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Marple Newtown
SCHOOL DISTRICT
2015 - 2016
Benefits Booklet
MNEA – Teachers
MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Table of Contents

General Overview . 1 
Opt-Out Provision . 1 
Contributions . 1 
Personal Choice 20/30/70 . 2 
Reimbursable Expenses . 5 
Prescription Drug Program . 6 
Vision . 8 
Delta Dental . 10 
Flexible Spending Accounts . 13 
Changing Your Election . 17 
Open Enrollment . 18 
Eligibility for Coverage . 18 
Pretax Premium Feature . 19 
COBRA . 20 
Marketplace Coverage Options . 25 
Privacy Notice of Your Health Plan . 27 
Prescription Drug Creditable Coverage Notice . 30 
If you (and/or your dependents) have Medicare or
will become eligible for Medicare in the next 12
months, a Federal law gives you more choices
about your prescription drug coverage.
Please see page 30 for more details.
MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
General Overview
It's time for you to think about the benefit options you and your family will want for the coming year. You are beginning a process which will take you
through the 2015-2016 plan year. For the July 1, 2015 through June 30, 2016 Plan Year, the Medical option offered by the district is: Personal Choice 20/30/70
In addition, you will have the opportunity to opt out of your coverage and receive a cash payment if you currently have alternative coverage. The School District also offers Prescription, Dental and Vision coverage to you and your family. In addition, you have the option to participate in the Flexible Spending Account (FSA) Program. With this Benefit Program, money that you choose to have directed from your pay goes into a Flexible Spending Account before taxes are withheld to be used for certain Health Care and/or Dependent Care expenses. When you "withdraw" from your accounts, you are actually using untaxed dollars to pay for qualifying Health Care and/or Dependent Care expenses, so you lower your net cost. It's important that you carefully review the descriptions of covered services and supplies for these Medical Plan options and assess the medical needs of you and your family before making your benefit selections. In this highlight booklet, we will summarize the plan coverages and elections that are available to you. For more details on the specific plan you must refer to the Summary Plan Description booklet. If you cannot locate a copy, please contact Gallagher Benefit Services. Terms of the contract will prevail. Opt-Out Provision
General Information about Spousal Coverage
In the event two persons are both eligible members of the bargaining unit, or are both eligible employees of the District for benefits, they each shall be entitled to elect couple coverage or choose to each have one individual coverage health benefit plan, with no dependents, unless the total cost to the District of such individual plans exceeds the cost to the District of a husband and wife plan. Opt-Out Provision
In the event that two persons are both employees of the District that are eligible for benefits, and each have one individual coverage health plan with no dependents with the District, both eligible employees must decline benefits from the district and "Opt-Out" pursuant to this provision to be entitled to receive an "Opt-Out" payment. In any event, only one "Opt-Out" payment shall be made per family Contributions
Pursuant to the Collective Bargaining Agreement between the District and the Education Association, the following contributions for medical,
prescription, and dental coverage are required by employees: Personal Choice 20/30/70
10% of premium
$10 generic / $40 brand Prescription Plan
10% of premium
Delta Dental
$60 per year
Vision Coverage
Fully paid by the District.
Opt Out Provision
District Payment lieu of Health Care Coverage
$1,500 Annually
COBRA Employees
You are responsible for the entire cost of the benefits which you elect, plus a two percent administration charge. Please consult the COBRA letter
that you received from the district after your qualifying event for more details. Rates will be adjusted annually in conjunction with plan costs. MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Personal Choice 20/30/70
MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Reimbursable Expenses
The District will reimburse you for Inpatient Hospital Copayments and Outpatient Hospital Surgery Copayments that you or your dependents must
pay. Claim forms are available by contacting Gallagher Benefit Services. You will need your Hospital Invoice and Blue Cross Explanation of Benefits to submit your claim for reimbursement. You will be reimbursed as follows: Description of Reimbursable Expense
In Network
Out of Network
Inpatient Hospital Copayment $150 Per Day Copayment Outpatient Hospital Surgery Copayment Please note you have 90 days after the close of the plan year (June 30th) to submit for the above reimbursements.
Additional Programs
Healthy Lifestyles Solutions Programs to Keep You Healthy
 Fitness Club Reimbursement Program  Weight Management with Weight Watchers  Smoking Cessation ConnectionsSM Health Management Program:
Support and Information You Need to Manage Your Health!
The Connections Health Management Program is designed to help members become more informed health care consumers. Members with chronic
conditions such as diabetes, lung or breathing problems, or heart conditions can learn how to improve their health and overall quality of life. In
addition, this program supports members who are facing a significant medical decision as well as members with everyday health concerns.
ConnectionsSM Health Management Program features:
 Access to a Connections Health Coach, 24 hours a day, 7 days a week, 365 days per year.  Personalized calls from your Health Coach about your chronic condition and other health concerns.  Educational materials and health reminders mailed to your home. Visit www.ibx.com or call 1-800-ASK-BLUE to inquire about
Healthy Lifestyles or the ConnectionsSM Program.
MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Prescription Drug Program
Who Administers the Plan?
Express Scripts, Inc. (711 Ridgedale Avenue, East Hanover, New Jersey, 07936-2000 Tel: 1-800-467-2006) administers the
program on behalf of Marple Newtown School District on a self-insured basis. This transition to Express Scripts from
Advance PCS was effective September 1, 2004 and was designed to duplicate the benefits under the existing Plan. The
Marple Newtown School District Division/Group Number is Z8M. The website is www.express-scripts.com and you will find valuable information
on this website.
Who is Covered?
All benefit eligible employees and dependents are entitled to prescription drug coverage provided the applicable contribution is made.
What is Covered?
Benefits will be provided for covered drugs for out-of-hospital use, when prescribed by a legally licensed physician and dispensed by a legally
licensed pharmacy on and after the coverage effective date. This benefit includes prescription orders which the pharmacy receives by phone from your doctor. Benefits are available at a retail pharmacy for up to a thirty-four (34) day supply and a ninety (90) day supply through the mail.
How Retail Pharmacy Benefits are Received:
When you purchase covered drugs from a participating pharmacy, you should present your prescription order and your identification card to the
pharmacist. The pharmacist will use a computerized system to confirm your eligibility for benefits and determine the cost of your prescription, including the share of the cost you will be asked to pay. If you utilize a pharmacy that does not participate with Express Scripts, or you do not present your Express Scripts card at a Participating Pharmacy, you will be required pay the pharmacy's regular charge for the prescription. Then you must submit a copy of your prescription receipt, including the specified drug, patient information and division number for reimbursement. Complete instructions and the address for submitting your claim are listed in the section entitled "How to File a Claim". Your reimbursement check should arrive in 10-14 business days from the day your claim form is received. Reimbursements are based on the Express Scripts allowance not the pharmacy's regular charge. You will be responsible for your copayment along with the difference between the allowable charge and the pharmacy's charge. Claim forms are available through by contacting Gallagher Benefit Services.
How Mail Order Prescriptions are Received
Express Scripts also administers the mail order prescription drug program. This program provides you with the convenience of receiving prescription
maintenance medication right at your home. If you are taking medications frequently and for a long period of time, a three-month supply can be delivered to your home. When your doctor prescribes chronic or "maintenance" drug therapies, request a prescription for a 90-day supply, plus 3 refills. "Chronic Drugs" are recognized by Express Scripts for the treatment of chronic or long term conditions such as, cardiac disease, hypertension, diabetes, lung disease and arthritis. Enclose your prescription (no photocopies) in the pre-addressed envelope. Follow the directions on the envelope. Make certain that you include appropriate payment. Envelopes are available through Express Scripts. Copayment: You will make the following co-payments for each separate prescription order and refill:
Copayment Schedule
Retail Pharmacy
Mail Order
(Up to a 90 day supply) Generic $10.00
Brand $40.00
Out of Pocket Maximum
$5,100 Individual and $10,200 Family
Out of Pocket Maximum: A specified dollar amount of copayments incurred by a subscriber for prescription medication. Once you have reached the
out of pocket maximum, the prescription plan will pay for most medications covered at 100%.
