You may obtain complaint forms and instructions online. OPERATING UNDER CONDITIONAL EXEMPTION: REACH is operating pursuant to an exemption from the Knox Keene Health Care Service. Plan Act of 1975 (Health and Safety Code section 1340 et seq).

March 2012

TO:

Campus Employees

FROM:

Human Resources

RE:

PRE-DESIGNATION OF PERSONAL PHYSICIAN

You may pre-designate a personal physician authorized to provide medical treatment for you in the event of a work-related industrial injury or illness. Due to a change in regulations governed by the Department of Industrial Relations the university can no longer accept or honor pre-designation forms that are not authorized by your designated physician. The attached Pre-Designation of Personal Physician form must be completed by you and signed by the personal physician (or accompanied by appropriate documentation as outlined below) that you have elected to receive treatment from in the event of an industrial injury or illness. If you wish to pre-designate your personal physician, please complete the following Pre-Designation form, obtain your physician’s signature and return to Human Resources & Risk Management. If you are unable to obtain a signature on the form, signed documentation is required from your personal physician on his/her letterhead and submitted with the Pre-Designation of Personal Physician form. Also attached is a Notice of Personal Chiropractor or Personal Acupuncturist form that does not require authorization and may be kept on file, however, the Pre-Designation of Personal Physician form may only be authorized by a medical doctor (M.D.) or doctor of osteopathic medicine (O.D.). In the event of a work-related injury or illness and a signed Pre-Designation of Personal Physician form is not on file for you, you must seek medical treatment at Mad River Occupational Health Services, 592 14th Street, Arcata, CA 95521, (707) 825-4907, during the first 30 days following industrial injury or illness. In the event of an emergency, you may seek medical treatment at Mad River Emergency Room, 3800 Janes Road, Arcata, CA 95521, (707) 826-8264. You may also seek treatment from St. Joseph’s Occupational Health Services, 2200 Harrison Ave, Eureka, (M-F 8:00-11:30 & 1:00-4:00; please call first) 445-8121, ext. 5688. In the event of an emergency, you may seek medical treatment at St. Joseph’s Hospital Emergency Room, 2700 Dolbeer Street, Eureka, ((24 Hours Day, 7 Days/Week - 269-4250. During times that classes are in session, the HSU Student Health Center may provide first aid only for minor industrial injuries. Thank you for your cooperation. If you have additional questions, please contact Human Resources at extension 3626.

Rev 03/12

HUMBOLDT STATE UNIVERSITY HUMAN RESOURCES & RISK MANAGEMENT PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness by your personal medical doctor (M.D.) or doctor of osteopathic medicine (D.O.) if: • your employer offers group health coverage; • the doctor is your regular physician, who shall be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner, and has previously directed your medical treatment, and retains your medical records; • prior to the injury your doctor agrees to treat you for work injuries or illnesses; • prior to the injury you provided your employer the following in writing: (1) notice that you want your personal doctor to treat you for a work-related injury or illness, and (2) your personal doctor's name and business address. You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work- related injury or illness and the above requirements are met. NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee: Complete this section. To: HUMBOLDT STATE UNIVERSITY: If I have a work-related injury or illness, I choose to be treated by: Name of doctor (M.D. or D.O.):___________________________________________________________ Street address, city, state & zip code:_______________________________________________________ Telephone number:_____________________________________________________________________ Employee Name (please print):____________________________________________________________

Employee’s Signature _________________________________________ Date: ____________________ Physician: I agree to this Predesignation: Signature: ___________________________________________________ Date: ____________________ (Physician or Designated Employee of the Physician) If your physician does not sign this form you must provide written documentation on letterhead authorized by the physician or designated employee of the physician, of the physician’s agreement to be predesignated for providing medical treatment to you for a work-related injury pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3). Title 8, California Code of Regulations, section 9783. (Optional DWC Form 9783-Effective date March 2006)

Rev 03/12

HUMBOLDT STATE UNIVERSITY HUMAN RESOURCES & RISK MANAGEMENT NOTICE OF PERSONAL CHIROPRACTOR OR PERSONAL ACUPUNCTURIST If your employer or your employer's insurer does not have a Medical Provider Network, you may be able to change your treating physician to your personal chiropractor or acupuncturist following a work-related injury or illness. In order to be eligible to make this change, you must give your employer the name and business address of a personal chiropractor or acupuncturist in writing prior to the injury or illness. Your claims administrator generally has the right to select your treating physician within the first 30 days after your employer knows of your injury or illness. After your claims administrator has initiated your treatment with another doctor during this period, you may then, upon request, have your treatment transferred to your personal chiropractor or acupuncturist. You may use this form to notify your employer of your personal chiropractor or acupuncturist. Your Chiropractor or Acupuncturist's Information: ___________________________________________________________________________ Name of chiropractor or acupuncturist ___________________________________________________________________________ Street address, city, state, zip code ___________________________________________________________________________ Telephone number ___________________________________________________________________________ Employee name (please print)

