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HEALTH | DENTAL | VISION | GROUP LIFE & AD&D | LONG TERM DISABILITY | HSA | VOLUNTARY BENEFITS | FSA

Employee Benefits Guide August 1, 2016 - July 31, 2017

Benefits Guide is intended for summary purposes only

2 Employee Benefits Guide

Welcome to your 2016 Employee Benefits Guide

We are committed to providing employees with a benefits program that is both comprehensive and competitive. Our program offers a range of plan options to meet the needs of our diverse workforce. We know that your benefits are important to you and your family. This program is designed to assist you in providing for the health, well–being and financial security of you and your covered dependents. Helping you understand the benefits First Atlantic Health Care offers is important to us. That is why we have created this Employee Benefits Guide.

Benefits Guide Overview

This guide provides a general overview of your benefit choices to help you select the coverage that is right for you. Be sure to make choices that work to your best advantage. Of course with choice, comes responsibility and planning. Please take time to read about and understand the benefit plan thoroughly, and enroll on time.

Included in this guide are summary explanations of the benefits and costs as well as contact information for each provider.

It is important to remember that only those benefit programs for which you are eligible and have enrolled in apply to you. We encourage you to review each section and to discuss your benefits with your family members. Be sure to pay close attention to applicable co-payments and deductibles, how to file claims, preauthorization requirements, networks and services that may be limited or not covered (exclusions). This guide is not an employee/employer contract. It is not intended to cover all provisions of all plans but rather is a quick reference to help answer most of your questions. Please see your Summary Plan Description for complete details. We hope this guide will give you a clear explanation of your benefits and help you be better prepared for the enrollment process.

Contents

Employee Advocate ........................................................................................................... 3

Benefit Contacts ................................................................................................................. 4

Eligibility Details ............................................................................................................... 5

Premium Conversion Account ........................................................................................... 6

Flexible Spending Account ................................................................................................ 7

Employee Responsibilities ................................................................................................. 8

Health Insurance Definitions ……………………………………………………………...9

Medical Insurance ………………………………………………………………………..10

Dental Insurance............................................................................................................... 12

Vision Insurance............................................................................................................... 13

Your Contributions ........................................................................................................... 14

Basic Life Insurance ......................................................................................................... 15

Long Term Disability ...................................................................................................... 16

HSA Plan Highlights ........................................................................................................ 17

HSA Q & A ……………………………………………………………………………...18

Employee Advocate

Employees occasionally need assistance in resolving issues with insurance carriers, such as unpaid or denied claims on medical and/or dental insurance, referral questions, and prescription coverage issues. Our goal is to provide truly expert personalized service, as well as assist employees of First Atlantic Health Care in becoming informed consumers.

We ask that employees and/or dependents contact the carrier at least once to resolve their issue. If assistance is still needed, please contact our Employee Advocate, Paula Green, whose services are provided at no cost.

Paula Green was employed for four years at a managed care company in Maine prior to joining Acadia Benefits, Inc. in 2000. She has an excellent understanding of insurance and what is required to “work within the system” to obtain timely resolution to problems. Paula is totally dedicated to resolving the claims issues of our customers employees and their families.

Contact Information

Email [email protected]

Telephone 207-523-0065

Toll Free 866-761-2426

Fax 207-854-1203

3

At Your Service...


Benefit Contacts

Vision Plan

VSP

PO Box 82520

Lincoln, NE 68501

800-877-7195

vsp.com

Group #130801

Basic Life Insurance

Anthem Life

6740 N High Street, Ste 200

Worthington, OH 43085

800-813-5682

www.anthem.com

Group #CL2533

Medical Plan

Harvard Pilgrim HealthCare

93 Worcester Street

Wellesley, MA 02481

888-333-4742

www.hphc.org

Group #021855 : HMO / #083970 HMO HSA / #021857 PPO HSA

Dental Plan

Ameritas

PO Box 82520

Lincoln, NE 68501

800-776-9446

[email protected]

Group #40968

Long Term Disability

Lincoln Financial

8801 Indian Hills Drive

Omaha, Nebraska

800-423-2765

www.LincolnFinancial.com

First Atlantic Health Care #01-0050292

Flexible Spending Account

Benefit Strategies

PO Box 1300

Manchester, NH 03105

888-401-FLEX (3539)

www.benstrat.com

First Atlantic Health Care

EAP (Employee Connect Services)

Lincoln Financial #1-877-757-7587 or www.eapadvantage.com

Are you eligible for benefits?

