THE OPEN ENROLLMENT PROCESS will be similar to last year. · Re: CEBG Open Enrollment– 5/1/19 through 5/31/2019 for Plan Year 7/1/2019‐6/30/2020 Premium changes will be communicated

1320 Greenway, Suite 170, Irving, TX 75038 Phone: 972.714.0004; Toll Free 888.600.7566 Website: www.cebg.org Fax: 972.580.1363; Toll Free 888.580.1363

Date: April 25, 2019 TO: Benefits Coordinator Re: CEBG Open Enrollment– 5/1/19 through 5/31/2019 for Plan Year 7/1/2019‐6/30/2020

Premium changes will be communicated from the Chancery Offices.

There will be no benefits or vendor changes to Catholic Employee Benefit Group (CEBG) medical,

prescription drug, dental, vision, employee assistance program, for the 2019‐2020 Plan Year. There

is a small reduction of Life Insurance benefits for those age 65‐69‐ now $12,500 and 70+ $10,000.

THE OPEN ENROLLMENT PROCESS will be similar to last year.

All employees currently enrolled will be automatically re‐enrolled.

Individual instruction letters for each Currently Enrolled Lay Employee will be mailed

directly to each employee at their home address by May 1, 2019.

All eligible employees (working 30 hours per week or more) should review or Waive

Coverage via the Benefit Harbor online enrollment website or by contacting Benefit Harbor

Customer Service by phone (888) 408‐3875 during the month of May.

o Enrollment is available to all eligible employees (For lay employees defined as working

a minimum of 30 hours a week and receiving W‐2 reportable wages at least at

minimum hourly rate).

o All benefit schedules are posted on the Benefit Harbor website and may be

downloaded for reference.

Enrollment and or Waiver forms will continue to be sent to the Diocese who will submit to

CEBG for processing.

Enclosure: Summary 7/1/19 changes Enrollment/Catholic Life form Waiver form

1500 Solana Blvd., Bldg. 3, Suite 3550, Westlake, TX 76462 Phone: 972.714.0004; Toll Free 888.600.7566 Website: www.cebg.org Fax: 972.580.1363; Toll Free 888.580.1363

(Over)

Summary of Employee Benefits Changes effective July 1, 2019

1. Open Enrollment. Open Enrollment will be held from May 1 through May 31, 2019. This is the time period in which an Eligible Employee may elect, drop or change Catholic Employee Benefit Group (CEBG) coverage. Unless a Special Event occurs, changes in participation status can only be made at Annual Open Enrollment.

2. There will be no benefits or vendor changes to Catholic Employee Benefit Group (CEBG) medical, prescription drug,

dental, vision, or employee assistance program for the 2019‐2020 Plan Year. Life insurance benefits have changed slightly. See item 17. below. Benefits are in a bundled package. There will be changes to the current premiums. Your Diocese HR will notify you of the increases.

3. We will continue using Benefit Harbor for the open enrollment process. All employees currently enrolled will be reenrolled automatically. If you wish to make changes you should review or Waive Coverage via the Benefit Harbor online enrollment website (www.mybenefitharbor.com/CEBG) or by contacting Benefit Harbor Customer service by phone at (888) 408‐3875 during the month of May (CEBG’s Open Enrollment Period). Your current enrollment information will be pre‐populated, thereby making the process as speedy as possible. The Benefit Harbor website is to be used during this open enrollment period, for all new hires throughout the year, for reference throughout the year for all benefits, and for making changes for a qualified life event (QLE). All CEBG Benefit Schedules (medical, prescription drug, dental, vision, life, EAP) are available online at www.mybenefitharbor.com/CEBG.

4. When benefits begin:

a. If you are employed by a CEBG Subscribing Employer and Not Currently a covered member, if you enroll, your coverage will begin July 1, 2019.

b. For newly hired and enrolled religious order and lay employees, coverage begins on the first day of the month following 60 days of employment.

c. If you are waiving coverage through CEBG, you must complete the Waiver of Group Health Benefits & Notice of Special Enrollment Rights form and return it to the Diocese HR/Benefits Office.

5. Eligibility Rules. The minimum eligibility requirements for participation in CEBG are:

a. Must be employed, on a permanent, full‐time basis defined as 30 hours or more per week, b. Performing the usual duties of his/her covered occupation in a place of business designated by the employer,

and c. For Lay employees, compensated in the form of W‐2 reportable wages of at least the Minimum Wage as set by

Federal or State standards.

6. Grandfathered Status. CEBG has again chosen a Grandfathered Status for the Plan. CEBG believes this Plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your Plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime and annual dollar limits on benefits. Questions regarding grandfathered health plan status can be directed to Catholic Employee Benefit Group, 1500 Solana Blvd, Bldg. 3, Suite 3550, Westlake, TX 76462.

