Mosaic Health System Comprehensive Employee Benefit Plan Overview

Effective Date: 01-01-2022

PLAN DESIGN & BENEFITS

PROVIDED BY Meritain Health, An Aetna Company

Definitions you should know:

Co-pay: A set dollar amount you pay each time you receive a covered service.
Deductible: The amount you pay to providers for services received during each benefit period before the plan pays.
Co-insurance: Shared costs between you AND insurance; generally applies after your deductible is met.
Out of pocket: The maximum dollar amount you pay toward covered services in a calendar year.

Type of Service
Tier 1 Tier 2 Tier 3 Tier 4
Mosaic Life Care Children's Mercy PPO In Network Out of Network
Deductible (per calendar year) $1,500 Individual $1,500 Individual $1,500 Individual $3,000 Individual
$3,000 Family $3,000 Family $3,000 Family $6,000 Family
All covered expenses, excluding copays and prescription drugs, accumulate toward both the preferred and non-preferred Deductible.
Unless otherwise indicated, the Deductible must be met prior to benefits being payable.
Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the calendar year.
Member Coinsurance 10% 20% 30% 50%
Applies to all expenses unless otherwise stated.
Out of Pocket Maximum (per calendar year) $3,000 Individual $3,000 Individual $4,000 Individual Unlimited
$6,000 Family $6,000 Family $8,000 Family Unlimited
All covered expenses, excluding prescription drugs and copays, accumulate toward both the preferred and non-preferred Out of Pocket Maximum.
Certain member cost sharing elements may not apply toward the Out of Pocket Maximum.
Only those out-of-pocket expenses resulting from the application of coinsurance percentage and deductibles (except any penalty amounts) may be used to satisfy the Out of pocket Maximum.

Once Family Out of Pocket Maximum is met, all family members will be considered as having met their Payment Limit for the remainder of the calendar year.
Lifetime Maximum
Unlimited except where otherwise indicated.
Certification Requirements -
Certification for certain types of Non-Preferred care must be obtained to avoid a reduction in benefits paid for that care. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care,
Hospice Care and Private Duty Nursing is required - excluded amount applied separately to each type of expense is $400 per occurrence.
Referral Requirement None None None None
PREVENTIVE CARE Tier 1 Tier 2 Tier 3 Tier 4
Mosaic Life Care Children's Mercy PPO In Network Out of Network
Routine Adult Physical Exams/ Covered 100% Covered 100% Covered 100% 50%; after deductible
Immunizations
Routine Well Child Exams/Immunizations Covered 100% Covered 100% Covered 100% 50%; after deductible

Routine Gynecological Care Exams Covered 100% Covered 100% Covered 100% 50%; after deductible
Includes routine tests and related lab
Women's Health Covered 100% Covered 100% Covered 100% 50%; after deductible
Includes: Pre-natal maternity, screening for gestational diabetes, HPV (Human Papillomavirus) DNA testing, counseling for sexually transmitted infections, counseling and screening for human immunodeficiency virus,
screening and counseling for interpersonal and domestic violence, breastfeeding supoort, supplies and counseling.
Contraceptive methods, sterilization procedures, patient education and counseling. Limitations may apply.
Routine Mammograms Covered 100% Covered 100% Covered 100% 50%; after deductible
One mammography exam per calendar
Routine Digital Rectal Exam / Covered 100% Covered 100% Covered 100% 50%; after deductible
Prostate-specific Antigen Test
Colorectal Cancer Screening Covered 100% Covered 100% Covered 100% 50%; after deductible
(Deductible and Co-insurance applies to services that are medical in nature)
Routine Hearing Exams/Screenings Covered 100% Covered 100% Covered 100% 50%; after deductible

Hearing Aids 20%; after deductible 20%; after deductible 30%; after deductible 50%; after deductible
Limited to a $1,000 benefit per ear every 2 calendar years
PHYSICIAN SERVICES Tier 1 Tier 2 Tier 3 Tier 4
Mosaic Life Care Children's Mercy PPO In Network Out of Network
Office Visits to PCP $10 office visit copay $40 office visit copay $60 office visit copay 50%; after deductible

Includes services of an internist, general physician, OB/GYN, family practitioner or pediatrician.

