Summary Plan Description for Columbia University Officer Post 65 Retiree Choice Plus 100 Plan, Study notes of Nursing

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Columbia University

Officer Post 65 Retiree Choice Plus 100 Plan

Effective: January 1, 2022

Group Number: 712790

Summary Plan Description

• SECTION 1 - WELCOME .................................................................................................................. TABLE OF CONTENTS
• SECTION 2 - INTRODUCTION..........................................................................................................
  • Eligibility.........................................................................................................................................
  • Cost of Coverage...........................................................................................................................
  • How to Enroll................................................................................................................................
  • When Coverage Begins ................................................................................................................
  • Changing Your Coverage.............................................................................................................
• SECTION 3 - HOW THE PLAN WORKS...........................................................................................
  • Accessing Benefits.........................................................................................................................
  • Eligible Expenses ........................................................................................................................
  • Annual Deductible ......................................................................................................................
  • Copayment ...................................................................................................................................
  • Coinsurance..................................................................................................................................
  • Out-of-Pocket Maximum ..........................................................................................................
• SECTION 4 - PLAN HIGHLIGHTS ..................................................................................................
  • Payment Terms and Features....................................................................................................
  • Schedule of Benefits ...................................................................................................................
• SECTION 5 - ADDITIONAL COVERAGE DETAILS .......................................................................
  • Acupuncture Services .................................................................................................................
  • Ambulance Services - Emergency Only ..................................................................................
  • Ambulance Services - Non-Emergency...................................................................................
  • Cellular and Gene Therapy........................................................................................................
  • Clinical Trials ...............................................................................................................................
  • Congenital Heart Disease (CHD) Surgeries............................................................................
  • Dental Services - Accident Only...............................................................................................
  • Diabetes Services.........................................................................................................................
  • Durable Medical Equipment (DME).......................................................................................
  • Emergency Health Services - Outpatient ................................................................................
  • Home Health Care......................................................................................................................
  • Hospice Care................................................................................................................................ II TABLE OF CONTENTS
  • Hospital - Inpatient Stay ............................................................................................................
  • Infertility Services........................................................................................................................
  • Injections in a Physician's Office..............................................................................................
  • Lab, X-Ray and Diagnostics - Outpatient...............................................................................
  • • Outpatient.................................................................................................................................. Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine
  • Mental Health Services...............................................................................................................
  • Obesity Surgery ...........................................................................................................................
  • Orthognathic Surgery .................................................................................................................
  • Ostomy Supplies .........................................................................................................................
  • Physician Fees for Surgical and Medical Services ..................................................................
  • Physician's Office Services - Sickness and Injury ..................................................................
  • Pregnancy - Maternity Services .................................................................................................
  • Preventive Care Services ............................................................................................................
  • Private Duty Nursing - Outpatient...........................................................................................
  • Prosthetic Devices ......................................................................................................................
  • Reconstructive Procedures ........................................................................................................
  • Rehabilitation Services - Outpatient Therapy and Manipulative Treatment .....................
  • Scopic Procedures - Outpatient Diagnostic and Therapeutic..............................................
  • Skilled Nursing Facility/Inpatient Rehabilitation Facility Services .....................................
  • Substance-Related and Addictive Disorders Services ...........................................................
  • Surgery - Outpatient ...................................................................................................................
  • Temporomandibular Joint Dysfunction (TMJ)......................................................................
  • Therapeutic Treatments - Outpatient ......................................................................................
  • Transplantation Services ............................................................................................................
  • Urgent Care Center Services .....................................................................................................
  • Urinary Catheters ........................................................................................................................
  • Wigs...............................................................................................................................................
• SECTION 6 - CLINICAL PROGRAMS AND RESOURCES............................................................
  • Consumer Solutions and Self-Service Tools...........................................................................
• COVER............................................................................................................................................. SECTION 7 - EXCLUSIONS AND LIMITATIONS: WHAT THE MEDICAL PLAN WILL NOT
  • Advance Bills ............................................................................................................................... III TABLE OF CONTENTS