___________________________________________________________________________ Employeeâ&#x20AC;&#x2122;s signature

Title 8, California Code of Regulations, section 9783.1. (DWC Form 9783.1-Effective date March 2006)

Rev 03/12

HR 2011-07 ATTACHMENT C

Privacy Notice Please carefully review this notice. It describes how medical information about you may be used and disclosed and how you can get access to this information. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) imposes numerous requirements on the use and disclosure of individual health information by employer health plans. This information, known as protected health information, includes almost all individually identifiable health information held by a plan – whether received in writing, in an electronic medium, or as an oral communication. This notice describes the privacy practices of the following group health plans: health care reimbursement account and employee assistance plans. The plans covered by this notice may share health information with each other if necessary, to carry out treatment, payment, or health care operations. These plans are collectively referred to as the Plan in this notice, unless specified otherwise.

The Plan’s duties with respect to health information about you The Plan is required by law to maintain the privacy of your health information and to provide you with this notice of the Plan’s legal duties and privacy practices with respect to your health information. If you participate in an insured plan option, you will receive a notice directly from the Insurer. It’s important to note that these rules apply to the Plan, not California State University as an employer – that’s the way the HIPAA rules work. Different policies may apply to other California State University programs or to data unrelated to the Plan.

How the Plan may use or disclose your health information The privacy rules generally allow the use and disclosure of your health information without your permission (known as an authorization) for purposes of health care treatment, payment activities, and health care operations. Here are some examples of what that might entail: 

Treatment includes providing, coordinating, or managing health care by one or more health care providers or doctors. Treatment can also include coordination or management of care between a provider and a third party, and consultation and referrals between providers. For example, the Plan may share your health information with physicians who are treating you.



Payment includes activities by this Plan, other plans, or providers to obtain premiums, make coverage determinations, and provide reimbursement for health care. This can include eligibility determinations, reviewing services for medical necessity or appropriateness, utilization management activities, claims management, and billing; as well as “behind the scenes” plan functions such as risk adjustment, collection, or reinsurance. For example, the Plan may share information about your coverage or the expenses you have incurred with another health plan in order to coordinate payment of benefits.



Health care operations include activities by this Plan (and in limited circumstances other plans or providers) such as wellness and risk assessment programs, quality assessment and improvement activities, customer service, and internal grievance resolution. Health care operations also include vendor evaluations, credentialing, training, accreditation activities, underwriting, premium rating, arranging for medical review and audit activities, and business planning and development. For

example, the Plan may use information about your claims to audit the third parties that approve payment for Plan benefits. The amount of health information used, disclosed or requested will be limited and, when needed, restricted to the minimum necessary to accomplish the intended purposes, as defined under the HIPAA rules. If the Plan uses or discloses PHI for underwriting purposes, the Plan will not use or disclose PHI that is your genetic information for such purposes. The Plan may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you, as permitted by law.

How the Plan may share your health information with California State University The Plan, or its health insurer or HMO, may disclose your health information without your written authorization to California State University for plan administration purposes. California State University may need your health information to administer benefits under the Plan. California State University agrees not to use or disclose your health information other than as permitted or required by the Plan documents and by law. Chancellor’s Office HR staff and campus HR and benefit officers are the only California State University employees who will have access to your health information for plan administration functions. Here’s how additional information may be shared between the Plan and California State University, as allowed under the HIPAA rules: 

The Plan, or its insurer or HMO, may disclose “summary health information” to California State University if requested, for purposes of obtaining premium bids to provide coverage under the Plan, or for modifying, amending, or terminating the Plan. Summary health information is information that summarizes participants’ claims information, from which names and other identifying information have been removed.



The Plan, or its insurer or HMO, may disclose to California State University information on whether an individual is participating in the Plan or has enrolled or disenrolled in an insurance option or HMO offered by the Plan.

In addition, you should know that California State University cannot and will not use health information obtained from the Plan for any employment-related actions. However, health information collected by California State University from other sources, for example under the Family and Medical Leave Act, Americans with Disabilities Act, or workers’ compensation is not protected under HIPAA (although this type of information may be protected under other federal or state laws).

