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ChoicesIntroduction toThis workbook is your guide to Choices – Montana University System’s benefits program that lets you match your benefits to yourindividual and family situation. To get the most out of this opportunity to design your own benefits package, you need to consideryour benefits needs, compare them to the options available under Choices and enroll for the benefits you’ve chosen. Coverageavailable to you includes:Must Choose:*Voluntary: MedicalDentalLong Term DisabilityBasic Life Insurance and AD&D* Unless you waive all coverageOptional Accidental Death & Dismemberment InsuranceOptional Supplemental LifeOptional Dependent Life InsuranceOptional Reimbursement AccountsOptional VisionLong Term CarePlease read the information in this workbook carefully. If you have any questions, please contact your campus Human Resources Department.This enrollment book is not a guarantee of benefits; please consult your group benefit plan booklets. (Summary Plan Descriptions)Who’s EligibleA person employed by a unit of the University System, Office of the Commissioner of Higher Education, or other agencyor organization affiliated with the University System or the Board of Regents of Higher Education is eligible to enroll inthe Employee Benefits Plan if qualified under one of the following categories:1.Permanent faculty or professional staff members regularlyscheduled to work at least 20 hours per week or 40 hoursover two weeks for a continuous period of more than sixmonths in a 12-month period.2.Temporary faculty or professional staff members scheduled towork at least 20 hours per week or 40 hours over two weeksfor a continuous period of six months or more, or who actuallydo so regardless of schedule.3.Seasonal faculty or professional staff members regularlyscheduled to work at least 20 hours per week or 40 hours overtwo weeks for a continuous period of six months or more, orwho actually do so regardless of schedule. Academic or professional employees with an individualcontract under the authority of the Board of Regentswhich provides for eligibility under one of the aboverequirements. 4.Note:Student employees who occupy positions designated asstudent positions by a campus are not eligible to join thePlan.-1-If you’re eligible, you may also enroll your family for certainbenefits under Choices, including medical, dental, vision, lifeinsurance and AD&D coverage. Eligible family membersinclude your: Legal spouse, as defined under Montana law, or one otherunrelated adult dependent as defined in the SummaryPlan Description. To enroll an adult dependent otherthan a spouse, you will need to obtain criteria fromyour campus Human Resources Office and completea Declaration of Adult Dependent form, also availablethere.Dependent children under age 26. Children include yournatural children, stepchildren, and children placed inyour home for adoption before age 18 or for whom youhave court-ordered custody or you are the legal guardian.Coverage may continue past age 26 for an unmarrieddependent child who is mentally or physically disabledand incapable of self-support.In-Network Hospitals - Managed Care PlansThis is subject to change. See plan websites for updates.Allegiance Network HospitalsAnacondaCommunity Hospital of AnacondaBig SandyBig Sandy Medical CenterBig TimberPioneer Medical CenterBillingsSt. Vincent HealthcareBillingsBillings ClinicBozemanBozeman Deaconess HospitalButteSt. James HealthcareChesterLiberty County HospitalChinookSweet Medical CenterChoteauTeton Medical CenterColumbusStillwater Community HospitalConradPondera Medical CenterCut BankNothern Rockies Medical CenterDeer LodgePowell County Medical CenterDillonBarrett Hospital and HealthcareForsythRosebud Health Care CenterFort BentonMissouri River Medical CenterGlasgowFrancis Mahon Deaconess HospitalGlendiveGlendive Medical CenterGreat FallsBenefis Health CareGreat FallsCentral Montana Surgery CenterHamiltonMarcus Daly Memorial HospitalHardinBig Horn County Memorial HospitalHarlowtonWheatland Memorial HospitalHavreNorthern Montana HospitalHelenaSt. Peter’s HospitalKalispellKalispell Regional Medical CenterLewistownCentral Montana Medical CenterLibbySt. John’s Lutheran HospitalMaltaPhillips County HospitalMiles CityHoly Rosary Health CareMissoulaMissoula Community Medical CenterMissoulaSt. Patrick HospitalPhillipsburgGranite CountyMedical CenterPlainsClark Fork Valley HospitalPlentywoodSheridan Memorial HospitalPolsonSt. Joseph HospitalRed LodgeBeartooth Hospital & Health CenterRonanSt. Luke Community HospitalRoundupRoundup Memorial HospitalScobeyDaniels Memorial HospitalShelbyMarias Medical CenterSheridanRuby Valley HospitalSidneySidney Health CenterSuperiorMineral Community HospitalTerryPrairie Community Health CareTownsendBroadwater Health CenterWhitefishNorth Valley HospitalWhite Sulphur SpringsMountain View Medical