To determine the benefits for which you may be eligible, please refer to the chart below. You are eligible to participate in these plans upon meeting each plan’s eligibility requirements. You also have the option to enroll your eligible dependents in some of these plans. Eligible dependents may include:

Medical/Dental

• All full time employees of FAHC who work at least thirty (30) hours per week are eligible for coverage the first of the month following 30 days of employment.

• Legal spouse of the subscriber

• Domestic partner (same or opposite gender)

• A child (including an adopted child or stepchild) of the subscriber or spouse of the subscriber until the child’s 26th birthday.

For a child to be eligible, they must be:

▪ Less than 26 years of age (ends on the day the dependent turns 26)

▪ Unmarried child of the subscriber or spouse, 26 years or older who meets the requirements as referenced in the HPHC Benefit Handbook *

* Refer to page 41 of the HPHC Benefit Handbook Section VIII Eligibility

Vision

• Employees of FAHC who work at least twenty (20) hours per week are eligible for coverage the first of the month following 30 days of employment.

• Legal spouse of the subscriber

• Domestic partner (same or opposite gender)

• A child (including an adopted child or stepchild) of the subscriber or spouse of the subscriber until the child’s 26th birthday.

For a child to be eligible, they must be:

▪ Less than 26 years of age (ends the end of the month in which the child attains age 26

▪ Unmarried child of the subscriber or spouse, 26 years or older who meets the requirements as referenced in the VSP Certificate of Coverage

Employee Benefits Guide 5

Eligibility Details

Benefit Plan Eligibility New Hire Waiting Period

Medical Full time employee : 30 hours First of the month following 30 days

Dental Full time employee : 30 hours First of the month following 30 days

Vision Full time employee : 20 hours First of the month following 30 days

Basic Life/AD&D Full time employee : 30 hours First of the month following 30 days

Flexible Spending Account Full time employee : 30 hours First of the month following 30 days

Long Term Disability Management Only : 30 hours First of the month following 30 days

EAP All employees First of the month following 30 days


Premium Conversion Account administered by Benefit Strategies

Benefit Overview

First Atlantic Health Care provides a Section 125 Premium Conversion Account plan that allows you to pay for your portion of the health insurance premium on a pre-tax basis. Participation in this plan can save you money on your taxable income.

A Section 125 Premium Conversion Account is part of a tax-saving benefit that is allowed under the Internal Revenue Service (IRS) tax code. This plan describes the tax savings on insurance premiums that are withheld on a pre-tax basis. This is not an insurance plan.

Plan Year

Our Section 125 Plan year is from August 1 thru July 31 each year. Your election to participate in Medical, Dental, and/or Vision, will constitute your election to participate under the Premium Conversion Account plan on a pre-tax basis.

Important Note: With the election of pre-tax payroll deductions, even on an “automatic basis”, you are locked into that election for the Plan Year unless you have a “Qualifying Life Event” or “Status Change”. That means, even though the insurance carrier will allow you to change or drop your coverage, the IRS tax code requires that your payroll deduction not be changed, until the end of the plan year, unless you have a “Qualifying Life Event/Status Change”. (Some qualifying status changes will not be eligible events for enrollment in the insurance plan). A partial list of the most currently used Qualified events is:

• Marriage

• Birth

• Adoption or Placement for Adoption

• Death

• Divorce or legal separation

• Open enrollment for yourself or your spouse

• Job status change for self or spouse

▪ Job Status change must result in loss of coverage or create new eligibility for benefit plans.

• Child ceasing to be an eligible dependent

Payroll changes that are consistent with health plan, dental plan or vision plan changes at the time of open enrollment or a qualifying event are permissible and will automatically be made at such time.

Benefits are subject to all terms, conditions, limitations, and exclusions outlined in the Contract. Should there be any discrepancies between this summary and the actual insurance policy or plan documents, the insurance policy or plan documents will govern in all instances. Nothing contained herein should be construed as a guarantee of coverage or benefits.


Flexible Benefit Plan administered by Benefit Strategies

Benefit Overview

First Atlantic Health Care offers a Flexible Benefit Plan which allows you to enroll in a Healthcare and/or Dependent Care Reimbursement Account.

A Healthcare Reimbursement Account allows you to have pre-tax deductions from your payroll that will go into an account to pay for eligible healthcare expenses. Eligible health expenses include professional medical expenses incurred by yourself and/or your dependents during the plan year for “the diagnosis, cure mitigation, treatment or prevention of disease, or for the purpose of affecting any structure or function of the body.”

A Dependent Care Reimbursement Account allows you to have pre-tax deductions from your payroll that can be used to pay for eligible dependent care expenses. Eligible dependent day care expenses are incurred to allow you and your spouse (if applicable) to be gainfully employed. The IRS requires you to disclose the Tax ID or Social Security Number of your day care provider (s) when you file your income taxes.

