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II. HMedical Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85II. IServices Requiring Prior Authorization . . . . . . . . . . . . . . . . . . . . . . 90II. JVision Care and Hearing Aids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95II. KDental Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97II. LPrescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101SECTION III – DISABILITY AND PAID FAMILY LEAVE BENEFITS. . . . . . . . 109III. AWhen You Are Eligible for Disability orPaid Family Leave Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111III. BDisability Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113III. CPaid Family Leave Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118III. DWorkers’ Compensation Leave Benefits . . . . . . . . . . . . . . . . . . . . 121SECTION IV – LIFE INSURANCE BENEFITS. . . . . . . . . . . . . . . . . . . . . . . . . 125IV. ALife Insurance Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127IV. BLife Insurance Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130IV. CAccidental Death and Dismemberment . . . . . . . . . . . . . . . . . . . . 132IV. DBurial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134SECTION V – OTHER BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135V. AAnne Shore Sleep-Away Camp Program . . . . . . . . . . . . . . . . . . . 138V. BJoseph Tauber Scholarship Program . . . . . . . . . . . . . . . . . . . . . . 140V. CSocial Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142V. DWage Class III Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145SECTION VI – RETIREE HEALTH BENEFITS. . . . . . . . . . . . . . . . . . . . . . . . . 147VI. ARetiree Health Benefit Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . 150VI. BRetiree Health Benefits for Medicare-eligible Retirees . . . . . . . . . 153VI. CUnreduced Early or Disability Retiree:Continued Benefit Fund Health Coverage . . . . . . . . . . . . . . . . . . 158VI. DReduced Early Retiree: Limited Benefit Fund Health Coverage . . 160VI. ERetired Members Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162Previous NextJanuary 2021 6 HOME TABLE OF CONTENTS

SECTION VII – GETTING YOUR BENEFITS. . . . . . . . . . . . . . . . . . . . . . . . . . 163VII. AGetting Your Healthcare Benefits . . . . . . . . . . . . . . . . . . . . . . . . . 165VII. BYour Rights Are Protected – Appeal Procedure . . . . . . . . . . . . . . 170VII. CWhen Benefits May Be Suspended, Withheld or Denied . . . . . . . 176VII. DWhat Is Not Covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177VII. EAdditional Provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179SECTION VIII – GENERAL INFORMATION. . . . . . . . . . . . . . . . . . . . . . . . . . . 181VIII. AYour ERISA Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182VIII. B Plan Amendment, Modification and Termination . . . . . . . . . . . . . 185VIII. C Authority of the Plan Administrator . . . . . . . . . . . . . . . . . . . . . . . . 186VIII. D Information on the Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187SECTION IX – DEFINITIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193Previous NextJanuary 2021 7 HOME TABLE OF CONTENTS

NEED TO KNOW WHAT “FAMILY” MEANSIN THIS SPD?Refer to the Definitions SectionSection IX lists the terms used in this SPD and explains how they are definedby the Benefit Fund.Refer to this section if you have any questions about the meaning of specificwords or phrases, such as “spouse,” “family,” “Contributing Employer,” etc.For example, “family” as used in this SPD, refers only to your spouse or yourchildren who are eligible for benefits from this Benefit Fund.If you have any further questions, please call our Benefit Fund’s MemberServices Department at (646) 473-9200.Previous NextJanuary 2021 8 HOME TABLE OF CONTENTS