7. Medical Claims Administration. There is no change in medical claims administrator (WebTPA).

8. Pharmacy Administration and Prescription Drug Co‐Pays. There is no change in Pharmacy Benefits Manager (Cerpass Rx) or in Prescription Drug co‐pays: $4 for generic drugs, $34 for brand name formulary drugs, and $64 for non‐formulary drugs. 90 day mail order via Cerpass Rx/Optum will remain at two times the 30‐day rate. A copy of the 2019 Cerpass Rx/Optum Rx National Formulary is available at www.mybenefitharbor.com/CEBG. However, please note that not all drugs listed on the National Formulary are covered by CEBG.

9. Medical Provider Network. The provider network for CEBG is Aetna Signature Administrators. A provider directory is available online at www.aetna.com/asa via Aetna’s DocFind program. (No change from prior year)

10. In‐Network. There are no changes in in‐network medical co‐pays, deductibles, coinsurance or out‐of‐pocket maximums. To maximize your CEBG benefits and minimize out‐of‐pocket costs to you, please use in‐network providers whenever possible. (Please Note: LabCorp is now an In‐Network provider.)

11. Out‐of‐Network. There is no change in out‐of‐network deductibles, coinsurance or out‐of‐pocket maximums.

12. Out‐of‐Network, Freestanding Emergency Rooms (ERs). A growing trend is in the establishment of stand‐alone ERs which advertise little or no wait time. Some of these facilities appear to be urgent care clinics, but are, in fact, Freestanding ERs, where they bill as an ER under ER benefits (with higher copays). Also, many of these freestanding ER facilities and their physicians do not contract with provider networks, including Aetna Signature Administrators. Therefore, when you use these facilities/providers, you may be financially responsible for a separate non‐PPO deductible amount, no discount, and higher coinsurance costs. If you are in need of emergency care, please go to the nearest hospital emergency room. In the event that your condition requires hospitalization, the ER copay is waived. Also, when using an urgent care facility, check to make certain that the facility is in‐network.

13. Precertification. You (or your physician) must initiate precertification for all inpatient admissions, certain outpatient surgical procedures, including heart catheterizations, vascular procedures, neurostimulator implants and nasal surgeries, Home Health Care, Hospice Care, Skilled Nursing Facility, Prosthetics, Durable Medical Equipment for purchases of $1,000 or more, Chemotherapy/Specialty Drugs, and Intraoperative Neurological Monitoring.

a. For emergency admissions, contact the Plan within 2 days of treatment. b. NOTE: IF PRE‐CERTIFICATION IS NOT OBTAINED, SERVICES ARE NOT COVERED. (No Change.)

14. Dental Benefits. There will be no change in dental benefits (co‐pays, deductibles, coinsurance, covered services, annual

calendar year maximums), dental administrator (United Concordia), or dental network (Alliance provided by United Concordia). A provider directory is available online at www.unitedconcordia.com, Find a Dentist.

15. Vision Benefits. Vision benefits for eye exams, contacts, glasses, are provided via Davis Vision (No Change).

16. I.D. CARDS. New ID cards will NOT be issued for Medical and Prescription Drug (Rx) Benefits, Dental Benefits, or Vision Benefits. Please use your current ID cards for each Plan.

17. Life Insurance. $25,000 life insurance and $25,000 accidental death and dismemberment insurance, for employees, are included in the CEBG benefits package, with Catholic Life Insurance as the insurer. (No change from prior year). There is a change in the over 65 benefits as follows: 65‐69+ $12,500 and 70+ $10,000

18. Additional Life Insurance. You have the opportunity to voluntarily purchase additional life insurance via Catholic Life Insurance Company for you, your spouse, or covered dependent(s), with the premiums handled via payroll deduction. Evidence of Insurability is required.

19. EAP Benefits. You or your CEBG‐enrolled spouse and/or dependent(s) have access to up to six counseling sessions annually, per issue, plus wellness and financial management resources, through the Interface EAP Network with no out‐of‐pocket expense. (No change from prior year)

20. Log in starting May 1, 2019, to Benefit Harbor Self‐Service to enroll in your benefits for the 2019‐2020 Plan Year: www.mybenefitharbor.com/CEBG. Your user ID is your Social Security Number + 703, and your password is your date of birth. See attached documents for additional details. Your online enrollments MUST be completed by May 31, 2019. Note: If you logged in last year you would have been prompted to change the password, so you will need that to login this year.

