February 1, 2015

Benefits Summary

February 1, 2015 Benefit Summary

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Hamel Builders

Medical Healthy Blue PPO The chart below is an overview of benefits, and this guide provides general plan information but does not guarantee payment for services. Please refer to the detailed benefit summary for the full details of this medical plan. Hamel Builders Health Plan summary plan description will always prevail.

Who is Eligible and When All full-time employees are eligible. New employees will become eligible for this coverage on the first of the month following the date of hire for salaried employees and first of the month following 60 days for hourly employees. Healthy Blue PPO

Benefits

In-Network

Out-of-Network

Deductible

$1,000 Individual; $2,000 Individual & Child(ren); $2,000 Individual & Adult; $2,000 Family

$2,000 Individual; $4,000 Individual & Child(ren); $4,000 Individual & Adult; $4,000 Family

Out of Pocket Maximum

$4,500 Individual; $9,000 Individual & Child(ren); $9,000 Individual & Adult; $9,000 Family

$6,500 Individual; $13,000 Individual & Child(ren); $13,000 Individual & Adult; $13,000 Family

None

None

No Charge No Charge No Charge PCP, $30 Specialist per visit

No Charge After Deductible No Charge Deductible, then $50 per visit

Deductible, then $300 per admission No Charge After Deductible

Deductible, then $500 per admission Deductible, then $50 per visit

No charge; Add $50 Copay for services rendered on a hospital campus

Deductible, then $50 per visit

Pregnancy & Maternity

Prenatal and postnatal visits: No charge; Delivery, Deductible, then $300 per admission

Prenatal and postnatal visits: Deductible, then $50 ; Delivery, Deductible, then $500 per admission

Prescription Drugs

$15 copay Generic, $35 Copay Brand Formulary, $60 copay Non-Formulary Brand ; $0 deductible

$15 copay Generic, $35 Copay Brand Formulary, $60 copay Non-Formulary Brand ; $0 deductible

Lifetime Maximum Physician Services Preventive Well Child Office Visits (illness) Hospitalization Inpatient Facility Services Inpatient Physician Services Diagnostic Testing

$200 copay

Emergency Room Outpatient Physicial, Occupational & Speech Therapies Outpatient Chiropractic Services Mental Health/Substance Abuse Inpatient Outpatient

Paid as in-network

(waived if admitted)

(limited to emergency services)

$30 per visit

Deductible, then $50 per visit

$30 per visit

Deductible, then $50 per visit

Physician Services—Covered in Full after Deductible; Facility Covered at $300 per admission after deductible No Charge

Physician Services—$50l after Deductible; Facility Covered at $500 per admission after deductible Deductible, then $50 per visit

(limited to 30 visits/condition/benefit period) (limited to 20 visits/benefit period)

Employee Costs Weekly Cost (52 pays/year)

Bi-Weekly Cost (26 pays/year)

Yearly

Employee

Employee Monthly Cost

$38.69

$77.39

$2,012.10

Employee & Spouse

$80.66

$161.33

$4,194.54

Employee & Children

$63.40

$126.80

$3,296.85

Employee & Family

$110.76

$221.52

$5,759.46

February 1, 2015 Benefit Summary

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Dental Guardian PPO Dental Guard Preferred Guardian’s dental PPO plan has a large network of dentists and covers both in- and out-of-network services. To find a list of providers, go to www.GuardianAnytime.com and click on Find a Provider, the name of the network for this plan is Dental Guard Preferred. The plan details listed below are some of the moth common services related to dental coverage, and limitations and age restrictions may apply for dependent coverage. The guide is an overview of benefits but does not guarantee payment for services. Please refer to Guardian’s detailed benefit summary for the complete plan information. The Guardian summary plan description will always prevail.