YOUR BENEFIT FUNDThe 1199SEIU National Benefit Fundis a self-administered, self-funded,labor-management, Taft-Hartley TrustFund. Your coverage is provided asa result of a Collective BargainingAgreement between your Employerand your Union, 1199SEIU UnitedHealthcare Workers East (“1199SEIU”).Wage Class I and II Benefits are“grandfathered” plans that meet orexceed the requirements for “minimumessential coverage” and providecoverage that is “affordable” andexceed “minimum value,” as thoseterms are defined by the PatientProtection and Affordable Care Act(the “Affordable Care Act”).Labor-management means that theBenefit Fund is run by Trustees appointedby 1199SEIU and by Employers whomake payments to the Benefit Fund onbehalf of their employees.Taft-Hartley is the name of the federallaw that allows these labor-managementtrust funds to be established.Self-funded means all of the moneyyour Employer pays to the BenefitFund on your behalf goes directly toproviding your benefits. The BenefitFund does not exist to make profits, likean insurance company does. It existsonly to provide you and your family,and other 1199SEIU members andtheir families, with quality health andwelfare benefits. It also means that theFund is not subject to state insurancelaws. Instead, the Fund is governed bya federal law known as the EmployeeRetirement Income Security Act of1974 (“ERISA”) (see Section VIII.A).The Fund believes it is a “grandfatheredhealth plan” under the Patient Protectionand Affordable Care Act (the “AffordableCare Act”). A grandfathered healthplan can preserve certain basic healthcoverage that was already in effectwhen that law was enacted in 2010.Being a grandfathered health plan meansthat this plan may not include certainconsumer protections of the AffordableCare Act that apply to other plans, forexample, the requirement for an externalreview process for claims appeals.However, grandfathered health plansmust comply with certain other consumerprotections in the Affordable Care Act, forexample, the elimination of lifetime limitson benefits. The Wage Class III plan is nota grandfathered health plan. Questionsregarding which protections apply andwhich protections do not apply to agrandfathered health plan can be directedto the Plan Administrator at (646) 473-9200.You may also contact the EmployeeBenefits Security Administration, U.S.Department of Labor at (866) 444-3272 ion/ask-ebsa. This website hasa table summarizing which protectionsdo and do not apply to grandfatheredhealth plans.HOME TABLE OF CONTENTSJanuary 2021 9Previous Next Self-administered means that theBenefit Fund staff is responsible forthe day-to-day administration of theFund, including processing your claims,answering your questions and performingother administrative operations.

Minimum essential coverage ishealth coverage that the AffordableCare Act requires most people to have.The Wage Class III benefit plan does notprovide minimum essential coverage.Minimum value is a standard of healthplan benefits established under theAffordable Care Act. A health plan meetsthis standard if it is designed to pay atleast 60% of the total cost of medicalservices for a standard population.Individuals who are offered Employersponsored minimum essentialcoverage that provides minimum valueand is affordable won’t be eligible for apremium tax credit for coverage throughthe Health Insurance Marketplace.This Benefit Fund is jointly administeredtogether with other Benefit Fundsserving people in 1199SEIU bargainingunits. All these funds are housedtogether and share staff, services andeligibility information. This allows yourbenefits to be administered efficiently.YOUR EMPLOYER PAYSFOR YOUR BENEFITSYour Union contract — the CollectiveBargaining Agreement between yourEmployer and 1199SEIU — requiresthat your Employer make paymentsto the Benefit Fund on your behalf forhealth and welfare benefits.The cost of your benefits is paid throughcontributions to the Benefit Fund byyour Employer. These payments arecalled contributions because they go intoa large pool of money used to pay for allthe benefits for all 1199SEIU membersand their families covered by the Plan.Your Union dues are paid to 1199SEIUto cover the cost of running the Union —not to the Benefit Fund to coverthe cost of providing health andwelfare benefits.Previous NextJanuary 2021 10 HOME TABLE OF CONTENTS

OVERVIEW OF YOUR BENEFITSIMPORTANT PHONE NUMBERSMember Services Department(646) 473-9200For answers to questions about yourbenefits or to be referred to anotherBenefit Fund department.Program for Behavioral Health(646) 473-6900For mental health and alcohol/substance abuse.1199SEIU CareReview Program(800) 227-9360For Prior Authorization of hospital stays.You can also visit our website atwww.1199SEIUBenefits.org for forms,directories and other information. Fromour website, you can also click on thelink to My Account and create your ownaccount to check your eligibility, find outwhether a claim has been paid, changeyour address or update other information.The Benefit Fund has no pre-existingcondition exclusions. A pre-existingcondition is a medical condition, illnessor health problem that existed beforeyou enrolled in the Fund.The Fund believes that it is a“grandfathered health plan” under thePatient Protection and Affordable CareAct (the “Affordable Care Act”).Previous NextJanuary 2021 11 HOME TABLE OF CONTENTS

OVERVIEW OF WAGE CLASS I AND II BENEFITSWAGE CLASSESWage Class I: Full-time or part-time members who earn 100% of the minimumfull-time wageWage Class II: Part-time members who earn at least 60%, but less than 100%,of the minimum full-time wageThe following is a quick reference guide that gives you an overview of yourbenefits. Do not rely on this guide alone. Please read the rest of this SPD for afull explanation of each benefit.LEGENDMemberYou, the memberSpouseYour spouse, if eligibleChildrenYour children, if eligibleFamilyYou, your spouse and your children, if eligibleSee Section I.A to determine if you, your spouse and/or your children are eligiblefor benefits.If you are an employee of the City of New York or an agent or authority of NewYork City, see Section I.D for a summary of the benefits you are eligible for.Previous NextJanuary 2021 12 HOME TABLE OF CONTENTS