Other allowable uses or disclosures of your health information In certain cases, your health information can be disclosed without authorization to a family member, close friend, or other person you identify who is involved in your care or payment for your care. Information about your location, general condition, or death may be provided to a similar person (or to a public or private entity authorized to assist in disaster relief efforts). You’ll generally be given the chance to agree or object to these disclosures (although exceptions may be made – for example, if you’re not present or if you’re incapacitated). In addition, your health information may be disclosed without authorization to your legal representative. CSU Privacy Notice 2010, Page 2 of 6

The Plan also is allowed to use or disclose your health information without your written authorization for the following activities: Workers’ compensation

Disclosures to workers’ compensation or similar legal programs that provide benefits for work-related injuries or illness without regard to fault, as authorized by and necessary to comply with the laws

Necessary to prevent serious threat to health or safety

Disclosures made in the good-faith belief that releasing your health information is necessary to prevent or lessen a serious and imminent threat to public or personal health or safety, if made to someone reasonably able to prevent or lessen the threat (or to the target of the threat); includes disclosures to help law enforcement officials identify or apprehend an individual who has admitted participation in a violent crime that the Plan reasonably believes may have caused serious physical harm to a victim, or where it appears the individual has escaped from prison or from lawful custody

Public health activities

Disclosures authorized by law to persons who may be at risk of contracting or spreading a disease or condition; disclosures to public health authorities to prevent or control disease or report child abuse or neglect; and disclosures to the Food and Drug Administration to collect or report adverse events or product defects

Victims of abuse, neglect, or domestic violence

Disclosures to government authorities, including social services or protected services agencies authorized by law to receive reports of abuse, neglect, or domestic violence, as required by law or if you agree or the Plan believes that disclosure is necessary to prevent serious harm to you or potential victims (you’ll be notified of the Plan’s disclosure if informing you won’t put you at further risk)

Judicial and administrative proceedings

Disclosures in response to a court or administrative order, subpoena, discovery request, or other lawful process (the Plan may be required to notify you of the request or receive satisfactory assurance from the party seeking your health information that efforts were made to notify you or to obtain a qualified protective order concerning the information)

Law enforcement purposes

Disclosures to law enforcement officials required by law or legal process, or to identify a suspect, fugitive, witness, or missing person; disclosures about a crime victim if you agree or if disclosure is necessary for immediate law enforcement activity; disclosure about a death that may have resulted from criminal conduct; and disclosure to provide evidence of criminal conduct on the Plan’s premises

Decedents

Disclosures to a coroner or medical examiner to identify the deceased or determine cause of death; and to funeral directors to carry out their duties

Organ, eye, or tissue donation

Disclosures to organ procurement organizations or other entities to facilitate organ, eye, or tissue donation and transplantation after death

Research purposes

Disclosures subject to approval by institutional or private privacy review boards, subject to certain assurances and representations by researchers about the necessity of using your health information and the treatment of the information during a research project

Health oversight activities

Disclosures to health agencies for activities authorized by law (audits, inspections, investigations, or licensing actions) for oversight of the health care system, government benefits programs for which health information is relevant to beneficiary eligibility, and compliance with regulatory programs or civil rights laws

Specialized government functions

Disclosures about individuals who are Armed Forces personnel or foreign military personnel under appropriate military command; disclosures to authorized federal officials for national security or intelligence activities; and disclosures to correctional facilities or custodial law enforcement officials about inmates

HHS investigations

Disclosures of your health information to the Department of Health and Human Services to investigate or determine the Plan’s compliance with the HIPAA privacy rule

Except as described in this notice, other uses and disclosures will be made only with your written authorization. You may revoke your authorization as allowed under the HIPAA rules. However, you can’t revoke your authorization with respect to disclosures the Plan has already made. You will be notified of any unauthorized access, use or disclosure of your unsecured health information as required by law. CSU Privacy Notice 2010, Page 3 of 6

Your individual rights You have the following rights with respect to your health information the Plan maintains. These rights are subject to certain limitations, as discussed below. This section of the notice describes how you may exercise each individual right. See the table at the end of this notice for information on how to submit requests. Right to request restrictions on certain uses and disclosures of your health information and the Plan’s right to refuse You have the right to ask the Plan to restrict the use and disclosure of your health information for treatment, payment, or health care operations, except for uses or disclosures required by law. You have the right to ask the Plan to restrict the use and disclosure of your health information to family members, close friends, or other persons you identify as being involved in your care or payment for your care. You also have the right to ask the Plan to restrict use and disclosure of health information to notify those persons of your location, general condition, or death – or to coordinate those efforts with entities assisting in disaster relief efforts. If you want to exercise this right, your request to the Plan must be in writing. The Plan is not required to agree to a requested restriction. If the Plan does agree, a restriction may later be terminated by your written request, by agreement between you and the Plan (including an oral agreement), or unilaterally by the Plan for health information created or received after you’re notified that the Plan has removed the restrictions. The Plan may also disclose health information about you if you need emergency treatment, even if the Plan has agreed to a restriction. Effective February 17, 2010, an entity covered by these HIPAA rules (such as your health care provider) or its business associate must comply with your request that health information regarding a specific health care item or service not be disclosed to the Plan for purposes of payment or health care operations if you have paid for the item or service, in full out of pocket. Right to receive confidential communications of your health information If you think that disclosure of your health information by the usual means could endanger you in some way, the Plan will accommodate reasonable requests to receive communications of health information from the Plan by alternative means or at alternative locations. If you want to exercise this right, your request to the Plan must be in writing and you must include a statement that disclosure of all or part of the information could endanger you. Right to inspect and copy your health information With certain exceptions, you have the right to inspect or obtain a copy of your health information in a “designated record set.” This may include medical and billing records maintained for a health care provider; enrollment, payment, claims adjudication, and case or medical management record systems maintained by a plan; or a group of records the Plan uses to make decisions about individuals. However, you do not have a right to inspect or obtain copies of psychotherapy notes or information compiled for civil, criminal, or administrative proceedings. The Plan may deny your right to access, although in certain circumstances you may request a review of the denial. If you want to exercise this right, your request to the Plan must be in writing. Within 30 days of receipt of your request (60 days if the health information is not accessible onsite), the Plan will provide you with: CSU Privacy Notice 2010, Page 4 of 6