To Log in to Benefit Harbor Self-Service:

Contact Benefit Harbor’s Dedicated Call Center for Catholic Employee Benefit Group

(To enroll, if you have questions or need assistance with Self-Service)

Benefit Harbor’s Dedicated Fax for Catholic Employee Benefit Group

(888) 687-0807

If you have a life event during the year and need to make changes to your elections, please use the

Qualified Life Event form to make your needed changes within 31 days of the event.

Adding/Removing a dependent spouse or child

Cancellation of benefits if you have gained alternate coverage

Adding coverage due to the loss of alternate coverage

You may acquire a copy of the Qualified Life Event form online by logging in to

www.mybenefitharbor.com/CEBG and clicking on the Tools & Resources tab at the top of the page,

then click on Documents & Links and the link for Qualified Life Event Form and Information.

To upload, mail or fax required documents for changes to coverage at Open Enrollment or

during the year for Qualified Life Events:

Mail a copy of the required document(s) to:

Benefit Harbor

Attention: CEBG Benefit Administrator

5445 Legacy Dr., Ste 250

Plano, TX. 75024

Fax a copy of the required document(s) to:

(888) 687-0807

Scan and Email the documents to: [email protected]

http://www.mybenefitharbor.com/CEBG

mailto:[email protected]

Catholic Employee Benefit Group Health Benefit Enrollment/Change Form

Today’s Date Hire Date Effective Date Group Number 2008CEBG

New hires must complete entire form. Changes should indicate only employee’s name, social security number and items changed.

Subgroup � 0001 Amarillo � 0002 Corpus � 0003 Lubbock � 0004 Tyler

CLASS LOCATION

Section 1 - Employee Information (please print clearly) Employee Name (last, first) Social Security # DOB Gender: (M/F)

Mailing Address(please use P.O.Box if applicable) City State Zip Home Phone

Section 2 - Enrollment/Change Section 3 – Plan Options Section 4 - Dependent Information: Adding Dependents

Name Sex (M/F)

DOB SS# Relationship Address (If Different)

Section 5 - Dependent Information: Dropping Dependents

Name Sex (M/F)

DOB SS# Relationship Address (If Different)

Reason for Enrollment/Change is due to: Date of Change: ___________

� New Employee � Open Enrollment � Late Enrollment � Marriage � Divorce � Death of Spouse or Child � Birth or Adoption of Child � Spouse becomes employed � Spouse ceases to be employed � Separation of Employment Other: ________________________

Medical: � Employee Only � Employee Plus Spouse � Employee Plus Child(ren) � Employee Plus Family Dental: � Employee Only � Employee +1 � Employee + 2

P.O. Box 99906 Grapevine, TX 76099-9706 800-953-2024

Page 1 of 2

Section 6 - Student Status/Disabled - Dependent Information (over age 19) Name Gender

(M/F DOB SS# Relationship Address

(If Different) Other Insurance

Available?

Section 7 - Other Health Insurance Information Do you or the other enrollees have additional health insurance? � Yes � No

Insured Name Insurance Company Name Policy Number Effective Date

Section 8 - Annual Health Plan Information Form and Initial Claim Authorization I have received, read, and understand materials including the Summary of Benefits in the Enrollment Packet explaining the Health Plan and the Dental Plan. I understand that full Summary Plan Descriptions are available upon request. I understand that by signing and submitting this form, I am making an election concerning my benefits for the enrollment period. This election is binding subject to my right to make changes according to provisions of the program and subject to any changes required to comply with federal tax laws. This enrollment form is not an employment agreement. If I submit a claim to the Health Plan for myself and/or covered dependents, I hereby authorize any hospital, physician, or other person who has attended me, or examined me to furnish the Health Plan, WEB-TPA or its authorized representative, any and all information requested with respect to any illness or injury, medical history, consultation, prescription, or treatment and copies of all hospital and medical records. I also authorize the Health Plan and WEB-TPA to disclose said information to third party organizations engaged in actuarial, financial, and statistical studies, as well as the State Insurance Regulator for an insurance regulatory purpose statutorily authorized by the state and to Peer Review Organizations, when necessary. A photocopy of this authorization shall be considered as effective and valid as the original. By signing this form, I submit my annual information review and initial claim authorization. I understand that claims submitted under this authorization will be processed subject to continued proof of eligibility and all plan provisions. I verify that the information on the reverse side of this form is true and correct. I understand that any intentional/knowing falsification of enrollment information is considered fraud and cause for immediate termination of the employee and dependents from the health and/or dental plan(s), with the employee subject to repayment of any funds paid by the Plan.