Wage ClassesBenefit CoverageIHOSPITAL CAREFamilyIIFamilyInpatient Hospital Care This benefit is for the hospital’s chargefor the use of its facility only. Coveragefor services rendered by doctors, labs,radiologists or other services that are billedseparately by these providers may becovered, as described in Section II.H. Up to 365 days per yearYou must call 1199SEIUCareReview at (800) 227-9360 Semi-private room and boardbefore going to the hospital or Acute care for Medically Necessary serviceswithin two business days of an Inpatient admissionsEmergency admission. Up to 30 days per year for inpatient physicalrehabilitation in an acute care facility Benefits are not provided for care in a sub-acutenursing home or skilled nursing facilityOutpatient Hospital Care Ambulatory care Observation care and servicesHOSPICE CAREFamily Coverage for a combined total of up to 210days per lifetime in a Medicare-certifiedhospice program in a hospice center,hospital, skilled nursing facility or at homeYou must call 1199SEIUCareReview at (800) 227-9360for Prior Authorization ofinpatient hospice care.Previous NextJanuary 2021 13 HOME TABLE OF CONTENTSFamily

Wage ClassesBenefit CoverageIEMERGENCY DEPARTMENT VISITSFamilyIIFamily This benefit is for the hospital’s chargefor the use of its facility only. Coveragefor services rendered by doctors, labs,radiologists or other services that are billedseparately by these providers may becovered, as described in Section II.H.Call the Benefit Fund Use of the Emergency Department mustat (646) 473-9200 forbe for a legitimate medical Emergencywithin 72 hours of an accident, injury, or the more information.onset of a sudden and serious illness Observation care and services Benefit Fund pays negotiated rate atParticipating Hospital or reasonable chargeat Non-participating HospitalPROGRAM FOR BEHAVIORAL HEALTHFamilyFamilyMental Health Outpatient care Intensive Outpatient Programs (IOP) Inpatient care Partial Hospitalization Programs (PHP)Alcohol/Substance Abuse Inpatient detoxification and rehabilitationYou must call 1199SEIUCareReview at (800) 227-9360to Pre-certify inpatient care.You must call the Benefit Fundat (646) 473-6868 to Pre-certifyPHP and IOP services. Outpatient care Intensive Outpatient Programs (IOP)SURGERYFamily Inpatient or outpatient (ambulatory) surgeryYou must call 1199SEIUCareReview at (800) 227-9360before having non-Emergencysurgery. Benefits based on the Fund’s allowance forthe surgical procedure Participating Surgeons bill the Benefit Funddirectly and accept the Fund’s payment aspayment in fullCall the Benefit Fund at(646) 473-9200 to makesure your surgeon is aParticipating Provider.January 2021 14 HOME TABLE OF CONTENTSPrevious NextFamily

Wage ClassesBenefit CoverageIIIANESTHESIAFamily Benefits based on the Fund’s Scheduleof AllowancesCall the Benefit Fund at(646) 473-9200 to make sureyour anesthesiologist is aParticipating Provider.MATERNITY CAREFamilyFamilyFamily An allowance which includes all prenataland postnatal visits and delivery chargesCall the Wellness Department Hospital Benefit for the mother and newborn, at (646) 473-8962 to registerfor the Prenatal Program.if the mother is you or your spouse Disability Benefit for you, if you are the mother Lactation consulting by a certified provider Breast pumpMEDICAL SERVICESCall the Benefit Fund at(646) 473-9200 for informationabout breast pump options.FamilyFamily Treatment in a doctor’s office, clinic, hospital,Emergency Department or your home Well-child care for dependent children Immunizations Acupuncture: up to 25 visits per year, whenperformed by a licensed medical physicianor licensed acupuncturist Allergy: up to 20 visits per year, includingup to two testing visits Chiropractic: up to 12 visits per year Dermatology: up to 20 visits per year Physical/Occupational/Speech therapy: upto 25 visits per discipline per year Podiatry: up to 15 visits per year for routinefoot care X-rays and laboratory tests Durable medical equipment and appliances Hospice care Ambulance servicesPrevious NextJanuary 2021 15 HOME TABLE OF CONTENTS