Exclusions The following items are not covered by the Prescription Plan:
 Drugs dispensed without a prescription drug order except insulin and diabetic supplies, such as diabetic blood testing strips, lancets and glucometers;  Drugs which by law may be dispensed without a prescription drug order even though a prescription drug order may be written for the drug;  Drugs obtained through mail order prescription drug services of a non-member mail order pharmacy;  Devices of any type even though such devices may require a prescription drug order including, but not limited to contraceptive devices, ostomy supplies, therapeutic devices, artificial appliances. This exclusion does not apply to devices used for treatment of diabetic conditions and syringes used for injection of insulin;  Drugs dispensed to you while you are a patient in a facility including, but not limited to, a hospital, skilled nursing facility, institution, health care practitioner's office or free-standing facility;  Drugs used for cosmetic purposes such but not limited to photo aged skin products, hair growth agents, injectable cosmetics; MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
 Tretinoin agents used in the treatment of acne and/or for cosmetic purposes for individuals beyond age 26;  Drugs which are experimental or investigative;  Drugs which are not prescribed by an appropriately licensed health care practitioner;  Drugs prescribed for persons other than you or your eligible dependents;  Drugs for any loss sustained or expenses incurred as a member of the armed forces of any nation while on active duty; or losses sustained or expenses incurred as a result of enemy action or act of war, whether declared or undeclared; drugs for which benefits are provided by the Veteran's Administration or by the Department of Defense for the covered person of the armed forces of any nation while on active duty;  Drugs for any occupational illness or bodily injury arising out of, or in the course of, employment for which you have a valid and collectible benefit under any Worker's Compensation Law, United States Longshoreman's Act or Harbor Worker's Compensation Act, Occupational Disease Act or Law, whether or not you claim the benefits or compensation;  Drugs for injuries resulting from the maintenance or use of a motor vehicle if such drugs are paid under a plan or policy of motor vehicle insurance including a certified self-insured plan, or payable in any manner under the Pennsylvania Motor Vehicle Financial Responsibility Law;  Drugs for which you have no obligation to pay; Drugs furnished without charge to the covered person; Drugs which have been paid under the Health Plan.  Drugs prescribed or requested after the date of termination of the covered person's coverage under this agreement, except as otherwise provided under the COBRA continuation provision;  Implants, Diaphragms, and IUD's  Agents used to suppress appetite and control fat absorption; Smoking deterrent agents;  Prescription Drugs with over the counter equivalents;  The administration or injection of drugs; Blood and blood products; Growth Hormones;  Intravenous drugs and intravenous solutions administered by home infusion companies;  Drugs for a use not approved by the U.S. Food and Drug Administration or a dosage that is not recommended by the U.S. Food and Drug Administration. Prior Authorization: The following prescriptions require prior authorization:
Amevive Injectable
Myobloc Injectable
Remicade Injectable
Aranesp Injectable
Penlac Topical Solution
Botox Injectable
Procrit Injectable
Sporanox Capsules
Diflucan (Excluding 150 Mg Tablets)
Prolastin/Aralast
Epogen Injectable
Provigil
FluMist (Incl. in serums, toxoids, and vaccines category)
Raptiva Injectable
Wellbutrin SR/XL
Forteo Injectable
Regranex
Xolair Injectable
Lamisil Tablets
Zonegran
If you need one of the drugs listed above, simply ask your doctor or pharmacist to contact one of the prior authorization representatives at Express
Scripts by Telephone: 1-800-522-6727 or Fax 1-800-357-9577 to obtain the necessary authorization.
How to File a Prescription Benefit Claim: If you utilize a Participating Pharmacy simply present your Express Scripts card to the pharmacist - all
claims are submitted to the prescription carrier by Participating Pharmacies. If you utilize a pharmacy that does not participate with Express Scripts, it will be necessary for you to pay the pharmacy's regular charge for the prescription. Then you must submit a copy of your prescription receipt, including the specified drug, patient information and division number. Send it to Express Scripts at: ATTN: Claims Processing, P.O. Box 390873, Bloomington, MN 55439-0873. Your reimbursement check should arrive in 10-14 business days from the day your claim form is received. Reimbursements are based on the Express Scripts allowance not the pharmacy's regular charge. You will be responsible for your copayment along with the difference between the allowable charge and the pharmacy's charge. Claims which are submitted later than December 31st of the calendar year following the year in which that claim was incurred will not be processed.
Claims Appeal
Claims Appeal: You or your eligible dependents will have a reasonable opportunity to appeal an adverse benefit determination under which there will
be a full and fair review of the claim and the adverse benefit determination. A claimant (or authorized representative) will have one hundred eighty (180) days after receiving notice that his/her claim is denied to appeal the decision in writing to Marple Newtown School District. The claimant may submit written comments, documents, records, and other information relevant to the claim. In addition, the claimant will be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim.
Limitations
 Oral Erectile Dysfunction/Oral Impotence medications will be limited to 6 tablets for a 34 day supply.
Prescription Drugs related to the diagnosis and therapy of infertility problems will be limited to a lifetime benefit of $5,000. Only medications filled after the contract settlement will be included in this calculation. MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Vision
Administrator
National Vision Administrators is the administrator of your vision care plan and as an innovative leader in the field, has designed the program with
your convenience in mind. Its staff is composed of qualified professional administrative personnel who are available to assist you if needed. If you have any questions or require information of any kind, please call or write: National Vision Administrators, P. O. Box 2187, Clifton, New Jersey 07015 (Tel: 800-672-7723) Program Benefits(1)
In Network Benefits (Participating Providers)
Routine Eye Examination
(Eye examinations for medical purposes are covered under Personal Choice)
Covered up to $300 Single / Bifocal / Trifocal / Lenticular (NVA Providers provide significant discounts) Contact Lenses (In Lieu of Frames and Lenses)
Out of Network Benefits (2) (Non-Participating Providers)
Routine Eye Examination
(Eye examinations for medical purposes are covered under Personal Choice)
Lenses Single / Bifocal / Trifocal / Lenticular
Covered up to $300 Contact Lenses (In Lieu of Frames and Lenses)
(1) Frequency:
Adults, age 19 and over, are eligible for an Examination once every 12 months and Lenses or Contacts once every 12 months and Frames once every 24 months.
Dependents under age 19 are eligible for an Examination once every 12 months and Lenses or Contacts once every 12 months and Frames once every 24 months.
(2) Out of Network Benefits. You may submit your invoice and claim form to Gallagher Benefit Services and you will be reimbursed directly unless NVA has already processed this
payment. You may not seek two payments for the same service. You may fax your invoice and claim form to 610-627-0256 or mail to Gallagher Benefit Services 100 Matsonford
Road, 4 Radnor Corporate Center, Suite 510, Radnor, PA 19087. If your provider submits out of network claims to NVA on your behalf, GBS will not provide additional
reimbursement for the same service.
(3) Out of Network Benefits (Routine Exam). If NVA processes the claim, NVA will reimburse a set fee for the examination and the District will self-fund the difference between
allowance and the charge.
How Your Program Works
Participating Provider: When making your appointment with an NVA Participating Provider, please notify them that your coverage is administered
by NVA and Sponsored by Marple Newtown School District . The provider will telephone NVA to verify your vision care eligibility.
At the time of your first appointment, simply present your NVA Vision Care identification card. You do not need to obtain a vision claim form. The
provider will inform you of your eligibility status prior to rendering services. To verify benefit eligibility yourself prior to scheduling your eye care
appointment, you may wish to contact NVA's Customer Service Department at the following toll free number 800-672-7723. When the services have been completed, the Provider will have you sign a claim form and he or she will then forward the form to NVA for processing and payment. Non-Participating Provider: If you select a non-participating eye care provider, you will be responsible for one-hundred percent (100%) of the cost
at the time of service. You should fax a copy of your detailed invoice and claim form to Gallagher Benefit Services, at 610-627-0256 or mail to 100 Matsonford Road, 4 Radnor Corporate Center, Suite 510, Radnor, PA 19087. If your provider submits out of network claims to NVA on your behalf, GBS will not provide additional reimbursement for the same service. Where To Get Benefits
NVA has a network of participating Ophthalmologist, Optometrists, and Opticians to serve you. A directory of local participating providers will be
supplied to each eligible employee. In addition to the directory, you can access the website at www.e-nva.com or contact customer service at 800-
672-7723 for participating providers.
MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Exclusions
Services and materials not covered under the plan are as follows. No benefits will be provided for the following services, supplies or charges:
1) For examinations or materials which are not listed as a covered service or item of supply; 2) For any lenses which do not require a prescription; 3) For replacement of lost, stolen, broken or damaged lenses, contact lenses or frames unless the covered person would otherwise meet the frequency limitations; 4) For the cost of any insurance premiums indemnifying the covered person against losses for lenses or frames; 5) For sunglasses, whether or not requiring a prescription, industrial safety glasses and safety goggles; 6) For medical or surgical treatment of the eye; 7) For diagnostic services, such as diagnostic x-rays, cardiographic, encephalographic examinations; 8) For drugs or any other medications; 9) For procedures determined by NVA to be special or unusual, such as but not limited to, orthoptics, vision training, subnormal vision aids, 10) For eye examinations or material necessitated by the covered person's employment or furnished as a condition of employment; 11) For any illness or bodily injury which occurs in the course of employment if benefits or compensation are available, in whole or in part, under the provisions of any legislation of any government unit; 12) To the extent benefit are provided by any governmental unit; 13) For which the covered person would have no legal obligation to pay in the absence of this or any similar coverage; 14) Received from a medical department by or on the behalf of an employer, a mutual benefit association, labor union, or similar person or 15) Performed prior to the covered person's effective date; 16) Incurred after the date of termination of the covered person's coverage except for lenses and frames prescribed prior to such termination and delivered within 31 days from such date; 17) For telephone consultations, charges for failure to keep a scheduled visit, or charges for completion of a claim form; 18) For duplicate and temporary devices, appliances and services; 19) For which the covered person incurs no charge; 20) The cost of which has been or is later recovered in any action at law or in compromise or settlement of any claim except where prohibited 21) In a facility performed by a Professional Provider who in any case is compensated by the facility for similar covered services performed for 22) Treatment or service for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under a plan or policy of motor vehicle insurance; If any item selected is from the exclusion list, you will be required to pay the total cost of the lenses.
For additional information you can access the website at:

The website allows you to check eligibility, print new cards,
review claims, find providers and review benefits.
MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Delta Dental
Who Administers the Plan?
Delta Dental (One Delta Drive, Mechanicsburg, PA 17055 Tel: 1-800-932-0783), administers the program on behalf of the District on a self-insured basis.
The Marple Newtown Sponsor number is #1235.
Who is Covered? All benefit eligible employees and dependents are eligible for the Dental benefits regardless of the Medical coverage selected.
