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Benefits and Eligibility Eligibility This booklet provides a summary of the benefits you are eligible to select as a benefits eligible employee of BRF Hospital Holdings. Benefits eligible employees are employees working at least 60 hours per bi-weekly pay period who have satisfied the company defined waiting periods. This booklet contains information that is important for you to know in order to select the benefits that are best for you and your family. All benefits and an individual’s right to them are subject to federal regulations, BRF Hospital Holding’s policies and procedures, the individual plan documents, and our receipt of your executed and recorded election. Effective Date of Coverage Benefits are effective the first day of the month following your first full calendar month of employment. For Example: Date of hire = August 20th, Effective Date = October 1st Dependent Coverage An eligible dependent is defined as: Your lawful spouse You or your spouse’s child who is under age 26, including a natural child, step child, a legally adopted child, a child placed for adoption, or a child for whom you or your spouse are the legal guardian; or An unmarried child age 26 or over who is or becomes disabled and dependent upon you Dependent Certification Required for Medical Insurance: To deter fraud, abuse, and assure the proper use of company funds and Plan Members’ premium dollars, BRF Hospital Holdings joins the majority of public and private health benefit programs by requiring proof that the dependents covered are your legal dependents. All Active employees are required to provide written proof that each dependent to be covered under Your Medical Plan is your actual legal dependent. This documentation is necessary ONLY if you are enrolling in Medical Insurance. Failure to provide this documentation within 30 days will result in the inability to enroll your dependents under your Medical Plan. If you have any questions about the dependent verification policy, contact your local HR/Benefits Department or HUB International. Written Verification Required for Dependents: If you are adding a dependent to your Medical Plan you MUST submit dependent eligibility documentation. Spouse: To document a Legal Spousal Relationship, submit a copy of: Marriage License, and Page 1 of your Federal Income Tax Return if your filing status is “joint” – or Marriage License, and if your filing status is “Married Filing Separate” also submit Page 1 of both Federal Income Tax Returns; and If you have not been married long enough to file a “joint” Federal Income Tax Return, please only submit a photocopy of your marriage license. Children up to age 26 and disabled children: Natural Child A copy of the Certified Birth Certificate showing the subscriber as the Parent; Step Child A copy of the Certified Birth Certificate showing the name of the natural Parent, and proof that the natural parent and the subscriber are married (e.g., Marriage License); Adopted Child Court documentation verifying completion of Adoption Proceedings; or A letter of placement from an Adoption Agency, an Attorney or the State Department of Social Services, verifying that adoption is in process; Foster Child A Court Order or other legal document placing the Child with the subscriber, who is a licensed foster parent; Other Children For all other children for whom a subscriber has legal custody, a Court Order or other legal document granting custody to the subscriber. Documentation must verify that the subscriber has guardianship responsibility for child, not merely financial responsibility. Incapacitated Child Proof that incapacitation was established at time of enrollment, and for the appropriate child type documentation as outlined above based on relationship. In addition, you should submit a copy of Page 1 of your Federal Income Tax Return to demonstrate that the child is principally dependent on you/the subscriber for support and maintenance. If your incapacitated child is employed, you may be asked to also submit a copy of Page 1 of his/ her Federal Income Tax Return. 1 BRF Hospital Holdings 2013 - 2014 Benefits
Benefits and Eligibility Qualifying Events Once you have enrolled in benefits, you cannot change your elections unless you have a “qualifying event”, and you must submit a change form to your HR/Benefits Department within 30 days of the event. You can obtain a change form from your HR/Benefits Department or from the enrollment website, www.enrollme.biz. For newly eligible dependents, coverage will be effective as of the date of the event, when a change form is submitted within 30 days. IMPORTANT NOTE: Newborns are not automatically added to your policy. You must complete a change form in order to effectively add them to your coverage. Change in Family Status affecting covered persons such as: Marriage or divorce Death of a spouse or dependent child Birth or adoption of a child Loss of other coverage Loss of dependent status (if a child reaches the age limit under the plan or is no longer eligible as a dependent) Change in your employment status affecting your benefits such as: Beginning or returning from a leave of absence Changing to/from part time Change in your spouse’s employment status causing a gain or loss of health coverage for you, your spouse or your eligible dependents: Beginning or ending employment Increasing or decreasing hours Changes associated with a spouse’s open enrollment period including changes in the type and cost of coverage Gain or loss of eligibility for Medicare/Medicaid for you, your spouse, or your eligible dependents (Note - Changes must be made within 60 days) Paid Time Off (PTO) Termination of Benefits Your benefits will terminate on your termination date. Continuation of Medical Coverage At Termination of Employment or Ineligibility of a Dependent: COBRA (Consolidated Omnibus Budget Reconciliation Act) is a federal law, which requires that group plans offer covered employees and dependents the opportunity to continue health insurance coverage when coverage would normally end for certain specified reasons. The following provisions outline the requirements for continued coverage in accordance with the law: You and your covered dependents may continue coverage for up to 18 months if coverage ends because of either a permanent reduction in the number of hours worked or termination of employment for any reason other than gross misconduct. You and/or your covered dependent must apply within 60 days of the date coverage ends or the date you are notified of your continuation rights, whichever is later Your dependents may continue their coverage under the group plan for up to 36 months if their coverage ends for any of the following reasons Divorce from the employee Death of the employee, or Dependent child reaches the maximum age or otherwise ceases to qualify as a dependent under the plan Coverage would be effective the day after the event. Paid time off will include between 15 and 25 days based on length of service, up to 10 days of Extended Sick Leave, and 9 paid holidays for all eligible employees (New Year’s Day, Memorial Day, Good Friday or Easter Sunday, 4 th of July, Labor Day, Thanksgiving Day, Christmas Eve, Christmas Day, and 1 Floating Holiday). Eligible employees are those that work at least 40 hours per bi-weekly pay period. Please refer to the employee manual for more information. Retirement Plan - Great-West Financial The Retirement Plan encourages personal savings. BRF Hospital Holdings will contribute 3% of your pay into a 401k retirement plan for all eligible employees. An eligible employee is one who works at least 40 hours per bi-weekly pay period. In addition, employees can receive a matched benefit of 50% if they choose to contribute pre tax dollars from their check. Employees can contribute up to $17,500 annually ($23,000 if over age 50). The maximum amount the hospital will match will not exceed 3% of employees compensation. You are eligible to participate after 1 year of service, however if you are employed on October 1, 2013 you are immediately eligible to participate. You can enroll on the first day of each quarter (January 1 st , April 1 st , July 1 st and October 1 st ). Gradual vesting applies to the matching contributions. Please refer to the Summary Plan Description and Enrollment Materials for more information. BRF Hospital Holdings 2013 - 2014 Benefits 2
Page 1 and 2: BRF Hospital Holdings Benefit Guide
Page 3: Table of Contents and Contact Infor
Page 7 and 8: Medical - BlueCross BlueShield Feat
Page 9 and 10: Vision - AlwaysCare EXAM covered ev
Page 11 and 12: Short Term Disability - Mutual of O
Page 13 and 14: Critical Illness - HM Life Covered
Page 15 and 16: Online Enrollment Instructions The

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