  • Alternative Treatments...............................................................................................................
  • Comfort and Convenience ........................................................................................................
  • Dental............................................................................................................................................
  • Drugs.............................................................................................................................................
  • Experimental or Investigational or Unproven Services........................................................
  • Foot Care......................................................................................................................................
  • Medical Supplies and Appliances..............................................................................................
  • Services/Substance-Related and Addictive Disorders Services........................................... Mental Health, Neurobiological Disorders - Autism Spectrum Disorder
  • Nutrition and Health Education...............................................................................................
  • Physical Appearance ...................................................................................................................
  • Procedures and Treatments.......................................................................................................
  • Providers.......................................................................................................................................
  • Reproduction ...............................................................................................................................
  • Services Provided under Another Plan....................................................................................
  • Transplants...................................................................................................................................
  • Travel ............................................................................................................................................
  • Vision and Hearing .....................................................................................................................
  • All Other Exclusions ..................................................................................................................
• SECTION 8 - CLAIMS PROCEDURES ...........................................................................................
  • In-Network Benefits...................................................................................................................
  • Out-of-Network Benefits ..........................................................................................................
  • If Your Provider Does Not File Your Claim .........................................................................
  • Health Statements .......................................................................................................................
  • Explanation of Benefits (EOB) ................................................................................................
  • Claim Denials and Appeals........................................................................................................
  • Review of an Appeal...................................................................................................................
  • External Review Program..........................................................................................................
  • Limitation of Action...................................................................................................................
• SECTION 9 - COORDINATION OF BENEFITS (COB)...................................................................
  • Benefits When You Have Coverage under More than One Plan .......................................
  • When Does Coordination of Benefits Apply? ....................................................................... IV TABLE OF CONTENTS
  • What Are the Rules for Determining the Order of Benefit Payments? .............................
  • How Are Benefits Paid When This Plan is Secondary?........................................................
  • How is the Allowable Expense Determined when this Plan is Secondary? ......................
  • What is Different When You Qualify for Medicare? ............................................................
  • Medicare Crossover Program....................................................................................................
  • Right to Receive and Release Needed Information?.............................................................
  • Does This Plan Have the Right of Recovery?........................................................................
• SECTION 10 - SUBROGATION AND REIMBURSEMENT.............................................................
  • Right of Recovery .......................................................................................................................
• SECTION 11 - WHEN COVERAGE ENDS......................................................................................
  • Coverage for a Disabled Child..................................................................................................
  • Continuing Coverage Through COBRA.................................................................................
  • When COBRA Ends ..................................................................................................................
  • Uniformed Services Employment and Reemployment Rights Act.....................................
• SECTION 12 - OTHER IMPORTANT INFORMATION....................................................................
  • Qualified Medical Child Support Orders (QMCSOs)...........................................................
  • Your Relationship with UnitedHealthcare and Columbia University.................................
  • Relationship with Providers ......................................................................................................
  • Your Relationship with Providers ..........................................................................................
  • Interpretation of Benefits ........................................................................................................
  • Information and Records ........................................................................................................
  • Incentives to Providers ............................................................................................................
  • Incentives to You......................................................................................................................
  • Rebates and Other Payments..................................................................................................
  • Workers' Compensation Not Affected..................................................................................
  • Future of the Plan .....................................................................................................................
  • Plan Document .........................................................................................................................
  • Medicare Eligibility ...................................................................................................................
  • Policies........................................................................................................................................ Review and Determine Benefits in Accordance with UnitedHealthcare Reimbursement
• SECTION 13 - GLOSSARY ...........................................................................................................
• SECTION 14 - IMPORTANT ADMINISTRATIVE INFORMATION: ERISA................................... V TABLE OF CONTENTS
• ATTACHMENT I - HEALTH CARE REFORM NOTICES..............................................................
  • Patient Protection and Affordable Care Act ("PPACA")...................................................
• ATTACHMENT II - LEGAL NOTICES ...........................................................................................
  • Women's Health and Cancer Rights Act of 1998................................................................
  • Statement of Rights under the Newborns' and Mothers' Health Protection Act...........
• ATTACHMENT III – NONDISCRIMINATION AND ACCESSIBILITY REQUIREMENTS .............