Section 9 - ELECTING COVERAGE (check box if electing coverage) I am electing coverage for my family or myself at this time. Employee’s Signature: _____________________________________ Date: _________

WAIVING COVERAGE -Section 10 (check box if waiving coverage)

Section 10 – WAIVING COVERAGE (check box if waiving coverage)

Note: If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 30 days after your coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll your dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. I am NOT electing coverage for my family or myself at this time. Employee’s Signature: ____________________________________ Date: ___________

Page 2 of 2

Page 1 of 2 AMGL ENR CRD (11/2013)

1635 NE Loop 410 • P.O. Box 659527 San Antonio, TX 78265-9527 • (210) 828-5529 •1-800-262-2548

EMPLOYEE GROUP ENROLLMENT CARD EMPLOYER INFORMATION PLEASE PRINT INFORMATION

EMPLOYER NAME MASTER GROUP CERTIFICATE NUMBER

EMPLOYEE INFORMATION MALE FEMALE MARRIED SINGLE DIVORCED

_________________________________________________________________________________________________________________________ NAME: FIRST MI LAST SS# DATE OF BIRTH

_________________________________________________________________________________________________________________________ ADDRESS - NUMBER AND STREET CITY STATE ZIP PHONE #

_________________________________________________________________________________________________$__________________________ DATE OF HIRE EFFECTIVE COVERAGE DATE OCCUPATION GROSS ANNUAL EARNINGS

BENEFICIARY INFORMATION

PRIMARY ____________________________________________________________________________________________________________________ FIRST MI LAST SS# RELATIONSHIP DATE OF BIRTH

ADDRESS ___________________________________________________________________________________________________________________ NUMBER AND STREET CITY STATE ZIP PHONE #

CONTINGENT_________________________________________________________________________________________________________________ FIRST MI LAST SS# RELATIONSHIP DATE OF BIRTH

ADDRESS____________________________________________________________________________________________________________________ NUMBER AND STREET CITY STATE ZIP PHONE #

COVERAGE EMPLOYEE AMOUNT

SPOUSE [Max50% of AMOUNT Emp. Amt]

CHILD AMOUNT

A person may not be covered under the Master Group Certificate as a dependent of more than one employee. Also, a person may not be covered as a dependent if that person is eligible as an employee.

Child Dependent(s) over age 19 are full-time students

o Yeso No

Basic Life & AD&D(Paid by employer) N/A N/A

Supplemental Life (Optional) N/A

Supplemental AD & D (Optional) Cannot exceed Supplemental Amt

N/A

Dependent Life: Child: [14] days to [6] months - [$1,000][6] months to age [19/25] if student

N/A N/A X ( )

DEPENDENT INFORMATION

_________________________________________________________________________________________________________________________ SPOUSE NAME: FIRST MI LAST SS# DATE OF BIRTH


_________________________________________________________________________________________________________________________ CHILD NAME: FIRST MI LAST SS# DATE OF BIRTH


_________________________________________________________________________________________________________________________ CHILD NAME: FIRST MI LAST SS# DATE OF BIRTH


For additional child dependents attach separate sheet and include same information as above.

Catholic Employee Benefit Group_________________________________________________________________________________________ CEBG-0717_______________

Page 2 of 2 AMGL ENR CRD (11/2013)

1635 NE Loop 410 • P.O. Box 659527 San Antonio, TX 78265-9527 • (210) 828-5529 •1-800-262-2548 I request insurance under the Master Group Certificate issued by Catholic Life Insurance and authorize the Master Group Certificate Holder to deduct from my earnings any required contributions. I have a regularly scheduled work week with the Master Group Certificate Holder named above at least equal to [30] hours or the minimum required for eligibility under the Master Group Certificate. I understand any misstatement on this enrollment card may result in a denial of a claim and/or discontinuance of coverage. WARNING: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement, may be guilty of insurance fraud. ___________________________________________________________________________________________________________________________ EMPLOYEE'S SIGNATURE DATE

Waiver of Group Health Benefits & Notice of Special Enrollment Rights

Employer Name Diocese Location Number

Employee Name: _______________________________________________________________________ (Last) (First) (MI)

Date of Hire: ______________________________

Are you a part time employee (working less than 30 hours per week or temporary)? If yes, you are not eligible for coverage but read and sign the form. If you are a full time employee, complete the rest of this form and sign.

Mailing Address: _______________________________________________________________________

SSN:_______________________

For the plan year effective 07/ 01/ 2019 I am a full time employee working 30 or more hours per week and am eligible for coverage but I am waiving coverage due to: _____ My preference not to have coverage

_____ Coverage under my spouse’s plan – name of carrier: _______

_____ Other coverage – name of carrier: ____________________

Certification and Special Enrollment Notice – Please review and sign below if you wish to waive coverage

By signing below, I certify that I have been given an opportunity to apply for coverage for myself and my eligible dependents, if any, and I am declining enrollment as indicated above.