CenterBCBSMT (Blue Choice)AnacondaCommunity Hospital of AnacondaBig TimberPioneer Medical CenterBillingsAdvanced Care HospitalBillingsBillings Clinic HospitalBillingsMorledge Family Surgery CenterBillingsSt. Vincent HealthcareBozemanBozeman Deaconess HospitalButte St. James HealthcareChester Liberty County HospitalChoteau Teton Medical CenterConrad Pondera Medical CenterDillonBarrett Hospital & HealthcareEnnisMadison Valley HospitalFort BentonMissouri River Medical CenterGreat FallsBenefis HealthcareGreat FallsOrth Center of MT Ambulatory Surg CtrGreat FallsCentral Montana Surgical CenterHamiltonMarcus Daly Memorial HospitalHardinBig Horn County Memorial HospitalHarlowtonWheatland Memorial HospitalHavreNorthern Montana HospitalHelenaShodair Children’s HospitalHelenaSt. Peter’s HospitalKalispellKalispell Regional Medical CenterKalispellHealthCenter NorthwestLivingstonLivingston Memorial hospitalMiles CityHoly Rosary HealthcareMissoulaSt. Patrick HospitalMissoulaCommunity Medical CenterPlainsClark Fork Valley HospitalPolsonSt. Joseph HospitalRed LodgeBeartooth Hospital & Health CenterRonanSt. Luke Community HospitalRoundupRoundup Memorial HospitalShelbyMarias Medical CenterSheridanRuby Valley HospitalSuperiorMineral Community HospitalWhite Sulphur SpMountain View Medical CenterWhitefishNorth Valley HospitalNew West Network HospitalsAnacondaCommunity Hospital of AnacondaBig SandyBig Sandy Medical CenterBig TimberPioneer Medical CenterBillingsBillings Clinic HospitalBozemanBozeman Deaconess HospitalButteSt. James HealthcareChesterLiberty County MemorialChinookSweet Medical CenterChoteauTeton Medical CenterColumbusStillwater Community HospitalConradPondera Medical CenterDeer LodgePowell County Memorial HospitalDillonBarrett Hospital & HealthcareForsythRosebud Health Care CenterFort BentonMissouri River Medical CenterGreat FallsBenefis Health CareHamiltonMarcus Daly Memorial HospitalHardinBig Horn County Memorial HospitalHarlowtonWheatland Memorial HospitalHavreNorthern Montana HospitalHelenaSt. Peter’s HospitalHelenaShodair HospitalJordanGarfield County Health CenterKalispellKalispell Regional Medical CenterLewistownCentral Montana Medical CenterLibbySt. John’s Lutheran HospitalLivingstonLivingston Memorial HospitalMaltaPhillips County HospitalMiles CityHoly Rosary HealthcareMissoulaCommunity Medical CenterMissoulaCosmetic Surgical AASPhillipsburgGranite Co. Medical Center HospitalPlainsClark Fork Valley HospitalIt is a good idea to contact the claims administrator for the plan you’ve chosen to make sure your provider is in-network prior toreceiving services. This will help you avoid unanticipated out of pocket expenses.- 38 -

HowAllegiance Managed Care Plan Service AreasCityZip CodeRamsay.58748Ravalli.59863Raynesford.59469Red 59071Saltese.59535Sand Coulee.59050Sand Springs.59847Santa Rita.59473Seeley pherd.59079Sheridan.59749Sidney.59270Silver 9932Springdale.59082St. Ignatius.59865St. Regis.59866St. tt.59480Styker.59933Sula.59871Sun Thompson Falls.59873Three out Creek.59874Troy.59935Twin Bridges.59754Two 9875West Glacier.59936Whitefish.59937White Sulphur 59353Willow ise River.59762Wolf Creek.59648Worden.59088Zurich.59547Choices WorksHow to Enroll1.If the benefits you choose cost . . .Each eligible faculty and/or staff member receives a The same as your employer contribution, you won’tsee any change in your paycheck.monthly employer contribution. This amount isbased on the Montana State legislature’s allocationtoward the cost of benefits for state employees. More than your employer contribution, you’ll pay thedifference through automatic payroll deductions.2. Within 30 days of first becoming eligible forbenefits, or during annual enrollment each year, youselect or make changes from among the benefit planoptions.Out of StateThere is a specific travelnetwork for elective/non-emergent services.Please contact AllegianceCustomer Service at 1-877778-8600 for assistancewith this travel network. Less than your employer contribution, you’ll eitherforfeit the remaining employer contribution or youmay apply it to a Medical Flexible Spending Accountin your name.3. Each benefit option in Choices has a monthly costassociated with it. These costs are shown on yourenrollment form or in this Enrollment Workbook.Your annual Choices elections remain in effect for theentire plan benefit period following enrollment, unlessyou have a change in status (qualifying event). Listedhere are examples of qualifying events:4. Complete an enrollment form. If you havequestions about the enrollment process, pleasecontact your campus Human Resources department. Marriage Birth of a child Adoption of a child Loss of eligibility for other health insurance coverage5. The enrollment form will walk you through yourcoverage options and monthly costs. To determinethe before-tax cost of your benefits, add up the totalcost of the benefits you’ve selected and compare itto the employer contribution provided to you by theMontana University System.All questions about qualifying events should be directedto your campus Human Resources Office.MSU Bozeman- 37 -Miles City Community College-2-

