Transcription
Benefits Handbook forHealth, Disability and LifeInsurance BenefitsYour benefits are a valuable part of the rewards of working at Citi. To make the most of your benefits, youneed to understand how they work.This Benefits Handbook will help you do just that. It contains the official documents for your Citi health careand insurance benefits plans to show you what’s covered and provides general information to help youmake the right decisions for you and your family.This Handbook describes benefits available as of January 1, 2022, and contains the official documents foryour Citi health care and insurance benefits plans.If you need information about benefits coverage that is not included in this Handbook, contact the healthplans directly as explained in the “Telephone and Website Directory” on page 122 or call the Citi BenefitsCenter through ConnectOne at 1 (800) 881-3938. From the “benefits” menu, choose the “health andinsurance benefits” option. You can choose to hear the enrollment menu in Spanish or in English.Representatives are available from 8 a.m. to 8 p.m. ET, Monday through Friday, excluding holidays.January 1, 2022Benefits Handbook for Health, Disability and Life Insurance Benefits1
ContentsBenefits Handbook for Health, Disability and Life Insurance Benefits . 1About this Handbook . 7Benefits Overview . 8Enrollment Instructions . 8What Happens if You Do Not Enroll . 9How to Enroll . 9Enrollment in Triple-S Medical and Dental . 10Confirmation of Enrollment . 10Confirmation of Default . 10Health Care ID Cards . 10Beneficiary Forms . 10Eligibility . 11Special Enrollment Rights . 11When You Are Not Eligible to Enroll . 11No Pre-Existing Condition Limitations . 12Definition of Eligible Dependents . 12About Disabled Children . 13Paying for Your Benefits . 13Benefits Eligible Pay and Your Benefits . 13Definition of Benefits Eligible Pay . 14If You Become Disabled . 14Coordination of Benefits. 14How Coordination of Benefits Works . 15Coverage Categories . 15Qualified Changes in Status. 16How to Report a Qualified Change in Status Event . 19Plan Changes You Can Make at Any Time . 20Long-Term Disability (LTD) . 20Group Universal Life (GUL) . 21Supplemental Accidental Death and Dismemberment (AD&D) Insurance . 21Partner Benefits . 21When You Can Enroll Your Partner in Citigroup Coverage . 21Eligibility. 22Newborns’ and Mothers’ Health Protection Act Notice . 23Women’s Health and Cancer Rights Act Notice . 24The Mental Health Parity and Addiction Equity Act of 2008. 24Genetic Information Nondiscrimination Act . 24Qualified Medical Child Support Orders (QMCSOs) . 25Medical . 272Benefits Handbook for Health, Disability and Life Insurance BenefitsJanuary 1, 2022
Triple-S PPO .27PPO Network Features .27Preventive Care .27Infertility .30PPO Out-of-Network Features .30Medical Plan Features .31Mental Health and Substance Abuse Benefits .34Precertification .34For Outpatient Services and Diagnostic Testing . 34Centers of Excellence (COEs) . 35Prescription Drugs . 35Retail Network Pharmacies .36Managed Drug Limitations .37Triple-S Mail-Order Pharmacy.37How to Use the Triple-S Mail-Order Pharmacy.37Triple-S Specialty Pharmacy Program .38Dental . 41Basic Dental .41Comprehensive Dental .42Claims and Appeals.42Vision . 43In-Network Services and Providers .44In-Network Benefits .44Mail-Order Contact Lenses .45Travel and Student Coverage .45Out-of-Network Benefits.45Laser Vision Correction .45What Is Not Covered .45Complaints .46Claims and Appeals.46Appeals Process .46External Review .48Wellness Benefits . 49Health Assessment .4924-Hour Teleconsulta Nurseline.49Healthy Choices Rewards .49Healthy Choices Rewards at a Glance .50Be Well Program . 51Short-term Counseling Services .51Text Messaging Therapy.51Resource & Referral Services .51Disability Coverage . 53Short-Term Disability (STD) .53When STD Benefits Are Payable . 54January 1, 2022Benefits Handbook for Health, Disability and Life Insurance Benefits3
Exclusions . 55Long-Term Disability (LTD) . 55Participation . 55Option to Decline LTD coverage . 55Pre-existing Condition . 56Converting Your Coverage. 56When LTD Benefits Are Payable . 57Claims and Appeals . 57Initial Determination. 58Appealing the Initial Determination . 59Insurance Benefits . 61Basic Life Insurance . 61If Your Benefits Eligible Pay Increases to 200,000 or Above . 61Basic Life Accelerated Benefits Option . 62Basic Accidental Death and Dismemberment (AD&D) Insurance . 62Naming a Beneficiary . 62Continuing Basic Life and Basic AD&D on an Individual Basis . 63Group Universal Life (GUL) Insurance . 63GUL Accelerated Benefits Option . 64Cash Accumulation Fund . 64Assignment . 65Naming a Beneficiary . 65Coverage for Your Spouse/Partner . 66Life Insurance for Your Children . 66Supplemental AD&D Insurance for You and Your Dependents . 66Details about AD&D Insurance. 67Additional Basic AD&D Benefits . 68Additional Supplemental AD&D Benefits . 68Exclusions . 69Continuing Your Coverage Once You Lose Eligibility . 70Business Travel Accident/Medical Insurance . 70Converting to an Individual Policy . 70Filing a Claim for Basic Life, Basic AD&D, GUL, Supplemental AD&D and BTA/Medical Insurance . 71Claims and Appeals . 71MetLife Legal Plans . 73Benefits at a Glance . 74How the Plan Works . 74Who’s Covered? . 74Cost of Coverage . 75How to Enroll . 75When Coverage Begins . 75When Coverage Ends . 75Continuing Coverage. 76About the Plan . 76What Is Covered . 774Benefits Handbook for Health, Disability and Life Insurance BenefitsJanuary 1, 2022
What Is Not Covered .81Claiming Benefits .82How to File Claims .82Claims and Appeals .83Legal and Administrative Information . 85When Coverage Ends .85Coverage When You Retire .86A Note for Employees Who Were Involuntarily Terminated.86Coverage for Surviving Spouse/Partner and/or Dependents .86Coverage if You Become Disabled .87Coverage if You Take a Leave of Absence . 89Continuing Coverage During an FMLA Leave .89Continuing Coverage During a Military Leave of Absence — Citi Policy .89Continuing Coverage During Military Leave — Federal Policy Applicable if No Citi Policy .89Important Notice from Citigroup about Your Prescription Drug Coverage and Medicare .90Creditable Coverage Disclosure Notice .90Prescription Drug Coverage and Medicare .90‘Creditable Coverage’ .91Understanding the Basics .91For More Information about Medicare. 92For More Information about This Notice .92Your HIPAA Rights .92Your Special Enrollment Rights .92Your Right to Privacy and Information Security . 93Notice of HIPAA Privacy Practices .94For Answers to Your Questions and for Additional Information .94Component Plans’ Responsibilities.94Uses and Disclosures of Protected Health Information . 94Other Uses and Disclosures of Your Protected Health Information .97Contacting You .97Your Rights .97Complaints .99Changes to This Notice .99Effective Date .99Contact Information .99Section 1557 of the Affordable Care Act Grievance Procedure . 100Procedure: . 100COBRA .
and insurance benefits plans to show you what's covered and provides general information to help you make the right decisions for you and your family. This Handbook describes benefits available as of January 1, 2022, and contains the official documents for your Citi health care and insurance benefits plans.