the access or copies you requested;



a written denial that explains why your request was denied and any rights you may have to have the denial reviewed or file a complaint; or



a written statement that the time period for reviewing your request will be extended for no more than 30 more days, along with the reasons for the delay and the date by which the Plan expects to address your request.

The Plan may provide you with a summary or explanation of the information instead of access to or copies of your health information, if you agree in advance and pay any applicable fees. The Plan also may charge reasonable fees for copies or postage. If the Plan doesn’t maintain the health information but knows where it is maintained, you will be informed of where to direct your request. Effective February 17, 2010, you may request an electronic copy of your health information if it is maintained in an electronic health record. You may also request that such electronic health information be sent to another entity or person, so long as that request is clear, conspicuous and specific. Any charge that is assessed to you for these copies, if any, must be reasonable and based on the Plan’s cost. Right to amend your health information that is inaccurate or incomplete With certain exceptions, you have a right to request that the Plan amend your health information in a designated record set. The Plan may deny your request for a number of reasons. For example, your request may be denied if the health information is accurate and complete, was not created by the Plan (unless the person or entity that created the information is no longer available), is not part of the designated record set, or is not available for inspection (e.g., psychotherapy notes or information compiled for civil, criminal, or administrative proceedings). If you want to exercise this right, your request to the Plan must be in writing, and you must include a statement to support the requested amendment. Within 60 days of receipt of your request, the Plan will: 

make the amendment as requested;



provide a written denial that explains why your request was denied and any rights you may have to disagree or file a complaint; or



provide a written statement that the time period for reviewing your request will be extended for no more than 30 more days, along with the reasons for the delay and the date by which the Plan expects to address your request.

Right to receive an accounting of disclosures of your health information You have the right to a list of certain disclosures of your health information the Plan has made. This is often referred to as an “accounting of disclosures.” You generally may receive this accounting if the disclosure is required by law, in connection with public health activities, or in similar situations listed in the table earlier in this notice, unless otherwise indicated below. You may receive information on disclosures of your health information for up to six years before the date of your request. You do not have a right to receive an accounting of any disclosures made: CSU Privacy Notice 2010, Page 5 of 6



for treatment, payment, or health care operations;



to you about your own health information;



incidental to other permitted or required disclosures;



where authorization was provided;



to family members or friends involved in your care (where disclosure is permitted without authorization);



for national security or intelligence purposes or to correctional institutions or law enforcement officials in certain circumstances; or



as part of a “limited data set” (health information that excludes certain identifying information).

In addition, your right to an accounting of disclosures to a health oversight agency or law enforcement official may be suspended at the request of the agency or official. If you want to exercise this right, your request to the Plan must be in writing. Within 60 days of the request, the Plan will provide you with the list of disclosures or a written statement that the time period for providing this list will be extended for no more than 30 more days, along with the reasons for the delay and the date by which the Plan expects to address your request. You may make one request in any 12month period at no cost to you, but the Plan may charge a fee for subsequent requests. You’ll be notified of the fee in advance and have the opportunity to change or revoke your request. Right to obtain a paper copy of this notice from the Plan upon request You have the right to obtain a paper copy of this privacy notice upon request.

Changes to the information in this notice The Plan must abide by the terms of the privacy notice currently in effect. This notice takes effect on February 17, 2010. However, the Plan reserves the right to change the terms of its privacy policies, as described in this notice, at any time and to make new provisions effective for all health information that the Plan maintains. This includes health information that was previously created or received, not just health information created or received after the policy is changed. If changes are made to the Plan’s privacy policies described in this notice, you will be provided with a revised privacy notice mailed to your home address on file.