Notices forChoices CoverageUnder a federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104191, as amended, group health plans must generally comply with the requirements listed below. However, the law alsopermits state and local governmental employers that sponsor health plans to elect to exempt a plan from these requirementsfor any part of the plan that is “self-funded” by the employer, rather than provided through a health insurance policy. TheMontana University System (MUS) Employee Group Benefit Plan, which is a non-federal, self-funded plan, has elected toexempt MUS from #5 and #7 of the following requirements:1.2.3.4.5.6.7.Limitations on preexisting condition exclusion periods.Special enrollment periods.Prohibitions against discriminating against individual participants and beneficiaries based on health status.Standards relating to benefits for mothers and newborns.Parity in the application of certain limits to mental health benefits.Required coverage for reconstructive surgery following mastectomies.Coverage of dependent students on medically necessary leave of absence.The exemption from these federal requirements will be in effect for the FY 2012 Plan Year which begins July 1, 2011 andends June 30, 2012. The election may be renewed for subsequent plan years.The MUS Plan presently provides dependent coverage independent of student status.HIPAA also requires the Plan to provide covered employees and dependents with “certificate of creditable coverage” whenthey cease to be covered under the Plan. There is no exemption from this requirement. The certificate provides evidencethat you were covered under this Plan, because if you can establish your prior coverage, you may be entitled to certainrights to reduce or eliminate a preexisting condition exclusion of you joining another employer’s health plan, or if you wishto purchase an individual health insurance policy. Please contact your chosen health plan administrator identified on yourMUS insurance card for more information regarding a certification of creditable coverage.THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED.The Montana University System self-insured employee health benefit plan has a duty to safeguard and protect the privacy ofall plan members’ personally identifiable health information that is created, maintained, sent or received by plan employeesor persons under our control.The Montana University System self-insured health plan has contracts with multiple business associates. Business associates do claims processing and perform other health-related services associated with the plan such as counseling, psychological services and pharmaceutical services, etc. The MUS self-insured plans business associates and health care provider(s)must also protect a plan member’s personally identifiable health information from inadvertent, improper or illegal disclosure.The Montana University System self-insured health plan, in administering plan benefits shares, and receives personallyidentifiable medical information concerning plan members as required by law and for routine transactions concerning eligibility, treatment, payment(s), wellness program (including WellChecks), disease management programs (i.e. Take Control,WellAwards, etc.) healthcare operations, claims processing, including review of payments or claims denied and appeals ofpayments or claims denied, premiums paid, liens and other reimbursements, health care fraud and abuse detection and compliance. Information concerning those areas may be shared between MUS authorized benefit employees, their supervisorsand our business associate(s), members’ provider(s) or legally authorized governmental entities without a member’s writtenconsent.Full HIPAA Policy Available on Web Site or by contacting Campus HR.-3-Allegiance Managed Care Plan Service AreasCityZip CodePeak Managed CarePlan Service t.59087Wisdom.59761Wise River.59762Wolf ortman.59546Zurich.59547AllegianceManaged Care PlanAbsarokee .59001Acton . 9007Belfry.59008Belgrade.59714Belt.59412Big Arm.59910Big Sandy.59520Big Sky.59716Big 9117Black man.59715597175971859719597715977259773CityZip .59419Canyon 2Clancy.59634Clinton.59825Clyde Park.59018Colstrip.59323Columbia ayton.59914DeBorgia.59830Deer 59432Dutton.59433East Helena.59635East 7Fortine.59918

- 39 - Table of Contents 1 Introduction to Choices 1 Who's Eligible 2 How Choices Works 3 How to Enroll 3 Notices for Choices Coverage 4 Glossary 5 Great Falls Your Medical Plan Choices 7 Schedule of Medical Plan Benefits 14 Prescription Drug 17 Dental Plan 22 Vision Plan 23 Life Insurance/Accidental Death Plains & Dismemberment 25 Flexible Spending Accounts 27 Long Term Care Insurance