Specialist Office Visits $20 office visit copay $40 office visit copay $60 office visit copay 50%; after deductible

E-Visit Covered 100% Not Covered Not Covered Not Covered

TeleHealth / TeleMedicine Applicable PCP or Specialist copay Applicable PCP or Specialist copay Applicable PCP or Specialist copay 50%; after deductible
CareGiver Quick Clinic Covered 100% Not Covered Not Covered Not Covered
(only available to Mosaic caregivers and their dependents (18 and older)that are enrolled in Health insurance)
Pre-Natal Maternity Covered 100% Covered 100% Covered 100% 50%; after deductible

Maternity Delivery / Post Partum $20 office visit copay $40 office visit copay $60 office visit copay 50%; after deductible

Allergy Testing 20%; after deductible 20%; after deductible 30%; after deductible 50%; after deductible
Allergy Injections PCP or specialist office visit PCP or specialist office visit PCP or specialist office visit 50%; after deductible
DIAGNOSTIC PROCEDURES Tier 1 Tier 2 Tier 3 Tier 4
Mosaic Life Care Children's Mercy PPO In Network Out of Network
Diagnostic Laboratory and X-ray Covered 100% 20%; after deductible 30%; after deductible 50%; after deductible
If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing.
Complex Imaging Services 15%; after deductible 20%; after deductible 30%; after deductible 50%; after deductible
EMERGENCY MEDICAL CARE Tier 1 Tier 2 Tier 3 Tier 4
Mosaic Life Care Children's Mercy PPO In Network Out of Network
Urgent Care Provider $30 copay; deductible waived 25%; after deductible 30%; after deductible 50%; after deductible
(benefit availability may vary by location)
Emergency Room 20% after $150 copay; after deductible 20% after $150 copay; after deductible 20% after $150 copay; after deductible 20% after $150 copay; after deductible
Copay waived if admitted
Ambulance 20%; after deductible 20%; after deductible 20%; after deductible 20%; after deductible
HOSPITAL CARE Tier 1 Tier 2 Tier 3 Tier 4
Mosaic Life Care Children's Mercy PPO In Network Out of Network
Inpatient Coverage 10%; after deductible 25%; after deductible 30%; after deductible 50%; after deductible
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Deductible waived for newborn.
Inpatient Maternity Coverage 10%; after deductible 25%; after deductible 30%; after deductible 50%; after deductible
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Deductible waived for newborn.
Outpatient Hospital Expenses 10%; after deductible 25%; after deductible 30%; after deductible 50%; after deductible
(including surgery)
The member cost sharing applies to all covered benefits incurred during a member's outpatient visit.

Prepared: 10/16/2014 05:43 PM 8/4/2021

 Mosaic Health System Comprehensive Employee Benefit Plan Overview
Effective Date: 01-01-2022

PLAN DESIGN & BENEFITS

PROVIDED BY Meritain Health, An Aetna Company
MENTAL HEALTH SERVICES Tier 1 Tier 2 Tier 3 Tier 4
Mosaic Life Care Children's Mercy PPO In Network Out of Network
Inpatient 10%; after deductible 25%; after deductible 30%; after deductible 50%; after deductible
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay.
Outpatient $10 office visit copay $40 office visit copay $60 office visit copay 50%; after deductible

The member cost sharing applies to all covered benefits incurred during a member's outpatient visit.
ALCOHOL/DRUG ABUSE SERVICES Tier 1 Tier 2 Tier 3 Tier 4
Mosaic Life Care Children's Mercy PPO In Network Out of Network
Inpatient 10%; after deductible 25%; after deductible 30%; after deductible 50%; after deductible
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay.
Outpatient $20 office visit copay $40 office visit copay $60 office visit copay 50%; after deductible

The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit.
Residential Treatment Facility 10%; after deductible 25%; after deductible 30%; after deductible 50%; after deductible
OTHER SERVICES Tier 1 Tier 2 Tier 3 Tier 4
Mosaic Life Care Children's Mercy PPO In Network Out of Network
Convalescent Facility 20%; after deductible 20%; after deductible 30%; after deductible 50%; after deductible
Limited to 30 days per calendar year.
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay.
Home Health Care 20%; after deductible 20%; after deductible 30%; after deductible 50%; after deductible
Limited to 120 visits per calendar year. Includes Private Duty Nursing limited to 70 eight hour shifts per calendar year.
Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health care aide is one visit.
Hospice Care - Inpatient 20%; after deductible 20%; after deductible 30%; after deductible 50%; after deductible
Limited to 30 days per lifetime.
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay
Hospice Care - Outpatient 20%; after deductible 20%; after deductible 30%; after deductible 50%; after deductible
The member cost sharing applies to all covered benefits incurred during a member's outpatient visit
Outpatient Short-Term Rehabilitation 20%; after deductible 20%; after deductible 30%; after deductible 50%; after deductible
Include Speech, Physical, and Occupational Therapy, limited to 60 visits per calendar year.
Chiropractor - Spinal Manipulation $20 office visit copay $40 office visit copay $60 office visit copay 50%; after deductible

