Visiting Scholar Benefit Plan  University of California Berkeley Visiting Scholar Benefit Plan (UCBVSBP) Effective December 1, 2010  

UCBVSBP The University of California, Berkeley (UCB) has partnered with Garnett-Powers & Associates to administer the Visiting Scholar Benefit Plan (UCBVSBP) December 1, 2010 is the effective date whereby all domestic and international Visiting Scholars and Visiting Student Researchers must be provide proof of adequate health insurance coverage The UCBVSP is available to both domestic and international Visiting Scholars and Visiting Student Researchers at UCB who are affiliates of the Visiting Scholar and Postdoc Affairs (VSPA) Program The UCBVSBP fully meets the U.S. State Department Exchange Scholar requirements for J-1 scholars and their J-2 dependents

UCBVSBP Healthcare Options PPO Plan A Plan B Plan C Benefits UnitedHealthcare In-Network UnitedHealthCare Out-of-Network IMG Standard Plan Platinum Plan Plan Type PPO Overall Plan Maximum There is no overall maximum dollar limit on the policy Visiting Scholar - $500,000 period of coverage Dependent - $100,000 period of coverage Visiting Scholar - $1,000,000 period of coverage Plan Deductible $250 per Insured Person, Per Policy Year $500 per Insured Person, Per Policy Year $500 per Illness/Injury PPO Provider: $25 per Illness/ Injury Non-PPO Provider: $50 per Illness/ Injury Out-of-Pocket Maximum $4,500 per Insured Person and $9,000 for all Insured Families Per Policy Year $9,000 per Insured Person and $18,000 for all Insured Families Per Policy Year No Out-of-Pocket Maximum Coinsurance Visiting Scholar pays 20% of Preferred Allowance Visiting Scholar pays 40% of Usual and Customary Charges PPO Provider: Visiting Scholar pays 0% of eligible expenses Non-PPO Provider: Visiting Scholar pays 20% of eligible expenses up to $1,000, then the plan pays 100% thereafter Prescription Drugs $20 Copay for Tier 1 $40 Copay for Tier 2 $80 Copay for Tier 3 No Benefits Visiting Scholar Pays 50% of actual charges Up to annual maximum of $1,500 $20 Copay for Generic $40 Copay for Brand $80 Copay for Non-Brand Up to the annual maximum of $3,000

UCBVSBP Healthcare Options PPO Plan A Plan B Plan C Benefits UnitedHealthcare In-Network Out-of-Network IMG Standard Plan Platinum Plan Maternity Paid as any other illness No Coverage Conception must occur during period of coverage Routine Newborn Care $750 maximum per period of coverage Emergency Medical Evacuation No Limit $50,000 lifetime maximum $500,000 lifetime maximum Repatriation of Remains $25,000 maximum $50,000 maximum Pre-Existing Conditions Pre-existing conditions are covered with no waiting period Pre-existing conditions are covered after 12 months of continuous coverage Pre-existing conditions are covered after 6 months of continuous coverage Emergency Room $100 Copay per visit (waived if admitted) + Visiting Scholar pays 20% of preferred allowance $100 Deductible per visit + Visiting Scholar pays 20% Usual and Customary Charges $250 Deductible

UCBVSBP Healthcare Options PPO Plan A Plan B Plan C Benefits UnitedHealthcare In-Network Out-of-Network IMG Standard Plan Platinum Plan Hospitalization Visiting Scholar pays 20% of Preferred Allowance Visiting Scholar pays 40% of Usual and Customary Charges $500 per Illness/Injury Usual and Customary Charges PPO Provider: $25 per Illness/ Injury Mental & Nervous Disorders $50 Copay with $500 lifetime maximum Eligibility U.S. Citizens, Non-U.S. Citizens & Dual Citizens Non-U.S. Citizens only Preventive Care Services including Immunizations Provided at No Cost No Benefits Well Exams covered at 100% (annual max of $500) Immunizations covered at 100% (annual max of $250)

UCBVSBP Rates* Plan Options Insurance Plan Visiting Scholar Additional Premium for Spouse or Domestic Partner Additional Premium for One Child Additional Premium for Two or more Children Additional Premium for Spouse & Two or more Children Plan A UnitedHealthcare $322 $644 $966 Plan B IMG Standard Plan Age Rated: 19-23 years old 24-30 years old 31-40 years old 41-50 years old 51-64 years old $69 $77 $122 $187 $242 $238 $260 $345 $356 $66 For every child dependent, the premium is an extra $66 N/A Plan C IMG Platinum Plan $151 $172 $294 $480 $641 $575 $635 $845 $873 $134 For every child dependent, the premium is an extra $134 * Rates are effective September 1, 2016 through August 31, 2017

