100_07_2016_SPD_ELCA_Medicare-Primary_Health_FINAL

ELCA Medicare-Primary Health Benefits Summary

SUMMARY PLAN DESCRIPTION EFFECTIVE JAN. 1, 2016

About This Document This plan summary, in conjunction with the ELCA Benefit Program Description, forms the summary plan description (SPD) for ELCA Medicare-Primary health benefits offered through the ELCA Medical and Dental Benefits Plan (ELCA Health Plan), effective Jan. 1, 2016. This plan summary describes plan rules and benefits, while the ELCA Benefit Program Description describes eligibility, enrollment, and how professional and life changes affect your benefits. Use these two documents together as a reference when you have questions about your ELCA Medicare-Primary health benefits. Together, these documents replace and supersede all previous versions. The ELCA Benefit Program Description is available by signing in to myPortico at PorticoBenefits.org/summaries or contacting the Portico Customer Care Center at [email protected] or 800.352.2876. The plan document of the ELCA Medical and Dental Benefits Plan is the full, legal description of the plan. Your rights under the plan are governed by the plan document. If this summary is found to be inconsistent with the plan document, the plan document will be considered the controlling document. A copy of the plan document is available from the Portico Customer Care Center. Portico reserves the right to change any term of the plan through the amendment or termination process described later in this summary. About Portico Benefit Services For over 25 years, Portico Benefit Services has offered health, retirement, and other benefits designed to enhance the well-being of those who serve. Because we focus on those who serve through the Evangelical Lutheran Church in America and other faith-based organizations, we can tailor our benefits to include advantages and options suited just for our membership. As part of the ministry community and as experienced professionals, we are qualified to design and manage all aspects of the ELCA’s benefit plans. Portico serves more than 7,000 congregations and organizations, and more than 50,000 people across the ELCA during their working years and in retirement — including pastors, associates in ministry, diaconal ministers, deaconesses, lay employees, retirees, and their family members. About Our Plans The ELCA Pension and Other Benefits Program provides health, flexible spending, retirement, disability, and survivor benefits presented as one comprehensive program to members. Benefit plans are governed and administered individually through separate plan documents. The Board of Pensions of the Evangelical Lutheran Church in America, doing business as Portico Benefit Services, maintains the following plans: ELCA Retirement Plan, ELCA Disability Benefits Plan, ELCA Survivor Benefits Plan, ELCA Medical and Dental Benefits Plan (which includes the ELCA post-retirement medical benefits obligation), and ELCA Flexible Benefits Plan. We also maintain three group retirement plans for ELCA-affiliated social ministry organizations — the ELCA Master Institutional Retirement Plan, the ELCA Retirement Plan for The Evangelical Lutheran Good Samaritan Society, and the ELCA 457(b) Deferred Compensation Plan. The assets of each plan are held in various trusts and therefore do not allow one plan to fund a shortfall of another plan. The plans are church plans, as defined in section 414(e) of the Internal Revenue Code and are not subject to the Employee Retirement Income Security Act (ERISA). The health and disability plans are self-insured and are not protected through any type of insurance program. Our ability to pay claims is dependent on continued contributions and market performance. The basic, supplemental, and dependent life insurance benefits are offered by Securian Life Insurance Company (Securian Life). Product guarantees are backed by the financial strength and claim paying ability of Securian Life. Premiums are not guaranteed to remain unchanged. Portico Benefit Services does not assume any responsibility or liability for the obligations of Securian Life under the insurance policies. Portico Benefit Services is not affiliated with Securian Life. We reserve the right to change any of the terms of the plans at any time through the amendment or termination process described in each plan’s summary plan description.

https://myportico.porticobenefits.org/OverviewLifeChanges/PlanSummariesDocuments

mailto:[email protected]

Contents

About ELCA Medicare-Primary Health Benefits ..................................................................................1 Eligibility ............................................................................................................................................................. 2

Medicare Supplement Benefit ...................................................................................................................3 2016 ELCA Medicare Supplement Benefit Chart ............................................................................................... 4 Hospital and Medical Claims ............................................................................................................................... 5 Part A Hospital Care Services .............................................................................................................................. 5 Part B Medical Services ....................................................................................................................................... 5 Part B Preventive Services ................................................................................................................................... 6 Claim Filing Deadline .......................................................................................................................................... 6 Medical Care Outside the United States .............................................................................................................. 6 Coordination of Benefits With Other Coverage .................................................................................................. 7 Transitioning From ELCA-Primary Health Benefits ........................................................................................... 7

Prescription Drug Benefit .........................................................................................................................8 Eligible Prescription Drugs .................................................................................................................................. 8 Preventive Medications ........................................................................................................................................ 8 Medications Not Covered .................................................................................................................................... 9 Formulary ........................................................................................................................................................... 10 Short-Term Prescriptions ................................................................................................................................... 10 Maintenance Medications .................................................................................................................................. 11 Cost Saving and Safety Programs ...................................................................................................................... 11 Hospital Stays .................................................................................................................................................... 12 Creditable Coverage ........................................................................................................................................... 12 If You Have the ELCA Part D Drug Benefit ..................................................................................................... 12 2016 ELCA Part D Drug Benefit Chart ............................................................................................................. 13 If You Have the ELCA Prescription Drug Benefit ............................................................................................ 15 2016 ELCA Prescription Drug Benefit Chart .................................................................................................... 15

Dental Benefit ...........................................................................................................................................16 2016 Dental Benefit Chart ................................................................................................................................. 16 Eligible Dental Expenses ................................................................................................................................... 17 Pre-Treatment Estimate ..................................................................................................................................... 17 Preventive Care .................................................................................................................................................. 17 Basic Dental Care .............................................................................................................................................. 17 Major Restorative Care ...................................................................................................................................... 18 Orthodontic Care ................................................................................................................................................ 18 Non-Eligible Expenses ....................................................................................................................................... 19 Out-of-Network Providers ................................................................................................................................. 19 Claims Payment ................................................................................................................................................. 19 Claim Filing Deadline ........................................................................................................................................ 19

Health and Wellness Benefits ..................................................................................................................20 ELCA NurseLineSM............................................................................................................................................ 20 Health Care Advocacy Team ............................................................................................................................. 20 Hearing Discount Program ................................................................................................................................ 20 Mayo Clinic Healthy Living .............................................................................................................................. 20 SilverSneakers® Fitness Program ....................................................................................................................... 21

Contribution Rates...................................................................................................................................22 If You’re Sponsored by an Eligible Employer ................................................................................................... 22 If You’re Not Sponsored by an Employer ......................................................................................................... 22 If You’re Self Sponsored ................................................................................................................................... 22 2016 Monthly Contribution Rates ..................................................................................................................... 23 Late Contributions ............................................................................................................................................. 23 Medicare Part B Reimbursement ....................................................................................................................... 23

Administrative and Miscellaneous Provisions.......................................................................................24 Appeals Procedure ............................................................................................................................................. 25

Glossary ....................................................................................................................................................29 Contact Information ................................................................................................................................33 Cards for Your Wallet .............................................................................................................................35

Find the most current version of this document, other plan summaries, and the ELCA Benefit Program Description on myPortico at PorticoBenefits.org/summaries. To learn more, contact the Portico Customer Care Center at [email protected] or 800.352.2876.

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About ELCA Medicare-Primary Health Benefits ELCA Medicare-Primary health benefits are part of the ELCA Health Plan, which is part of the ELCA Pension and Other Benefits Program. Also called the ELCA benefit program, it includes:

x ELCA Medical and Dental Benefits Plan (ELCA Health Plan) x ELCA Flexible Benefits Plan x ELCA Survivor Benefits Plan x ELCA Disability Benefits Plan x ELCA Retirement Plan

Combined, these plans offer resources to help you and those you care about live well, so you’re better able to enhance the lives of others. What ELCA Medicare-Primary Health Benefits Provide Portico offers a choice of three ELCA Medicare-Primary health benefit options. The options differ by their monthly contribution rate and Medicare supplement.

x Economy — If you rarely visit the doctor or don’t travel outside the United States, the Economy option’s lower monthly contribution rate may help you save money.

x Standard — If you seek regular medical care, the Standard option provides a mid-level contribution rate.

x Premium — If medical costs have been high or you want the option to see doctors who don’t accept Medicare assignment, consider the Premium option.

Each option includes:

x Medicare supplement benefit x Prescription drug benefit

� ELCA Part D drug benefit for retired members � ELCA prescription drug benefit for sponsored or on leave from call members and those

living outside the United States x Dental benefit* x Health and wellness benefits

� ELCA NurseLineSM � Health Care Advocacy Team � Hearing discount program � Mayo Clinic Healthy Living online website � SilverSneakers® Fitness Program

*The dental benefit is not available if you opted out of dental coverage in 1996. ELCA-Primary health benefits are described in a separate document. For a copy of the ELCA-Primary Health Benefits Summary, visit myPortico at PorticoBenefits.org/summaries or contact the Portico Customer Care Center at [email protected] or 800.352.2876.