Forfeitures Any amounts remaining in your account at the end of the Plan Year will be forfeited after all claims are paid. In addition, any balance remaining in your account on the date you terminate employment with the Company will be forfeited after all claims are paid.

Grace Period

However, the unused balance in your account that remains at the end of a Plan Year may be used for expenses that you incur during the grace period. The grace period is the 2-1/2 month period after the end of the Plan Year.

Claims You must submit claims for reimbursement within 90 days after the end of the Plan Year. However, the unused balance in your account that remains at the end of a Plan Year may be used for expenses that you incur during the grace period. The grace period is the 2-1/2 month period after the end of the Plan Year. You must submit claims incurred during the grace period for reimbursement within 90 days after the end of the plan year.

Refer to Benefit Strategies SPD for specific plan details.


Health Care FSA

Minimum Election Allowed: $260

Maximum Election Allowed: $1,500

Dependent Care FSA

Minimum Election: $0

Maximum Election Allowed: $5,000

($2,500 if married filing separately)


Employee Responsibilities

Marriage

You are required to report a marriage to your employer within 30 days in order to add your spouse to your insurance plans. A copy of the marriage license and insurance company applications may be required to change your name, beneficiary, address, or to add or delete dependents from the benefit plans.

Birth/Adoption:

If you are enrolling a new dependent, you have 30 days from the date of birth or acquisition to complete the required enrollment forms. A copy of the Birth Certificate or Court document is required.

Court Orders:

If you are enrolling a dependent child(ren) whose coverage might be governed by a divorce decree or other support order, please look at your documents carefully. Depending upon how your divorce or court order was written, the dependent may NOT be eligible for this plan. A copy of the court documents or Medical support Notice is required to enroll a dependent child(ren).

Different last name for spouse or children:

Insurance companies or your employer may require proof such as a marriage license, birth certificate, court documents, or recent tax form, to show that dependents with different names are your legal dependents. Enrollment or payment of claims may be pended until proof is received. Please be prepared to submit this documentation if requested by the insurance carrier or your employer. Your dependent may not be enrolled if documentation is not received when requested.

Divorce or Legal Separation:

If you become legally separated or divorced, it is your responsibility to notify your employer of your status change within 30 days of the event in order to make any changes to your plan elections. You may be required to provide a copy of the appropriate finalized court paper to verify the event date. Please contact Acadia Benefits, Inc. at 207-761-2426 if you would like further explanation.

Life Events:

It is the employee’s responsibility to report any dependent changes which result in loss of or entitlement to eligibility and any other “life” events to the Human Resources Department for COBRA purposes.


Health Insurance Definitions

Copayment (co-pay)

A Copayment is a fixed dollar amount you must pay for certain Covered Benefits. The Copayment is due at the time of service of when billed by the Provider. You may have to pay a set amount every time you have an office visit, a different amount for lab work, and various amounts for different types of prescription drugs.

Deductible:

A specific dollar amount that you pay for most Covered Benefits each calendar year before any benefits subject to the Deductible are payable by the Plan.

Coinsurance:

A percentage of the allowed amount for certain Covered Benefits that must be paid by the Member. Coinsurance amounts applicable to your plan are stated in your Schedule of Benefits.

Covered Benefit(s):

The products and services that a Member is eligible to receive, or obtain payment for, under the Plan.

Out-of-pocket Maximum:

Money you pay toward the cost of healthcare services. It generally is the deductible and the coinsurance amount added together. In some cases it may also include the co-pays you have for medical services. Plans vary widely in the amount of out-of-pocket costs you pay.

Plan Year:

The one-year period for which benefits are purchased and administered. Benefits for which limited yearly coverage is provided renew at the beginning of the Plan Year. Generally, the Plan year begins on the Plan’s Anniversary Date. Benefits under your Plan are administered on a Calendar Year basis. Please refer to your Schedule of Benefits for details.

Premium:

The cost of a health plan. Your employer may pay part of your premium if you get your health benefits through your company.


Medical Plan administered by Harvard Pilgrim

Benefits HMO $2000 In-Network

MEMBER PAYS

HMO HSA $5000 In-Network

MEMBER PAYS

PPO HSA $2600 In-Network

MEMBER PAYS

Deductible per Benefit Period

Per Member Per Family

$2,000 $4,000

$5,000 $10,000

$2,600 $5,200

(All family members can contribute with no one member contributing more than the individual deductible amount.)

