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Health Care in A foreign CountryPage 5What if I need medical care in a foreign country?If you are enrolled in the MTS Medical PlanIf you are outside the US, the Commonwealth of Puerto Rico, and the US Virgin Islands, you may be able to takeadvantage of the BlueCross BlueShield Global Core Program when accessing covered health care services. TheBlueCross BlueShield Global Core Program is unlike the BlueCard Program available in the BlueCard service area incertain ways. For instance, although the BlueCross BlueShield Global Core Program assists you with accessing anetwork of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, whenyou receive care from providers outside the BlueCard service area, you will typically have to pay the providers andsubmit the claims yourself to obtain reimbursement for these services.If you need medical assistance services (including locating a doctor or hospital) outside the BlueCard service area, callthe BlueCross BlueShield Global Core Service Center at 1-800-810-BLUE (2583) or call collect at 1-804-673-1177,24/7. An assistance coordinator, working with a medical professional, can arrange a physician appointment orhospitalization, if necessary.1. Before you leave, review the coverage details for the MTS Medical Plan PPO and HSA found on pages 12-21.2. Always carry your current MTS Medical Plan ID card. Note: The phone number for Blue Cross Blue Shield, the MTSMedical Plan claims administrator, is found on the back of your MTS Medical Plan ID card.3. In an emergency, go directly to the nearest doctor or hospital, then call the BlueCross BlueShield Global CoreService Center if hospitalized.4. In most cases, for inpatient care arranged by BlueCross BlueShield Global Core Service Center, hospitals will notrequire you to pay for covered inpatient services, except for your deductibles, coinsurance, etc. In such cases, thehospital will submit your claims to BlueCross BlueShield Global Core Service Center to begin claims processing.However, if you paid in full at the time of service, you must submit a claim to receive reimbursement for coveredhealth care services. You must contact the Claims Administrator to obtain precertification for non-emergencyinpatient services.5. If you are hospitalized, call Blue Cross Blue Shield of Minnesota at 1-866-340-8652 within two working days or assoon as reasonably possible to help manage your care effectively and ensure you receive the maximum benefitcoverage.6. For outpatient services, physicians, urgent care centers and other outpatient providers located outside theBlueCard service area will typically require you to pay in full at the time of service. You must submit a claim toobtain reimbursement for covered health care services.7. Review a-d below on when you may need to make a payment upfront, when to report an inpatient admission, andthe definition of inpatient care.a. When You Are Required to Make An Upfront Payment: If the patient is seen by a GlobalCore provider ina clinic, urgent care, emergency room or a hospital as an outpatient, the patient is responsible forsubmitting any/all charges to the health plan (via GlobalCore) and may be asked to pay upfront forservices. Here’s the link to the claim form.b. When You Are Not Required to Make an Upfront Payment: If the patient is admitted to the hospital andthe facility participates with GlobalCore, the facility will not bill the patient upfront and will submit the facilityclaim on the patient’s behalf.c. When to Report an Inpatient Admission: If the inpatient admission is not coordinated by GlobalCore, thepatient must call 1-800-340-8652 within 2 business days or as soon as reasonably possible to report theadmission.d. Definition of Inpatient Care – Confinement of at least 23 hours. Hospital services under 23 hours isconsidered outpatient and the patient may be responsible for submitting their own claims and may be billedupfront by the facility.8. When you pay for covered health care services outside the BlueCard service area, you must submit a claim toobtain reimbursement. For institutional and professional claims, you should complete a BlueCross BlueShieldGlobal Core International claim form and send the claim form with the provider’s itemized bill(s) to the BlueCrossBlueShield Global Core Service Center (the address is on the form) to initiate claims processing. Following theinstructions on the claim form will help ensure timely processing of your claim. The claim form is available from theClaims Administrator, the BlueCross BlueShield Global Core Service Center, or online at www.bcbsglobalcore.com.If you need assistance with your claim submission, you should call the BlueCross BlueShield Global Core ServiceCenter at 1-800-810-BLUE (2583) or call collect at 1-804-673-1177, 24 hours a day, seven days a week.

Health Care in A foreign CountryPage 6What if I need medical care in a foreign country?If you are or are not enrolled in the MTS Medical Plan .1. If you need to locate a doctor or hospital, or need medical assistance services, call Zurich. An assistancecoordinator, in conjunction with a medical professional, can arrange a physician appointment or hospitalization, ifnecessary.2. If you need to pay upfront for care received by a doctor and/or non-participating hospital, take this action: Review the Hospital Admissions and Medical Payments on page 4. Follow the steps on page #8 for submitting an out-of-network claim.Flexible Spending Account (FSA)You may seek reimbursement of eligible medical expenses from a non-US provider.The MTS FSA claims Administrator, benefitexpress, recommends that claims be translated to English andconverted to US dollars prior to submission.Health Savings Account (HSA)You can use the funds in your HSA account to pay for medical expenses, including expenses that count towardthe MTS PPO BlueCard with HSA medical plan deductible.You can also pay qualified dental and vision expenses.Emergency DentalYou will need to pay for services out-of-pocket and submit your claim to Delta.Reimbursement checks will be sent to your home address.