Complaints If you believe your privacy rights have been violated or your Plan has not followed its legal obligations under HIPAA, you may complain to the Plan and to the Secretary of Health and Human Services. You won’t be retaliated against for filing a complaint. For complaints regarding the Employee Assistance Program (EAP), contact the campus benefits officer. For complaints regarding the Health Care Reimbursement Account Plan, contact CSU Systemwide Human Resources Management (HRM) at CSU Office of the Chancellor – Attention Human Resources Management, 401 Golden Shore, Long Beach, CA 90802. Complaints should be filed in writing and such written document should include a description of the nature of the particular complaint. Contact For more information on the Plan’s privacy policies or your rights under HIPAA, contact the campus benefits office. CSU Privacy Notice 2010, Page 6 of 6

PRIVACY NOTICE

The Information Practice Act of 1977 (Civil Code Section 1798.17) and the Federal Privacy Act (Public Law 93-579) require that this notice be provided when collecting personal information from individuals. Information requested on this form is used by the State Controller's Office and the program administrator for the pmposes of .identification and account processing. It is mandatory to furnish all info1mation requested on this fotm except for marital status, which may be furnished on. a voluntaiy basis: Failure to provide the ma.tidatory information may result in the enrolhnent elections not being processed or being processed inconectly. The State Controller's Office requires employee's social security number and name for identification ,pmposes. Legal references authorizing maintenance. of this information include Government Code Sections 1151 and 1153, Sections 6011 a.tid 6051 of the Internal Revenue Code, and Regulation 4, Section 404.1256, Code of Federal Regulations, under Section 218, Title II of the Social Security Act. . Copies of the FlexCash Enrolhnent Authorization are maintained in confidential files of tlte State Controller's Office for five years. 路Employees have the right of access to copies of their Enrollment Autltorization fotms upon request. The offi!)ial responsible for the maintenance of tlte forms is: Chief of Pers01111el/Payroll Services. Division, State Controller's Office, Post Office Box 942?0, Sacramento, California 94250-5S78. 路

STATilOPOAUfORNIA

DENTAL PLAN ENR01-LMENT AUTHORIZATION

· PRIVACY NO'flCIE.

. The rnf6nnat[on Practices Act of i 977 (Ci'vil Code Se ctron '.17911.17) and the Federal Privacy Act (Ptiblio Law 9S-579) require that ihis noUce be provided when collecting personal informatfon from individuals. •

Information requ(lsted on thfs form is used by the Sfale .Cohtrollefs Otffce and the denial insurance company for the purposes of identification and dental coverage processing. It is mandafoiy to furnish all information requested oil tlifs form except for employee's gender and malital status, Which may be furnished on a· \/ofuntfjry basis and are used by the dental insurance company for s!atlsUcal and actuarial purpose. Faffure to provide the. mandatory information may result in the dental enrollment action not being processed or being processed incorrectly.

Thi;) State Confroller's Office requires emp!byee's social seomify number and na·ma fcir identification purposes. legal references auffionzing maintenance of .this information inc/urfe Government Code Sections 1151, 1153, Sec!(ons 6011and6051 of the Infernal Revenue Code, and Regulation 4, Settion 404.1256, Code of Federal Regulations, under SecUon 218, Title II of the Soolal Security;Acf. /nf?rmation proVfded on the form will be foiwa_tded to th.a dental insurance company providing .coverage for the employee. Copies of the Dental Plan Enrollment Aulhorlzatlon ara maintained in ccinfldential •.

files of the State CoJ]troller's Offic£> for five years. Employees have the right of access to copies of tfielr Dental Plan Enrollment Authorization fonns upon request. Send requests to: Sfate Controller's Office, · PersonneiJPayroll Operations Bureau, P.O. Box 94285(), Sacramento, Califomla 94250-5.878, Attention: Beneflts Unit. ·

;

tsuJJCBA AN.lJHCRA AJJM!NISTRA'f'l'flE (J'{JJ))E

APPENJJIXA,PAGE)

Tho California State University . DEPENDENT CARE/HEALTH CARE RE:IMlltlRSEMENT ACCOUNT PLANS

ENROLLMENT AUTHORIZATION

(llEll, OS/02) Qm'ERSE}

· PR.lVACYNOl'ICE The fnformatlon Practice Act of 1977 {Civil Coqe Sectioil.1798.17) anq th.e Federal Privacy Act (Public La1V 9;3-579) require tli~t this notice be provided when collecting personal information from individuals.