Maximum Out of Pocket per Benefit Period

Per Member Per Family

$4,000 $8,000

$6,000 $12,000

$5,000 $10,000

Primary Care

Office Services Preventive Care

$30 $0

Deductible, then 20% $0

Deductible, then 0% $0

Specialty Care

Office Services Hospital Services (includes inpatient, outpatient & ambulatory services) Emergency Care

$30 or $50 Deductible, then 20%

$200

Deductible, then 20% Deductible, then 20%

Deductible, then 20%

Deductible, then 0% Deductible, then 0%

Deductible, then 0%

Other Routine Care

GYN Exam Routine Screening Mammogram Routine Screening Colonoscopy

$0 $0 $0

$0 $0 $0

$0 $0 $0

Maternity Care

Routine Maternity Physician Services Delivery

$0 Deductible, then 20%



Inpatient Hospital/Facility Services

Admission (including maternity) Skilled Nursing Facility Long-Term Care Facility

Deductible, then 20%Deductible, then 20% Deductible, then 20%

Deductible, then 20%Deductible, then 20% Deductible, then 20%

Deductible, then 0% Deductible, then 0% Deductible, then 0%

Outpatient Hospital/Ambulatory Care Facilities

All services (including maternity) Emergency Room Services Urgent Care

Deductible, then 20% $200 $30



Prescription Drug Coverage—Retail Premium 4 Tier (up to 30 day supply) Tier 1 Tier 2 Tier 3 Tier 4

($1000 Ind/$2000 Fam

Maximum) $5

$20 $30 $50

Deductible then $5 Deductible then $20 Deductible then $30 Deductible then $50


Prescription Drug Coverage—Mail or Maine Pharmacy Premium 4 Tier (up to 90 day supply) Tier 1 Tier 2 Tier 3 Tier 4

$10 $40 $60

$100


Deductible then $10 Deductible then $40 Deductible then $60

Deductible then $100

Preventive Drug Benefit : Deductible waived N/A Yes Yes



Medical Plan administered by Harvard Pilgrim

Benefits HMO $2000 In-Network

MEMBER PAYS

HMO HSA $5000 In-Network

MEMBER PAYS

PPO HSA $2600 In-Network

MEMBER PAYS

Other Services

Acupuncture Treatment for Injury or Illness Ambulance Durable Medical Equipment (DME) Home Health Hospice Skilled Nursing Facility Occupational Therapy Physical Therapy Speech Therapy Chiropractic Services

$30 $0

Deductible, then 20% Deductible, then 20% Deductible, then 20% Deductible, then 20%

$30 $30 $30 $30

Deductible, then 20% Deductible, then 20% Deductible, then 20% Deductible, then 20% Deductible, then 20% Deductible, then 20% Deductible, then 20% Deductible, then 20% Deductible, then 20% Deductible, then 20%

Deductible, then 0% Deductible, then 0% Deductible, then 0% Deductible, then 0% Deductible, then 0% Deductible, then 0% Deductible, then 0% Deductible, then 0% Deductible, then 0% Deductible, then 0%

Members or providers are required to notify HPHC before the start of any planned inpatient admission to a Non-Plan Medical Facility. Members are also required to obtain Prior Approval from HPHC for certain services. Before you receive services from a Non-Plan Provider, please refer to tour internet site, www.harvardpilgrim.org, or contact the Member Services Department at 1-888-333-4742 for a list of services for which Prior Approval is required. If you do not provide notification or obtain Prior Approval when required, you will be responsible for paying the Penalty amount stated in the Schedule of Benefits in additional to any applicable Member Cost Sharing. No coverage will be provided if HPHC determines that the services is not Medically Necessary, and you will be responsible for the entire cost of the services.

Maximums

Annual Benefit Maximum Acupuncture Treatment for Injury or Illness Occupational Therapy Physical Therapy Skilled Nursing Facility Speech Therapy Chiropractic Care

Unlimited 20 visits per calendar year

40 visits per calendar year combined with PT & ST 40 visits per calendar year combined with OT & ST

100 days per calendar year 40 visits per calendar year combined with OT & PT

20 or 36 visits per contract year (refer to SOB)

Benefit Period Calendar Year


Dental Plan administered by Ameritas

Coverage Type Home Office Employees All Others

Calendar Year Deductible—Individual/Family

$25/$75 $25/$75

Deductible Waived for Preventive Services Preventive Services

Coinsurance

Preventive (Type 1) 100% 100%

Basic (Type 2) 80% 80%

Major (Type 3) 50% 50%

Waiting Period None None

Orthodontia (Child Only to age 19) 50% N/A

Waiting Period None None

* Calendar Year Maximum (per person) $1,000 $1,000 each

Orthodontia Maximum (Lifetime) $1,500 N/A

Eye Care Summary

Maximum $150 $150

Deductible None None

* The member can use up to $1000 toward any covered dental expense. * The member can use up to $150 towards any covered eye care expense. * Total benefits paid between the two coverages will not exceed $1000

Fusion: Combined dental and eye care benefits in one easy-to-administer plan. This plan combines the annual maximum between the dental and eye care plans.