Who is Eligible and When All full-time employees are eligible. New employees will become eligible for this coverage on the first of the month following the date of hire for salaried employees and first of the month following 60 days for hourly employees. Guardian PPO Dental Guard Preferred

Benefits Plan Year Deductible (waived for Preventive)

In-Network

Out-of-Network

$50 (Family Limit: 3 per Family)

$50 (Family Limit: 3 per Family)

Annual Maximum Benefit

$1,500 per person

Type I – Preventative • X-Rays • Cleaning • Oral Exams • Sealants (per tooth) • Fluoride Treatments

100%

100%

Type II – Basic • Fillings • Anesthesia • Scaling & Root Planing (per quadrant) • Simple Extractions • Perio Surgery • Root Canal • Surgical Extractions

80%

80%

Type III – Major • Dentures • Single Crowns • Bridges • Inlays, Onlays, Veneers • Dental Implants

50%

50%

Orthodontia

Not Covered

*OrthoSelect Individual discount program through DentaQuest*

Employee Costs Employee Monthly Cost

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Weekly Cost (52 pays/year)

Bi-Weekly Cost (26 pays/year)

Employee

$1.49

$2.98

Employee & Spouse

$3.38

$6.75

Employee & Children

$3.38

$6.75

Employee & Family

$4.81

$9.62

Hamel Builders

Life & Disability Insurance Mutual of Omaha Life and AD&D Insurance – Paid 100% by Hamel Builders Hamel Builders, Inc. offers all eligible full time employees, those working a minimum of 30 hours per week, life insurance and AD&D benefits in the amount of two times annual earnings, to a maximum of $200,000, through Mutual of Omaha. An Accidental Death & Dismemberment (AD&D) benefit is also provided at an amount equal to the life benefit described above. AD&D provides an additional benefit for losses caused by an accident. Partial benefits are paid in the event of certain specific accidental injuries, such as loss of limb or sight.

Disability Evidence of Insurability Employees who are not currently enrolled for Short Term Disability and/or Long Term Disability who wish to enroll for Mutual of Omaha Disability coverage will be subject to medical Evidence of Insurability prior to receiving benefits.

Short Term Disability – Optional Short Term Disability coverage is provided to all eligible employees, those working a minimum of 30 hours per week, though Mutual of Omaha. This coverage will pay up to 60% of your weekly salary, to a maximum weekly benefit of $500, if you are unable to work due to illness or injury. Benefits, which begin on the 1st day of disability due to an accident and on the 8th day due to an illness, are payable for up to 13 weeks. If you’d like to elect Short-Term Disability, follow the below instructions to calculate your monthly premium on the Mutual of Omaha application:

Annual salary (divided by) 52 = weekly salary Weekly salary x .60 = weekly benefit amount (not to exceed $500) Weekly benefit amount x .35 (divided by 10) = monthly premium due

Hamel Builders, Inc. sponsors 75% of the cost of this coverage for all eligible employees.

Long Term Disability – Optional Long Term Disability coverage is provided to all eligible employees, those working a minimum of 30 hours per week, though Mutual of Omaha. This coverage will pay up to 66.67% of your monthly salary, to a maximum of $10,000, if you are unable to work due to an extensive injury or illness. Benefits begin after 90 days and are payable if you are disabled from your own occupation for 2 years, then to Social Security Normal Retirement Age (SSNRA) if you are disabled from any occupation. If you’d like to elect Long-Term Disability, follow the below instructions to calculate your monthly premium of the Mutual of Omaha application:

Annual salary (divided by) 12 = monthly salary (not to exceed $15,000) Monthly salary (not to exceed $15,000) x .61 (divided by) 100 = monthly premium due

Hamel Builders, Inc. sponsors 75% of the cost of this coverage for all eligible employees.

February 1, 2015 Benefit Summary

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Flexible Spending & Dependent Care GBS Section 125 Plan Hamel Builders, Inc. has established a Section 125 Plan. This plan allows employees to use pre-tax dollars to pay for any required contributions to their medical and dental plan coverage. Medical and dental plan premiums will be on a pre-tax basis, deducted from your pay before Federal, State and Social Security taxes are withheld.

Flexible Spending Account – Optional Hamel Builders, Inc. offers employees a benefit that saves money on taxes and makes it easier to budget for expected healthcare and dependent care expenses. This benefit is called a Flexible Spending Account, or FSA. There are two types of FSAs available to you. One is for healthcare expenses and one is for dependent care expenses. Both are optional benefits. You may elect to open one or both. This is how they work: •

Estimate your expected expenses for dependent or medical care needs for the calendar year.

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Divide the annual amount by the number of pay periods in the plan year to get your payroll deduction amount.

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Make an annual election on your Benefits Enrollment Worksheet to contribute that amount of your salary each pay into the FSA.