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Eligibility You’re eligible for ELCA Medicare-Primary health benefits if you meet the program eligibility requirements as described in the ELCA Benefit Program Description. You (and your family members) may be eligible for primary health coverage under Medicare and ELCA Medicare-Primary benefits if you (or your family members) are:

x Age 65 or older and retired x Age 65 or older and employed by an organization with fewer than 20 employees x Under age 65 and entitled to Medicare due to disability or end-stage renal disease

You are also eligible for ELCA Medicare-Primary benefits if you are not eligible for Medicare coverage because you:

x Chose to opt out of Social Security, or x Waived participation in all or part of Medicare

In these situations, when a claim is received, your supplement to Medicare Parts A and B claims are paid assuming what Medicare would have paid if you had Medicare coverage. The plan pays benefits, subject to the deductible, coinsurance, and out-of-pocket amounts, on the remaining portion of your claim. You will be responsible for ineligible expenses, the portion that Medicare would have paid, and deductible and out-of-pocket amounts. If you’re retired or not sponsored by an employer in the ELCA benefit program — ELCA Medicare-Primary health benefits offer you and your spouse or eligible same gender partner (ESGP) (see Glossary) three health benefit options: Economy, Standard, and Premium. See the chart on page 4. If you’re sponsored by an employer in the ELCA benefit program (that is, you’re employed or receiving ELCA disability benefits), on leave from call, or living outside the United States — You and your family are eligible for the Standard health benefit option only. You’re also assigned to the ELCA Medicare-Primary Standard option if you’re not eligible for Medicare coverage because you:

x Chose to opt out of Social Security, or x Waived participation in all or part of Medicare




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Medicare Supplement Benefit Administered by Mercer Health & Benefits Administration LLC, the Medicare supplement benefit helps you pay for eligible Medicare Part A and Part B services not fully paid for by Medicare. For each option — Economy, Standard, and Premium — Mercer coordinates with Medicare, your primary hospital and medical coverage. This means the ELCA Medicare supplement benefit helps pay some of the hospital and medical costs (“gaps”) that Medicare doesn’t cover (like copayments, coinsurance, and deductibles). If you have both Medicare and the ELCA Medicare supplement benefit:

x First, Medicare pays its share of Medicare-approved amounts for your eligible health care claims. x Then, the remaining eligible expenses are sent to Mercer for processing. The plan pays its

portion subject to the benefits described in the chart on the next page. x You pay the ELCA plan’s deductible and coinsurance until you meet the out-of-pocket limit.

Your ELCA Medicare supplement benefit is described in the chart on the next page. IMPORTANT:

x If Medicare does not cover a service, the ELCA Health Plan also won’t cover that service except as noted in the chart on the next page.

x Benefit is subject to change without notice.




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2016 ELCA Medicare Supplement Benefit Chart Administered by Mercer

Economy (Similar to Medigap L)

Standard (Portico Design)

Premium (Similar to Medigap F)

You Pay (per person)

ELCA deductible $0 $180 $0

Out-of-pocket annual limit $2,470 $3,500 $0

ELCA Health Plan Pays

Medicare Part A (Hospital) x Part A deductible1 75% 80%2 100% x Part A coinsurance 100% 80%2 100% x Hospice care or skilled nursing

facility coinsurance or copayment 75% 80%2 100%

x Blood (first three pints) 75% 80%2 100% x Coinsurance and hospital costs up

to an additional 365 days after Medicare benefits are used up

100% $0 100%

Medicare Part B (Medical) x Part B deductible1 $0 80%2 100% x Part B coinsurance 75% 80%2 100% Other x Charges beyond Medicare

approved amount3 $0 $0 100%

x Foreign travel and emergency care $0

80%2 for services Medicare covers in

the U.S.; no lifetime maximum

80% after a $250 deductible; $50,000 lifetime maximum

x Eligible expenses after your annual out-of-pocket limit 100% 100% N/A

1. The 2016 Medicare Part A deductible is $1,288 and Part B deductible is $166. See medicare.gov for more information on Medicare benefits.

2. After the Standard health benefit option deductible of $180 is met. 3. The approved amount is the amount a doctor or other health care provider is legally permitted to charge for a Medicare-

eligible service.



http://medicare.gov/


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Hospital and Medical Claims Your provider electronically sends your hospital and medical claims to Medicare first because your primary coverage is with Medicare. Medicare Part A hospital claims and Part B medical claims are then sent electronically from Medicare to Mercer using your health insurance claims number. With automatic claim submission, you don’t submit claims. After Medicare pays its portion of your eligible expenses, the ELCA Health Plan pays its portion. See the benefit chart for details. What you pay depends on which ELCA Medicare-Primary option you’re enrolled in.

x Economy — You’re responsible for the Medicare Part A deductible and the ELCA Medicare supplement coinsurance up to the annual ELCA out-of-pocket limit. The plan pays 100% of eligible expenses after you reach the annual out-of-pocket limit.

x Standard — You’re responsible for the ELCA Medicare supplement annual deductible, then 20% coinsurance up to the annual out-of-pocket limit. The plan pays 100% of eligible expenses after you reach the annual out-of-pocket limit.

x Premium — You pay nothing for Medicare-eligible services in the U.S., even if you receive Medicare-eligible services from a provider that doesn’t accept Medicare assignment (doesn’t participate in Medicare). For emergency services received outside the U.S., the plan pays 80% of eligible expenses up to a lifetime maximum after you meet the foreign care and travel emergency deductible for this option.

Part A Hospital Care Services Services that Medicare covers under Medicare Part A include:

x Inpatient hospital care x Inpatient skilled nursing facility care x Hospice care (doesn’t include room and board) x Some home health care

NOTE: Your ELCA Medicare-Primary health benefits cover medically necessary inpatient services in a qualified skilled nursing facility for up to 90 days of continuous care after Medicare becomes your primary health coverage if the care:

x Is authorized by Blue Cross and Blue Shield of Minnesota, and x Begins and continues without interruption while under ELCA-Primary coverage, and x Continues while you transition to ELCA Medicare-Primary coverage

Part B Medical Services Eligible Medicare Part B services include doctor services, outpatient hospital care, tests, and X-rays. Part B also covers:

x Most medications administered in your doctor’s office x Certain oral cancer medications x Certain agents used with a nebulizer or infusion pump x Diabetes test strips and supplies x Immunosuppressants x Certain antiemetic medications




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Part B Preventive Services Medicare Part B also covers certain preventive services. Contact Medicare or review the Medicare & You book (found at medicare.gov) to learn about Medicare’s benefit for these services. Subject to Medicare’s age and frequency guidelines, covered preventive services include:

x Cardiovascular screening blood tests x Diabetes screening and self-management training x Pelvic exams x Pap tests x Glaucoma screening x Colorectal cancer screenings x Counseling to quit smoking x Mammograms x One-time “Welcome to Medicare” physical exam within the first 12 months you have Part B x Prostate cancer screenings x Influenza, pneumonia, and hepatitis B shots x Bone mass measurements x Alcohol misuse screening and counseling x Depression screening x HIV screening x Obesity screening and counseling x Sexually transmitted diseases screening and counseling x Tobacco cessation counseling x Yearly wellness visit

Claim Filing Deadline The claim filing deadline is 12 months from the date you incurred the expense. For example, if you incur expenses on Feb. 12, 2016, you or the provider must file the claim before Feb. 12, 2017. Any claims filed after the 12-month deadline will be denied. Medical Care Outside the United States In most situations, Medicare doesn’t pay for medical care or supplies received outside the United States or its territories. If you select the Standard or Premium option, and you become ill or injured while traveling outside the United States, medically necessary care is covered. For benefits, see the chart on page 4. The Economy option has no foreign emergency coverage. If you have the Standard or Premium option and you receive care outside the United States, the ELCA Health Plan will cover expenses that Medicare would normally cover if the services had been received in the United States, applying the benefits described on page 4. An itemized bill, including the diagnosis and description of services, translated into English, and the U.S. currency exchange rate in effect at the time you received care should be sent to Mercer. Keep a copy for your records.



http://medicare.gov/


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Coordination of Benefits With Other Coverage When you have other valid health coverage in addition to Medicare and ELCA Medicare-Primary health benefits, coordination of benefits applies. Call the Portico Health Care Advocacy Team to determine which coverage is primary, secondary, or tertiary. Call Mercer with questions about claims payment when there is coordination of benefits. Transitioning From ELCA-Primary Health Benefits For the year you become eligible for Medicare and ELCA Medicare-Primary health benefits, your out-of-pocket hospital and medical costs incurred while eligible for ELCA-Primary health benefits don’t apply to your ELCA Medicare-Primary deductible. You’re no longer eligible to earn wellness dollars, although you may continue to use any unclaimed dollars previously earned to reimburse eligible medical expenses. Contact the Portico Customer Care Center for more information.