Limited to 26 visits per calendar year

Durable Medical Equipment 20%; after deductible 20%; after deductible 30%; after deductible 50%; after deductible
Purchases or rentals over $1,000 must be pre-authorized. Up to $5,000 benefit maximum every calendar year
Diabetic Supplies Covered same as any other medical Covered same as any other medical Covered same as any other medical Covered same as any other medical
expense. expense. expense. expense.
Contraceptive drugs and devices not Covered same as any other medical Covered same as any other medical Covered same as any other medical Covered same as any other medical
obtainable at a pharmacy (includes expense. expense. expense. expense.
coverage for contraceptive visits)

Transplants 20% (preferred coverage is provided 20% (preferred coverage is provided 30% (preferred coverage is provided Not Covered
at an IOE contracted facility only) at an IOE contracted facility only) at an IOE contracted facility only)
Bariatric 10% coinsurance; after deductible Not Covered Not Covered Not Covered
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Will apply to the plan Payment Limits.

FAMILY PLANNING Tier 1 Tier 2 Tier 3 Tier 4

Mosaic Life Care
Infertility Treatment Member cost sharing is based on the
type of service performed and the place
of service where it is rendered
Diagnosis and treatment of the underlying medical condition.
Vasectomy Member cost sharing is based on the
type of service performed and the place
of service where it is rendered; after
deductible
Tubal Ligation Covered 100%; deductible waived
GENERAL PROVISIONS
Children's Mercy
Member cost sharing is based on the
type of service performed and the place
of service where it is rendered
Member cost sharing is based on the
type of service performed and the place
of service where it is rendered; after
deductible
Covered 100%; deductible waived
PPO In Network
Member cost sharing is based on the
type of service performed and the place
of service where it is rendered
Member cost sharing is based on the
type of service performed and the place
of service where it is rendered; after
deductible
Covered 100%; deductible waived
Out of Network
Member cost sharing is based on the
type of service performed and the place
of service where it is rendered
Member cost sharing is based on the
type of service performed and the place
of service where it is rendered; after
deductible
Member cost sharing is based on the type
of service performed and the place of
service where it is rendered

Dependents Eligibility Spouse, children from birth to end of the month they turn age 26

Meritain Customer Services 1-800-952-2272

This is a brief outline of your benefits. It is not a Summary Plan Description or intended to replace the Schedule of Benefits contained within the Plan Document. If any provision is inconsistent with the language of the
Plan Document, the Plan Document will govern.

Prepared: 10/16/2014 05:43 PM 8/4/2021

 Dental Benefits Summary

HEARTLAND HEALTH Delta Dental Delta Dental Out-of-Network

PPOSM Network Premier® Network
BASE PLAN
Based on applicable Based on applicable Based on applicable
PPO Maximum Plan Premier Maximum Plan Maximum Plan
Allowance - No balance Allowance - No balance Allowance for Out-of-
billing billing Network dentist -
Balance billing is possible
Preventive Services
 Oral examinations (all types), twice in any calendar year
 Dental prophylaxis (cleaning, scaling, and polishing, including
periodontal maintenance visits), twice in any calendar year
 Bitewing x-rays, as required
 Periapical x-rays, as required 100% 100% 100%
 Full mouth x-rays, once per benefit period
 Space maintainers for dependent children under age 16, once in
5 years
 Topical fluoride treatments for dependent children under age
19, once in any calendar year
Basic Services
 Sealants for dependent children under age 19, once in 5 years,
for caries-free permanent molars
 Fillings
 Non-surgical periodontics
 Endodontics
 Simple and surgical extractions 60% 60% 60%
 Oral surgery
 Crown repairs & recement
 Crowns, once in 5 years
 General Anesthesia in conjunction with a covered surgical
procedure
 Emergency palliative treatment