Wage ClassesBenefit CoverageIMEDICAL SERVICES (continued)IIFamilyFamilyFamilyFamily Participating Providers bill the Benefit Funddirectly and accept the Fund’s payment aspayment in fullTELELHEALTH VISITS Through telehealth, you can have anoffice visit by phone or video with yourown Participating Provider or with theBenefit Fund’s telehealth provider, whocan diagnose, recommend treatment andprescribe medication for many of yourmedical or mental health needs If your doctor is unavailable, use the BenefitFund’s telehealth provider for on-demandnon-Emergency visits by phone or video(available 24 hours a day, 7 days a week),with doctors and pediatricians licensed inyour stateCall the Benefit Fund at(646) 473-9200 for informationon how to access the Fund’stelehealth provider. If you prefer to access a licensed mentalhealth professional through the Benefit Fund’stelehealth provider, you can schedule a phoneor video appointment (available 7 days a week),and choose from a variety of board-certifiedcounselors, therapists, psychologists andpsychiatrists. You must be age 18 or olderto use this benefit.Previous NextJanuary 2021 16 HOME TABLE OF CONTENTS

Wage ClassesBenefit CoverageIIISERVICES REQUIRINGPRIOR AUTHORIZATIONFamily Home health careYou must call the PriorAuthorization Departmentat (646) 473-9200 for PriorAuthorization of services,except Emergency ambulanceand the services listed below. Long-term acute care hospital services Hospital transfer ambulance services Durable medical equipment and appliances Medical supplies Cellular and gene therapy Specific medications, including specialty drugs MRI, MRA, PET and CAT scans, and certainnuclear cardiology tests Molecular, genomic and other diagnosticlaboratory tests Radiation therapy and medicaloncology services Hospice care Ambulatory surgery or inpatient admissions Certain mental health and alcohol/substanceabuse services Certain infusion drugs administered on anoutpatient basisVISION CAREFamilyYou must call eviCore healthcareat (888) 910-1199 for PriorAuthorization of radiologicaltests, molecular and genomictesting, radiation therapy andmedical oncology services.Call One Call Care Managementat (800) 398-8999 for a referralto a preferred radiology facility.You must call 1199SEIUCareReview at (800) 227-9360for Prior Authorization of inpatienthospice care, ambulatorysurgery or inpatient admissions.You must call CareContinuumat (877) 273-2122 for PriorAuthorization of certaininfusion drugs administeredon an outpatient basis.FamilyFamily One eye exam every two years One pair of eyeglasses every two years;In lieu of eyeglasses, one order of contactlenses every two years No out-of-pocket costs when using aParticipating Provider for lenses and framesincluded in the Benefit Fund’s vision programCall the Benefit Fund at(646) 473-9200 for a referralto a Participating Provider.Previous NextJanuary 2021 17 HOME TABLE OF CONTENTS

Wage ClassesBenefit CoverageIIIHEARING AIDSFamily Once every three years Co-payments may apply when usingParticipating ProvidersCall the Benefit Fund at(646) 473-9200 for a referralto a Participating Provider.DENTAL BENEFITSFamilyFamilyNot Covered Coverage through a Plan Network for basicand preventive services, major restorativecare and orthodontia treatment Annual benefit limits or network restrictionsmay applyCall the Benefit Fund at(646) 473-9200 for a referralto a Participating Provider. Network Dentists bill the Benefit Fund’sPlan Network Administrator directlyand accept the Network Administrator’sSchedule of Allowances as payment in fullfor Covered Services For certain upgrades and materials,co-payments may applyPRESCRIPTION DRUGSFamilyNot Covered Coverage of FDA-approved prescriptionmedications for FDA-approved indications,except Plan exclusions No co-payments when you use PreferredDrugs where available Use Participating PharmaciesCall Express Scriptsat (800) 818-6720 formore information. Use The 1199SEIU 90-Day Rx Solution(Mandatory Maintenance Drug AccessProgram) for chronic conditions Comply with the Benefit Fund’s prescriptiondrug programs, including Prior Authorizationwhere required Please refer to “What Is Not Covered” inSection II.LPrevious NextJanuary 2021 18 HOME TABLE OF CONTENTS

Wage ClassesBenefit CoverageIIILIFE INSURANCEMember OnlyMember Only Wage Class I: During your first year ofservice, amount is 1,250. After your firstyear, benefit is based on your Wage Classand annual base pay up t

The Fund believes it is a "grandfathered health plan" under the Patient Protection and Affordable Care Act (the "Affordable Care Act"). A grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted in 2010. Being a grandfathered health plan means that this