I understand that my employer is required in compliance with the Affordable Care Act to report to the Internal Revenue Service (IRS) that I have been offered coverage. If I am eligible for coverage and have waived coverage due to preference, I understand that I will not be eligible for a subsidy on the Federal or State Exchange and that I may be subject to an individual mandate penalty by the IRS.

I understand that if I am declining enrollment for myself or my eligible dependents (including my spouse) because of other health insurance or group health plan coverage, I may be able to enroll myself and my eligible dependents in this plan if I lose and my eligible dependents lose eligibility for that other coverage (or if the employer stops contributing towards my and my eligible dependents’ other coverage).

I understand that I must request enrollment no more than 30 days after the date the other health plan coverage ends (or after the employer stops contributing toward the other coverage). If I do not do so, I will not be able to enroll until my employer's next annual open enrollment period. In addition, I understand that if I have a newly eligible dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my eligible dependent(s). However, I must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

I understand that in order to request special enrollment or obtain more information, I should contact my Diocese’s Human Resources Department.

Signature of Employee Date of Signature

Return to your Diocese’s Human Resources/Benefits Office.

AFN 1104-April 2017

PPO Plan Summary

Catholic Employee Benefit Group Group Number: 2008CEBG

Plan Effective Date: July 1, 2019 In-Network Out-of-Network

Calendar Year Deductible (Does not cross-allocate) • Individual

• Family

• $ 750

• $ 2,000

• $ 1,700

• $ 5,000

Out-of-Pocket Limit (does not cross allocate) • Individual

• Family

NOTE: The plan pays 100% for most covered services after deductibles

and out-of-pocket expenses are reached.

• $ 3,000

• $ 5,000

• $ 5,100

• $15,250

Annual Maximum while covered under the plan.

• Unlimited • Unlimited

Covered Services

In-Network

(The plan pays the % shown after

any copay and/or the calendar year

deductible)

Out-of-Network

(The plan pays the % shown

after any copay and/or the

calendar year deductible)

Physician Services

• Office Visits

- Primary Care Physician

- Specialist

• Allergy Injections

• $25 copay each visit, then

100%, deductible waived



• 80%

• 60%

• 60%

• 60%

• Maternity Services – includes prenatal, delivery and postnatal

physician services

• 80% • 60%

• Surgical Services

- Inpatient

- Outpatient

• 80%

• 80%

• 60%

• 60%

• Nonsurgical Services • 80% • 60%

• Routine Physical Exam (age 18 or older)


- Specialist


100% , deductible waived



• 60%

• 60%

• Routine Mammogram (age 35 and over)

• Routine Preventative (through age 17)


- Specialist

• Childhood Immunization (through age 6)

• 100%, deductible waived





• 100%, deductible waived

• 60%

• 60%

• 60%

• 60%

Hospital Services

• Room & Board and Services & Supplies

• Rehabilitation (up to 30 days each calendar year)

• 80%

• 80%

• 60%

• 60%

AFN 1104-April 2017

Covered Services In-Network



deductible)

Out-of-Network



deductible)

Emergency Care

• Hospital Emergency Room Facility (each visit copay waived if

admitted to the hospital)


80%


60%

• Urgent Care Center



• 60%

• Ambulance Services • 80% , deductible waived • 80% , deductible waived

Mental & Nervous Disorders & Substance Abuse • Not Covered • Not Covered

Other Covered Services

NOTE: In-Network and Out-of-Network maximums and limitations are

combined.

• High End Radiology (MRIs, PET Scans, CT Scans, etc)

• Independent Radiology and Pathology Center

• Outpatient Facility

• 80%

• 80%

• ..80%

• 60%

• 60%

• 60%

• Outpatient Therapy Services (up to 30 days of Physical Therapy, 30

days of Occupational Therapy and 30 days of Speech Therapy each

calendar year)



• 60%

• Spinal Treatment (up to 30 visits each calendar year)



• 60%

• Skilled Nursing Facility (up to 30 days each calendar year) • 80% • 60%, up to a max. allowable

amount of $200 per day

• Home Health Care (up to 60 visits each calendar year)

• 80% • 60%, up to a max. allowable

amount of $55 per visit

• Hospice Care (up to 185 days/visits calendar maximum)

- Inpatient

-

- Outpatient

• 80%

• 80%

• 60%, up to a max. allowable

amount of $55 per day

• 60%, up to max. allowable

amount of $55 per visit

• Durable Medical Equipment • 80% • 60%

• Prosthetics

• Specialty Pharmacy Drugs and Medicines

• Transplants

• 80%

• 80%

• 80%

• 60%

• 60%

• Not Covered

Prescription Drugs Retail (up to a 30-day supply)

• Generic Drugs

• Brand Name Drugs on Formulary

• Brand Name Drugs not on Formulary

Mail Order (up to a 90-day supply)

• Generic Drugs

• Brand Name Drugs on Formulary

• Brand Name Drugs not on Formulary

Contraceptives are excluded. A restricted generic substitution

program applies to covered drugs. Compound drugs limit

$500/script.