Major Services
 Inlays and onlays, once in 5 years
 Bridges and dentures, once in 5 years
 Bridge repairs & recement 40% 40% 40%
 Bridges, once in 5 years
 Denture repairs & adjustments
 Surgical Periodontics
Orthodontia N/A N/A N/A
 Orthodontia for dependent children under age 19
MAXAdvantage Claims paid for cleanings, exams, x-rays, and fluoride treatments do
not apply towards the annual benefit maximum.
Calendar Year Deductible
$50 individual / $150 family limit
(Applied to Basic and Major services)
Annual Maximum (Applied to Preventive, Basic and Major services) $1,000 per person

Dependent Age Limit: 26

This is intended to be a summary only. If a discrepancy occurs the Summary Plan Document will govern. Please refer to your Summary Plan Description (SPD) for a more complete listing of
services including plan limitations and exclusions. Orthodontic treatment in progress may be covered. Benefits provided by the prior carrier will be subtracted from the lifetime maximum
available from Delta Dental.

Heartland Health_Base Plan_1/1/2019

 Dental Benefits Summary

HEARTLAND HEALTH Delta Dental Delta Dental Out-of-Network

PPOSM Network Premier® Network
BUY-UP PLAN
Based on applicable Based on applicable Based on applicable
PPO Maximum Plan Premier Maximum Plan Maximum Plan
Allowance - No balance Allowance - No balance Allowance for Out-of-
billing billing Network dentist -
Balance billing is possible
Preventive Services
 Oral examinations (all types), twice in any calendar year
 Dental prophylaxis (cleaning, scaling, and polishing, including
periodontal maintenance visits), twice in any calendar year
 Bitewing x-rays, as required
 Periapical x-rays, as required 100% 100% 100%
 Full mouth x-rays, once per benefit period
 Space maintainers for dependent children under age 16, once in
5 years
 Topical fluoride treatments for dependent children under age
19, once in any calendar year
Basic Services
 Sealants for dependent children under age 19, once in 5 years,
for caries-free permanent molars
 Fillings
 Non-surgical periodontics
 Endodontics
 Simple and surgical extractions 90% 80% 80%
 Oral surgery
 Crown repairs & recement
 Crowns, once in 5 years
 General Anesthesia in conjunction with a covered surgical
procedure
 Emergency palliative treatment

Major Services
 Inlays and onlays, once in 5 years
 Bridges and dentures, once in 5 years
 Bridge repairs & recement 60% 50% 50%
 Bridges, once in 5 years
 Denture repairs & adjustments
 Surgical periodontics

Orthodontia 50% 50% 50%

 Orthodontia for dependent children under age 19
MAXAdvantage Claims paid for cleanings, exams, x-rays, and fluoride treatments do
not apply towards the annual benefit maximum.
Calendar Year Deductible
$50 individual / $150 family limit
(Applied to Basic and Major services)
Annual Maximum (Applied to Preventive, Basic and Major services) $1,500 per person

Orthodontic Lifetime Maximum $1,500 per eligible dependent

Dependent Age Limit: 26

This is intended to be a summary only. If a discrepancy occurs the Summary Plan Document will govern. Please refer to your Summary Plan Description (SPD) for a more complete listing of
services including plan limitations and exclusions. Orthodontic treatment in progress may be covered. Benefits provided by the prior carrier will be subtracted from the lifetime maximum
available from Delta Dental.

Heartland Health_Buy-Up Plan_1/1/2019

 Life is
better in
focus. TM

Get access to the best in eye care and

eyewear with MOSAIC LIFE CARE and
VSP® Vision Care.
Why enroll in VSP? As a member, you’ll receive access to care
from great eye doctors, quality eyewear, and the affordability
you deserve, all at low out-of-pocket costs.
You’ll like what you see with VSP.
High Quality Vision Care. You’ll get great care from a VSP network doctor, Using your VSP benefit is easy.
including a WellVision Exam®—a comprehensive exam designed to detect Create an account at vsp.com. Once your plan
eye and health conditions. is effective, review your benefit information.
Choice of Providers. The decision is yours to make—with the largest Find an eye doctor who’s right for you. Visit
national network of private-practice doctors, plus participating retail vsp.com or call 800.877.7195.
chains, it's easy to find the in-network doctor who's right for you. At your appointment, tell them you have VSP.
Great Eyewear. It’s easy to find the perfect frame at a price that fits your There’s no ID card necessary. If you’d like a
budget. card as a reference, you can print one on
vsp.com.
Without VSP With Buy-Up That’s it! We’ll handle the rest—there are no
Save with VSP Coverage
Coverage Coverage claim forms to complete when you see a VSP
Eye Exam $171 $10 provider.
Frame $250
$25 Choice in Eyewear
Bifocal Lenses $150
From classic styles to the latest designer frames,
Photochromic Adaptive Lenses $113 $70 you’ll find hundreds of options. Choose from
Anti-reflective Coating $115 $69 featured frame brands like bebe, CALVIN KLEIN,
Employee-only Annual Contribution N/A $98.16 Cole Haan, Flexon®, Lacoste, Nike, Nine West,
1
and more. Visit vsp.com to find a Premier
Total $799 $272.16
Program location that carries these brands. Plus,
Comparison based on national averages for comprehensive 2
save up to 40% on popular lens enhancements.
eye exams and most commonly purchased brands
Average Annual Savings with a Prefer to shop online? Check out all of the brands
NOTE: Dollar amounts in the savings chart are estimates
and don't reflect additional discounts from current VSP
offers and promotions.
VSP Provider: $526.84 at eyeconic.com®, VSP's preferred online eyewear
store.