1 SECTION 1 - WELCOME

SECTION 1 - WELCOME

Quick Reference Box ■ Member services, claim inquiries, Mental Health/Substance-Related and Addictive Disorder Administrator: 1-888-265-9945. ■ Claims submittal address: UnitedHealthcare - Claims, P.O. Box 704809, Atlanta, GA

■ Online assistance: www.myuhc.com.

Columbia University is pleased to provide you with this Summary Plan Description (SPD), which describes the health Benefits available to you, your spouse and your dependents who are Medicare eligible under the Columbia University Retiree Medical Benefits Plan. It includes summaries of:

■ Who is eligible.

■ Services that are covered, called Covered Health Services.

■ Services that are not covered, called Exclusions and Limitations.

■ How Benefits are paid.

■ Your rights and responsibilities under the Plan.

This SPD is designed to meet your information needs and the disclosure requirements of the Employee Retirement Income Security Act of 1974 (ERISA). It supersedes any previous printed or electronic SPD for this Plan.

IMPORTANT The healthcare service, supply or Pharmaceutical Product is only a Covered Health Service if it is Medically Necessary. (See definitions of Medically Necessary and Covered Health Service in Section 13, Glossary .) The fact that a Physician or other provider has performed or prescribed a procedure or treatment, or the fact that it may be the only available treatment for a Sickness, Injury, Mental Illness, substance-related and addictive disorders, disease or its symptoms does not mean that the procedure or treatment is a Covered Health Service under the Plan.

Columbia University intends to continue this Plan, but reserves the right, in its sole discretion, to modify, change, revise, amend or terminate the Plan at any time, for any reason, and without prior notice subject to any collective bargaining agreements between the Employer and various unions, if applicable. This SPD is not to be construed as a contract of or for employment. If there should be an inconsistency between the contents of this summary and the contents of the Plan, your rights shall be determined under the Plan and not under this summary.

3 SECTION 1 - WELCOME

How To Use This SPD ■ Read the entire SPD, and share it with your family. Then keep it in a safe place for future reference. ■ Many of the sections of this SPD are related to other sections. You may not have all the information you need by reading just one section. ■ You can find copies of your SPD and any future amendments at www.hr.columbia.edu or request printed copies by contacting the number on your ID card. ■ Capitalized words in the SPD have special meanings and are defined in Section 13, Glossary. ■ If eligible for coverage, the words "you" and "your" refer to Covered Persons as defined in Section 13, Glossary. ■ Columbia University is also referred to as University. ■ If there is a conflict between this SPD and any benefit summaries (other than Summaries of Material Modifications) provided to you, this SPD will control.

4 SECTION 2 - INTRODUCTION

SECTION 2 - INTRODUCTION

What this section includes: ■ Who's eligible for coverage under the Plan. ■ The factors that impact your cost for coverage. ■ Instructions and timeframes for enrolling yourself and your eligible Dependents. ■ When coverage begins. ■ When you can make coverage changes under the Plan.

Eligibility

You are eligible to enroll in the Plan if you separate from service and have attained age 55 years of age with 10 or more years of service after the age of 45 under the Columbia University Retirement Plan for Officers. The 10 years or more of service does not need to be continuous for you to be eligible to participate in the Columbia University Retiree Medical and Life Insurance Benefits Plan.

If you are age 65 or older and separate from service as an Officer with the required 10 or more years of service, you and any eligible dependents who are Medicare eligible are eligible for the Post 65 Retiree Choice Plus 100 coverage under the terms of the Columbia University Retiree Medical and Life Insurance Benefits Plan. In addition, if you become disabled and begin receiving benefits under the Columbia Long Term Disability Plan you will be eligible to participate in the Columbia University Retiree Medical and Life Insurance Plan when your Long Term Disability benefits terminate provided that you had 10 years of service when you first began to receive LTD benefits. You must be age 65 and over when your Long Term Disability benefits terminate to be eligible for this Plan.t

If you qualify for and elect to participate in the Columbia University Retiree Medical and Life Insurance Benefits Plan, you and your covered dependents will remain covered by your selected active medical plan until the end of the month in which your employment ends (retirement date). Your active medical plan will be your primary coverage or your secondary coverage depending on your retirement date. Please note that if you retire on the last day of a month your active medical plan ends on the same day for you and your dependents.