SELECTED COVERED SERVICES AND FREQUENCY LIMITATION

Type I - Preventive Services

Oral Exams (2 in 12 months) Space Maintainers

Cleanings (4 in 12 months) Sealants (age 14 and under)

Bitewing X-Ray (1 in 12 months) Fluoride for Children 17 and under (2 in 12 months)

Full Mouth X-rays 1 in 3 years

Type II - Basic Services

Restorative Amalgams Periodontics (nonsurgical)

Restorative Composites (anterior and posterior teeth) Periodontics (surgical)

Simple and Complex Extractions Endodontics (nonsurgical)

Anesthesia Endodontics (surgical)

Type III - Major Services

Onlays Denture Repair

Crowns (1 in 7 years per tooth) Implants

Crown Repair Prosthetics (fixed bridge; removable complete/partial dentures (1 in 7 years)



Vision Plan administered by VSP

Coverage Type In-Network

MEMBER PAYS Out-of-Network Reimbursement

Vision Exam (Limit One every 12 months) $10 copay Up to $45

Lenses (Limit one paid every 12 months)

Single Vision

Lined Bifocal

Lined Trifocal

Polycarbonate lenses for dependent children

$30 copay

$30 copay

$30 copay

$30 copay

Up to $30

Up to $50

Up to $65

Up to $50

Frames (Limit one every 12 months) $130 allowance after $30 copay

20% off amount over your allowance Up to $70

Contact Lenses (Limited one every 12 months : instead of

glasses)

Medically Necessary

Elective

Contact lens exam (fitting and evaluation)

Covered in Full

$130 allowance; copay does not apply

Up to $60

Up to $210

Up to $105

Additional Discounts and Features Glasses and Sunglasses: 20% off additional glasses and sunglasses including lens options from any VSP doctor within 12 months of your last Well Vision Exam Laster Vision Correction: Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities Laser vision correction - 15% off the retail price or 5% off the promotional price for LASIK or PRK procedures.



Your Contributions

Dental Plan Deduction per bi-weekly

pay period

Employee Only $2.71

Employee + Spouse $22.94

Employee + Domestic Partner $2.71 / $20.23

Employee + Children $15.76

Family $22.94 Dent

al

Vision Plan Deduction per bi-weekly

pay period

Employee Only $2.75

Employee + One Person $4.40

Employee + Children $4.50

Family $7.25 Visio

n HMO $2000 Deduction per bi-weekly pay period

With Healthy Behavior Credit Without Healthy Behavior Credit

Employee Only $104.18 $109.18

Employee + Spouse $365.99 $375.99

Employee + Children $259.64 $264.64

Family $472.03 $482.03

HMO HSA $5000 Deduction per bi-weekly pay period





Family $283.76 $293.76 Med

ical

PPO HSA $2600 Deduction per bi-weekly pay period





Family $380.95 $390.95

Living Benefit

If the certificate holder is diagnosed as terminally ill, as defined in the provisions, the certificate holder may elect to receive an accelerated payment of a portion of the group term life insurance benefit. This accelerated payment is called the Living Benefit and is equal to 50% of the certificate holders group term life insurance amount.

AD&D benefits are equal to the amount of Life benefits.

The amount of your Basic Accidental Death and Dismemberment Insurance is equal to the amount of your Basic Group Term Life Insurance amounts in force. Basic Accidental Death and Dismemberment Insurance Coverage is 24-hour. Age reduction rules apply to all Basic coverages. The full AD&D benefit is payable for the following losses if such loss is caused solely by an accident: Life, sight of both eyes, either both hands or both feet, one hand and one foot, sight of one eye and either one hand or one foot, speech and hearing in both ears, quadriplegia, paraplegia and hemiplegia. One half of the principal sum is payable due to a loss of; either one hand or one foot, the sight of one eye, speech or hearing in both ears. One quarter of the principal sum is payable due to loss of; both thumb and index finger of one hand, both thumbs of both hands, all four fingers of one hand, and uniplegia. One eighth of the principal sum is payable due to loss of all of the toes on one foot. Refer to Certificate of Coverage for complete policy details.