DeltaPreferred Option with Point of Service
The DeltaPreferred Option program with Point of Service (POS) actually gives you access to two dentist networks at once. You have lower out-of-
pocket expenses with a DeltaPreferred Option participating dentist. In addition, if you visit a dentist who participates in only the DeltaPremier program, Delta limits the dentist's total collectable charge, though your copayment may be higher because Delta's allowance for DeltaPremier dentists is usually higher. Only with a non-participating dentist is there no contracted fee limit of any kind. The POS variation gives you maximum network access while offering deeper savings from the DeltaPreferred Option network and the safety-net feature from the DeltaPremier network. These are hypothetical numbers for illustrative purposes. DeltaPreferred Option
Example of Fee Charged Sample Plan Payment Allowance Percentage of Allowance Paid by Delta $120 - $72 = $48 Remember to check what network your Dentist belongs, and keep in mind that you are enrolled in a Pennsylvania Delta Dental plan. Out of state Dentists have different allowance schedules which may result in higher out-of-pocket expenses for you. Diagnostic: . Procedures to evaluate existing conditions and dental care required, to include visits, exams, diagnosis and x-rays.
Preventive: . Prophylaxis (cleaning); fluoride, space maintainers, limited to age nineteen (19); and sealants, limited to age ten (14).
Basic Restorative: . Amalgam and composite fillings (on anterior teeth only).
Major Restorative: . . Crowns, inlays, and onlays are benefited where above materials are not adequate.
Oral Surgery: . Extraction and oral surgery procedures, including pre- and post-operative care.
Endodontic: . Procedures for pulpal therapy and root canal filling.
Periodontic: . Surgical and non-surgical procedures for treatment of gums and supporting structures of teeth.
Prosthodontic: . Procedures for construction or repair of fixed bridges, partial or complete dentures.
Orthodontic: . Procedures for straightening teeth. Orthodontics is a benefit for dependent children to age nineteen (19).
Denture Repair: . Repair of existing dentures.
Co-Insurance Schedule
Paid by Delta
Paid by Subscriber
Diagnostic
Preventive
Basic Restorative
Major Restorative
Oral Surgery
Fissure Sealants
Endodontic
Periodontic
Denture Repair
* Orthodontics is a benefit for dependent children to age 19, with a separate maximum of $1,500 per lifetime.
The Maximum benefit is $2,500 per person per calendar year.
Three periodontal treatments are allowed per year.
The percentages listed in the coinsurance schedule are payable to participating dentists or subscribers and subject to limitations and exclusions as
specified in the Group Dental Contract. MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Services Not Covered:
 Prescription drugs, premedications, and relative analgesia.  Charges for hospitalization, including hospital visits.  Plaque control programs, including oral hygiene and dietary instruction.  Procedures to correct congenital or developmental malformations except for children eligible at birth.  Procedures, appliances or restorations primarily for cosmetic purposes.  Increasing vertical dimension.  Replacing tooth structure lost by attrition.  Periodontal splinting.  Gnathological recordings.  Equilibration.  Treatment of dysfunctions of the temporomandibular joint.  Experimental procedures. Benefit Limitations:
 Prophylaxis and exams are a benefit once in any six month period.  Bitewing x-rays are a benefit once in any six month period.  Full mouth x-rays are a benefit once in any three year period.  Replacement of restorative crowns, inlays and onlays is a benefit once only in any five-year period irrespective of who provided previous restoration or paid benefits.  Replacement of prosthodontic devices is a benefit once only in any five-year period irrespective of who provided previous devices or paid  Episodes of surgical periodontal treatment must be separated by a period of no less than five years to qualify the patient for additional periodontal benefits.  Substandard work until corrected. Special Note: Dental benefits may be based on the least costly treatment that confirms to generally accept dental practice.
Participating Dentists:
These are licensed dentists who have entered into an agreement with Delta to abide by Delta's policies regarding services, your portion of the
charged fees, and other matters pertinent to Delta's obligations to its subscribers. Names of participating dentists can be obtained, upon request, by
calling Delta, accessing its website at www.deltadental.com, or from directory listings furnished to your employer. DeltaPreferred participating dentists are paid at the DeltaPreferred Maximum Plan Allowance (MPA). DeltaPremier participating dentists are paid at the DeltaPremier MPA. Participating dentists accept the MPA as payment in full. Participating dentists are paid directly by Delta Dental, and by agreement cannot bill the patient more than the applicable copayments or deductibles for the services provided. Non-Participating dentists are paid at the DeltaPremier MPA. The benefit payment is sent directly to the employee. It is the employee's responsibility to pay the provider. The employee is responsible for paying the difference between the DeltaPremier MPA and the amount billed by the Non- Participating dentist, plus any applicable copayments or deductibles.
Predetermination of Benefits:
If total charges for a treatment plan exceed an amount which Delta establishes ($200), predetermination is a condition of approval of the charges for
payment. You should ask the attending dentist to submit the claim form in advance of performing services. Delta will act promptly in returning a predetermination voucher to you and the attending dentist with verification of your eligibility, scope of benefits and definition of sixty (60) day period for completion of services. The notification shall also state the amount which will be paid providing you are eligible on the date when each respective procedure is commenced, the procedures are completed within a sixty (60) day period following the date of the predetermination notice, the claim is submitted not more than six (6) months after the date of service, and the benefits continue to be within applicable benefit maximums and frequency of procedure limitations. Subject to your continuing eligibility, applicable benefit maximums not being exhausted and the continuing inapplicability of frequency of procedure limitations, Delta will grant extensions of a benefit predetermination period upon request from your attending dentist or you. MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Coordination of Dental Benefits:
If separate dental benefits are available to the employee, spouse or dependents under other programs, there are specific conditions applicable to
determination of payment. The ratio of each carrier's liability to total cost incurred is reviewed. Payment is made according to the "birthday" rule adopted by most insurance carriers, but in no case does Delta pay in excess of its total contractual obligation, if it were the only carrier involved. If the other carrier determines its benefits first, Delta will pay any difference between the amount paid by the other carrier and the charge for the covered service, to the extent of Delta's benefit for a given procedure.
Payment for Services:
Services performed by participating dentists for you are paid to the Participating Dentist. Delta advises you of any charges not payable by Delta for
which you are responsible. These are generally your share of co-insurance, deductibles, charges where maximums have been exceeded, or charges
for services not covered by the Group Dental Contract. Payment for services performed for you by a non-participating dentist is paid to you. You are responsible for payment of the non-participating dentist's total fee, which may include amounts in addition to your share of Delta's calculation of UCR and services not covered by the Group Dental
Contract.
Important: The benefit explanations contained herein are subject to all provisions of the Group Dental Contract, and do not
modify such Contract in any way, nor shall the subscriber accrue any rights because of any statement in or omission from
this material.
Additional Benefits included:
Benefits for pregnant women include:
• An additional oral exam and
• An additional cleaning or, for women with signs of gum (periodontal) disease, an additional
periodontal scaling/root planing of up to all four quadrants
Benefit Enhancement – Implants
• Coverage for dental implants, implant-supported prosthetics and other implant services
• Covered under Prosthodontics with no separate maximum
• To provide more treatment options for tooth replacement • An alternative to a bridge or partial denture MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Flexible Spending Accounts
Flexible Spending Accounts are a special tax-saving feature of your District Flexible Benefits Plan. If you choose to take advantage of this tax
savings feature, you can direct part of your pay to one or both of these accounts. Separate accounts will be set up in your name for each type of account. Any money redirected from your pay goes into your account before taxes are withheld. That means your taxable income is lower - so you pay less Federal income, Social Security and in some cases state or local taxes. When you "withdraw" from your accounts, you are actually using untaxed dollars to pay qualifying expenses, so you lower your net cost.
How Do Flexible Spending Accounts Work?
1. Estimate. The first step you must take is to estimate how much money you want to direct into the Health Care Spending Account, Dependent
Account or both for the Plan Year. Because of the federal tax guidelines that govern these types of plans, take time to carefully estimate the amount of money you direct into your account(s) so you do not put too much into the account(s). 2. Authorize.
Next, you authorize the District to reduce your pay and have the payroll reductions credited to your Health Care and/or Dependent Care Spending Account during each payroll period by completing the appropriate form(s) provided by the District. Those form(s) must be
completed prior to your effective date or by the date specified by the District.
Health Care Account: You may direct up to $2,000 in payroll deduction dollars each year (July through June) to your Health Care
Account. The minimum amount per year is $200.
Dependent Care Account: Generally, you can direct up to a maximum amount of $5,000 in payroll deductions to this Account
for the Plan Year. The minimum amount per year is $200. (See Dependent Care section for certain limitations which may apply)
Guidelines
You can gain valuable tax advantages if you estimate your expected expenses carefully and have an appropriate amount placed in your Account(s).
However, because of the tax advantages that these Accounts offer, the Internal Revenue Service (IRS) imposes certain restrictions. The following special rules apply:
Forfeiture
The IRS rules require than any unused money remaining in your Account(s) at year end (or after the grace period) will be forfeited. Stated simply,
you will lose any money that is not used at the end of the year. This is known as the "use-it-or-lose-it" rule. This may seem unfair, but remember,
this account is not intended to be a tax shelter. It is meant to provide a tax-saving way to pay eligible medical or dependent care expenses. Therefore, the left over money will not be returned to participants. If you plan your contributions carefully, these rules shouldn't create a problem. It's
important to estimate your eligible expenses as accurately as possible. Remember, you must submit claims within 90 days after the end of the
plan year, or you will forfeit any money remaining in your account.