Out-of-Network MTS MedicalPage 7HOW TO FILE AN OUT-OF-NETWORK CLAIMThe information below will explain: The steps you or your out-of-network provider will need to follow when submitting an out-of-network medicalclaim to the MTS Medical Plan claims administrator (Blue Cross Blue Shield Global Core) and The approximate timeframe it will take for a medical claim to be processed.StepInstructionsDetails1If the out-of-network Provideris .1. Able or willing to submit a claim on your behalf, present your MTSMedical Plan ID card to ensure your claim is submitted correctly tothe BlueCross BlueShield Global Core claims address found on theInternational Claim Form.2. Not able or willing to submit a claim on your behalf, you may submita claim yourself. Blue Cross Blue Shield of Minnesota willreimburse you at the converted currency rate for the date of servicefor foreign currency.2Go here for an out-of-networkclaim form www.bcbsglobalcore.com3Take the following action onthe claim form 1. Review claim filing instructions on back side of claim form, and2. Complete sections 1-5 and sign and date the form.4Send the claim form with yourout-of-network provider’sreceipt to BlueCrossBlueShield Global Core nolater than one year followingyour date of service.BlueCross BlueShield Global Core Service CenterP.O. Box 2048Southeastern, PA 19399 USAAny missing or incomplete information may result in delay of payment or the form being returned.Time to CompleteThe time to complete the following claims process depends on when you submit the claim after your office visit,hospital stay, etc. On average, Blue Cross Blue Shield processes MTS claims within 10 days of receipt of theclaim. Claims requiring medical information, accident investigation, or coordination of benefits may experience adelay as the additional information is requested.You or your out-of-networkprovider submits claim toBlueCross BlueShieldGlobal Core.Blue Cross Blue Shield ofMinnesota then processesthe claim according toMTS Medical Plan design.Can take up to 30 days.You and your provider receive an explanation of benefits that will includea payment if healthcare received iscovered under the MTS Medical Plan.

Immunizations and RxPage 8Foreign travel and your prescriptionsGetting an Early RefillTypically, prescription refills authorizedby your doctor may be filled after youhave used 70% of the medication. Forexample, if you’ve used 21 days ofmedication out of a 30-day supply.If you travel outside the US and wish to refill yourmedication early to ensure you have enough medicationto last the length of your travel, contact BCBS customerservice (1-866-340-8653) and request an early refillauthorization (one month supply) or vacation override(more than one-month supply). Make sure to include allapplicable prescriptions in your request. BCBS will workwith MTS HR/Benefits to assess your request.Filling a Prescription Outsidethe United StatesIn the event you need to refill your prescriptionwhile outside the United States, it is best to geta written prescription from your doctor prior totravel. Take the prescription to a pharmacy inthe country you are visiting to receive yourmedication.If you fall ill while traveling and are given awritten prescription by a local doctor, simply fillthat prescription at an area pharmacy.If you must fill a prescription while outside theUS, you will be responsible for paying the retailprice and filing for a reimbursement. Be sure tosave your pharmacy receipts.Manual Claim ReimbursementFor reimbursement on your eligible prescriptions, contact BCBS customer service and request a PrescriptionDrug Claim form. When you complete this form, please note that the prescription was purchased outside theUS in the space provided.Your completed form must be accompanied by your pharmacy receipt(s). Pharmacy receipts provide detailson medication name, prescription number (Rx#), quantity, days supply, and amount paid. Cash/credit registerreceipts are not valid for processing.Immunizations or vaccinationsIf you are enrolled in the MTS Medical Plan, coverage for immunizationsand vaccinations are included in your preventive benefit andare covered at 100 percent.Note: If business travel to a country outside the US requires you to start a newprescription before you begin business travel, contact MTS HR/Benefits on havingyour new prescription covered at 100%.

Additional Medical InsurancePurchasing Additional Medical InsurancePage 9Factors to Consider BeforePurchasing AdditionalMedical InsuranceYou may purchase a supplemental medical insurance policy throughGateway Plans. Their contact information bal.comPhone1-877-808-7434Fax1-317-655-4505Note: MTS will not compensate you or provide reimbursement forthe additional cost of private insurance.How to Enroll in GatewayIf paying by check or money order, enclose checkwith completed Application (available on website)and mail to the Gateway Plan Administrator. Ifpaying by credit card, you may either mail or faxyour Application. (Please do not mail and faxyour Application, duplication may delayprocessing.)International Medical GroupPO Box 88509Indianapolis, IN 46208-0509Selecting the right plandepends on factors such asdestination, length of timeaway from country ofresidence, frequency oftravel, and most importantly,what type of coverage andservices are needed.What is the Claim PaymentProcess under the GatewaySupplemental Medical Plan?The claim payment process includes theemployee being reimbursed or the insurancecompany paying the provider directly.Will I get an ID Card?Yes. The ID card can be mailed to you ordownloaded from the insurance company’swebsite.