Seat Belt, Airbag, Educational Benefit

If the certificate holder dies as a result of an automobile accident while wearing a seat belt, there is an additional benefit equal to 10% of the principal sum, subject to a maximum benefit of $15,000. If the certificate holder dies as a result of an automobile accident that was equipped with an air bag, an additional $10,000 benefit is payable. An Education Benefit the lesser of 1 1/4% of the principal sum; or $2,500 per academic term, 8 per lifetime to a maximum amount of $20,000 will be paid to an eligible surviving qualified child should the certificate holders death result in an accident.

Conversion Privilege

Employees may convert to an individual life policy within 31 days of leaving active employment. No evidence of insurability will be required.

Value Added Services ; Resource Advisor, Travel Assist, Special Offers

Basic Term Life Insurance administered by Anthem Life


Basic Term Life /AD&D

Benefit Amount Managers : Flat $50,000

Supervisors : Flat $25,000 All Others : Flat $15,000

Percent Reduction At Age

Reduction Schedule 35% 70

50% 75

Benefits Terminate at retirement unless provided for in the Schedule of Benefits.

Basic Life insurance includes waiver of premium

Long Term Disability Insurance administered by Lincoln Financial


Long Term Disability

Benefit Coverage

Your benefits will begin 90 days following a sickness or accidental injury. Your monthly Long Term Disability benefit will be 60% of your monthly pre-disability earnings.

Monthly Benefit 60% of salary

Maximum Benefit

$10,000

Benefit Period To age 65

Pre-existing Clause

You may not be eligible for benefits if you have received treatment for a sickness or injury within 3 months prior to the effective date for this benefit. This benefit will not be payable for a Loss of Activities of Daily Living or Cognitive Impairment which begins in the first 12 months after your effective date.

Survivor Income Benefit

A survivor benefit may be paid to your beneficiary if you should die while receiving qualifying disability payments.

Definition of Disability - You are considered disabled when, because of injury or sickness, you are under the regular care of the doctor, are unable to perform the material and substantial duties of your regular occupation and your disability results in a loss of weekly income of at least 20% . After receiving benefits for 24 months, you are considered disabled when, due to the same sickness or injury, you are unable to perform the material and substantial duties of any gainful occupation for which you are reasonably fitted by education, training or experience and disability results in a loss of income of a specified percentage determined by your plan.

Partial Disability Benefit- You are considered partially disabled if you are unable , due to an injury or illness, to perform the main duties of your regular occupation o a fill-time basis. Partial Disability benefits may be payable if you are earning at least 20% of the income you earned prior to becoming disabled. Partial disability benefits allow you t work and earn income from your employer as well as continue to receive benefits, which may enable you to receive 100% of your income during your time of disability.

Recurrent Disability- If you return to work full-time but become disabled from the same disability within six months of returning to work, you will begin receiving benefits again immediately.

Waiver of Premium - You will not be required to pay premium during any time of approved total or partial disability.


Eligibility You are eligible to open a Health Savings Account (HSA) if you are:

• Covered by a HSA-qualified High Deductible Health Plan (HDHP).

• Not covered by other health insurance that is not a HDHP. (Including a plan your spouse may have where he/she has

selected family coverage)*

• Not enrolled in a FSA (unless limited benefit) or an HRA without an initial minimum deductible (Including plans

offered by your spouses employer)

• Not enrolled in Medicare Part A or Part B or Medicaid.

• Not eligible to be claimed as a dependent (child) on another’s tax return.

*There are exceptions: Insurance coverage for accidents, dental care, disability, long-term care, and vision care do not disqualify you from opening a HSA

Benefit Overview First Atlantic HealthCare provides all employee who meet the eligibility requirements and are enrolled in HSA medical plan the option to open a Health Savings Account through People’s United Bank.

A HSA is a tax-free savings account you can use to save money and pay for qualified health care expenses. Qualified expenses include the deductible, coinsurance, prescriptions, chiropractic and alternative medicine, dental/orthodontia, vision hardware/LASIK surgery, certain health insurance and retiree insurance premium, certain long-term care insurance premims. and most medically necessary non-covered medical services.

Health Savings Accounts are employee owned and more importantly, unused funds carry over each year and continue to earn interest, tax-free.

Contributions The maximum amount you can deposit into your account is $3,350 if you have single coverage and $6,750 for family coverage in 2016, even if your policy’s deductible is less than that. If you are age 55 or older, you can also make additional “catch-up” contribution of $1,000 per year.

Tax Benefits

• Cash contributions you make to a HSA during a tax year are deductible from your federal gross income.

• Interest earnings are tax-deferred - and you will never pay taxes on them if you eventually spend the money on qualified medical expenses.

• Withdrawals from your HSA for qualified medical expenses are free from taxation. Withdrawals for non-qualified are subject to ordinary income and a 20% penalty.