By using a FSA, you have the opportunity to pay for many healthcare and dependent care expenses with dollars that are not taxed; therefore, reducing your taxable income. The result is more money in your pocket! The plan is administered through GBS. When you incur an eligible expense, you may use your GBS payment card for eligible medical expenses or submit a claim to your GBS for reimbursement. The maximum annual contribution is $2,500 to the Medical FSA and $5,000 to the Dependent Care FSA. Due to Health Care Reform, over the counter drugs (allergy medications, cough syrup, etc.) now require a prescription. Careful planning of your FSA contributions is a must. Under federal law, if you do not use your entire FSA deposit for eligible expenses, the unused amount will be forfeited. Medical FSA annual election amounts are available for use on the first day of the plan year, however the Dependent Care Account funds are available to be withdrawn only as they are contributed via payroll deduction.

Employee FSA Account Online Portal To find information on your FSA transactions and card balance, you can log on to: www.benefitspaymentsystem.com employer ID: GBS479

Submitting FSA Documentation When submitting documentation, members may file claims online, fax, scan and email, or mail to GBS. Online: www.g-b-s.com Fax: 410-321-8053 Phone: 800-337-4973 Email: [email protected] Mail: FSA Claims Department 6 North Park Drive, Suite 310 Hunt Valley, MD 21030

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Hamel Builders

Employee Assistance Program Lifework Strategies Balancing your work and home life is not always easy. With your confidential, company-paid Employee Assistance Program (EAP) you do not have to face life’s challenges alone. This program provides support and guidance for matters that range from personal issues you might be facing to providing information on every day topics that affect your life. This program is made available to your employer through the Lifework Strategies. You and your dependents have unlimited access to consult with a professional counselor via telephone free of charge. When you call 877-252-8550 (you can also email at [email protected]) a counselor will arrange a session with a professional either through phone support or six sessions face-to-face for individuals, families, and/or couples. Counseling

Legal

• Face-to-face and phone support counseling

• Unlimited phone support

• 6 Sessions per issue per year

• Advice on personal legal issues

• Assessments and referrals

• Referrals to local attorneys

• Solution-focused counseling

• Free � hour face-to-face meeting and 25% discount on additional services

Child Care • Unlimited phone support

Financial

• Adoption resources

• Consultation on budgeting

• Expecting parent resources

• Guidance on financial strategy

• Child care provider search

• Resources and tip sheets

Elder Care

Website

• Unlimited phone support

• Articles and tip sheets

• Consultation for caregivers

• Tools and calculators

• Tips for communication

• Self-paced tutorials

• Elder care resources • Referrals to providers When real-life issues demand your time and attention, we can help you navigate the way. The EAP is an employer-sponsored benefit that is available to you and your dependents. You do not need to pre-enroll or fill out claim forms. An interactive website is also available for Hamel Builders employees. Simply go to www.LifeWorkStrategies.com and use the login information below: Username: hameleap Password: employee

February 1, 2015 Benefit Summary

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COBRA Consolidated Omnibus Budget Reconciliation Act Continuation of Coverage Public law requires Hamel Builders to offer enrolled employees and their dependents to opportunity for a temporary extension of health coverage at group rates in certain instances where coverage under the current plan would otherwise end, which is called Continuation of Coverage or COBRA.

Who is Eligible and When Employees must have coverage under the current plan the day before the qualifying event and must become ineligible for group coverage due to one of the following qualifying events: •

Termination of employment (for voluntary reasons and reasons other than gross misconduct)

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Reduction of hours

A covered spouse or child has the right to choose continuation of group coverage due to any one of the following qualifying events: •

Death of employee

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Termination of the employee’s employment (for voluntary reasons and reasons other than gross misconduct)

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Divorce or legal separation

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The employee becoming entitled to Medicare

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A dependent child losing dependent status

Notice Requirements The qualified employee or family member must notify Hamel Builders of the intent to continue coverage within 60 days of the event. The first payment must be made within 45 days and consists of paying 102% of the full premium for the coverage.