How To File A Reimbursement Request
When you have reimbursable expenses, you must send a completed claim form and the itemized bill or invoice for the service received to:
Gallagher Benefit Services, 100 Matsonford Road, 4 Radnor Corporate Center, Suite 510, Radnor, PA 19087
 Dependent care expense bills or invoices MUST include: name of provider and recipient, Tax Identification Number or Social Security Number for dependent care providers, date service was received, total charge and description of service.  Medical expense bills or invoices MUST include: date service was received, total charge and description of service. Once your form has been processed, you will receive a check, mailed to your home, which reimburses you for the expense. There is no minimum amount required when you submit for reimbursement. You cannot be reimbursed for more money than has been deposited into your Dependent Care Account by the date you make the claim. Remember, your contributions are deducted from your pay in equal installments. So funds build up gradually in your account. If you do submit a Dependent Care claim for more than the amount available in your account at that time, the remainder will be held in a pending file and paid as soon as more deposits are made to your account. You do not have to resubmit a claim. On the other hand, the medical expense reimbursed may be for expenses claimed up to the maximum benefit amount you elected for the year. If you have any balance left in your account after submitting all timely requests for reimbursement of expenses incurred during that year or the grace period (July- Sept 15), you will forfeit your remaining account balance. This result is from the IRS "use-it or lose-it rule." If you have any questions about the process or about what expenses can be reimbursed, please contact Gallagher Benefit Services. MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Timeframe For Submitting Reimbursement Requests
You can be reimbursed only for qualifying expenses that you incur during the Plan Year (July – June) or during the grace period. The grace period is
July through September 15th. However, you may submit requests for reimbursement for those expenses which were incurred during the Plan Year or the grace period up to three months after the end of the Plan Year. You incur an expense when you receive the services, regardless of when you are
billed or pay for the services.
Transferring Contributions
IRS rules require that each account operate independently of the other. Therefore, you cannot transfer money from one account to the other. Nor
can you be reimbursed for eligible health care expenses from the Dependent Care Spending Account or vice versa. Health Care Spending Accounts
No health insurance plan covers all expenses. There are always out-of-pocket medical, vision, and dental costs for which you are responsible such
as deductibles, co-payments, and miscellaneous expenses that are not covered. You may direct up to $2,000 in payroll deduction dollars each
year (July through June) to your Health Care Account. The minimum amount per year is $200.
You can use your Health Care Spending Account to pay expenses for yourself and your dependent. Neither you nor your dependents have to be
enrolled in The District's Health Plans to use your Account. A dependent must be either a "qualifying child" or a "qualifying relative" as defined by IRC
Section 152.
Health Care Expenses Eligible For Reimbursement
Generally, tax-free reimbursement up to the annual maximum amount of your contribution is available for any qualifying health-care expense which:
 the IRS would allow you to deduct for tax purposes,  you do not claim on your tax return, and  is not reimbursed by your Health care coverage or any other group health plan. Health-related expenses that qualify for reimbursement are defined under the Internal Revenue Code. Keep in mind that eligible tax expenses may change if the tax laws are revised. The following is a partial list of expenses which are eligible for reimbursement through the Health Care Spending  deductibles and other portions of medical, vision, dental or HMO costs that you, your spouse or dependents must pay (such as co-  charges above the Usual Customary and Reasonable (UCR) fee;  vision care expenses such as eye exams, contact lenses and glasses;  hearing care, including hearing exams and hearing aids;  dental expenses not fully covered by your dental plan (if any);  hospital services not fully covered by your medical plan (excluding personal items);  prescription medications not reimbursed under any insurance plan;  medically required supplies and equipment, if not covered under any insurance plan;  special equipment/devices, including: seeing eye dog, Braille equipment, TDD/TTY device and closed captioning device;  special classes which are required due to a diagnosed medical cause. IMPORTANT CHANGES TO YOUR FLEXIBLE SPENDING ACCOUNT AS A RESULT OF THE HEALTH CARE REFORM
Effective January 2011: Your Flexible Spending Account will no longer reimburse certain Over-The-Counter (OTC) drugs,
medicines and biologicals unless accompanied by a physician's prescription. These include: Acid Controllers, Allergy & Sinus,
Antibiotic Products, Anti-Diarrheal, Anti-Gas, Anti-Itch & Insect Bite, Anti-parasitic Treatments, Baby Rash Ointments/Creams, Cold Sore Remedies,
Cough, Cold & Flu, Digestive Aids, Feminine Anti-Fungal/Anti-Itch, Hemorrhoidal Preps, Laxatives, Motion Sickness, Pain Relief, Respiratory Treatments, Sleep Aids & Sedatives, Stomach Remedies. The following items will remain available without a doctor's prescription: Band Aids, Birth Control, Braces & Supports, Catheters, Contact Lens
Supplies & Solutions, Denture Adhesives, Diagnostic Tests & Monitors, Elastic Bandages & Wraps, First Aid Supplies, Insulin & Diabetic Supplies, Ostomy Products, Reading Glasses, Wheelchairs, Walkers, and Canes MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Reimbursement for Orthodontic Services
Please note that special rules govern expenses for orthodontic care because Orthodontics is an ongoing treatment and the IRS prohibits prepayment
of these services. For orthodontia reimbursement, send a copy of your orthodontia agreement (orthodontic contract) along with your completed form when treatment begins. The orthodontic agreement must state: 1. the beginning date of service 5. initial fee (down payment) 2. the approximate length of service 6. subsequent monthly fees 3. total cost of service 7. total insurance coverage (if applicable) The fee for orthodontic records is eligible for reimbursement on the date the x-rays, photos, and casts are taken. Proper documentation is a statement of services rendered from orthodontists. The initial fee (down payment) is eligible for reimbursement on the date of the first treatment. Subsequent monthly fees are eligible for reimbursement as monthly orthodontic adjustments occur. Proper documentation is a statement of services rendered, a receipt from orthodontist showing date of payment ("orthodontic" clearly noted on receipt), or a copy of payment stub from orthodontic payment booklet. Special payment schedules, which do not coincide with dates of service (such as full payment at banding), will be paid in equal installments over the period of the service. REMEMBER: Orthodontia services that are cosmetic are not eligible for reimbursement.
Health Care Expenses That Cannot Be Reimbursed
Not all health related expenses are eligible for reimbursement under a Health Care Spending Account. The following is a partial list of expenses that
cannot be reimbursed through this Account:  premiums for healthcare coverage; or premiums/contributions to outside health plans including COBRA continuation coverage, individual health policies, Medicare or plans of another employer;  amounts reimbursed by any health insurance carriers or pre-paid plan;  medical expenses for which you take an itemized tax deduction on your federal tax return (expenses must exceed 7.5% of your annual adjusted gross income):  cosmetic surgery or procedures;  payments to domestic help who render primarily non-medical services;  charges for a nurse to care for a healthy infant;  diaper services;  expenses for recreation, health clubs, and nutrition for general health and well-being, even if prescribed by a physician; and  expenses relating to an eligible dependent residing outside your home under custodial care (for example, your elder parent or grandparent who resides in a nursing home);  expenses not incurred during the Plan Year (July – June) or the grace period (July- Sept. 15);  marriage counseling; Dependent Care Spending Accounts
The Dependent Care Spending Account can help you stretch your dependent care dollars by saving you money on taxes. You may reduce your
taxable income to provide for expenses for the care of a dependent if that care is necessary for you to be able to continue working. If you are married, you and your spouse must both work to be eligible to use this account, or your spouse must be disabled or a full-time student. You must be at work when your eligible dependents receive care.
Generally, you can direct up to a maximum amount of $5,000 in payroll deductions to this Account for the Plan Year. The minimum
amount per year is $200. Certain limitations may apply as follows:
 If you and your spouse each earn an income and are married to each other at the end of the year, you cannot direct more than an amount equal to the lower income. For example, if you earn $30,000 and your spouse earns only $4,500, your Dependent Care Spending Account is limited to $4,500, not $5,000.  If your spouse has no earned income, you generally cannot direct anything to a Dependent Care Spending Account. However, if your spouse is a full-time student, or is physically or mentally incapable of caring for him or herself, the IRS rules deem your spouse to have earned income during each month that the spouse is incapacitated or is a full-time student. The amount of monthly earned income is deemed to be $250 if you have one eligible dependent and $500 if you have two or more eligible dependents. For example, if you have one child under the age 13 and a spouse who attends college for nine months during the year, your spouse's earned income will be deemed by the IRS to be $2,250 for that year ($250 times nine months). You will be able to direct $2,250 to your Dependent Care Spending Account for that year. MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
 If you and your spouse file separate federal income tax returns, you generally cannot deposit more than $2,500 in a Dependent Care Spending Account. However, you can still deposit up to $5,000 in your Account if you and your spouse file separate returns, as long as you meet one of these conditions: You are legally separated from your spouse under a divorce or separate maintenance agreement, or Your household is the eligible dependent's principal residence for more than six months during the year, you furnish over one- half of the cost to maintain the household, and your spouse has not lived in the household during the last six months of the year. Who Is An Eligible Dependent?
You can use a Dependent Care Account if you spend money for dependent care for "eligible dependents" in order for you to be gainfully employed.