Workers’ CompensationPage 10Workers’ compensationIn general, workers’ compensation pays necessary medicalexpenses (physicians, hospital and prescription drugs) arising froman injury or illness incurred in the course of and arising out ofemployment. Injuries or illnesses occurring during personal activities(e.g., sightseeing excursions, personal shopping, entertainment,etc.) are generally not covered by workers’ compensation.You should report any work-related injuries or illnesses to MTS HR/Benefits (benefits@mts.com at 952-937-4171) immediately andmaintain all documentation of medical treatment, prescription drugs,and associated expenses. Claims must be reported as soon as possible.If an injury is determined to be work related1, all medical bills associated with the injury are coveredunder MTS' worker's compensation insurance program.If an injury is not the result of a work related injury, all medical expenses are considered under yourregular medical insurance. If you have signed up for a medical plan offered through MTS, please seethe Appendix “MTS Medical Plan Summary of Benefits & Coverage (SBC)”.1The Minnesota Department of Labor and Industry defines the types of injuries covered by workers’ compensation as “A work-related injury can be anycondition that is caused, aggravated or accelerated by employment activities. This includes traumatic injuries, gradual injuries or occupationaldiseases”. Our workers’ compensation insurance carrier makes all determinations of workers’ compensation compensability when they are filed byemployees. For more information about workers’ compensation, visit the Department of Labor website at https://www.dli.mn.gov/workcomp.aspEmergency travel Assistance from Euro AssistanceAdditional travel assistance services, beyond those provided by Zurich (described above), areavailable to international business travelers who have a work-related illness or injury.For example, hotel arrangements for convalescence is available through Euro Assistance. EuroAssistance will assist the employee with hotel stays and room requirements before or afterhospitalization. See the card below for contact information:For more details on this travel assistance benefit, contact benefits@mts.com or call 952-937-4171.

Appendix A: Healthcare Summary of Benefits & CoveragePage 11NOTE: The format of the Summary of Benefits & Coverage (SBC) is prescribed by the U.S. Department of Labor and the U.S.Department of Health & Human Services. As a result, you’ll see the following pages in a different format.MTS Medical Plan—PPO

Appendix A: Healthcare Summary of Benefits & CoverageMTS Medical Plan—PPO (continued pg. 2)Page 12

Appendix A: Healthcare Summary of Benefits & CoverageMTS Medical Plan—PPO (continued pg. 3)Page 13

Appendix A: Healthcare Summary of Benefits & CoverageMTS Medical Plan—PPO (continued pg. 4)Page 14

Appendix A: Healthcare Summary of Benefits & CoverageMTS Medical Plan—PPO (continued pg. 5)PPO Coverage ExamplesPage 15

Appendix B: Healthcare Summary of Benefits & CoveragePage 16NOTE: The format of the Summary of Benefits & Coverage (SBC) is prescribed by the U.S. Department of Labor and the U.S.Department of Health & Human Services. As a result, you’ll see the following pages in a different format.MTS Medical Plan—HDHP with HSA

Appendix A: Healthcare Summary of Benefits & CoverageMTS Medical Plan—HDHP (continued pg. 2)Page 17

Appendix A: Healthcare Summary of Benefits & CoverageMTS Medical Plan—HDHP (continued pg. 2)Page 18

Appendix A: Healthcare Summary of Benefits & CoverageMTS Medical Plan—HDHP (continued pg. 3)Page 19

Appendix A: Healthcare Summary of Benefits & CoverageMTS Medical Plan—HDHP (continued pg. 4)HDHP Coverage ExamplesPage 20

Appendix CPage 21

Appendix DPage 22

Appendix EPage 23

Page 24If you have questions and/or need clarification about this benefit guide,please contact the MTS HR Benefits Department.This is only a summary and is subject to the terms of the Plan Document and/or Summary Plan Description.MTS Systems Corporation14000 Technology DriveEden Prairie, MN 55344

your illness or injury, Zurich Travel Assist will pay the lessor of the change fee or for one way economy transportation. Emergency Cash Upon your request, Zurich Travel Assist will provide funds with a satisfactory guarantee of reimbursement. Zurich Travel Assist will debit your credit card and arrange for you to obtain the funds in local .