Important: Medicare is the primary payer under this plan. Please refer to Section 9, Coordination of Benefits, for further details regarding claim processing.

Medicare eligible Retirees, Spouses and Dependents must be enrolled in the same Medical Plan, i.e. in the Indemnity Medical Plan or in the Post-65 Retiree Choice Plus 100 Medical Plan.

Contact the Benefits Service Center (CUBSC) at 212-851-7000 if you think you have attained the age and service requirements for Officer Retiree Medical Benefits Plan. The Benefits Service Center (CUBSC) will confirm your retirement eligibility. You then are responsible for communicating to your department administrator your effective date of retirement. Before you can begin participating in the Columbia University Retiree Medical Benefits Plan,

6 SECTION 2 - INTRODUCTION

If you and your Spouse are both covered under the Columbia University Retiree Medical Benefits Plan, you may each be enrolled as an Employee or be covered as a Dependent of the other person, but not both. In addition, if you and your Spouse are both covered under the Columbia University Retiree Medical Benefits Plan only one parent may enroll your child as a Dependent.

A Dependent also includes a child for whom health care coverage is required through a Qualified Medical Child Support Order or other court or administrative order, as described in Section 12, Other Important Information.

Cost of Coverage

You and Columbia University share in the cost of the Plan. The University has determined its level of support for benefit coverage for you and your eligible Dependents. Your contribution amount depends on the Plan you select and the number of eligible dependents you choose to enroll.

Your contributions are subject to review and Columbia University reserves the right to change your contribution amount from time to time.

Information about your share of the cost is provided with your enrollment materials at retirement and during annual open enrollment.

How to Enroll

If you separate from your position as an Officer and are eligible to participate in the Plan, you may enroll in the Plan effective as of the first day of the month following your retirement date.

After your initial enrollment, you have the opportunity to make changes each fall during the Benefits Open Enrollment period. If you are enrolled in retiree medical benefits, you will receive notification from the University about this opportunity to change your health plan and the eligible dependents you want to cover. The selections you make during annual Benefits Open Enrollment will become effective the following January 1.

Please contact the Columbia Benefits Service Center at 212-851-7000 or hrbenefits@columbia.edu with any questions you have regarding enrollment under the Plan.

Important If you wish to change your benefit elections following your birth, adoption of a child, placement for adoption of a child or other Qualified Life Status Change, you must notify the Columbia Benefits Service Center (CUBSC) at 212-851-7000 within 31 days of the event. Otherwise, you will need to wait until the next annual Open Enrollment to change your elections.

When Coverage Begins

Once the Columbia Benefits Service Center (CUBSC) receives your properly completed enrollment form, coverage will begin on your date of retirement. Coverage for your

7 SECTION 2 - INTRODUCTION

Dependents will start on the date your coverage begins, provided you have enrolled them in a timely manner.

Coverage for Dependent children acquired through birth, adoption, or placement for adoption is effective the date of the Qualified Life Status Change, provided you notify the Columbia Benefits Service Center (CUBSC) at 212-851-7000 within 31 days of the birth, adoption, or placement.

If You Are Hospitalized When Your Coverage Begins

If you are an inpatient in a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility on the day your coverage begins, the Plan will pay Benefits for Covered Health Services related to that Inpatient Stay as long as you receive Covered Health Services in accordance with the terms of the Plan.

You should notify UnitedHealthcare within 48 hours of the day your coverage begins, or as soon as is reasonably possible. In-Network Benefits are available only if you receive Covered Health Services from In-Network providers.

Changing Your Coverage

You may make coverage changes during the year only if you experience a change in family status. The change in coverage must be consistent with the change in status (e.g., you cover , your child following an adoption, etc.). The following are considered qualified life status changes for purposes of the Plan:

■ Your divorce, legal separation or annulment.

■ The birth, legal adoption, placement for adoption or legal guardianship of a child.

■ A change in your Spouse's employment or involuntary loss of health coverage (other than coverage under the Medicare or Medicaid programs) under another employer's plan.

■ Loss of coverage due to the exhaustion of another employer's COBRA benefits, provided you were paying for premiums on a timely basis.