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Prescription Drug Benefit When you have ELCA Medicare-Primary health benefits, your prescription drug benefit will differ depending on whether you are retired or sponsored. This section includes provisions common to all ELCA Medicare-Primary prescription drug benefits — the ELCA Part D drug benefit (for retired members) and the ELCA prescription drug benefit (for sponsored, on leave from call, and non-U.S. members) — and their eligible family members. Express Scripts, Inc. is your prescription drug benefit administrator.

x If you are retired, see the information starting on page 12 for specifics about the ELCA Part D drug benefit.

x If you are sponsored, on leave from call, or live outside the United States, see page 15 for specifics about the ELCA prescription drug benefit.

With the ELCA Part D drug benefit and the ELCA prescription drug benefit, you have coverage for most FDA-approved prescription drugs purchased for the treatment or prevention of illness and conditions. ELCA prescription benefits don’t affect coverage under Medicare Part A or Part B or your ELCA Medicare supplement benefit. If you’re eligible for Medicare Part A and Part B, you will continue to receive those benefits from Medicare whether you have ELCA prescription drug coverage or non-ELCA prescription drug coverage. You pay a copayment for each drug purchase, and then the ELCA Health Plan pays 100% after the copayment. You pay the lowest copayment for generic drugs, mid-level for preferred brand drugs (on formulary), and highest for non-formulary drugs. Eligible Prescription Drugs Eligible prescription drugs include medically necessary:

x Injectable and oral drugs determined to be specialty drugs by Express Scripts (when purchased through Accredo Specialty Pharmacy for members with the ELCA prescription drug benefit)

x Disposable diabetes supplies (not eligible under ELCA Part D drug benefit) x Certain drugs requiring preventive drug coverage by the Patient Protection and Affordable Care

Act Drugs must be medically necessary for the condition, diagnosis, or symptoms, based on:

x FDA-specific indications x Outcome data from clinical trials x National care and treatment standards x Express Scripts’ determination of appropriate use through the formulary and such programs as

prior authorization, drug quantity management, and step therapy Preventive Medications Under the Patient Protection and Affordable Care Act of 2010, you pay nothing when you meet the age and condition requirements and purchase certain prescription drugs from an in-network retail pharmacy or through Express Scripts home delivery, including:

x Folic acid for women ages 18 – 50




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x Smoking cessation drugs age 18 and older x Vitamin D supplements age 65 and older at increased risk for falls x Bowel preparation for colonoscopy screening ages 50 – 75 years x Breast cancer preventive drugs for women age 35 or older x Generic and certain brand name oral contraceptives x Oral fluoride for children ages six months through five years x Iron supplements for children ages six – 12 months x Immunizations x Aspirin for men ages 45 – 79 years and women ages 55 – 79 years at risk for cardiovascular

disease Contact Express Scripts for specific drug information. Medications Not Covered

x Over-the-counter medications, except insulin and certain drugs requiring preventive coverage by the Affordable Care Act when prescribed by a physician

x Drugs for cosmetic treatment of hair loss or other cosmetic purposes x Vitamins for preventive purposes, except those required under the Affordable Care Act x Drugs taken in preparation for, or in conjunction with, artificial insemination x Drugs taken to terminate a pregnancy x Drugs considered not medically necessary, based on FDA-specific indications, clinical trial

outcomes, and national care and treatment standards x Drugs deemed by the benefit administrator as investigational or experimental because FDA

approval for marketing hasn’t been granted x Herbal, mineral, and nutritional supplements x Drugs that are covered under any other plan including those covered under a non-ELCA

Medicare prescription drug plan x Specialty drugs not purchased from Accredo (except members with the ELCA Part D drug

benefit) x Drugs covered as medical expenses under Medicare Part B for members with the ELCA Part D

drug benefit x Drugs excluded from the formulary x Most compounded medications due to lack of FDA approved uses




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Formulary A formulary is a list of preferred medications reviewed and approved by a group of doctors and pharmacists based on clinical effectiveness and cost. Formulary drugs include generic and preferred brand-name medications that provide an affordable alternative to non-formulary drugs. If a generic version of a drug becomes available midyear, the brand-name drug will become non-formulary from that time forward.

x Generic drugs — Typically are the lowest cost drugs for the plan and have the lowest of the ELCA copayments. The FDA requires generics to have the same quality, strength, purity, and stability as their brand-name equivalents.

x Preferred drugs — Are brand-name drugs that have the mid-level costs for the plan and have mid-level ELCA copayments. Preferred drugs are reviewed and approved for formulary inclusion by an independent committee of doctors and pharmacists.

x Non-formulary drugs — Are brand-name drugs that are the most expensive for the plan and have the highest ELCA copayments. These drugs aren’t included on the formulary because they are new to the marketplace or therapeutically equivalent to drugs available for less money.

x Excluded drugs — Are drugs not covered by the plan. You pay the full price of any excluded drug. Safe and clinically effective alternative drugs are covered by the plan.

The current formulary is available on myPortico and is subject to change without notice. Short-Term Prescriptions Prescriptions for up to a 31-day supply may be purchased at a local in-network pharmacy using your Express Scripts identification card. You pay one of three copayments based on the type of drug: generic, preferred brand-name, and non-formulary. At the time of purchase, show your Express Scripts identification card, and the pharmacist will process your prescription claim. There are no claims for you to file. If you use an out-of-network pharmacy or a pharmacy outside the United States, you pay the full price at the time of purchase and submit a claim to Express Scripts for reimbursement. For each up-to-31-day supply, you are responsible for your copayment plus the difference between the purchase price and the Express Scripts contracted rate for your prescription. Network Pharmacies Network pharmacies that participate in the Express Scripts network can be found using the Pharmacy Locator at express-scripts.com or by calling Express Scripts. If you forget to show your identification card at a participating pharmacy, you may be charged the full price for your prescription drug. Contact the Portico Health Care Advocacy Team for assistance. Out-of-Network Pharmacies If you use an out-of-network pharmacy or a pharmacy outside the United States, you pay the full price at the time of purchase and submit a claim to Express Scripts for reimbursement. For each up-to-31-day supply, you’re responsible for your copayment plus the difference between the purchase price and the Express Scripts contracted rate for your prescription.



http://www.express-scripts.com/


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Maintenance Medications Home Delivery Service When you order a 90-day supply through Express Scripts home delivery service, you’ll pay less than you would if you filled a 31-day supply three times at your local retail pharmacy. Standard shipping is free. Express Scripts ships the order to your home or another address you designate. Most maintenance medications ordered through Express Scripts home delivery are shipped by first-class mail. Perishable drugs are shipped in temperature-controlled containers or cold packs via an overnight delivery service. If you won’t be home to receive the package, you may request to have your order delivered to another location, such as your office. This also helps protect perishable medications, such as insulin. To request order forms for home delivery, contact Express Scripts. Cost Saving and Safety Programs Step Therapy This program reduces the cost of drugs by requiring that specific high-cost, “step-two” drugs are covered by the plan only after a clinically appropriate, proven, and more cost-effective “step-one” drug is tried. If a step-one drug doesn’t provide the desired therapeutic benefit, the plan covers a step-two drug. Step therapy drugs are subject to change without notice. If you have certain medical conditions, you’ll need to ask your doctor to prescribe a step-one drug first. For more information about step therapy, or if you have a question about a specific drug, contact Express Scripts customer service or visit express-scripts.com. Drug Quantity Management A per-prescription quantity limit for certain medications promotes patient safety and avoids waste. Quantity limits are based on FDA-approved prescription drug dosing guidelines. Quantity limits may change midyear. If your medication has a quantity limit, you make one copayment for each purchase of the maximum allowed quantity. Even if your prescription is written for more than the allowed quantity, Express Scripts fills only the maximum allowed quantity unless you obtain a medical necessity exception. To obtain a medical necessity exception to the quantity limit, your doctor must contact Express Scripts and request authorization for an exception. Authorization is required before an exception can be made. If you have questions about quantity limits for a specific drug, contact Express Scripts. Prior Authorization Certain prescription drugs require approval by Express Scripts before a doctor’s prescription can be dispensed, because the drugs are costly or may be used inappropriately. Your doctor should call Express Scripts to request a prior authorization before writing a prescription. Standard medical necessity criteria are used to review all coverage requests. If you have a question about a specific drug, contact Express Scripts customer service or visit express-scripts.com.