Plan pays 100% after

• $ 4 copay

• $34 copay

• $64 copay

Plan pays 100% after:

• $ 8 copay

• $68 copay

• $128 copay

Plan pays 100% after

• 40% coinsurance

• 40% coinsurance

• 40% coinsurance

Plan pays:

• No benefit

• No benefit

• No benefit

AFN 1104-April 2017

PPO Plan Summary

Catholic Employee Benefit Group and Web-TPA want to help you and your family to obtain the highest quality healthcare possible. This PPO

plan, with administrative services provided by Web-TPA and provider network arrangements through Aetna Signature Administrators and

Catholic Employee Benefit Group’s direct provider relationships, is designed to provide you well-coordinated medical services, at a

reasonable price, through a network of carefully selected providers.

To get the most out of this plan, please remember the following:

You will receive the higher level of benefits, the in-network benefits, if you seek care from a provider participating

in the PPO network. A directory of network providers is available on-line at www.aetna.com/asa.

Certain Covered Services are subject to a Maximum Allowable Amount. Maximum Allowable Amount means the

charge considered for Covered Services before the applicable Deductible and Coinsurance are applied. In cases

where the Usual and Customary Charge is less than the Maximum Allowable Amount, the Usual and Customary

Charge would apply.

To Verify Eligibility or Obtain Claim Information Call Web-TPA at 1-800-953-2024.

You (or your physician) must initiate precertification for all inpatient admissions, certain outpatient surgical

procedures, Home Health Care, Hospice Care, Skilled Nursing Facility, Prosthetics and Durable Medical

Equipment for purchases of $1,000 or more, and Chemotherapy/Specialty Drugs. For emergency admissions,

contact the Plan within 2 days of treatment. For Pre-Certification, the Provider must call Web-TPA Pre-

Certification at 1-800-697-9757.

NOTE: IF PRE-CERTIFICATION IS NOT OBTAINED, SERVICES ARE NOT COVERED.

This plan has a restricted generic program. This means that if you request a brand name drug that has a generic

equivalent, when your physician allows substitution, you will be responsible for the brand name Copayment stated

above and the cost difference between the brand name drug and its generic equivalent.

A formulary is a list of preferred medications that have been clinically reviewed by the Plan. To find if a

medication is on the formulary, call Cerpass Rx. at 1-877-990-5553.

A prescription drug claim form may be used for claim reimbursement until you receive your prescription drug

identification card. These forms can also be used if out-of-network benefits apply to your plan.

If you have any questions about your benefits, call the Customer Service phone number on your ID card.

Please note...

This Plan Summary provides a brief description of some of the features and benefits of your group health plan. This Summary is not a

contract. A copy of the Plan Document is available at www.webtpaes.com.

CEBG believes this Plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). As

permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that

law was enacted. Being a grandfathered health plan means that your Plan may not include certain consumer protections of the Affordable Care

Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However,

grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime

and annual dollar limits on benefits. Questions regarding grandfathered health plan status can be directed to Catholic Employee Benefit Group,

1320 Greenway Drive, Suite 170, Irving, TX 75038.

PLEASE READ YOUR BENEFITS DOCUMENT CAREFULLY.

http://www.aetna.com/asa

http://www.webtpaes.com/

AFN 1104-April 2011 ASO

PPO Plan General Exclusions and Limitations

NOTE: Services and supplies which may be Medically Necessary are not covered by the Plan if they are specifically excluded or

limited in this General Exclusions and Limitations provision.