■ Your death or the death of a Dependent.

■ Your Dependent child no longer qualifying as an eligible Dependent.

■ A change in your or your Spouse's position or work schedule that impacts eligibility for health coverage.

■ Contributions were no longer paid by the employer (this is true even if you or your eligible Dependent continues to receive coverage under the prior plan and to pay the amounts previously paid by the employer).

■ You or your eligible Dependent who were enrolled in an HMO no longer live or work in that HMO's service area and no other benefit option is available to you or your eligible Dependent.

9 SECTION 3 - HOW THE PLAN WORKS

SECTION 3 - HOW THE PLAN WORKS

What this section includes: ■ Accessing Benefits. ■ Eligible Expenses. ■ Annual Deductible. ■ Copayment. ■ Coinsurance. ■ Out-of-Pocket Maximum.

Accessing Benefits

As a participant in this Plan, you have the freedom to choose the Physician or health care professional you prefer each time you need to receive Covered Health Services. The choices you make affect the amounts you pay, as well as the level of Benefits you receive and any benefit limitations that may apply.

Please Note: Medicare is the primary carrier for all participants in this Plan. It is important to check your provider’s participation with Medicare and refer to the subsection Determining the Allowable Expense When This Plan is Secondary to Medicare under Section 9 Coordination of Benefits section of this SPD for more information.

You are eligible for the In-Network level of Benefits under this Plan when you receive Covered Health Services from Physicians and other health care professionals who have contracted with UnitedHealthcare to provide those services.

You can choose to receive In-Network Benefits or Out-of-Network Benefits.

In-Network Benefits apply to Covered Health Services that are provided by an In-Network Physician or other In-Network provider.

Out-of-Network Benefits apply to Covered Health Services that are provided by an Out- of-Network Physician or other Out-of-Network provider, or Covered Health Services that are provided at an Out-of-Network facility.

You must show your Medicare and UnitedHealthcare identification cards (ID cards) every time you request health care services from an In-Network provider. If you do not show your ID cards, In-Network providers have no way of knowing that you are enrolled in Medicare and this Plan. As a result, they may bill you for the entire cost of the services you receive.

Generally, when you receive Covered Health Services from an In-Network provider, you pay less than you would if you receive the same care from an Out-of-Network provider. Therefore, in most instances, your out-of-pocket expenses will be less if you use an In- Network provider.

10 SECTION 3 - HOW THE PLAN WORKS

If you choose to seek care outside the In-Network, the Plan generally pays Benefits at a lower level. It is important that you also seek care from a provider that participate in Medicare as they are limited in what they can charge you. If you seek care from a provider that does not participate in Medicare, there is no limit in what they can charge you. You are required to pay the amount that exceeds the Eligible Expense. The amount in excess of the Eligible Expense could be significant, and this amount does not apply to the Out-of-Pocket Maximum.

Health Services from Out-of-Network Providers Paid as In-Network Benefits

If specific Covered Health Services are not available from an In-Network provider, you may be eligible to receive In-Network Benefits when Covered Health Services are received from an Out-of-Network provider. In this situation, your In-Network Physician will notify UnitedHealthcare, and if UnitedHealthcare confirms that care is not available from an In- Network provider, UnitedHealthcare will work with you and your In-Network Physician to coordinate care through an Out-of-Network provider.

Looking for an In-Network Provider? In addition to other helpful information, www.myuhc.com, UnitedHealthcare's consumer website, contains a directory of health care professionals and facilities in UnitedHealthcare's In-Network. While In-Network status may change from time to time, www.myuhc.com has the most current source of In-Network information. Use www.myuhc.com to search for Physicians available in your Plan. You can also go to http://columbia.welcometouhc.com/home to search for In-Network providers.

In-Network Providers

UnitedHealthcare or its affiliates arrange for health care providers to participate in an In- Network. At your request, UnitedHealthcare will send you a directory of In-Network providers free of charge. Keep in mind, a provider's In-Network status may change. To verify a provider's status or request a provider directory, you can call UnitedHealthcare at the number on your ID card or log onto www.myuhc.com.

In-Network providers are independent practitioners and are not employees of UnitedHealthcare.