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Hospital Stays Prescription drugs administered during an inpatient hospital stay are considered medical expenses. Prescription drugs purchased at a hospital pharmacy for use at home are considered prescription drug expenses. To save money on drugs you will use at home, verify that the hospital pharmacy is in the Express Scripts network and show your Express Scripts identification card. If the hospital pharmacy isn’t in the Express Scripts network, you can save money by filling your prescription at your local participating pharmacy. NOTE: Generally, prescription drugs you take at home as part of outpatient treatment (for example, after an emergency room visit), aren’t covered as a medical expense by Medicare Part B. You pay out-of-pocket for these drugs and submit a claim to Express Scripts for reimbursement. Call the Portico Health Care Advocacy Team for assistance. Creditable Coverage If you’re enrolled in the ELCA Medicare-Primary Premium, Standard, or Economy health benefit option or the ELCA-Primary Platinum+, Gold+, or Silver+ health benefit option — ELCA prescription drug coverage is creditable coverage. “Creditable coverage” means your ELCA prescription drug coverage is, on average, as good as or better than Medicare’s standard prescription drug coverage. Because you have creditable coverage, you can keep your ELCA coverage and not pay a late enrollment penalty if you decide to enroll in Medicare prescription drug coverage within 63 days of ending ELCA coverage. If you’re enrolled in the ELCA-Primary Bronze+ health benefit option when you are eligible for Medicare coverage — Your prescription drug coverage is non-creditable. That means the ELCA prescription drug benefit included in the ELCA-Primary Bronze+ option is, on average, expected to pay less than Medicare’s standard prescription drug coverage. If you have non-creditable coverage for any period after your initial Medicare enrollment period when you are first eligible for Medicare, you will be subject to a late-enrollment penalty (such as higher premiums) if you enroll in Medicare Part D prescription drug coverage in the future. If You Have the ELCA Part D Drug Benefit If you’ve retired from sponsored employment and live in the United States or its territories, you and any family members eligible for ELCA Medicare-Primary health benefits receive the ELCA Part D drug benefit. IMPORTANT:

x If you have limited income and you qualify for extra help from Medicare with prescription drug expenses, your copayments are less than shown in the chart on the next page.

x If you have high yearly income (modified adjustable gross income of more than $85,000 per individual or $170,000 for married couples filing jointly), you are required to pay an extra amount to Social Security.

x Certain diabetes and cancer-related medications — including diabetes test strips and supplies, certain immunosuppressants, oral cancer drugs, agents used with a nebulizer, and antiemetic drugs — are covered by Medicare Part B and can’t be filled by Express Scripts. Show your




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Medicare card when you buy Part B drugs and supplies at a local participating Medicare pharmacy.

x In most cases, your prescriptions are covered only if they are filled by Express Scripts home delivery or an in-network Express Scripts pharmacy. If you use a non-participating pharmacy or don’t present your Express Scripts card to an in-network pharmacy at the time of purchase, in addition to the copayment, you’re responsible for the difference between the Express Scripts contracted rate and the purchase price of your prescription.


2016 ELCA Part D Drug Benefit Chart Administered by Express Scripts

Generic Drug Preferred

Brand-Name Drug Non-Formulary

Drug

Express Scripts/Medicare Network Retail Pharmacy Up to 31-day supply

100% after $10 copayment 100% and no copayment for certain preventive drugs. See list on page 8.

100% after $47 copayment


Express Scripts Home Delivery Up to 90-day supply




Retail Maintenance Drug Program Pharmacy Up to 31-day supply




32- to 63-day supply 100% after $20 copayment



64- to 90-day supply 100% after $30 copayment



Accredo Specialty Pharmacy Up to 31-day supply




Non-Participating Pharmacy Up to 31-day supply

100% after $10 copayment plus difference between contracted rate and billed amount






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Maintenance Medications With the ELCA Part D drug benefit, you have two ways to order long-term prescriptions (90-day supplies):

x Home Delivery Service — Described on page 11. x Retail Maintenance Drug Program — You can fill up to a 90-day supply at a retail

maintenance drug program pharmacy that participates in Medicare’s network. Using this option may cost more than Express Scripts home delivery. See the chart on the previous page for copayment information.

Specialty Drugs Specialty drugs are limited to a 31-day supply due to the high cost (average monthly cost is $1,500), special storage needs, limited shelf life, and frequent dosage changes. Members with the ELCA Part D drug benefit may purchase specialty drugs through the Express Scripts specialty pharmacy, Accredo. Specialty drugs aren’t available through Express Scripts home delivery. Medicare and ELCA Part D Drug Benefit You cannot simultaneously have the ELCA Part D drug benefit and be covered under a non-ELCA Medicare prescription drug plan. If you enroll in a non-ELCA Medicare prescription drug plan:

x Your ELCA prescription drug benefit ends. Your Express Scripts card won’t work at retail pharmacies, and you won’t be able to use Express Scripts home delivery service.

x You’ll pay the monthly premium for non-ELCA Part D prescription drug coverage in addition to the monthly contribution you already pay for your ELCA Medicare-Primary health benefits. However, you won’t have the ELCA prescription drug benefit.

x If you’re eligible for Medicare Part A and Part B, you continue to receive those benefits from Medicare whether you have ELCA prescription drug coverage or non-ELCA prescription drug coverage.

The ELCA Part D drug benefit is subject to Medicare’s rules and regulations for Medicare prescription drug plans (Part D). Medicare determines which prescription drugs and quantities are eligible for the ELCA Part D drug benefit. Certain additional drugs may be deemed eligible by the ELCA Health Plan.




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If You Have the ELCA Prescription Drug Benefit If you’re eligible for Medicare and are sponsored, on leave from call, or living outside the United States, you and any family members eligible for ELCA Medicare-Primary health benefits will receive the ELCA prescription drug benefit. It’s the same prescription drug benefit received by plan members with ELCA-Primary benefits. See page 8 for general information about your prescription drug benefit. IMPORTANT:

x Specialty drugs are limited to a 31-day supply and must be purchased from the Express Scripts specialty pharmacy, Accredo.

x Prescription drugs purchased at an in-network retail pharmacy are limited to a 31-day supply; if purchased through Express Scripts home delivery, they’re limited to a 90-day supply.

x If you use a non-participating pharmacy or don’t present your Express Scripts card to an in-network pharmacy at the time of purchase, in addition to the copayment, you’re responsible for the difference between the Express Scripts contracted rate and the purchase price of your prescription.


2016 ELCA Prescription Drug Benefit Chart Administered by Express Scripts

Generic Drug Preferred

Brand-Name Drug Non-Formulary

Drug Express Scripts/Medicare Network Retail Pharmacy Up to 31-day supply




Express Scripts Home Delivery Up to 90-day supply




Accredo Specialty Pharmacy Up to 31-day supply

100% after $10 copayment 100% after $47 copayment


Non-Participating Pharmacy Up to 31-day supply




Specialty Drugs Specialty drugs must be purchased through the Express Scripts specialty pharmacy, Accredo, to receive coverage under the ELCA prescription drug benefit. Specialty drugs aren’t available at any time through Express Scripts home delivery service or through your local retail pharmacy after the initial fill. To purchase specialty drugs through an Accredo pharmacy, contact an Accredo patient care coordinator. Syringes and needles for administering specialty drugs are provided to you by Accredo at no additional cost. There is no shipping cost for specialty drugs.




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Dental Benefit The dental benefit, administered by Delta Dental of Minnesota, covers preventive, basic, major restorative, and orthodontic care. It covers allowed amounts for your eligible dental expenses subject to the deductible, coinsurance, and maximum benefits payable amounts. Reimbursement percentages are the same for any dentist, but you may have lower out-of-pocket expenses if you use a dentist participating in a Delta Dental network. Network providers have agreed to accept Delta Dental’s allowed amount as complete reimbursement for services, along with any coinsurance or deductible for which you’re responsible. IMPORTANT:

x Out-of-network services are subject to the amount Delta Dental allows. x Benefit is subject to change without notice. x The dental benefit is not available if you opted out of dental coverage in 1996.

2016 Dental Benefit Chart

Administered by Delta Dental Deductible and Benefit Limits You Pay

Annual Deductible (member’s responsibility)

$150 per person $300 per family

Annual Benefit Maximum (Other Than Orthodontia) (maximum benefit paid per year by the plan for preventive, basic, and major restorative care)

$2,850 per person

Lifetime Orthodontia Benefit Maximum (maximum set in year services first received)

$2,850 per person

Type of Service Plan Pays Diagnostic/Preventive Care x Teeth cleaning, twice per calendar year x Periodontal maintenance, twice per calendar year x Topical fluoride application, once per calendar year for age 18 or under x Oral examinations, twice per calendar year x Bite-wing X-rays, once every two calendar years for adults and one per

year for age 18 or under x Full mouth X-rays or Panorex, once every 60 months x Sealants for permanent molars, once per lifetime for age 18 or under x Space maintainers for extracted posterior primary teeth for age 18 or under

100%; no deductible

Basic Care (fillings, tooth extractions, root canal therapy, oral surgery)

80% after deductible

Major Restorative Care (crowns, bridges, dentures, implants)

50% after deductible

Orthodontia 50%; no deductible




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Eligible Dental Expenses This benefit covers eligible dental expenses for procedures, services, or supplies received from a qualified dentist or licensed dental care practitioner acting within the scope of her or his license or under the supervision of a qualified dentist or doctor. The expenses must be for procedures, services, and supplies that are:

x Typically used for treatment of the dental condition x Rendered on the basis of generally accepted standards of dental practice x Medically necessary (except for specified preventive dental care)