An "eligible dependent" is a person who:
 qualifies as your dependent for federal tax purposes, and is either: a child under age 13 or; any person age 13 or older including a spouse or dependent relative who is physically or mentally incapable of caring for him or herself and resides in your home at least eight hours per day. Expenses Eligible For Reimbursement
The IRS has published regulations that explain what an "eligible expense" is for the Dependent Care Spending Account. The kinds of care that can
be covered vary considerably. The general rule is that amounts you spend for household services or personal care while you work will qualify as dependent care expenses so long as the service or care are at least in part required for the qualifying individual. You can consult Publication 503 to be certain that dependent care expenses you submit for reimbursement do qualify. Dependent care generally includes:  expenses for a day care center, pre-school or nursery school for your child but the facility must be licensed under state or local law if it cares for seven or more children;  expenses for an unlicensed day care center which cares for six or fewer children;  expenses for summer day camp;  expenses at a day care facility for adults if the dependent adult resides in your home at least eight hours per day (but not expenses for overnight, nursing home facilities); and  the cost of day care and housekeeping services in your home for your child or other eligible dependents. For children too young for kindergarten, the cost of pre-school or nursery school is eligible as long as it is primarily for the health and wellbeing of the child as opposed to being for educational purposes. For older children, tuition expense is assumed to be incurred for educational purposes only, unless the tuition can be split between education and after-school care. Then the portion of expenses for after-school care may be eligible. In all cases, a Tax ID# must be obtained from the institution providing the service.
Expenses That Cannot Be Reimbursed
In general, expenses for any care provided to an eligible dependent by your dependents (or your spouse's dependents), or by your children under
age 19 do not qualify for reimbursement. Some other examples of expenses not eligible for reimbursement include:  housekeeping expenses not related to dependent care;  overnight camp;  transportation expenses between your home and the location where the dependent care is provided;  food or clothing expenses for a dependent;  Kindergarten fees are almost always an education expense and are not reimbursable;  schooling costs for children in first grade and older, and  the same expenses for which you (or your spouse) claim a dependent care tax credit on your federal income tax return. Dependent Care Reimbursement Account vs. Tax Credit
For some it may be more advantageous to use the Dependent Care Account. For others, the Dependent Care Tax Credit on the federal income tax return may prove more suitable. Generally, you may not use both of these approaches, so you need to consider which is best for you. You can get detailed information on how this credit works from IRS Publication 503. MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Changing Your Election
The benefits you elect during this enrollment period will remain in effect through June 30, 2016. During the year, you can make certain changes only
if you have a Qualifying Change in Status or a Special Enrollment Event. If you wish to change your coverage, you must submit the appropriate form. If you are not making any changes, no forms are required. Any benefit changes must be made within 30 days of the event and must be consistent with the Qualifying Change in Status or Special Enrollment Event. A Qualifying Change in Status includes a change in:  Employee's legal marital status;  Number of employee's dependents;  Employment status of employee, employee's spouse or dependent that is a termination or commencement of employment, a strike or lockout, a commencement of or a return from a leave of absence, or a change in worksite;  Employment status of employee, employee's spouse or dependent that causes the individual to become or cease to be eligible for  Eligibility of employee's dependent for benefits;  Judgment, decree or court order for coverage of children;  Medicare/Medicaid eligibility;  Residence or worksite of employee, employee's spouse or dependent. HIPAA Special Enrollment Rights
Loss of Other Coverage (Excluding Medicaid or a State Children's Health Insurance Program). If you decline enrollment for yourself or for an
eligible dependent (including spouse) while other health insurance or group health plan coverage is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or
your dependent's other coverage). However, you must request enrollment within 30 days after you or your dependent's other coverage ends (or after
the employer stops contributing toward the other coverage).
Loss of Coverage for Medicaid or a State Children's Health Insurance Program. If you decline enrollment for yourself or for an eligible
dependent (including spouse) while Medicaid coverage or coverage in a state children's health insurance program is in effect, you may be able to
enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after you or your dependents' coverage ends under Medicaid or state children's health insurance program.
New Dependent by Marriage, Birth, Adoption or Placement for Adoption. In addition, if you have a new dependent as a result of marriage, birth,
adoption or placement for adoption, you may be able to enroll yourself and your new dependents. However, you must request enrollment within 30
days after the marriage, birth, adoption or placement for adoption.
Eligibility for Medicaid or State Children's Health Insurance Program. If you or your dependents (including spouse) become eligible for a state
premium assistance subsidy from Medicaid or a state children's health insurance program with respect to coverage under this plan, you may be able
to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days after you or your dependent's
determination of eligibility for assistance.
To request special enrollment or obtain more information, contact:
Marple Newtown School District Human Resources Department Gallagher Benefit Services, Benefits Department 36 Media Line Road Newtown Square, PA 19073 100 Matsonford Road, 4 Radnor Corporate Center, Suite 510, Radnor, PA 19087 Significant Cost and Coverage Changes
If the cost of a benefit provided under the Plan increases or decreases during a Plan Year, then we will automatically increase or decrease, as the
case may be, your salary redirection election. If the cost increases significantly, you will be permitted to either make corresponding changes in your payments or revoke your election and obtain coverage under another benefit package option with similar coverage. If the coverage under a Benefit is significantly curtailed or ceases during a Plan Year, then you may revoke your elections and elect to receive on a prospective basis coverage under another plan with similar coverage. In addition, if we add a new coverage option or eliminate an existing option, you may elect the newly-added option (or elect another option if an option has been eliminated) and make corresponding election changes to other options providing similar coverage. There are also certain situations when you may be able to change your elections on account of a change under the plan of your spouse's, former spouse's or dependent's employer. Rules allowing a change due to significant cost or coverage changes do not apply to the Health Care Spending Account, and you may not change your election to participate in the Health Care Spending Plan if you make a change due to a cost or coverage change for insurance. You may not change your election to participate in the Dependent Care Spending Account if the cost change is imposed by a dependent care provider who is your MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Consistency Rule
In all cases, any election change as a result of any change in status must be on account of and must correspond with a change in status that affects
eligibility for coverage under the Plan. For example, if the change in status is the employee's divorce, annulment or legal separation from a spouse, the death of a spouse or dependent child, or a dependent ceasing to satisfy the eligibility requirements for coverage, an employee's election to cancel health coverage will apply only to the spouse involved in the divorce, annulment or legal separation, the deceased spouse or dependent child, or the dependent that ceased to satisfy the eligibility requirements.
Open Enrollment
There will be an annual two week open enrollment period. During this time, employees will be able to change some of their benefit decisions based
on which benefits are right for them. Benefit choices made during open enrollment will become effective July 1st and remain in effect until the following June 30th. Please refer to the "Changing Your Election" section for more information regarding benefit changes outside of the open enrollment period.
Eligibility for Coverage
You and your dependents are eligible for health benefits coverage from the District. Each dependent of an employee will become covered at the
same time as the employee's coverage begins. New dependents of employees become covered on the first day of the month following the qualifying date except in the case of a birth, in which case, the dependent becomes active immediately. You are required to contact Human Resources any time you have a change in your family status so that your benefits are properly administered. If you do not notify Human Resources within 30 days of an event, you will be responsible for the cost of the claims or the difference in premium expenses, (whichever is greater). For instance, if you do not advise Marple Newtown of a divorce, you will be responsible for the cost of your ex-
spouse's claims or the difference in premium expenses (whichever is greater) after the date of the divorce.
Dependents Eligible for Enrollment
Eligible dependents include your lawful spouse and children under 26 years of age. If you intentionally misrepresent your adult dependent eligibility you may be liable for full repayment of any benefits and/or premiums paid on behalf the dependent and may be subject to legal remedies and/or disciplinary action including termination for falsifying employment related documents. Your lawful spouse means your legally recognized marital partner. Gallagher Benefit Services will require documentation proving a legal marital relationship. Dependent children shall include your natural children, stepchildren, adopted children or children placed with you in anticipation of adoption. The phrase "child placed with you in anticipation of adoption" refers to a child whom the Marple Newtown School District employee intends to adopt, whether or not the adoption has become final, who has not attained the limiting age as of the date of such placement for adoption. The child must be available for adoption and the legal process must have been commenced. A Dependent child who is incapable of self-sustaining employment by reason of mental illness, mental retardation or physical handicap, and who is primarily dependent upon you for support and maintenance, unmarried and covered by the District when reaching the limiting age shall be eligible for coverage under the Plan. You will be required to show periodic proof of continued eligibility for coverage under the rules of the Plan and subsequent proof of the child's disability and dependency. Any child of a Marple Newtown School District employee who is an alternate recipient under a Qualified Medical Child Support Order ("QMCSO") shall be considered as having a right to Dependent coverage under this Plan. When the District receives a medical child support order, the District will provide a notice to the employee and each alternate recipient stating that a medical child support order has been received and outlining the procedure(s) to determine if the order is qualified.
Student Status Verification: Student Status Verification will continue, for Dental only, twice a year.
Continuation of Coverage During Periods of Disability or Leave of Absence An employee, in accordance with the appropriate Marple Newtown
School District employment policy, may remain eligible for a limited time if active, full-time work ceases due to disability or leave of absence.
Continuation of Coverage During Family and Medical Leave (FMLA) This District shall at all times comply with the Family and Medical Leave Act
of 1993 as promulgated in regulations issued by the Dept. of Labor. During any leave taken under the Family and Medical Leave Act, the Marple Newtown School District will maintain coverage under this Plan on the same conditions as coverage would have been provided if the employee had been continuously employed during the entire leave period. If coverage terminates during the FMLA leave, coverage will be reinstated for the employee if the employee returns to work in accordance with the terms of the FMLA leave. Coverage will be reinstated only if the person was covered when the FMLA leave started, and will be reinstated to the same extent that it was in force when coverage terminated.