Jiiformatio.11 requested on this form if!entlllqatlon andaccount processing.

rs u;ea by ,the State .Controller's Office and tl!p program adminietr~tor, for the pltr.iJOses of ·

It is mandato,J·~o :furnish all information requested on this fori11 exceptfor marital stains,' which may be furnished on a voluntary basis. Failnre to provide the mandatory information may result. in the eI!folfment action not beJng processed or jleing processed incorrectly. · . · . · . ' . ·· . ·

The Staie Controller's Office requires employee's social security number and name for identification purposes. Legal referelicilS authorizing maintenance of this information include Government ·code Sections 1151 and 1!53, Sections 6011 and 6051 .of.tile Internal Revenue Code, and Regulation 4, Section 404.1256, Code of Federal Regulations, nnder Section 218, Tit!<> U of the Social S~cUtity Act. . Tnfbnnation provided. 011 the form wit! be forwarded to the program. m!miqlstrator. Copies of the H<Jalth Care /Dependent Caro Reimbursement Enrollment Authoriz~tlon Form(s) are maintained l!J conflc!ential files oftl1e State Controller'~ Office for five years. Employees have the right of access to copies of their Enrollment Autliorization forms upon request. The ofilcial responsible for the ">aintenance of the forms is: Chief of Persoimel/Payroll Services Division, State Controller's Office, P. 0. Box 94250, Sacramento, Jifomia 94250-5878, Telephone (916) 445-5361. · · ·

Benefits Enrollment Worksheet If you are enrolling for the first time or adding dependents to medical and/or dental plans, you must provide a copy of the appropriate documentation as follows: Marriage certificate or domestic partnership certification issued by the California Secretary of State; birth or adoption documentation for all dependent children; and/or social security numbers for all dependents. First Name, MI, Last Name

Employee Identification Number

Social Security Number

Department

Home Phone Number

Marital Status

Single

Registered Domestic Partner (RDP)

Married

Campus Extension

Date of Marriage or Domestic Partnership

If a new employee, please mark any of the following that apply: I am transferring from a CalPERS / State agency? If so, which agency: I am currently working at another CalPERS / State / Public agency? If so, which agency: I am a CalPERS retiree. Check action to be taken: New enrollment - eligible for benefits but not currently enrolled Open enrollment change Add eligible dependents State reason:

Date:

State reason:

Date:

Delete dependents Cancel plan

Please check the medical plan of your choice or FlexCash. Blue Shield Access + HMO PERS Care PPO Anthem Blue Cross Traditional HMO

PERS Choice PPO

PERS Select

Other, if currently residing outside Humboldt County Please specify plan:

PORAC PPO ( Limited to Unit 8)

FlexCash (must provide proof of other coverage)

Please check the dental plan of your choice. Delta Dental

DeltaCare USA

FlexCash (must provide proof of other coverage)

Please list below the name, birthdate and relationship of all family members to be covered (including yourself). Use an additional enrollment worksheet if necessary. All dependents listed, other than spouse or domestic partner, must be under the age of 26. You may not enroll your spouse if he or she is already covered by a CalPERS health plan. Eligible Enrollees

Social Security (required)

Relationship Self

Birthdate

Medical

Dental

Vision

Add

Delete

Add

Delete

Add

Delete

Add

Delete

Add

Delete

Add

Delete

Add

Delete

Add

Delete

Add

Delete

Add

Delete

Add

Delete

Add

Delete

Add

Delete

Add

Delete

Add

Delete

Your health plan cards will be mailed to your official address on file with the university. To update this address, use the Employee Action Request (EAR) form. I elect to enroll in (or change) the health benefits plans as indicated above and authorize deductions to be made from my salary to cover my share of the cost of enrollment as it is now or as it may be in the future. I also certify that the names of all dependents listed above are eligible family members as defined in the Public Employees' Medical and Hospital Care Act and that they are not enrolled in another CalPERS medical plan or State of California dental plan. I understand that my effective date is based on the date this form is received by the Human Resources Department (HR). I also understand that I will be called to return to HR to sign official documents once they are prepared on my behalf. I hereby certify under penalty of perjury that the information provided on this document is true and correct.

Signature

Date Signed

HR Use Only

Reason code:

Qual. event date:

Coverage begin date:

Processed in PS:

Processed in CalPERS:

Notes:

Office of Employer and Member Health Services PO Box 942714 Sacramento, CA 94229-2714 Toll free: (888) CalPERS (225-7377) Fax: (916) 795-1313 Telecommunications Device for the Deaf: (916) 795-3240

Declaration of Health Coverage: HBD-12A Employee Information

First Name, MI, Last Name

Social Security Number

Part A I elect to enroll myself and all eligible dependents. Part B-1 I elect to enroll myself. My eligible dependents have other health insurance coverage. Part B-2 I elect to enroll myself and eligible dependents. I also have eligible dependents who have other health insurance coverage. Part C-1 I decline enrollment for myself and my eligible dependents because we have other health insurance coverage. Part C-2 I decline for myself and/or my eligible family members for reasons other than having health insurance coverage.

If you or your dependents lose health insurance coverage, you can enroll in the CalPERS Health Benefits Program. You must request enrollment within 60 days from the date you lose coverage. If you do not request enrollment within 60 days, you or your dependents must wait at least 90 days or until the next Open Enrollment period before you can enroll in the Program. Your effective date of coverage will be the first of the month following the 90 day waiting period or the Open Enrollment effective date.