Most dental procedures are performed and completed on the same day. However, some dental procedures require multiple appointment dates. The claim is paid after the completion of all services related to the procedure. Pre-Treatment Estimate If your dentist recommends dental care that is estimated to cost more than $300, have your dentist call Delta Dental before you receive service to determine the allowed amount for the procedure. Preventive Care Your dental benefit pays 100% of eligible expenses for the following preventive dental care:

x Routine dental cleaning — two per calendar year x Periodontal maintenance cleaning — two per calendar year x Oral exam — two per calendar year x Full-mouth X-ray or Panorex — one every 60 months x Bitewing X-rays — once every two calendar years for adults and once per year for dependents

through age 18 x Topical application of fluoride — one per calendar year for dependents through age 18 x Sealants or preventive resin restorations for permanent molars — one per lifetime for dependents

through age 18 x Space maintainers for extracted posterior primary teeth for dependents through age 18 x Oral hygiene instructions as prescribed by the dentist — one per lifetime per individual

Basic Dental Care Your dental benefit pays 80% of eligible diagnostic, therapeutic, and restorative expenses (after deductible) for the following basic dental care:

x Oral exams, including specialist exams and those done in the course of emergency treatment for the relief of pain

x Tests and laboratory exams, including bacteriologic cultures and pulp vitality tests x Dental X-rays, including full-mouth or other dental X-rays required to diagnose and treat a

specific condition x Oral surgery:

� Routine oral surgery for tooth removal (including alveolectomy, if indicated, and pre- and post-operative care)




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� All other oral surgeries, such as alveoloplasty, vestibuloplasty, removal of cysts, tumors, growths, neoplasms, and treatment of simple fractures that can be managed in the office of a qualified dentist or licensed dental care practitioner

x Treatment of periodontal and other diseases of the gums and tissues of the mouth, including gingivectomy, osseous surgery, and splinting. This includes periodontal scaling and root-planing, repeat non-surgical treatment every 24 months, and repeat surgical treatment every 36 months.

x Endodontic treatment, including root canal therapy and pulpotomies on primary and permanent teeth (doesn’t cover retreatment of pulpotomies)

x The following services and supplies, if provided in the office of a qualified dentist or licensed dental care practitioner: � Anesthetics (conscious sedation), when medically necessary and administered in connection

with cutting procedures in the oral cavity � Injection of antibiotic drugs by an attending dentist � Application of desensitizing medications

x Restoration of lost tooth structure as a result of tooth decay or fracture, when restored with amalgams (silver alloys), resin (white-colored filling) restorations, or pre-formed crowns for primary teeth

x Removable appliances for the treatment of bruxism and other harmful habits Major Restorative Care Your dental benefit pays 50% of eligible expenses (after deductible) for the following services and supplies related to major restorative dental care:

x Repair or recementing of crowns, inlays, onlays, and fixed or removable dentures (including one relining or rebasing of dentures every 36 consecutive months, if the relining or rebasing occurs more than six months after the installation of an initial or replacement denture)

x Crowns, onlays, or porcelain inlays when the amount of lost tooth structure cannot be restored with filling restorations as described under Basic Dental Care above

x Bridges, standard partial dentures, and full dentures for the replacement of extracted permanent teeth. Eligible expenses are limited to the commonly performed method of tooth replacement.

x Repairs and adjustments to prosthetic appliances if they serve as the permanent prosthetic appliance

x Replacement of an existing prosthetic appliance, if five years have elapsed from when last benefited and only if the existing appliance is not and cannot be made satisfactory. Services that are necessary to make an appliance satisfactory will be eligible.

Orthodontic Care Your dental benefit covers orthodontic treatment for the prevention and correction of malocclusion of teeth and associated dental and facial disharmonies. It pays 50% of eligible orthodontic expenses, up to a lifetime benefit limit, including initial orthodontic examinations, X-rays, and models. The lifetime benefit limit for each individual is fixed in the first year orthodontic expenses are incurred.




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Non-Eligible Expenses Your dental benefit does not cover:

x Charges that exceed allowed amounts x Procedures, services, or supplies primarily for cosmetic reasons and beautification, including

charges for personalization and characterization of dentures x Procedures, services, or supplies that aren’t necessary according to accepted standards of dental

practice. If a dentist or member elects an alternative or more expensive dental procedure, service, or supply, the plan covers only the portion of the charge for the adequate treatment of the dental condition.

x Procedures, services, or supplies that don’t meet accepted standards of dental practice, including those that are experimental

x Replacement of a lost, missing, or stolen orthodontic or prosthetic device or any dental appliance x Precision attachments x Diagnosis or treatment of any disease, illness, injury, or physical condition that is covered under

medical or prescription drug benefits x Costs for dental veneers and related services and supplies x Costs for procedures, services, or supplies, including retreatment, that exceed the frequency

limits established by Delta Dental x Costs for procedures, services, or supplies that are medical in nature, including but not limited to

oral surgery services performed in a hospital x Inpatient and outpatient hospital expenses x Costs for prescription drug expenses

Out-of-Network Providers If you receive care from an out-of-network provider, Delta Dental uses data for allowed amounts from the Health Insurance Association of America. If your out-of-network dentist’s fee for a service is higher than the fee charged by 80% of dentists in the same geographic area, the portion of the fee that exceeds the allowed amount isn’t covered by this benefit. You’re responsible for paying any portion of the fee that exceeds the allowed amount. The data is specific to each procedure performed by dentists and grouped by geographic area. Claims Payment Ask your dentist to submit claims to the Delta Dental address on the back of your identification card. If your dentist participates in Delta Dental networks, eligible dental expenses are paid directly to your in-network provider. If your dentist doesn’t participate in Delta Dental’s networks, you’ll need to pay the bill and Delta Dental sends payment to you rather than your out-of-network dentist. Claim Filing Deadline The claim filing deadline is 12 months from the date you incurred the expense. For example, if you incur expenses on Feb. 12, 2016, you or the provider must file the claim before Feb. 12, 2017. Any claims filed after the 12-month deadline will be denied.




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Health and Wellness Benefits ELCA NurseLineSM This service is provided by OptumSM and is available to you 24 hours a day, seven days a week. Call the ELCA NurseLineSM at 877.856.8145 if you need help:

x Deciding when self-care, a doctor visit, or the emergency room is appropriate x Knowing how to handle a common health problem x Understanding a medical condition, recent diagnosis, test results, or treatment options x Planning for your doctor visit x Understanding medication interactions and side effects

Health Care Advocacy Team Portico provides plan members with a team of professionals who understand how the various parts of the health care system fit together. Portico health care advocates know the ins and outs of our health plan benefits including aspects like insurance billing and coding, Medicare payment rules and procedures, insurance industry policies, and procedures. They work with you and our benefit administrators to answer your questions and assist in resolving your problem. Contact the Portico Health Care Advocacy Team (see Contact Information) for assistance. Hearing Discount Program Delta Dental of Minnesota partners with Amplifon to offer ELCA Health Plan members a hearing discount program. Whether or not you have dental coverage, you and eligible family members can use this program to save money. It offers:

x Discounts on more than 1,000 models of digital hearing aids from leading manufacturers x A 40% discount on hearing diagnostic testing, including advanced audiology tests x A three-year warranty on most hearing aids, covering repairs, loss, and damage x A 60-day free trial with no restocking fee x Free batteries for two years with a new hearing aid purchase (maximum 160 cells per hearing aid) x One year of free aftercare services x More than 4,000 locations nationwide

Contact Amplifon (see Contact Information) for assistance. Mayo Clinic Healthy Living Portico contracts with Mayo Clinic Global Business Solutions to provide plan members access to Mayo Clinic Healthy Living online. This website connects you with health and wellness information based on the experience, knowledge, and credibility of more than 2,000 Mayo Clinic doctors and scientists. Healthy Living also offers you an annual opportunity to complete the Mayo Clinic health assessment. This online tool helps you take stock of your health and lifestyle habits in less than 30 minutes. You enter personal health information (height, weight, cholesterol, blood sugar, etc.), and the tool identifies your health strengths and risks. It also recommends strategies to maintain or improve health, and delivers a personal action plan. Sign in to myPortico to access Mayo Clinic Healthy Living.




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SilverSneakers® Fitness Program This benefit gives you access to a basic fitness center membership at more than 13,000 participating locations across the nation, at no cost to you. Whichever location you choose, you have access to the equipment, group classes, and other services included in a basic fitness center membership. Use one location or many to fit your needs. To start a basic membership, visit a participating fitness center and present your SilverSneakers identification card. The SilverSneakers Fitness Program also supports a healthy, active lifestyle outside the gym:

x The FLEX™ program offers instructor-led classes like tai chi, yoga, and walking groups in locations outside the gym, such as churches, community centers, and parks.

x A SilverSneakers Steps® kit helps you exercise at home or on the go. Contact SilverSneakers to request a general fitness, strength, walking, or yoga kit.

x The Healthways FIT website offers exercise demonstration videos, meal plans, healthy recipes, inspirational stories, and discussion boards.