Rehiring a Terminated Employee A terminated employee who is returning to work would be eligible for coverage on the first day of the month
following the satisfaction of all eligibility and enrollment requirements.
Employees on Military Leave An employee going into or returning from military service will have rights mandated by the Uniformed Services Employment
and Re-employment Rights Act. These rights include up to twenty-four (24) months of extended health care coverage upon payment by the employee of the entire cost of coverage plus a reasonable administration fee and immediate coverage with no preexisting conditions exclusions applied upon return from MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
service. These rights apply only to persons covered before leaving for military service. Plan exclusions and waiting periods may be imposed for any illness or injury determined by the Secretary of Veterans Affairs to have been incurred in, or aggravated during, military service.
Effect of Termination of Coverage No benefits shall be payable under the Plan for expenses incurred after the date coverage has terminated for
that individual. Expenses incurred for benefits covered under the Plan while that individual was covered under the Plan will be payable, subject to all
other Plan conditions and procedures.
Conversion Policy In most cases, Personal Choice will give you the opportunity to purchase an individual policy, if you and your family lose
coverage under the Plan. You must generally apply within a specific period of time. Please refer to your Summary Plan Description for more details including your rights, procedures and the timeframe in which you must apply.
Pretax Premium Feature
Who Is Eligible? As a "benefit eligible employee" you are eligible for this feature. If you are required to make contributions for coverage for your
health care benefit options, your contributions will automatically be withheld from your pay on a pretax basis unless you specify otherwise.
Through the Pretax Premium Feature, you can pay your monthly cost for health care plan elections with dollars deducted from your gross pay -
before any federal, Social Security and, in most states, state and local taxes are withheld. This reduces the amount of your taxable income and is sometimes referred to as a "payroll reduction." Very simply, this feature allows you to lower the amount of your taxable income by the amount you contribute for your health care plan selections. The amount of taxes you will pay is reduced because each dollar of payroll reduction is a dollar not taxed by the federal and state governments. Keep in mind that the tax savings you realize through use of the Pretax Premium Feature will vary depending upon your personal situation.
Other Considerations If you participate in the feature, your pay-related benefits, such as life insurance and disability income will not be affected by
your payroll reductions. If your pay after your payroll reductions is less than the Social Security wage base ($118,500 for 2015), your future Social Security benefits may be slightly reduced because you will be paying less in FICA taxes. If your pay is more than the Social Security Wage Base, your Social Security benefit will not be reduced at all.
When Payroll Reductions End: Your participation in the Pretax Premium Feature will end as soon as one of the following events occurs:
 your pay ceases due to your disability or election to take an unpaid leave of absence,  your transfer to an ineligible employee status, your employment terminates, your retirement, In most cases if your benefits continue after your salary ends (such as COBRA or FMLA coverage), all required premium payments for your benefit selections must be paid with "after-tax" dollars. For more information, contact Gallagher Benefit Services. MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Introduction
This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the
Plan. You should maintain this information in the event that you lose your coverage through the County. This notice explains COBRA
continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it as
well as other health coverage options that may be available to you, including coverage through the Health Insurance Marketplace at
www.HealthCare.gov or call 1-800-318-2596. You may be able to get coverage through the Health Insurance Marketplace that costs less
than COBRA continuation coverage (see page 30).
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).
COBRA continuation coverage can become available to you when you would otherwise lose your group health coverage. It can also become
available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. For
additional information about your rights and obligations under the Plan and under federal law, contact the District's Human Resources
Department.
You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan
through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse's plan), even if that plan generally doesn't accept late enrollees. What is COBRA Continuation Coverage?
Federal law requires that most group health plans (including Marple Newtown School District) give employees and their families the opportunity to
continue their health care coverage. COBRA continuation coverage is a continuation of Health coverage when coverage would otherwise end because of a life event known as a "qualifying event." Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a "qualified beneficiary." You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens:  Your hours of employment are reduced, or  Your employment ends for any reason other than your gross misconduct. If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because any of the following qualifying events happens:  Your spouse dies;  Your spouse's hours of employment are reduced;  Your spouse's employment ends for any reason other than his or her gross misconduct;  Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or  You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage because any of the following qualifying events happens:  The parent-employee dies;  The parent-employee's hours of employment are reduced;  The parent-employee's employment ends for any reason other than his or her gross misconduct;  The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);  The parents become divorced or legally separated; or  The child stops being eligible for coverage under the plan as a "dependent child." Continuation coverage is the same Health Care coverage that the Plan gives to other participants or beneficiaries under the Plan who are not receiving continuation coverage. Each qualified beneficiary who elects continuation coverage will have the same rights under the Plan as other participants covered under the Plan, including open enrollment rights.
Are there other coverage options besides COBRA Continuation Coverage?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other more affordable coverage options for you and your family through the
Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse's plan) through what is called a "special enrollment period." Some of these options may cost less than COBRA continuation coverage. You should compare your other coverage options with COBRA continuation coverage and choose the coverage that is best for you. For example, if MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
you move to other coverage you may pay more out of pocket than you would under COBRA because the new coverage may impose a new deductible. When you lose job-based health coverage, it's important that you choose carefully between COBRA continuation coverage and other coverage options, because once you've made your choice, it can be difficult to switch to another coverage option.
When is COBRA Coverage Available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the COBRA Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, or enrollment of the employee in Medicare (Part A, Part B, or both), Marple Newtown School District must notify the COBRA Administrator of the qualifying event within 30 days. For the other qualifying events such as divorce or legal separation of the employee and spouse, or a dependent child's losing eligibility for coverage as a dependent child, you must notify ), Marple Newtown School District's Personnel Department within 60 days after the qualifying event occurs by completing the "Employee Notification" form. This form is available by contacting the Personnel Department. The failure to provide timely notice can result in the loss of COBRA rights to purchase coverage.
How is COBRA Coverage Provided?
Once the COBRA Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the
qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage. In the case of a loss of coverage due to end of employment or reduction in hours of employment, coverage generally may be continued for up to a total of 18 months. When the qualifying event is the death of the employee, the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), the Employee's divorce or legal separation, or a dependent child's losing eligibility as a dependent child, COBRA continuation coverage lasts for up to a total of 36 months. When the qualifying event is the end of employment or reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the employee's hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months. There are ways in which this 18-month period of COBRA coverage can be extended. The following describes in detail those potential extensions:
Disability extension of 18-month period of continuation coverage If you or anyone in your family covered under the Plan is determined by the
Social Security Administration to be disabled and you notify the COBRA Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. You must use the "Employee Notification" form which may be obtained by contacting the Personnel Department or the COBRA Administrator. This notification must be sent to the COBRA Administrator within sixty (60) days of the date of the Social Security Administration's determination and before the end of the 18-month period of COBRA continuation coverage.
Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event while
receiving 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of
COBRA continuation coverage, for a maximum of 36 months, by completing the "Employee Notification" form which may be obtained from the Personnel Department or the COBRA Administrator. This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies, gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse's plan) through what is called a "special enrollment period." Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.HealthCare.gov.
What is the Health Insurance Marketplace?
The Marketplace offers "one-stop shopping" to find and compare private health insurance options. In the Marketplace, you could be eligible for a new kind of tax credit that lowers your monthly premiums and cost-sharing reductions (amounts that lower your out-of-pocket costs for deductibles, coinsurance, and copayments) right away, and you can see what your premium, deductibles, and out-of-pocket costs will be before you make a decision to enroll. Through the Marketplace you'll also learn if you qualify for free or low-cost coverage from Medicaid or the Children's Health Insurance Program (CHIP). You can access the Marketplace for your state at www.HealthCare.gov. Coverage through the Health Insurance Marketplace may cost less than COBRA continuation coverage. Being offered COBRA continuation coverage won't limit your eligibility for coverage or for a tax credit through the Marketplace. MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
When can I enroll in Marketplace coverage?
You always have 60 days from the time you lose your job-based coverage to enroll in the Marketplace. That is because losing your job-based health
coverage is a "special enrollment" event. After 60 days your special enrollment period will end and you may not be able to enroll, so you
should take action right away. In addition, during what is called an "open enrollment" period, anyone can enroll in Marketplace coverage.
To find out more about enrolling in the Marketplace, such as when the next open enrollment period will be and what you need to know about
qualifying events and special enrollment periods, visit www.HealthCare.gov. If I sign up for COBRA continuation coverage, can I switch to coverage in the Marketplace? What about if I choose Marketplace coverage
and want to switch back to COBRA continuation coverage?
If you sign up for COBRA continuation coverage, you can switch to a Marketplace plan during a Marketplace open enrollment period. You can also
end your COBRA continuation coverage early and switch to a Marketplace plan if you have another qualifying event such as marriage or birth of a child through something called a "special enrollment period." But be careful though - if you terminate your COBRA continuation coverage early without another qualifying event, you'll have to wait to enroll in Marketplace coverage until the next open enrollment period, and could end up without any health coverage in the interim. Once you've exhausted your COBRA continuation coverage and the coverage expires, you'll be eligible to enroll in Marketplace coverage through a special enrollment period, even if Marketplace open enrollment has ended.
If you sign up for Marketplace coverage instead of COBRA continuation coverage, you cannot switch to COBRA continuation coverage under any
circumstances.
Can I enroll in another group health plan?