For more information check out the IRS website: http://www.irs.gov/publications/p969/index.html


HSA Plan Highlights

Acadia Benefits, Inc. does not provide tax, legal or accounting advice. This material has been prepared for informational purposes only , and is not intended to provide, and should not be relied on for, tax, legal or accounting advice. You should consult your own tax, legal and accounting advisors before engaging in any transaction.

What would my allowed contribution amount be if I became eligible for a HSA Mid-year?

Individuals who are eligible on the first day of the last month of the taxable year (December for most taxpayers) are allowed the full annual contribution, subject to staying enrolled in a HDHP the following calendar year (plus catch up contribution, if 55 or older by year end), regardless of the number of months the individual was an eligible individual in the year. For individuals who are no longer eligible individuals on that date, both the HSA contribution and catch up contribution apply pro rata based on the number on months of the year a taxpayer is an eligible individual.

Do my HSA contributions have to be made in equal amounts each month?

No, you can contribute in a lump sum or in any amounts or frequency you wish. However, your account trustee/custodian (bank, credit union, insurer, etc.) can impose minimum deposit and balance requirements.

What are the tax benefits of a HSA?

1. Cash contributions you make to a HSA during a tax year are deductible from your federal gross income. Contributions made through payroll deduction are made pre-tax. Contributions made by your employer also are not included in your gross income.

2. Interest earnings are tax-deferred and you will never pay federal taxes on them if you eventually spend the money on qualified medical expenses.

3. Withdrawals from your HSA for qualified medical expenses are free from federal income tax.

Does tax filing status (joint vs. separate) affect my contribution?

Tax filing status does not affect your contribution.

What happens if I don’t use the money in the HSA for medical expenses?

If the money is used for other than qualified medical expenses, the expenditure will be taxed and, for individuals who are not disabled or over age 65, subject to a 20% tax penalty.

I have a HSA but no longer have HDHP coverage. Can I still use the money that is already in the HSA for medical expenses tax-free?

Once funds are deposited into the HSA, the account can be used to pay for qualified medical expenses tax-free, even if you no longer have HDHP coverage. There is no time limit on using the funds.

What if my dependents are not covered by my HSA qualified plan?

You may still pay for their qualified medical expenses with your account, if they are an IRS tax dependent.

What if I incur more expenses than I have funds available in my account?

You can pay yourself back at anytime. As you fund your account you can withdraw money for prior medical expenses provided the account was open on or before the date the expense was incurred.

What happens to my HSA if I enrolled in Medicare?

Participation in any type of Medicare (Part A, Part B, Part C -Medicare Advantage Plans, Part D, and Medicare Supplement Insurance -Medigap), makes you ineligible to contribute to an HSA. However, you can continue to use your HSA for qualified medical expenses and for other expenses for as long as you have funds in your HSA. Loss of Eligibility in Month You Turn 65; You lose eligibility as of the first day of the month you turn 65 and enroll in Medicare.

Example. Jim was covered by a self-only HDHP and eligible for an HSA in 2016 but turned 65 on July 2, 2016, and enrolled in Medicare. Jim lost eligibility for an HSA as of July 1, 2016. For 2016, Jim was eligible for 6 months of the year. The federal HSA limit for Jim is $4,350 ($3,350 individual HSA limit plus a $1,000 catch-up). Accordingly, Jim’s calculation is 6/12 X $4,350 = $2,175. Jim’s maximum contribution for 2015 is $2,175.


HSA Q & A


HSA Q & A

Can I use the money in my HSA to pay for medical care for a family member?

Yes, you may withdraw funds to pay for the qualified medical expenses of yourself, your spouse or a tax dependent without tax penalty.

So what exactly is a “qualified” medical expense?

It is an expense for medical care as defined by IRS Code Section 213(d), which states that the expense must be primarily to alleviate or prevent a physical or mental defect or illness. Many expenses for medical care will fall under this Code Section. IRS Publication 502 - Medical and Dental Expenses, also proved information on eligible expenses. Please note that some items listed as not eligible in Publication 502, such as non-prescription medications, are HSA eligible. Examples of appropriate qualified expenses:

• Prescription Drugs

• Physician office visits

• Durable medical equipment

• Physical Therapy

However, some expenses do not qualify. For example:

• Surgery for purely cosmetic reasons

• Health club dues (with exceptions)

• Illegal operations or treatment

Examples of Over-the-counter (OTC) expenses

In order to use your HSA account for OTC expenses, you must retain the cash register receipt and the receipt must include 1. name and address of the provider, 2. date of purchase, 3. name of the OTC item and 4. amount charged. If the name of the item is not shown on the cash register receipt, you must retain a tear off portion of the box or package that includes the name of the item and price along with the cash register receipt. Beginning January 1, 2011, over-the-counter medicines or drugs will not be eligible for reimbursement under Health Savings Accounts (HSA) without a doctor’s Prescription or letter of medical necessity.