UnitedHealthcare's credentialing process confirms public information about the providers' licenses and other credentials, but does not assure the quality of the services provided.

Before obtaining services you should always verify the In-Network status of a provider. A provider's status may change. You can verify the provider's status by calling UnitedHealthcare. A directory of providers is available online at www.myuhc.com or by calling the number on your ID card to request a copy.

It is possible that you might not be able to obtain services from a particular In-Network provider. The In-Network of providers is subject to change. Or you might find that a particular In-Network provider may not be accepting new patients. If a provider is no longer In-Network or is otherwise not available to you, you must choose another In-Network provider to get In-Network Benefits.

12 SECTION 3 - HOW THE PLAN WORKS

Advocacy Services Through Naviguard

The Plan has contracted with UnitedHealthcare to provide advocacy services on your behalf with respect to out-of-network providers that have questions about the Eligible Expenses and how UnitedHealthcare or its designee, Naviguard, determined those amounts. Please call UnitedHealthcare at the number on your ID card to access these advocacy services, or if you are billed for amounts in excess of your applicable coinsurance or copayment. In addition, if UnitedHealthcare, or its designee, Naviguard, reasonably concludes that the particular facts and circumstances related to a claim provide justification for reimbursement greater than that which would result from the application of the Eligible Expense, and UnitedHealthcare, or its designee, Naviguard, determines that it would serve the best interests of the Plan and its Participants (including interests in avoiding costs and expenses of disputes over payment of claims), UnitedHealthcare, or its designee, Naviguard, may use its sole discretion to increase the Eligible Expense for that particular claim.

Don't Forget Your ID Card Remember to show your Medicare and UHC ID card every time you receive health care services from a provider. If you do not show your ID cards, a provider has no way of knowing that you are enrolled under the Plans.

Annual Deductible

The Annual Deductible is the amount of Eligible Expenses you must pay each calendar year for Covered Health Services before you are eligible to begin receiving Benefits. There are separate In-Network and Out-of-Network Annual Deductibles for this Plan. The amounts you pay toward your Annual Deductible accumulate over the course of the calendar year.

Amounts paid toward the Annual Deductible for Covered Health Services that are subject to a visit or day limit will also be calculated against that maximum benefit limit. As a result, the limited benefit will be reduced by the number of days or visits you used toward meeting the Annual Deductible.

Eligible Expenses charged by Out-of-Network providers apply toward the In-Network individual and family Deductibles.

Copayment

A Copayment (Copay) is the amount you pay each time you receive certain Covered Health Services. The Copay is a flat dollar amount and is paid at the time of service or when billed by the provider. Copays count toward the Out-of-Pocket Maximum. Copays do not count toward the Annual Deductible. If the Eligible Expense is less than the Copay, you are only responsible for paying the Eligible Expense and not the Copay.

Coinsurance

Coinsurance is the percentage of Eligible Expenses that you are responsible for paying. Coinsurance is a fixed percentage that applies to certain Covered Health Services after you meet the Annual Deductible.

13 SECTION 3 - HOW THE PLAN WORKS

Out-of-Pocket Maximum

The annual Out-of-Pocket Maximum is the most you pay each calendar year for Covered Health Services. There are separate In-Network and Out-of-Network Out-of-Pocket Maximums for this Plan. If your eligible out-of-pocket expenses in a calendar year exceed the annual maximum, the Plan pays 100% of Eligible Expenses for Covered Health Services through the end of the calendar year.

Eligible Expenses charged by Out-of-Network providers apply toward the In-Network individual and family Out-of-Pocket Maximums.

The following table identifies what does and does not apply toward your In-Network and Out-of-Network Out-of-Pocket Maximums:

Plan Features

Applies to the In- Network Out-of- Pocket Maximum?

Applies to the Out- of-Network Out- of-Pocket Maximum?

Medical Copays Yes Yes

Prescription Copays No No

Payments toward the Annual Deductible Yes Yes

Coinsurance Payments Yes Yes

Charges for non-Covered Health Services No No

The amounts of any reductions in Benefits you incur by not obtaining prior authorization as required by Medicare

No No

Charges that exceed Eligible Expenses No No