You may be eligible to enroll in coverage under another group health plan (like a spouse's plan), if you request enrollment within 30 days of the loss
of coverage. If you or your dependent chooses to elect COBRA continuation coverage instead of enrolling in another group health plan for which you're eligible, you'll have another opportunity to enroll in the other group health plan within 30 days of losing your COBRA continuation coverage.
What factors should I consider when choosing coverage options?
When considering your options for health coverage, you may want to think about:
 Premiums: Your previous plan can charge up to 102% of total plan premiums for COBRA coverage. Other options, like coverage on a
spouse's plan or through the Marketplace, may be less expensive.  Provider Networks: If you're currently getting care or treatment for a condition, a change in your health coverage may affect your access
to a particular health care provider. You may want to check to see if your current health care providers participate in a network as you consider options for health coverage.  Drug Formularies: If you're currently taking medication, a change in your health coverage may affect your costs for medication – and in
some cases, your medication may not be covered by another plan. You may want to check to see if your current medications are listed in drug formularies for other health coverage.  Severance payments: If you lost your job and got a severance package from your former employer, your former employer may have
offered to pay some or all of your COBRA payments for a period of time. In this scenario, you may want to contact the Department of Labor at 1-866-444-3272 to discuss your options.  Service Areas: Some plans limit their benefits to specific service or coverage areas – so if you move to another area of the country, you
may not be able to use your benefits. You may want to see if your plan has a service or coverage area, or other similar limitations.  Other Cost-Sharing: In addition to premiums or contributions for health coverage, you probably pay copayments, deductibles,
coinsurance, or other amounts as you use your benefits. You may want to check to see what the cost-sharing requirements are for other health coverage options. For example, one option may have much lower monthly premiums, but a much higher deductible and higher COBRA Continuation coverage will be terminated before the end of the maximum period if:
 any required premium is not paid in full on time;  a qualified beneficiary becomes covered, after electing continuation coverage, under another group health plan that does not impose any pre-existing condition exclusion for a pre-existing condition of the qualified beneficiary;  a qualified beneficiary becomes entitled to Medicare benefits (under Part A, Part B, or both) after electing continuation coverage; or  the employer ceases to provide any group health plan for its employees. Continuation coverage may also be terminated for any reason the Plan would terminate coverage of a participant or beneficiary not receiving continuation coverage (such as fraud).
How can you elect COBRA continuation coverage?
After the notification of a qualifying event has been received, an Election Form and Notice of Rights will be mailed to the home of the employee. To
elect continuation coverage, you must complete the Election Form and furnish it according to the directions on the Election Form. Each qualified MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
beneficiary has a separate right to elect continuation coverage. For example, the employee's spouse may elect continuation coverage even if the employee does not. Continuation coverage may be elected for only one, several, or for all dependent children who are qualified beneficiaries. A parent may elect to continue coverage on behalf of any dependent children. The employee or the employee's spouse can elect continuation coverage on behalf of all of the qualified beneficiaries.
How much does COBRA continuation coverage cost?
Generally, each qualified beneficiary may be required to pay the entire cost of continuation coverage. The amount a qualified beneficiary may be
required to pay may not exceed 102 percent (or, in the case of an extension of continuation coverage due to a disability, 160 percent) of the cost to the group health plan (including both employer and employee contributions) for coverage of a similarly situated plan participant or beneficiary who is not receiving continuation coverage. The required payment for each continuation coverage period for each option is described in the Election Form. Other coverage options may cost less. If you choose to elect continuation coverage, you don't have to send any payment with the Election Form. Additional information about payment will be provided to you after the election form is received by the Plan. Important information about paying your premium can be found at the end of this notice. You may be able to get coverage through the Health Insurance Marketplace that costs less than COBRA continuation coverage. You can learn more about the Marketplace below.
When and how must payment for COBRA continuation coverage be made?
First payment for continuation coverage If you elect continuation coverage, you do not have to send any payment with the Election Form. However,
you must make your first payment for continuation coverage no later than 45 days after the date of your election. (This is the date the Election Form is
post-marked, if mailed.) If you do not make your first payment for continuation coverage in full no later than 45 days after the date of your election, you will lose all continuation coverage rights under the Plan. You are responsible for making sure that the amount of your first payment is correct.
You may contact Gallagher Benefit Services, the COBRA Administrator, at 1-866-515-5899 to confirm the correct amount of your first payment.
Periodic payments for continuation coverage After you make your first payment for continuation coverage, you will be required to make periodic
payments for each subsequent coverage period. The amount due for each coverage period for each qualified beneficiary is shown on the Election Form. The periodic payments can be made on a monthly basis. Under the Plan, each of these periodic payments for continuation coverage is due on the first of the month for that coverage period. If you make a periodic payment on or before the first day of the coverage period to which it applies,
your coverage under the Plan will continue for that coverage period without any break. The Plan will not send periodic notices of payments due.
Grace periods for periodic payments Although periodic payments are due on the dates shown on the Election Form, you will be given a grace
period of 30 days after the first day of the coverage period to make each periodic payment. Your continuation coverage will be provided for each coverage period as long as payment for that coverage period is made before the end of the grace period for that payment. However, if you pay a periodic payment later than the first day of the coverage period to which it applies, but before the end of the grace period for the coverage period, your coverage under the Plan will be suspended as of the first day of the coverage period and then retroactively reinstated (going back to the first day of the coverage period) when the periodic payment is received. This means that any claims you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated. If you fail to make a periodic payment before the end of the grace period for that coverage period, you will lose all rights to continuation coverage under the Plan. Instructions for your first payment and all periodic payments for continuation coverage will be included with your Election Form.
If You Have Questions: Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or
contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA,
the Health Insurance Portability and Accountability (HIPAA), the Patient Protection and Affordable Care Act, and other laws affecting group
health plans, contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa or call their toll-free number at 1-866-444-3272. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website.) For more information about the Marketplace, and to locate an assister in your area who you can talk to about the different options, visit www.HealthCare.gov.
Keep Your Plan Informed of Address Changes In order to protect your family's rights, you should keep the Marple Newtown School District and the
COBRA Administrator if you are enrolled in COBRA informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send. Plan Contact Information
COBRA Administrator
Marple Newtown School District Gallagher Benefit Services Human Resources Department 100 Matsonford Road, 4 Radnor Corporate Center, Suite 510, 36 Media Line Road, Newtown Square, PA 19073 Radnor, PA 19087 MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
NOTIFICATION FORM FOR COBRA QUALIFYING EVENT

Name of Employee

Name [of person who may lose health coverage]
Date of Birth:
Social Security Number

Street [or Mailing] Address with City, State, Zip of person losing coverage

Qualifying Events for COBRA: 
 Divorce (Attach a copy of the final divorce decree) Date of Divorce:    
 Legal Separation (Attach a copy of the legal separation)  
Date of Legal Separation:     
MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Marketplace Coverage Options

Important Information About Your Benefits


PART A: General Information
When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To
assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment based health coverage offered by your employer.
What is the Health Insurance Marketplace?
The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop
shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.
Can I Save Money on my Health Insurance Premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't
meet certain standards. The savings on your premium that you're eligible for depends on your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the
Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit.1
Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the
employer contribution (if any) to the employer-offered coverage. Also, this employer contribution – as well as your employee contribution to employer – offered coverage – is offered coverage – is often excluded from income for Federal and State income tax purposes. Your payments for coverage
through the Marketplace are made on an after-tax basis.
How Can I Get More Information?
For more information about your coverage offered by your employer, please check your summary plan description or contact the Personnel
Department. The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health
Insurance Marketplace in your area. _ 1An Employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs-covered by the plan is no less than 60 percent of such costs. MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year

Part B: Information About Health Coverage Offered by Your Employer
This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application. 3. Employer name
4. Employer Identification Number (EIN)
Marple Newtown School District 5. Employer address
6. Employer phone number
36 Media Line Road 10. Who can we contact about employee health coverage at this job
Human Resources
11. Phone number (if difference from above)
12. Email address

Here is some basic information about health coverage offered by this employer:
As your employer, we offer a health plan to:
All full-time employees who work a minimum of 30 hours per week, spouses, dependents/children up to age 26. This coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages. Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Visit HealthCare.gov to find out if you
can get a tax credit to lower your monthly premiums.
MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Privacy Notice of Your Health Plan
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Please review it carefully.