Contact SilverSneakers (see Contact Information) to learn more or find a participating fitness center.




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Contribution Rates Contribution rates for ELCA Medicare-Primary health benefits reflect Medicare as primary payer for hospital and medical expenses and are set annually by Portico. If You’re Sponsored by an Eligible Employer Your employer is responsible for paying the contribution amount for your coverage (for you and your family). Rates are expressed as a percentage of your defined compensation (see Glossary). If You’re Not Sponsored by an Employer You’re responsible for paying all contributions associated with your participation in the health plan (including coverage for your family). Your contribution is a flat rate per person per month. NOTE: Former AELC clergy, ALC clergy and lay employees, and LCA clergy and certain churchwide lay employees may have a portion of the cost of their coverage paid by the ELCA if they previously participated in an AELC, ALC, or LCA health benefits plan and are eligible for a health subsidy. If you’re retired and receiving a monthly participating annuity payment from the ELCA Retirement Plan — You can deduct your health coverage contribution from your annuity payment (if the annuity amount is greater than the cost of the health coverage). You are also eligible to waive health benefits. If you’re on leave from call — ELCA pastors and rostered laypersons on leave from call and wanting to continue benefits must continue both health benefits (or waive health benefits, if eligible) and ELCA basic group life insurance. To continue benefits, you pay the health contribution and the contribution for basic group life insurance. If you’re a called interim pastor or interim rostered layperson serving under a term call from a synod council and between assignments after completing an interim or term call from a synod council, you can choose to purchase disability coverage for interims for up to 12 months at your own expense. If You’re Self Sponsored You’re responsible for paying all contributions associated with your participation in the health plan (including coverage for your family).




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2016 Monthly Contribution Rates ELCA Medicare-Primary Benefits (Including Dental) Economy Standard Premium Members who are: x Retired x On leave from call x Spouses, ESGPs, surviving spouses x Continuing coverage after loss of

eligibility

$326 per person1,2 $652 per couple1,2



Children3 of members who are: x Retired x On leave from call x Divorced x Deceased x Continuing coverage after loss of

eligibility

$326 $340 $385

1. The ELCA may pay a portion for retired members and spouses who participated in a predecessor church plan. These rates do not reflect any subsidies.

2. Less $49 for former retired LCA members who opted out of dental coverage in 1996. 3. If all children are eligible for Medicare coverage, this rate is for all children in a family. NOTE: For ELCA-Primary health benefit contribution rates, visit myPortico or contact the Portico Customer Care Center. Late Contributions If you’re responsible for paying the cost of your health coverage and don’t make the full payment within 60 days of the due date, your coverage under the ELCA Health Plan ends on the last day for which contributions have been paid. If you’re a sponsored member and your employer can’t or won’t pay the contribution, you may continue health coverage for up to 18 months at your own expense. Medicare Part B Reimbursement The ELCA Health Plan reimburses you for the cost of the Medicare Part B premium for you and your spouse if you are enrolled in ELCA Medicare-Primary benefits and meet one of these criteria:

x You or your spouse or ESGP are eligible for Medicare (age 65 or over) and you’re sponsored by an organization with fewer than 20 employees

x You’re disabled and receiving benefits from the ELCA Disability Benefits Trust If you meet the criteria, to receive reimbursement, provide Portico proof of enrollment in Medicare Part B within 60 days of your date of Part B eligibility. If proof is received after 60 days of eligibility, you’ll be reimbursed the first of the month after Portico receives proof.




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Administrative and Miscellaneous Provisions Confidentiality and Privacy Practices The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires health plans to protect the confidentiality and privacy of individually identifiable health information. Portico is the plan administrator of the ELCA Health Plan and is committed to maintaining the privacy of your personal health information under the plan in accordance with HIPAA privacy standards. The plan and its benefit administrators use and disclose health information only as allowed by federal law. The plan has provided you with a Notice of Privacy Practices, describing how health information about you may be used or disclosed by the plan. If you would like to receive another copy of this notice, please contact the Portico Health Care Advocacy Team. (See Glossary for a brief list of your HIPAA rights and page 33 for privacy contact information.) Protected Health Information (PHI) PHI is the identifiable health information about you that is created, received, or maintained by the ELCA Health Plan. The privacy of your health information that is used or disclosed by the plan is protected by HIPAA. The plan is required by law to:

x Maintain the privacy of your PHI x Provide you with a notice of the plan’s legal duties and privacy practices with respect to your PHI

The ELCA Health Plan may use, share, or disclose PHI to pay your health benefits, operate the plan, or for treatment by a health care provider. In addition, the plan may use or disclose your information in other special circumstances described in the privacy notice. For any other purpose, the plan requires your authorization for the use or disclosure of your PHI. An authorization form is available by calling the Portico Health Care Advocacy Team (see Contact Information). Third-Party Liability (Subrogation) Subrogation is a legal process that allows Portico to substitute itself in your place regarding a claim or legal right to compensation from a third party (person or entity) who was responsible for your injury or illness. Upon payment of benefits under the ELCA Health Plan, Portico will be subrogated to your rights of recovery against any third party, including recoveries from:

x People who commit wrongful acts, injuries, or damages for which a civil action can be brought (tort-feasor)

x Underinsured/uninsured motorist coverage x Employers’ and/or workers’ compensation insurers x Other substitute coverage or any other right of recovery, whether based on tort or contract

This applies to you and any person claiming benefits through you or on your behalf (trustee, personal representative, executor, next of kin, heirs, etc.).




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Reimbursed first — Portico will be reimbursed from any recovery before payment of any other existing claims, including any claim by you for general damages. The entire amount of any damages recovered (not only the part specifically allocated to health care expenses) is considered reimbursement for eligible expenses. If you fail to remit to Portico any amount to which it is entitled, Portico may withhold the amount from future payments under this plan. Mandated insurance — If you fail to obtain any type of state or federal mandated insurance coverage (Medicare, Medicaid, workers’ compensation, or no-fault insurance), Portico will be allowed to fully assert our subrogation rights. Lump-sum settlements — If you voluntarily accept a lump-sum (or other) settlement without the consent of Portico and the settlement results in a waiver or abolishment of our subrogation rights against the third party, we will be relieved of any obligation to pay past, present, or future claims or expenses relating to the illness or injury. Appeals Procedure Initial steps — The health plan’s administrators are responsible for making decisions about claims or requests for benefits according to the terms of the ELCA Health Plan. The initial determination of benefits is made by the benefit administrator. If you are dissatisfied with the administrator’s initial decision, you may pursue the administrator’s internal appeals procedures. If that process doesn’t satisfy you, you can pursue next steps as follows:

x Prescription drug benefit appeal — If the prescription drug benefit administrator denies your

initial benefit appeal, you can request an external independent review with an organization contracted by the prescription benefit administrator to perform an independent review. The decision of this review organization is final and binding.

x Portico enrollment, eligibility, Medicare supplement, or dental benefit appeals � Presidential appeal — You may appeal in writing to the president of Portico within 180

days of your receipt of any adverse determination. Include the facts of your case, any new or additional information not considered in the initial decision, and the outcome you desire. Portico’s president reviews your claim with the advice and counsel of the internal appeals committee, which consists of at least three staff members not involved with the initial decision. The president will respond in writing within 30 days of receipt of your appeal and signed authorization for disclosure of protected health information unless the president notifies you of the need for an additional 30 days. Portico’s president may approve an appeal only if it’s determined that an error was made in the initial determination or the appeal involves matters relating to plan interpretation. In the case of changing technology or circumstances, the president may recommend an expansion of coverage requiring a plan amendment, which may or may not be retroactive. All




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plan amendments must be approved by the president, the board of trustees of Portico, and/or the ELCA Church Council in accordance with the provisions described on page 28.

� Appeals committee — An appeal may be filed with the appeals committee of Portico’s

board of trustees within 60 days of your receipt of the president’s written response if you are dissatisfied with the decision of the president. The appeals committee will consist of five to seven members of the board of trustees, at least one of whom must be a participant in the ELCA Pension and Other Benefits Program. Additionally, the committee may include independent consultants with expertise in the area of the appeal, to serve with voice but not vote. The appeals committee will schedule a meeting within 30 days of receiving your appeal and signed authorization. The final decision of the appeals committee will be forwarded to you within 60 days of receipt of the appeal. All decisions of the appeals committee are final.

� Court system — In the event you have exhausted the previously described appeals procedures and are dissatisfied with the final decision of the appeals committee of Portico, you may initiate legal action in the Minnesota Fourth Judicial District Court, Hennepin County. Any removal of such action must be to the United States Court for the District of Minnesota. Legal action cannot be taken more than three years after the date of the event on which the claim is based.