Enroll in VSP today. You'll be glad you did.

Contact us. 800.877.7195
vsp.com
Your VSP Vision Benefits Summary VSP Coverage Effective Date: 01/01/2019

MOSAIC LIFE CARE and VSP provide you with a choice of affordable vision plans – choose the plan that's right for you.
Core VSP Provider Network: VSP Choice Buy-Up VSP Provider Network: VSP Choice
Benefit Description Copay Benefit Description Copay
Your Coverage with a VSP Provider Your Coverage with a VSP Provider
Focuses on your eyes and overall Focuses on your eyes and overall
WellVision WellVision
wellness $10 wellness $10
Exam Exam
Every calendar year Every calendar year
Glasses and Sunglasses Prescription Glasses $25
20% savings on complete pair of prescription glasses $250 allowance for a wide selection
and sunglasses, including lens enhancements, from of frames
any VSP provider within 12 months from your last $270 allowance for featured frame
WellVision Exam. Included in
brands
Frame Prescription
Contacts 20% savings on the amount over your
Extra Savings Glasses
15% savings on a contact lens exam (fitting and allowance
evaluation) $110 Costco® frame allowance
Laser Vision Correction Every other calendar year
Average 15% off the regular price or 5% off the Single vision, lined bifocal, and lined
promotional price; discounts only available from trifocal lenses Included in
contracted facilities Lenses Polycarbonate lenses for dependent Prescription
children Glasses
Your Per Pay Every calendar year
$0 Employee only $0 Employee + child(ren)
Period
$0 Employee + spouse $0 Employee + family Standard progressive lenses $0
Contribution
Premium progressive lenses $95 - $105
Lens Custom progressive lenses $150 - $175
Enhancements Average savings of 20-25% on other
lens enhancements
Every calendar year
$250 allowance for contacts; copay
Contacts does not apply
(instead of Contact lens exam (fitting and Up to $60
glasses) evaluation)
Every calendar year
Glasses and Sunglasses
Extra $50 to spend on featured frame brands. Go to
vsp.com/specialoffers for details.
20% savings on additional glasses and sunglasses,
including lens enhancements, from any VSP provider
within 12 months of your last WellVision Exam.
Extra Savings Retinal Screening
No more than a $39 copay on routine retinal
screening as an enhancement to a WellVision Exam
Laser Vision Correction
Average 15% off the regular price or 5% off the
promotional price; discounts only available from
contracted facilities
Your Per Pay $3.78 Employee only $7.97 Employee +
Period $7.45 Employee + spouse child(ren)
Contribution $12.72 Employee + family
Your Coverage with Out-of-Network Providers
Get the most out of your benefits and greater savings with a VSP network doctor. Call Member Services for out-of-network plan details.

Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change. In the event of a conflict between this information
and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. In the state of Washington, VSP Vision Care, Inc., is the legal name
of the corporation through which VSP does business.
1. Brands/Promotion subject to change.
2. Savings based on network doctor's retail price and vary by plan and purchase selection; average savings determined after benefits are applied. Available only through VSP network doctors to VSP
members with applicable plan benefits. Ask your VSP network doctor for details.
©2018 Vision Service Plan. All rights reserved.
VSP, VSP Vision care for life, eyeconic.com and WellVision Exam are registered trademarks, and "Life is better in focus." is a trademark of Vision Service Plan. Flexon is a registered trademark of Marchon
Eyewear, Inc. All other company names and brands are trademarks or registered trademarks of their respective owners.