▪ Allergy and sinus medications: Claritin, Sudafed, Tylenol Allergy Sinus, Benadryl, Motrin Sinus, etc.

▪ Contraceptives and family planning: Condoms, male infertility test, ovulation test and pregnancy test

▪ Cough and cold medications: Advil Cold & Sinus, Alka-Seltzer Plus, Breathe Right Nasal Strips for colds, Comtrex, Contac, Drixoral, Sudafed Cold, TheraFlu, Tylenol Cold, Vicks Nyquil, etc.

▪ Diabetes care: Test strips for blood glucose, glucometer, injection devices, lancet devices, urinalysis test strips, etc.

▪ Digestion: Antacid liquid and tablets, anti-diarrheal medication, laxatives, anti-gas tablets, hemorrhoid suppositories and cream, lactose intolerance, motion sickness, etc.

▪ First aid: Bandages, tape, gauze pads, antibiotic ointments (Neosporin, Polysporin), antiseptic (Bactine, Curad alcohol swabs), itch and rash (Aveeno anti-itch lotion, Benadryl, Cortaid), lice treatment (Rid, Nix)

▪ Pain and fever: Arthritis caplets (Aleve, Tylenol Arthritis Pain), aspirin (Bayer, Excedrin), non-aspirin pain relief (Advil, Ibuprofen, Tylenol), canker and cold sore relief, menstrual relief (Pamprin, Midol), pain relief patch (Migraine Ice, Icy Hot, TheraPatch), rubs and ointments (BenGay, Heet, Icy Hot)

▪ Smoking cessation: Nicorette gum, Nicoderm Patches, Commit stop smoking lozenges

▪ Supports and braces: Ankle brace, arm and elbow brace, neck brace, surgical support hosiery, wrist and hand brace

• Birth control pills

• Chiropractor services

• Vision and dental care

• Over the counter medications (physicians script required)

• Maternity clothing

• Toothpaste, toiletries, cosmetics


HSA Q & A

Do all expenses that are considered “qualified” apply to my medical plan?

No, under the IRS rules for Health Savings Accounts, many additional expenses are HSA qualified but are not covered by medical plans.

For example, you can use your HSA to pay for:

• Dental services

• Orthodontic services

• Over the counter medications (physicians script required)

And many other services like these. However, these services are not typically a covered expense for purposes of payment by your medical plan.

Can I use my HSA to pay for medical expenses incurred before I set up my account?

No. You cannot reimburse qualified medical expenses incurred before your account is established. We recommend you establish your account as soon as possible, even if you only fund it with the minimum amount required to open the account.

Do unused funds in a Health Savings Account roll over year after year?

Yes, the unused balance in a Health Savings Account automatically rolls over year after year. You won’t lose your money if you don’t spend it within the year.

Can I borrow against the money in my HSA?

No. You may not borrow against it or pledge the funds in it. For more information on prohibited activities, see Section 4975 of the Internal Revenue Code.

Can I roll the money in a Health Savings Account over into an IRA?

You cannot roll the HSA funds over into an IRA. They will stay in the HSA or be rolled into another HSA, (unless age 65 or older).

Can I rollover funds from an IRA into a HSA?

There is a provision which allows for a one-time contribution to a HSA distributed from an IRA. The contribution must be transferred directly from trustee to trustee. This one-time distribution from an IRA is not included in income. In addition, such distributions are not subject to the 10 percent additional tax on early distributions.

The distribution amount is limited to the maximum contribution allowed to the HSA under a HDHP in the year the distribution is made. The allowed amount that would otherwise be contributed to the HSA in the year of an IRA distribution is thus reduced by that IRA distribution. No tax deduction is allowed for the amount distributed from an IRA to a HSA. The provision allows for only one distribution from an IRA to a HSA to occur during the lifetime of an individual.

• Massage therapy for a medical condition

• Acupuncture

First Atlantic healthcre 100 waterman drive #401

South portland, maine 04106

Phone: 207-874-2700

These summaries are for Information Purposes Only The information in this booklet is only a brief description of the benefits and insurance plans, and is not a Summary Plan Description (SPD) for the plan. For complete details on any benefit, refer to your member handbook, or the plan’s benefit booklet. If there are any inconsistencies between the descriptions in this booklet and the insurance contracts, the insurance contract and plan agreements will contain legal, binding provisions and will prevail.

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