Medical Evacuation & Repatriation Coverage The UCBVSBP plan includes includes medical evacuation and repatriation of remains benefits that meet the U.S. State Department requirements International J-1 scholars and their J-2 dependents do not need to purchase supplemental coverage to meet their J Visa requirements

UCBVSBP Administrative Process Department staff prepares an affiliate application in the VSPA Gateway VSPA Program confirms approval of affiliate application VSPA sends notification of eligibility to GPA for new and extended appointments Department creates a Human Capital Management (HCM) Contingent Worker Job Organizational Instance .NOTE: Staff can create record up to 3 months in advance of appointment Cal Numerical ID is generated Continued next page…

UCBVSBP Administrative Process Affiliate has 31 days from appointment date to visit the GPA website and enroll in VSBP or opt out of the plan When enrollment form is completed and premiums are paid, GPA will notify the scholar. The insurance company will provide an insurance ID card If waiving or opting out: Affiliate must provide proof of comparable coverage to GPA for verification. Upon approval, GPA will notify the affiliate, department staff and VSPA Program that health insurance requirement has been satisfied

UCBVSBP Administrative Process VSPA creates a Person of Interest (POI) record in HCM, which activates the HCM Contingent Worker Job Organizational Instance If the affiliate’s insurance does not meet the waiver requirements, or if the affiliate drops coverage early, GPA will notify department staff of the deficiency If the requirements are not satisfied by the affiliate, GPA will inform the VSPA Program and the POI record will be deactivated, resulting in loss of campus services

VSPA Affiliate Enrollment Process Affiliate must enroll online through Garnett-Powers & Associates’ UCVSBP website: www.garnett-powers.com/vs/ucb Affiliates must follow the enrollment process carefully. To get started, the affiliate clicks on the ‘Enrollment’ link and prints (or reads) the ‘Enrollment/Payment Instructions.’ These instructions are written to guide the affiliate’s completion of the enrollment form. Once the affiliate has filled out the form, the affiliate should print the completed form for record-keeping purposes. IMPORTANT: Failure to adhere to the recommended enrollment process may result in a long delay in becoming active in the insurance carrier’s system

VSPA Affiliate Enrollment Process Affiliate must provide a current and correct email address because all correspondence between GPA and the affiliate will transacted by email  including confirmation of enrollment and quarterly invoices for subsequent quarterly enrollment. Enrollment is not complete until GPA receives: 1) confirmation of eligibility from the campus, and 2) initial payment Health insurance ID cards will be mailed to the affiliate’s U.S. mailing address listed on the enrollment form 7 to 10 business days after the enrollment process is complete If the affiliate would like to make changes to enrollment in the future, the affiliate must click ‘Making Changes to Your Enrollment’ link and print (or read) the ‘Instructions on Making Changes’ link for detailed instructions.

VSPA Affiliate Payment Process Upon completion of the enrollment form, the affiliate is directed to ‘Submit and Create Printable Enrollment Form’. A reminder that payment is due immediately is issued. Payment is due for the current quarter (or portion as determined by the affiliate’s insurance start date) at initial enrollment (whole months only  no pro-rated amounts when enrolling after the first of the month) When the affiliate clicks on the ‘Calculate Premium’ button, the system automatically ‘populates’ both the initial premium owed for the first quarter and premium owed for subsequent quarter(s) on the payment coupon at the bottom of the enrollment form. The affiliate should print this document for record-keeping purposes.

VSPA Affiliate Payment Process The affiliate can pay by debit or credit card or with a check. If the affiliate is paying by check, the affiliate should return the payment coupon with a check to Garnett-Powers & Associates. After the initial premium has been paid, the GPA billing department will send the affiliate an electronic invoice for subsequent billing(s) prior to the expiration date of the insurance policy. If affiliate’s appointment ends before the end of any quarter, affiliate will only be billed the premium through the end of the last month of appointment.

Family Member Eligibility* Family member categories (including J-2 dependents) are the following: Spouse Domestic partner Same-sex domestic partner Opposite-sex domestic partner only if one partner is over age 62 Unmarried natural or adopted children to age 19 or to age 23 if a full-time student who is not self-supporting NOTE: Other family members (e.g., parents, nieces or nephews) are NOT eligible *See Eligibility and Definitions sections in policy brochure

Information Sources www.garnett-powers.com/vs/ucb 888-441-3719 Website: Garnett-Powers’ UCBVSBP website: www.garnett-powers.com/vs/ucb Toll Free Phone: Garnett-Powers’ UCBVSBP customer service number: 888-441-3719 Email Address: Garnett-Powers’ email address: UCBVSBP@Garnett-Powers.com