Limitation of Liability Portico is not liable for the failure of any employer to enroll its rostered leader or lay employee as a sponsored member in the ELCA Health Plan or for the failure of any employer to make contributions to the plan on the member’s behalf. Also, Portico is not liable to any member or other person or entity for any of its acts carried out in good faith and based upon information available at the time. Obligations of a Sponsored Member As a sponsored member of the ELCA Health Plan, you agree to comply with all of Portico’s requirements regarding enrollment and administration of the plan. This includes, but is not limited to, providing your:

x Date of birth x Disability status x Marital status x Social Security number x Family support obligations x Medicare status

If you fraudulently or inappropriately use, misuse, or overuse these plan services and/or supplies, Portico has the right to terminate your participation in the ELCA Pension and Other Benefits Program. In addition, you won’t be eligible for coverage continuation under the ELCA Health Plan.




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Obligations of a Sponsoring Employer By sponsoring an eligible employee in the ELCA Health Plan, the sponsoring employer agrees to:

x Be bound by the terms of the ELCA Health Plan x Provide the necessary information to Portico for the administration of the ELCA Health Plan x Promptly notify Portico of any IRS audit or change in status that could cause the employer to

cease to be eligible to participate in the plan An employer may discontinue participating in the ELCA Pension and Other Benefits Program by notifying Portico and complying with any procedures established by Portico for discontinuing participation. Portico may discontinue the participation of an employer if Portico, in its sole discretion, determines the employer is no longer an eligible employer, as defined by the program, or if the employer has failed to comply with the provisions of the program. Correction of Errors It is recognized that in the operation and administration of the ELCA Health Plan, certain mathematical and accounting errors may be made or mistakes may arise for various reasons, including factual errors in information supplied to the benefit administrators, Portico, or the board of trustees. Portico has the power to make equitable adjustments to correct such errors as Portico, in its sole discretion, considers appropriate. Adjustments will be final and binding on all persons. Plan Information While every effort has been made to ensure that the information contained in this communication is correct, if there is any omission or misstatement, the applicable legal plan document will control. The eligibility for any benefit will be governed by the terms of the applicable plan, program, or policy. Portico (and its designee or the insurer or claims administrator, as applicable) shall have the power, including, without limitation, discretionary power to make all determinations that the plan requires for its administration, and to construe and interpret the plan for purposes of determining eligibility and benefits. The assets of each plan are held in various trusts and therefore do not allow one plan to fund a net shortfall of another plan. Self-Insured Plan The ELCA Health Plan is self-insured and is not provided through an insurance company. Portico’s ability to pay claims is dependent on continued contributions, claims experience, and market performance. Portico reserves the right to amend, modify, or terminate any plan or benefit policies or programs, in whole or in part, at any time. Plan documents are available by contacting Portico. Our policies, programs, and plans are not subject to the Employee Retirement Income Security Act (ERISA). Although Portico has contracted with other companies to administer certain benefits of the plan, these companies do not insure any part of the plan. All benefits to which a person becomes entitled hereunder shall be provided only out of the ELCA Medical and Dental Benefits Trust and only to the extent that such trust is adequate therefore.




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Amendment to the Plan The ELCA Churchwide Assembly, the ELCA Church Council, or Portico may propose amendments to the ELCA Health Plan. All proposed amendments must be submitted to Portico for recommendation before final action is taken by the Church Council.

x The president of Portico will approve amendments involving no change in policy and little or no change in cost or benefits. Amendments approved by the president will be reported to the board of trustees of Portico.

x The Church Council will approve amendments involving a significant change in policy or a significant change in cost or benefits. The Church Council may, in its sole discretion, submit any proposed amendment to the Churchwide Assembly for final action.

x The board of trustees of Portico will approve all other amendments. Amendments approved by the board of trustees will be reported to the Church Council.

No amendment will reduce entitlement under the ELCA Health Plan for expenses incurred prior to the effective date of the amendment. No Guarantee of Tax Consequences Portico makes no commitment or guarantee that any amounts paid to or for the benefit of a member under the ELCA Health Plan will be excludable from the member’s gross income for federal, state, or local income tax purposes. It is the member’s responsibility to determine whether each payment is excludable from his or her gross income for income tax purposes. It is also the member’s responsibility to notify Portico if he or she has any reason to believe a payment is not excludable for income tax purposes. Non-Assignability of Rights The member’s rights to receive any reimbursement under the ELCA Health Plan are not transferable by the member through assignment or any other method and are not subject to claims by the member’s creditors by any process whatsoever. Any attempt to do so will not be recognized by Portico, except as required by law. Termination of the Plan The ELCA Health Plan is designed, and contribution rates are established, to maintain long-term plan viability. However, the ELCA Church Council may terminate the plan by following the previously described amendment procedure. If the plan is terminated, the existing funds will be used to pay benefits for expenses incurred prior to the effective date of the termination. Any surplus funds will be distributed back to the ELCA. If the funds are distributed, no future benefit payments will be made from the plan.




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Glossary Affordable Care Act Signed into law March 23, 2010, the Patient Protection and Affordable Care Act offers comprehensive health reform. Some key health coverage provisions of the law include an expansion of Medicaid eligibility, the creation of health insurance exchanges through which eligible individuals are able to purchase insurance with premium and cost-sharing credits, regulations that prevent health insurers from denying coverage to people, the requirement that most individuals have health insurance beginning in 2015, and penalties to large employers that don’t offer affordable coverage to their employees. Brand-Name Drug A drug that has a trade name and is typically protected by a patent. It is known by this name rather than its chemical name. Brand-name drugs are usually sold for higher prices than their generic equivalents. Coinsurance The percentage of eligible health care costs you pay after meeting the deductible, up to the annual out-of-pocket limit. Copayment A fixed dollar amount that ELCA Health Plan members with certain health benefit options pay for certain eligible health care services, such as prescription drugs, usually when the services are received. Coverage Continuation When eligible members pay the cost to keep ELCA health benefits following a change in employment. In some cases, coverage is available for a limited period of time. Includes members who are retired, on leave from call, and separated from service, as well as surviving

spouses or eligible same gender partners, former spouses, and other family members. Coverage Continuation Members Individuals who were previously sponsored by an employer in the ELCA benefit program but now purchase ELCA benefits at their own expense. Includes plan members who are retired, on leave from call, and separated from service, as well as surviving spouses or eligible same gender partners, former spouses, and other family members. Eligibility rules apply. Deductible The annual amount you pay for certain eligible health care services before the health plan pays anything. Defined Compensation Defined compensation includes base salary before pretax benefit contributions are deducted. If you’re a pastor, it includes Social Security tax allowance paid to you and one of the following: x If housing isn’t provided, the amount of cash

housing allowance paid to you x If housing is provided, an additional 30% of

your base salary and Social Security tax allowance, plus any household furnishings or utilities allowance paid to you

Defined compensation doesn’t include: x Utilities paid directly by your congregation

or organization x Employer contributions including clergy

housing equity contributions made to the ELCA Retirement Plan or another eligible retirement plan

x Non-taxable reimbursements or expense allowances (auto and mileage, continuing education, books, or professional expenses)




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Dental Benefit Administrator Delta Dental, the entity contracted with Portico to administer dental benefits. Responsibilities include: x Credentials and contracts with dental

providers to provide treatment and services to members who have dental coverage and to accept negotiated rates as payment in full

x Administers claims for eligible dental expenses

x Administers medical-necessity requirements and allowed amount limits for dental services

ELCA Medicare-Primary Health Benefits Health benefits available to ELCA Health Plan members and their eligible family members who are age 65 and over (unless sponsored by an organization with 20 or more employees); in addition to those under age 65 and receiving Medicare due to a disability. Includes a choice of three health benefit options: Premium, Standard, and Economy; however, members who are sponsored by an employer, on leave from call, living outside the United States, or receiving ELCA disability benefits are eligible for the Standard option only. Eligible Expense A service or supply that is considered for reimbursement under the ELCA Health Plan, because it generally: x Is incurred while you or your family

member(s) are covered under the plan x Is billed to you (or your dependent) x Is ordered by an eligible plan provider x Is medically necessary x Is not specifically limited or excluded under

the rules of this plan x Meets the allowed amount guidelines used

by one of the plan’s benefit administrators

Eligible Same Gender Partner (ESGP) An individual who, together with a member of the ELCA benefit program, properly completed and signed an Affidavit of Partnership attesting that they are not legally married but financially interdependent (share financial obligations), not married to or legally separated from anyone else, and live in a publicly accountable, lifelong, monogamous, same gender relationship. Formulary A list of both generic and preferred drugs maintained by a prescription drug benefit administrator. Formulary prescription drugs generally cost ELCA Health Plan members, and the plan, less than non-formulary drugs. Generic Drug A drug known by its chemical name rather than by a brand name and not protected by patents. The FDA requires generics to have the same quality, strength, purity, and stability as brand-name drugs. Generic drugs are usually sold for significantly lower prices than their name-brand equivalents. Health Insurance Portability and Accountability Act (HIPAA) Rights With respect to your protected health information, under the Health Insurance Portability and Accountability Act (HIPAA), you have the right to: x Inspect and copy certain portions of your