The Plan may use your health information, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provision of the Health Insurance Portability and Accounting Act of 1996 (HIPAA), for purposes of making or obtaining payment for your care, facilitating your treatment by health care providers and conducting health care operations. This Plan has established a Privacy Policy to establish the rules of the use and disclosure of protected health information ("health information") by the Plan and to guard against unlawful or unnecessary disclosure of your health information. The Plan is required by law to maintain the privacy of your health information maintained by the Plan and to provide you with notice of its legal duties and privacy practices with respect to this information. The Plan is required to follow the terms of this notice until it is replaced. The Plan reserves the right to change the terms of this notice at any time. If the Plan makes any material changes to this notice, the Plan will revise it and send a new notice to all Participants within 60 days. The Plan reserves the right to make new changes apply to your health information maintained by the Plan before and after the effective date of the new notice. Purposes for which the Plan May Use or Disclose Your Health Information Without Your Consent or Authorization
The Plan may use and disclose your health information for the following purposes:  Health Care Providers' Treatment Purposes. For example, the Plan may disclose your health information to your doctor, at the doctor's request, for your treatment by him.  Payment. For example, the Plan may use or disclose your health information to pay claims for covered health care services or to provide eligibility information to your doctor when you receive treatment.  Health Care Operations. For example, the Plan may use or disclose your health information (i) to conduct quality assessment and improvement activities, (ii) for underwriting, premium rating, or other activities relating to the creation, renewal or replacement of a contract of health insurance, (iii) to authorize business associates to perform data aggregation services, (iv) to engage in care coordination or case management, and (v) to manage, plan or develop the Plan's business.  Health Services. The Plan may use your health information to contact you to give you information about treatment alternatives or other health- related benefits and services that may be of interest to you. The Plan may disclose your health information to its business associates to assist the Plan in these activities.  As required by law. For example, the Plan must allow the U.S. Department of Health and Human Services to audit Plan records. The Plan may also disclose your health information as authorized by and to the extent necessary to comply with workers' compensation or other similar laws.  To Business Associates. The Plan may disclose your health information to business associates the Plan hires to assist the Plan. Each business associate of the Plan must agree in writing to ensure the continuing confidentiality and security of your health information.  To Plan Sponsor. The Plan may disclose your health information to the Plan Sponsor to carry out Plan administration functions performed by the Plan Sponsor. Where feasible, the information provided to the Plan Sponsor will be in summary form or with identifying information such as names, addresses and other similar information deleted. The Plan may also disclose to the Plan Sponsor that fact that you are enrolled in, or disenrolled from the Plan. The Plan may disclose your health information to the Plan Sponsor only to the extent permitted by the Plan documents and Plan Privacy Policy and only if the Plan Sponsor agrees in writing to ensure the continuing confidentiality and security of your health information. The Plan Sponsor must also agree not to use or disclose your health information for employment-related activities or for any other benefit or benefit plans of the Plan Sponsor. The Plan may also use and disclose your health information as follows:  To comply with legal proceedings, such as a court or administrative order or subpoena.  To law enforcement officials for limited law enforcement purposes such as complying with a subpoena.  To a family member, friend or other person, for the purpose of helping you with your health care or with payment for your health care, if you are in a situation such as a medical emergency and you cannot give your agreement to the Plan to do this.  To your personal representatives appointed by you or designated by applicable law.  For research purposes in limited circumstances.  To assist law enforcement officials in identifying a suspect, fugitive, material witness or missing person.  To law enforcement officials if they believe your death was the result of a crime.  To correctional facilities where you are being held.  To a coroner, medical examiner, or funeral director about a deceased person.  To an organ procurement organization in limited circumstances.  To avert a serious threat to your health or safety or the health or safety of others. MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
 To the appropriate governmental authority to protect a victim of abuse, neglect or domestic violence.  To a governmental agency authorized to oversee the health care system or government programs.  To federal officials for lawful intelligence, counterintelligence and other national security purposes.  To public health authorities for public health purposes such as reporting disease, injury, births or deaths; notifying a person at risk of contracting or spreading a disease; ensuring qualify or safety of an FDA-regulated product; participating in public health investigations; or reporting about a work-related illness or injury to permit an employer to comply with OSHA or similar federal or state laws.  To the extent necessary to comply with workers' compensation laws and similar programs.
 To appropriate military authorities, if you are a member of the armed forces.
Uses and Disclosures with Your Permission
The Plan will not use or disclose your health information for any other purposes nor will it provide it to another person, even a family member (unless
you are a minor and not permitted to act on your own behalf under law in which case it may be disclosed to a parent), unless you give the Plan your
written authorization to do so. If you give the Plan written authorization to use or disclose your health information for a purpose that is not described in this notice, then, in most cases, you may revoke it in writing at any time. Your revocation will be effective for all your health information the Plan maintains, unless the Plan has taken action in reliance on your authorization. You may also be required to file a written request form if you are
seeking health information about yourself. Authorization, revocation and request forms are available from the Human Resources Department.
Personal Representative
You have the right to designate a Personal Representative (such as an Attorney or other representative) to act on your behalf and have access to
your health Information as authorized by you. You must submit a written authorization to the Plan designating your Personal Representative and the information to which the representative may have access.
Your Rights
You may make a written request to the Plan to do one or more of the following concerning your health information that the Plan maintains:
 To put additional restrictions on the Plan's use and disclosure of your health information. The Plan does not have to agree to your request.
 To communicate with you in confidence about your health information by a different means or at a different location than the Plan is currently
doing. The Plan does not have to agree to your request unless such confidential communications are necessary to avoid endangering you and your request continues to allow the Plan to collect premiums and pay claims. Your request must specify the alternative means or location to communicate with you in confidence. Even though you requested that we communicate with you in confidence, the Plan may give subscribers cost information.  To see and get copies of your health information. In limited cases, the Plan does not have to agree to your request.  To correct your health information. In some cases, the Plan does not have to agree to your request.  To receive a list of disclosures, not authorized by the Privacy Rule, of your health information that the Plan and its business associates made for certain purposes for the last 6 years (but not for disclosures before April 14, 2003).  To send you a paper copy of this notice upon request or to provide you with a copy of the Plan's Privacy Policy. If you want to exercise any of these rights described in this notice, please contact the Privacy Officer (below). The Plan will give you the necessary information and forms for you to complete and return to the Contact Office. In some cases, the Plan may charge you a nominal, cost-based fee to
carry out your request.
Complaints If you believe your privacy rights have been violated by the Plan, you have the right to complain to the Plan or to the
Secretary of the U.S. Department of Health and Human Services. You may file a complaint with the Plan at our Contact Office (below).
You will not be retaliated against if you choose to file a complaint with the Plan or with the U.S. Department of Health and Human
Services.
Contact Office To request additional copies of this notice or to receive more information about our privacy practices or your rights, please contact us
at the following Contact Office:
Human Resources, Marple Newtown School District 36 Media Line Road, Newtown Square, PA 19073 Phone- 610-359-4267/Fax 610-356-8947 MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Additional Legal Notices
Women's Health and Cancer Rights Act of 1998:
As required by the Women's Health and Cancer Rights Act (WHCRA) of 1998, this plan provides coverage for:
1. All stages of reconstruction of the breast on which the mastectomy has been performed; 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and 3. Prostheses, and 4. Physical complications of mastectomy, including lymphedemas, in a manner determined in consultation with the attending physician and the patient. Such coverage may be subject to annual deductibles and coinsurance provisions as may be deemed appropriate and are consistent with those established for other benefits under the plan or coverage. The provider of our group health plan coverage reports that they have always provided coverage for these services and will continue to do so in consultation with the attending physician and the patient. Any deductibles or coinsurance will apply consistent with other benefits in your plan. Newborns' and Mother's Health Protection Act:
Group health plans and health insurance issuers generally may not, under Federal Law, restrict benefits for any hospital length of stay in connection
with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section.
However, Federal Law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal Law, require that a provider obtain authorization from the Plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). Availability of Summary Health Information
You are offered a series of health plan options. Choosing a health coverage option is an important decision. To help you make an informed choice,
your plan makes available a Summary of Benefits and Coverage (SBC), which summarizes important information about each health plan option in a standard format, to help you compare plans. You may access the SBCs by contacting The Plan Administrator. MARPLE NEWTOWN SCHOOL DISTRICT
MNEA Health Benefits 2015 – 2016 Plan Year
Prescription Drug Creditable Coverage Notice
This section is included in your benefit booklet in order to provide you with your annual Notice of Creditable Coverage which is issued in conjunction
with the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA). While this notice must be provided to all individuals enrolled in a District Prescription Plan, this notice only pertains to individuals eligible for Medicare. Important Notice from the District About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the District and about your options under Medicare's prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare's prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. The District has determined that the prescription drug coverage offered by the District is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. If you do decide to join a Medicare drug plan and drop your District prescription drug coverage, be aware that you and your dependents
may not be able to get this coverage back. Please contact the District for more information about what happens to your coverage if you
enroll in a Medicare prescription drug plan.
As an active employee, if you choose to enroll in Medicare Part D, your coverage with the District will remain as the primary coverage and the Medicare
Part D coverage will be your secondary coverage. However, you wil be responsible for the applicable monthly premium required for the Medicare Part D
Program in addition to any applicable contribution required. If you choose to drop your District Prescription Coverage, you will have the opportunity to re-
enroll at open enrollment.
You should also know that if you drop or lose your current coverage with the District and don't join a Medicare drug plan within 63 continuous days after your
current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base
beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage,
your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (penalty) as
long as you have Medicare prescription coverage. In addition, you may have to wait until the following November to join.
For more information about this notice or your current prescription drug coverage contact:
Marple Newtown School District, Human Resources
36 Media Line Road, Newtown Square, PA 19073 Phone- 610-359-4267/Fax 610-356-8947
NOTE: You'll get this notice each year and at other times in the future such as before the next period you can join a Medicare drug plan, and if this
coverage through the District changes. You also may request a copy of this notice at any time. For more information about your options under Medicare prescription drug coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the "Medicare & You" handbook. You'll get a copy of the
handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:  Visit www.medicare.gov  Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the "Medicare & You" handbook for their telephone number) for personalized help or Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a
copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are
required to pay a higher premium (a penalty).
Name of Entity:
Marple Newtown School District Contact Office:
Human Resources Office Address:
36 Media Line Road Newtown Square, PA 19073 Phone: 610-359-4267
Fax: 610-356-8947

Source: http://www.mnsd.net/docs//district/depts/18/2015-2016%20employee%20benefit%20booklets/15%2016%20mns%20booklet%20mnea.pdf