You can request enrollment for yourself and/or your dependents at any time. You must wait at least 90 days after you request enrollment or until the next Open Enrollment period before you can enroll in the Program. Your effective date of coverage will be the first of the month following the 90 day waiting period or the Open Enrollment effective date.

Part B: If you are currently enrolled in the Health Benefits Program and you acquire new dependents or if a court orders health coverage for your dependents, you can add your new dependents. See your Health Benefits Officer or visit your personnel office for applicable time limits. Part C: If you are not currently enrolled in the Health Benefits Program and you acquire new dependents as a result of marriage, birth, adoption, or placement for adoption, or if a court orders health coverage for your dependents, you can enroll yourself and dependents. See your Health Benefits Officer or visit your personnel office for applicable time limits. Special rules apply to retirement and death. Please read the following page carefully.

Signature

Original: Employee's Personnel File

Date Signed

Copy: Employee

Health Benefits Officer's Signature

Instructions - Declaration of Health Coverage: HB-12A Please contact your Health Benefits Officer if you have any questions regarding the HB-12A Employee Information

Complete with the appropriate employee information.

Part A

Mark this box if you are: a. Enrolling in the Health Benefits Program and have no dependents, or b. Enrolling yourself and ALL eligible dependents in the Health Benefits Program.

Part B-1

Part B-2

Part C-1

Part C-2

Mark this box if you are: a. Enrolling yourself only, your dependents have other health insurance coverage, or b. Cancelling your dependents' coverage because they have other health insurance coverage. Mark this box if you are: a. Enrolling yourself and SOME of your dependents, your other dependents have health insurance coverage, or b. Cancelling coverage for some of your dependents because they have other health insurance coverage. Mark this box if you are: a. Declining enrollment or cancelling your health insurance coverage, you have no dependents and you have other health coverage, or b. Declining enrollment or cancelling your health insurance coverage for yourself and eligible dependents and you have other health insurance coverage. Mark this box if you are: a. Declining enrollment or cancelling your health insurance coverage for reasons other than having health insurance coverage and you have no dependents, or b. Declining enrollment or cancelling your health insurance coverage for yourself and eligible dependents for reasons other than having health insurance coverage.

Important: It is your responsibility to notify your personnel office when there are any changes in your family situation. Changes include marriage, acquisition of a dependent child, divorce, legal separation, and death. Failure to notify your personnel office may result in adverse consequences. Special rules for retirement and death: Consider these points as you decide whether to enroll, decline, or cancel enrollment for yourself or dependents. â&#x20AC;˘ If you are not eligible to be enrolled in a CalPERS-sponsored health plan on the date you separate employment, you will not be eligible for health benefits into retirement. â&#x20AC;˘ If your retirement date is over 120 days from your separation date, you will not be eligible for health benefits into retirement. â&#x20AC;˘ If you die and your eligible family members are enrolled on your CalPERS-sponsored health plan at this time, they may be eligible for continued enrollment in a CalPERSsponsored health plan if they qualify for monthly survivor benefits.

Information regarding Workers Compensation can be found on the Human Resources website at: www2.humboldt.edu/hsuhr/employee/compensation/

CO t lC GC

reor!SSION~L

SIVl>l l

•

--~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-- ~SEARCH

Healthy-CT . If you are interested in signing up for the faculty/staff Healthy-U program , please download the sign up form and follow the instructions on the form.

Healthy-U/Lap Swim: • Pool Use $30/Semester • Must .show fa culty/staff ID to enter pool Pool Hours: • KA111 Monday-Friday 7:00- 8:30 am & 12:00-2:00pm • KA111 Monday, Wednesday, Friday 3:00 - 5:00 pm • KA111 Tuesday/ Thursday 4:00 - 6:00 pm • KA111Saturday/Sunday12 :00 - 4:00 pm

)

Healthy-U/Weight Room: • We igh t Room Use $30/Semester (located ·in Student Recreation Center) o

Must show faculty/staff ID to enter weight room

Weight Room Hours:

• SRC 181 Monday-Friday 12:00-2:00pm*

Physical Education Courses $20/class

Hours: Varies See course listings on line

* These are t he only ava ilable hours for faculty/staff in the Healthy-U Program.

For those

wanting to use the facility during other hours an $80 Semester Pass or $200 Annual Pass

CO l l ( O (

0 , f $ $ 1 0NAI

STUDl(S

â&#x20AC;˘ <\SE ARCH

may be purchased at the Student Recreation Center. For more information, call the Student Recreation Center at x4 197.