PHI maintained by the plan x Request an amendment of your PHI x Request restriction on the uses and

disclosure of your PHI x Request communication be made to you

through an alternate means or location x Obtain an accounting of disclosures the plan

has made for reasons other than treatment,




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payment, health care operations, or for required or authorized disclosures

x Request that your provider not share PHI with the plan if you paid for the entire service

x Request copies of your health records in electronic format, if available

Maintenance Medication Medication taken on an ongoing basis for a chronic condition. Medigap Policy A Medigap policy is private insurance that helps you pay for some of the costs that Medicare doesn’t cover, such as copayments, coinsurance, and deductibles. Also called a Medicare supplement policy. Medicare first pays its share of Medicare-approved amounts, then a Medigap policy pays its share. The ELCA Medicare-Primary Economy health benefit option provides similar benefits to the Medigap L policy and the Premium option provides similar benefits to the Medigap F policy. Member Any individual who is entitled to a benefit from this plan including a sponsored member, spouse, eligible same gender partner, alternate payee, surviving spouse, surviving eligible same gender partner, coannuitant, child of a sponsored member, or a designated beneficiary. Non-Formulary Drugs Brand-name drugs that are not included on the formulary because they are new to the marketplace or there are therapeutically equivalent drugs that cost less. Preferred Brand-Name Drug Preferred drugs are brand-name drugs that have been reviewed and placed on the formulary by an independent committee of doctors and pharmacists.

Prescription Drug Benefit Administrator Express Scripts, Inc., the entity contracted with Portico to administer the ELCA Part D drug benefit and the ELCA prescription drug benefit. Responsibilities include: x Contracts with participating network

pharmacies to provide prescription drugs to members who have prescription drug coverage and to accept negotiated rates as payment in full

x Operates the prescription drug home delivery service

x Establishes and administers medical-necessity criteria

x Administers claims for eligible prescription drug expenses

x Determines the list of eligible specialty drugs and operates the specialty drug pharmacy

x Administers Medicare prescription drug plans

Self-Insured Plan A type of employer-provided benefit plan that covers its own risk rather than insuring that risk through a commercial insurance provider. The ELCA health and disability plans and the retiree survivor benefit are self-insured. While Portico may contract with third-party administrators to process claims, Portico pays the entire cost of all our claims. Self-insured plans generally cost less than fully-insured plans due to fewer fees and the absence of sales commissions. Separation from Service When a member: x Who is not on the ELCA roster is no longer

serving in a participating congregation or organization due to resignation, discharge, retirement or death; or,

x Who is on the ELCA roster is: (a) retired; or (b) removed from the roster and is no longer employed.




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NOTE: A member who is on the ELCA roster and on leave from call is not considered separated from service.

Supplement to Medicare Benefit Administrator Mercer Health & Benefits Administration LLC, the entity contracted with Portico to administer the ELCA Medicare supplement benefit and responsible for administering supplement to Medicare claims for eligible medical and hospital expenses.




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Contact Information Portico Benefit Services myPortico.PorticoBenefits.org Portico Customer Care Center Call or email with questions about your eligibility or contribution rates or if you have a change of family status, address, or coverage. 800.352.2876 or 612.333.7651 / F 612.334.5399 [email protected] Hours 7:30 a.m. – 6 p.m. (Central) Monday – Friday Mailing address Portico Benefit Services 800 Marquette Ave., Ste. 1050 Minneapolis, MN 55402-2892 Health Care Advocacy Team Call or email if you need help understanding your health benefits. 800.352.2876 or 612.333.7651 / F 612.752.4367 [email protected] Hours 7:30 a.m. – 6 p.m. (Central) Monday – Friday Privacy Contact Call or email for information about the plan’s privacy practice, to exercise your rights, or to complain about how the plan is handling your protected health information. 800.352.2876 or 612.333.7651, ext. 4420 [email protected] Portico Benefit Services Attn: Privacy Contact 800 Marquette Ave., Ste. 1050 Minneapolis, MN 55402-2892

Medicare medicare.gov Contact Medicare with questions about Medicare coverage, 24 hours a day, seven days a week. 800.MEDICARE [633.4227] / TTY 877.486.2048 Mercer Health & Benefits Administration LLC Medicare Supplement Benefit Contact Mercer with questions about supplement to Medicare hospital and medical benefits and claims. 800.245.6728 Hours 7:30 a.m. – 5 p.m. (Central) Monday – Friday Claims address Mercer P.O. Box 14426 Des Moines, IA 50306-3426 Amplifon Hearing Discount Program amplifonusa.com/deltadentalmn Offered through a partnership with Delta Dental of Minnesota, contact Amplifon to get discounts on hearing aids and other hearing services. 855.531.4694 Hours 7 a.m. – 7 p.m. (Central) Monday – Friday Delta Dental of Minnesota Dental Benefit deltadentalmn.org Register or sign in to view claims history and to locate a participating provider: choose Delta Dental PPO or Delta Dental Premier providers.



https://myportico.porticobenefits.org/

https://myportico.porticobenefits.org/




http://www.medicare.gov/

http://www.amplifonusa.com/deltadentalmn

http://www.amplifonusa.com/deltadentalmn

http://www.deltadentalmn.org/


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Customer service Call about the benefit, claims, pretreatment estimates, getting additional identification cards, or to find a participating dentist. 800.448.3815 or 651.406.5901 Hours 7 a.m. – 7 p.m. (Central) Monday – Friday Claims address Delta Dental P.O. Box 59238 Minneapolis, MN 55459-0238 Express Scripts, Inc. Prescription Drug Benefit express-scripts.com Call or visit online to find participating pharmacies in your area (select Pharmacy Locator), order home delivery service prescription refills, find opportunities to save money, transfer a prescription to home delivery service, and find information about drugs and health conditions. Hours Accessible 24 hours a day, seven days a week For Retired Members 877.866.6048 / TTY 800.899.2114 For Sponsored, On Leave from Call, and Non-U.S. Members 800.575.8090 / TTY 800.899.2114 Prior Authorization (for Doctors Only) Sometimes your doctor must request authorization for certain drugs before the prescription can be filled (for example, if the quantity exceeds the limit or if a drug is prescribed before the comparable, less expensive step-one drug has been tried). 800.417.8164

Accredo Specialty Pharmacy Contact Accredo (an Express Scripts subsidiary) for assistance with specialty drugs, including injectable and oral drugs with specific storage and handling requirements. 800.803.2523 Hours 7 a.m. – 8 p.m. (Central) Monday – Friday 8 a.m. – 12 p.m. (Central) Saturday Healthways SilverSneakers® Fitness Program silversneakers.com Contact Healthways SilverSneakers with questions about your basic fitness membership at participating fitness centers. 888.423.4632 Hours 7 a.m. – 7 p.m. (Central) Monday – Friday Mayo Clinic Global Business Solutions Healthy Living Online Web Portal, Health Assessment Sign in to myPortico to access the Healthy Living online web portal, take the health assessment, and use wellness resources. OptumSM ELCA NurseLineSM Call a registered nurse with health questions or concerns 24 hours a day, seven days a week. 877.856.8145 / TTY 800.855.2880; ask to be connected to 877.856.8145 Outside the United States: 800.411.7998 and press “2” to speak to a nurse Hours Accessible 24 hours a day, seven days a week




http://www.silversneakers.com/


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Cards for Your Wallet The ELCA Medicare supplement benefit is administered by Mercer Health & Benefits Administration LLC (formerly Marsh). Show this card and your Medicare card to your hospital and medical care providers. Contact Mercer at 800.245.6728 if you need additional identification cards. Details of this benefit begin on page 3.

The ELCA Part D drug benefit for retired members with ELCA Medicare-Primary benefits or those receiving ELCA disability benefits is a Medicare Part D drug benefit administered by Express Scripts, Inc. Show this card when you purchase prescriptions at your local pharmacy. Use the information on this card when you purchase prescription drugs through Express Scripts home delivery service. Contact Express Scripts at 877.866.6048 or visit express-scripts.com if you need additional identification cards. Details of this benefit begin on page 12.

The ELCA prescription drug benefit for members sponsored by an employer, those on leave from call, or living outside the United States is administered by Express Scripts, Inc. Show this card when you purchase prescriptions at your local pharmacy. Use the information on this card when you purchase prescription drugs through Express Scripts home delivery service. Contact Express Scripts at 800.575.8090 or visit express-scripts.com if you need additional identification cards. Details of this benefit begin on page 15. The ELCA dental benefit is administered by Delta Dental of Minnesota. Show this card to your dental care provider. Contact Delta Dental at 800.448.3815 if you need additional identification cards. Details of this benefit begin on page 16.






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100-07 (4/2016)