We do not pay benefits under the Plan for any Expense or loss unless otherwise specifically provided in the Plan:

(a) for an Injury or Sickness:

(1) which arises out of, or in the course of, any employment with any employer; or

(2) for which the Covered Person:

a. is entitled to benefits under any workers’ compensation or occupational disease law, employer’s liability or similar laws;

or

b. receives any settlement from a workers’ compensation carrier;

(b) which is in excess of the Usual and Customary Charge, the Facility Charge Allowance or the Allowable Charge;

(c) for services or supplies that are not Medically Necessary;

(d) incurred after coverage ends;

(e) which is not the result of an Injury or Sickness;

(f) for an Injury or Sickness that occurred while committing a felony or participating in a riot;

(g) incurred by a Covered Person while incarcerated in a jail, penitentiary, correctional facility or Hospital;

(h) which the Covered Person does not have to pay;

(i) for Custodial Care, except as part of a Home Health Care Plan approved by Us;

(j) for Developmental Care;

(k) which results from Reconstructive Surgery, except:

(1) for an Injury;

(2) for repair of defects which result from surgery; or

(3) for the reconstructive (not cosmetic) repair of a congenital defect which materially corrects a bodily malfunction;

(l) which results from Cosmetic Surgery;

(m) which relates to appetite control, food addictions, eating disorders (except for documented cases of bulimia or anorexia that

meet standard diagnostic criteria, and present significant symptomatic medical problems) or any treatment of obesity (including

surgery to treat morbid obesity);

(n) for routine foot care, orthopedic shoes, orthotics or other supportive devices for the feet;

(o) in connection with dental work, dental surgery, or oral surgery (unless otherwise specifically provided in the

Plan) including:

(1) treatment or replacement of any tooth or tooth structure, alveolar process, abscess or disease of the periodontal

or gingival tissue; or

(2) surgery or splinting to adjust dental occlusion;

(p) for the treatment of Jaw Joint Disorders (unless otherwise specifically provided in the Plan);

(q) related to sexual and gender identity disorders, including but not limited to:

(1) sexual dysfunctions;

(2) paraphilias; or

(3) gender transformations;

(r) for services and supplies for the treatment of impotence/erectile dysfunction;

(s) for the diagnosis or treatment of the inability to conceive or become pregnant, or the promotion of fertility including, but not

limited to:

(1) fertility tests and procedures;

(2) reversal of surgical sterilization; or

(3) any similar method or treatment which attempts to cause conception or pregnancy by hormone therapy, artificial


insemination, in vitro fertilization and/or embryo transfer;

(t) for birth control drugs or devices including, but not limited to, oral contraceptives, IUDs, contraceptive implants and

any similar drugs, devices or other birth control methods and all related expenses;

(u) for chelation therapy, except for acute arsenic, gold, mercury or lead poisoning;

(v) for services or supplies which are not provided in accordance with generally accepted professional standards and/or

practice;

(w) for services or supplies which:

(1) are considered an Experimental or Investigational Drug or Treatment; or

(2) result from or relate to the application of an Experimental or Investigational Drug or Treatment;

(x) for services or supplies which are primarily for the Covered Person’s education, training or development of

skills needed to cope with an Injury or Sickness;

(y) related to smoking cessation or treatment for nicotine addiction;

(z) for Acupuncture Treatment (except when used in lieu of an anesthetic agent for surgery);

(aa) which is primarily for the Covered Person’s convenience or comfort or that of the Covered Person’s family, caregiver,

companion, sitter, Physician or other person;

(bb) for bills for telephone calls, mailings, faxes, e-mails or any other communications to or from a Physician, Hospital or

other medical provider;

(cc) which results from breast augmentation or reduction, whether or not Medically Necessary, except for breast

reconstruction following a mastectomy as required under state or federal law/regulation;

(dd) which results from:

(1) pervasive developmental disorders;

(2) mental retardation;

(3) conduct disorders; or

(4) developmental disorders;

(ee) for educational testing or educational remediation;

(ff) for therapies designed to promote personal growth or enhancement;

(gg) for exercise equipment;

(hh) for services or supplies which are provided or paid for by the federal government or its agencies, except for:

(1) the Veterans Administration, when services are provided to a veteran for a disability which is not service-

connected;

(2) a military Hospital or facility, when services are provided to a retiree (or dependent of a retiree) from the armed

services;

(3) a group health plan established by a government or its agencies for its own civilian employees and their dependents;

or

(4) Medicaid, if required by a Medicaid assignment of benefits;

(ii) which results from an act of declared or undeclared war or armed aggression;

(jj) which:

(1) is incurred while the Covered Person is on active duty or training in the Armed Forces, National Guard or Reserves

of a state or country; and

(2) for which any governmental body or its agencies are liable;

(kk) for contact lenses, except as provided under the Other Covered Services;

(ll) for routine eye refractions or the fitting or cost of visual aids, vision therapy, radial keratotomy or similar surgery done

for the correction of any refraction error or astigmatism, except for corneal graft;

(mm) for the fitting or cost of hearing aids and related supplies;