Period of Continuation The continuation of group coverage varies based on the type of qualifying event: •

18 months if loss of coverage is due to termination of employment or reduction in hours

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29 months for a qualified beneficiary who is determined under Title II (OASDI) or Title XVI (SSI) of the Social Security Act to have been disabled within 60 days of the qualifying event

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36 months if loss of coverage is due to any other qualifying event (death, divorce or legal separation, or loss of dependent status)

Generally, continuation of coverage will remain in force until one of the following occurs: •

The date you fail to submit payments on a timely basis (there is a grace period of at least 30 days for payment of the regularly scheduled premium)

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The expiration of your continuation period or the date you notify Hamel Builders of your intent to terminate your continuation of coverage

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The employer no longer provides group health coverage, or you or your spouse/dependents become covered by another plan

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You become entitled to Medicare an you extend coverage for up to 29 months due to your disability and there has been a final determination that you are no longer disabled

For additional information about specific details of COBRA coverage, rights, and costs, please contact the Human Resources Department or your Dedicated Internal Service Representative.

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Hamel Builders

HIPAA Health Insurance Portability and Accountability Act Creditable Coverage Congress has instituted a protection for employees in the form of Health Insurance Portability Act. This allows you to receive credit for “creditable coverage” under a group insurance plan to be used against any waiting period for pre-existing conditions that might appear in any employer sponsored health plan. Creditable coverage includes coverage under a group health plan (including government or church plans), health insurance coverage (group or individual plans), Medicare, Medicaid, military-sponsored healthcare (Champus), a program of the Indian Health Service, State Health Benefit Risk Pool, the FEHBP, a public health plan as defined in the regulations, and any health plan under Section 5(c), or the Peace Corps Act.

Pre-Existing Conditions Hamel Builders is required to provide proof of creditable coverage in the form of a certificate to allow waiver of any preexisting limitations that might occur in your current plan or any plan that you might enroll in the future. Included in this provision is coverage that is creditable for dependents as well. A Certificate of Coverage will be provided upon termination of a group plan that illustrates coverage under that program.

Credits and Limitations A certificate should be shown to a new employer to receive a one-month credit for every month of prior coverage. If there is a break in coverage greater than 63 days, the new employer does not have to provide any prior coverage credit.

Expiration of COBRA In addition, if you have exhausted your 18-, 19, or 36-month time frame under COBRA, you may be eligible for coverage under an individual plan on a guaranteed issue basis without any pre-existing condition limitations. HIPAA allows you to pay COBRA premiums from withdrawals from an Individual retirement Account (IRA). Withdrawals may be made penalty free for medical insurance if you have received unemployment for at least 12 weeks. This provision only eliminates the 10% penalty fee and not the standard income tax. If you require any additional information regarding this provision, please contact the Human Resources Department.

February 1, 2015 Benefit Summary

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Contact Information For claims and benefit information, please contact Human Resources or your dedicated internal service representative. To contact any of the benefit vendors, please refer to the list below.

Medical CareFirst Member Services: 800-735-2285 www.carefirst.com CareMark Prescription Services: 800-241-3371

Dental Guardian Customer Service: 866-302-4542 www.guardiananytime.com

Life & Disability Mutual of Omaha Life Claims: 800-775-8805 Disability Claims: 800-877-5176 www.mutualofomaha.com

Flexible Spending Accounts Group Benefit Services Member Services: 800-337-4973

Your Broker HMS Insurance Associates 410-337-9755 [email protected]

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Hamel Builders

The information presented in this Benefits Summary is presented for illustrative purposes and is based on information provided by the employer. The text contained in this summary was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Benefits Summary and the actual plan documents, the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any questions about this summary, please contact Human Resources.

February 1, 2015 Benefit Summary

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Kelly & Associates Insurance Group, Inc (KELLY) provides administrative services that include: billing, enrollment and call center service for insurance benefits. The administration of benefits by KELLY does not guarantee coverage. Billing and collecting premiums or sending payroll deduction files, does not constitute coverage being bound. Please refer to specific insurance carrier contract for rules requiring evidence of insurability (EOI) or other underwriting requirements regarding final insurance carrier approval. KELLY is not an insurer and is not responsible for paying insurance benefit claims relative to KELLY's involvement with billing and collecting insurance premiums. *This booklet summary is only intended as a brief summary of your benefits. Benefits are subject to the contractual terms, limitations and exclusions as set forth in the master contracts.

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