** Some of the most popular classes are : aerobics, ai kido, basketball, one of our many dance classes, Pilates, stretch and rela xation technique, and yoga. Please check the schedu le online for a full list of our course offerings and their days and times. TO RENT A LOCKER: Please go to th e Cashier's Office (SBS 285) and pay the appropriate

rental fee: $30 for one semester, $40 for fall and spring semeste r, or $50 for the year (July 1- June 30). Bring the yellow half sheet to the Kinesiology Office (KA 305) . You will be assigned a locker (lock is included) . If you have any questions about renting a locker please email ka lockers@humboldt.edu or call (707) 826-4532.

HEALTHY-U

POOL, WEIGHT ROOM & PHYSICAL ACTIVITY COURSE OPTIONS Healthy-U is available to all faculty and staff and provides opportunities to use the pool, weight room, and enroll in a physical activity class. To sign up for the Healthy-U Program go to the Cashier’s office (SBS 285) to make your payment. Bring your pink half sheet from the Cashier’s Office marked with your payment stamp to KA 305. Name: Extension:

Office:

Email: Class/Classes -see reverseTotal Cost/Check paid to Cashier’s Office (SBS 285): Make all checks payable to Humboldt State University Attention: Healthy-U/Kinesiology & Recreation Administration Question/Comments 826-4536

Healthy-U/Lap Swim Pool Hours: Pool Use $30/Semester Must show faculty/staff ID to enter pool

KA111

Monday-Friday

7:00– 8:30 am & 12:00-2:00pm

KA111

Monday, Wednesday, Friday

3:00 – 5:00 pm

KA111 KA111

Tuesday/Thursday Saturday/Sunday

4:00 – 6:00 pm 12:00 – 4:00 pm

Healthy-U/Weight Room Hours: Weight Room Use $30/Semester (located in Student Recreation Center) Must show faculty/staff ID to enter weight room

SRC 181

Monday-Friday

12:00-2:00pm*

Physical Education Classes $20/class

Varies

See course listings online**

* These are the only available hours for faculty/staff in the Healthy-U Program. For those wanting

to use the facility during other hours an $80 Semester Pass or $200 Annual Pass may be purchased at the Student Recreation Center. For more information, call the Student Recreation Center at x4197. ** Some of the most popular classes are: aerobics, aikido, basketball, one of our many dance classes, Pilates, stretch and relaxation technique, and yoga. Please check the schedule online for a full list of our course offerings and their days and times. TO RENT A LOCKER: Please go to the Cashier’s Office (SBS 285) and pay the appropriate rental fee: $30 for one semester, $40 for fall and spring semester, or $50 for the year (July 1 - June 30). Bring the yellow half sheet to the Kinesiology Office (KA 305). You will be assigned a locker (lock is included). If you have any questions about renting a locker please email kalockers@humboldt. edu or call (707) 826- 4532.

Healthy-U Physical Activity Class Enrollment Select a class from the listing of physical activity classes. Enrollment is contingent on available space in the class. Verify with the instructor that there is room in the class. Bring this form to the KRA Office (KA 305). After Department approval, go to the Cashierâ&#x20AC;&#x2122;s Office (SBS 285) to make your payment. Bring your pink half sheet from the Cashierâ&#x20AC;&#x2122;s Office marked with your payment stamp to KA 305 to receive your card.

Your name: ________________________________ Campus Extension: __________

(Check one) Fall ___ Spring ___

20___

Office: ______________________

Email: ______________________________

Class selected: _____________________________________________ Day & Time: _______________________________________________ Name of Instructor: _________________________________________

Instructor Approval: _________________________________________ Date_____________

Department Approval: ________________________________________ Date_____________

EMPLOYEE ASSISTANCE PROGRAM (EAP) Are You Concerned With....? o Job stress

o Marital problems

o Family problems

o Problems with children

o Stresses of illness

o Emotional problems

o Financial difficulties

o Alcohol problems

o Drug problems

o Other life crisis

The Employee Assistance Program: Whether the source of the problem is psychological, chemical, marital, family or workplace related, this service puts you or your dependents in touch with a skilled counselor who has training and experience in helping people. At no cost to you, a counselor will assist you in defining and recognizing a problem. The counselor will offer two, one-hour sessions of counseling and refer you to the appropriate agency or therapist if further help is necessary. This may range from a no-cost support group to private counseling. EAP Services Are Confidential: When you request assistance, no information is reported to supervisors, dean, chairs, or the Academic Personnel Services and Human Resources Department. To ensure confidentiality, this service is provided by Elizabeth Seals of Humboldt Family Service Center. Who Can Use The Service? The Employee Assistance Program is available to all employees and their families. The service provides assistance with personal problems which affect job performance, including those of substance abuse.

For more information or to make a confidential appointment, please contact: Elizabeth Seal Humboldt Family Service Center 707.443.7358 www.humboldtfamilyservice.org Offices located in Eureka and Arcata

If you have questions regarding HSU's Employee Assistance Program, please contact: Colleen Mullery Academic Personnel Services and Human Resources 707.826.5086 colleen.mullery@humboldt.edu