(nn) for services provided by a person who lives with You in Your home or is a member of Your family (Your spouse; or a

child, brother, sister or parent of you or Your spouse);

(oo) for Substance Abuse treatment, except as provided in the Plan;

(pp) for Mental and Nervous Disorders treatment, except as specifically provided in the Plan;


(qq) for Nonsurgical Spinal Treatment, except as specifically provided in the Plan;

(rr) for body organ(s)/tissue transplants, except as specifically provided in the Plan;

(ss) for Specialty Drugs and Medicines which exceed a Usual and Customary maximum allowable charge of 115% of Average

Wholesale Price (AWP);

(tt) for any treatment, service or supply unless it is shown under Covered Services in the Plan;

(uu) any Expense which is paid under any other provision of the Plan;

(vv) for dependent child pregnancy or complications of pregnancy of dependent child;

(ww) for abortions, terminations of pregnancy, or complications resulting from abortions or terminations of pregnancy;

(xx) for direct sterilization procedures unless required for treatment of an injury or illness; or

(yy) for any services not in keeping with Ethical and Religious Directives for Catholic Health Care Services.

Hospital Definition

Hospital means any of the following facilities that are licensed by the proper authority in the jurisdiction in which they are located:

(a) a facility which:

(1) provides inpatient services for the care and treatment of patients;

(2) has a registered graduate nurse (RN) always on duty;

(3) has a laboratory and X-ray facility;

(4) as a regular practice, charges the patient for its services; and

(5) has a resident Physician on duty or call at all times; or

(b) a facility which is accredited by the Joint Commission on the Accreditation of Healthcare Organizations, the American

Osteopathic Association or the Commission on the Accreditation of Rehabilitative Facilities, if the function of such facility is

primarily to provide rehabilitation specifically for treatment of a physical disability. Rehabilitative facilities need not have

major surgical facilities.

A hospital does not include a facility or institution or units within a facility or institution, which is licensed or used principally as a

clinic, convalescent home, rest home, nursing home, home for the aged, halfway house, board and care facility, residential treatment

center, “wilderness” program, treatment group home or “boot camp”.

Medical Emergency means a medical condition or behavioral condition of sudden onset that manifests itself by acute symptoms of

sufficient severity (including severe pain) such that a person who possesses an average knowledge of health and medicine could reasonably

expect the absence of immediate medical attention to result in:

(a) placing the health of the Covered Person (or, with respect to a pregnant woman, the health of the woman or her unborn child) in

serious jeopardy;

(b) serious impairment to bodily functions;

(c) serious disfigurement of the Covered Person;

(d) serious impairment of any bodily organ or part of the Covered Person; or

(c) in the case of a behavioral condition, placing the health of the Covered Person or other persons in serious jeopardy.

PLEASE READ YOUR BENEFITS DOCUMENT CAREFULLY A copy of the Plan Document is available at www.webtpaes.com.

http://www.webtpaes.com/

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Dental Benefits Summary for Catholic Employee Benefit Group

EFFECTIVE 7-1-2019 GROUP # 895650-000 Network: Alliance

Benefit Category1

CONCORDIA FLEX PLAN

In-Network2

Non-Network2

Class I – Diagnostic/Preventive Services

Exams

100%

100%

Bitewing X-rays

All Other X-rays

Cleanings & Fluoride Treatments

Sealants

Space Maintainers

Class II – Basic Services

Basic Restorative (Fillings)

80%

80%

Simple Extractions

Palliative Treatment

Endodontics

Nonsurgical Periodontics

Surgical Periodontics

Complex Oral Surgery

General Anesthesia

Class III – Major Services

Inlays, Onlays, Crowns 50%

50% Repairs of Crowns, Inlays, Onlays, Bridges & Dentures

Prosthetics (Bridges, Dentures)

Orthodontics for dependent children to age 19

Diagnostic, Active, Retention Treatment 50% 50%

Maximums & Deductibles (applies to the combination of services received from network and non-network dentists)

Annual Program Deductible (per person/per family) $25/$75

Excludes Class I & Orthodontics

Annual Program Maximum (per person) $1,000

Excludes Orthodontics

Lifetime Orthodontic Maximum (per person) $1,000

Reimbursement Alliance 90th

Percentile

Representative listing of covered services – certificate of coverage provides a detailed description of benefits.

1. Dependent children covered to age 26. 2. Reimbursement is based on our schedule of maximum allowable charges (MACs). Network dentists agree to accept our allowances as payment in full for covered services. Non-network dentists may bill the member for any difference between our allowance and their fee (also known as balance billing). United Concordia Dental’s standard exclusions and limitations apply.

EEM-0142-0214

UnitedConcordia.com • 1-800-332-0366