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State Street Health and Insurance Benefits Programs ...

Publication Date: October 1, 2014 i State Street Health and Insurance Benefits Programs summary plan Description State Street CORPORATION January 1, 2014 This booklet is a summary plan Description (SPD) of the State Street Corporation Employee Benefit plan ( plan ), and replaces all prior descriptions of this plan . The information contained in this booklet is intended as a summary of the plan in effect as of January 1, 2014 . This booklet is intended to be an easy-to-understand explanation of your Benefits . It is not, however, a comprehensive explanation of all provisions of the plan , which are described in detail in the official plan documents (including contracts, plan documents and certificates), which legally govern the operation of the plan . In the event of any conflict between the plan provisions as stated in the plan documents and this SPD, the provisions of the plan documents will govern. State Street reserves the right to amend or terminate the plan at any time, for current and/or future participants, retirees, beneficiaries and dependents, and no provision in this SPD shall grant a vested or guaranteed right in any future benefit.

State Street Health and Insurance Benefits Programs Summary Plan Description STATE STREET CORPORATION January 1, 2014 This booklet is a Summary Plan Description (SPD) of the State Street Corporation Employee Benefit Plan (Plan), and replaces all prior descriptions of this Plan. The information contained in this booklet is

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Transcription of State Street Health and Insurance Benefits Programs ...

1 Publication Date: October 1, 2014 i State Street Health and Insurance Benefits Programs summary plan Description State Street CORPORATION January 1, 2014 This booklet is a summary plan Description (SPD) of the State Street Corporation Employee Benefit plan ( plan ), and replaces all prior descriptions of this plan . The information contained in this booklet is intended as a summary of the plan in effect as of January 1, 2014 . This booklet is intended to be an easy-to-understand explanation of your Benefits . It is not, however, a comprehensive explanation of all provisions of the plan , which are described in detail in the official plan documents (including contracts, plan documents and certificates), which legally govern the operation of the plan . In the event of any conflict between the plan provisions as stated in the plan documents and this SPD, the provisions of the plan documents will govern. State Street reserves the right to amend or terminate the plan at any time, for current and/or future participants, retirees, beneficiaries and dependents, and no provision in this SPD shall grant a vested or guaranteed right in any future benefit.

2 You may refer to the applicable plan certificate of coverage or description of coverage for complete details on specific provisions, such as benefit coverage, definitions, coordination of Benefits , waiting periods, exclusions, limitations and how to file claims. Such certificates of coverage and descriptions of coverage are incorporated into this SPD by reference. The plan is subject to approval by the Internal Revenue Service (IRS). Participation in the plan is not an offer or guarantee of employment or an employment contract. State Street reserves the right to change, terminate or merge the plan at any time. This document and more information about your Benefits plan are available on NetBenefits at or b y calling the GHR Service Center at +1 855 447 7007, Option 1 (hours: 8:30 to 8:30 Eastern time). For International access, dial the toll-free AT&T Direct access number, then enter 770 281 4858. For TDD communication services for the hearing impaired, call +1 888 343 0860.

3 Publication Date: October 1, 2014 ii What s Inside Highlights .. 1 Eligibility, Enrollment and Participation .. 2 Eligibility Active Employees .. 2 Full-Time Employees .. 2 Part-Time Employees .. 2 Eligibility Retired Employees .. 3 Eligible Dependents .. 3 Dependent Definitions .. 3 Enrollment .. 4 How to Enroll .. 5 When Coverage Begins .. 5 Coverage Levels .. 6 Pretax Benefits .. 7 Domestic Partner Tax Treatment .. 7 Other Adult Dependent Tax Treatment .. 8 Changing Your Elections .. 8 Annual Enrollment .. 8 IRS-Qualified Status Changes .. 8 Dependent Eligibility .. 10 Qualified Medical Child Support Orders .. 10 When Your Employment Ends .. 10 Life Insurance and Accidental Death & Dismemberment (AD&D) .. 11 Certification of Health Care Coverage .. 11 Family Status Changes .. 11 Family and Medical Leave Act (FMLA) Leave .. 14 Paid FMLA Leave .. 14 Unpaid FMLA Leave .. 14 Military Leave of Absence .. 14 Medical plan .

4 16 Waiver Option .. 16 If You and Your Spouse/Domestic Partner Both Work at State Street .. 16 Your Cost .. 16 Tobacco Surcharge .. 17 Participating Providers .. 17 Preventive Care .. 17 Newborns and Mothers Health Protection Act .. 17 Women s Health and Cancer Rights Act .. 18 Medical plan summary of Benefits and Coverage .. 19 Publication Date: October 1, 2014 iii Health Savings Account (HSA) .. 20 HSA Eligibility .. 20 HSA Contributions .. 20 Setting Up Your HSA Account .. 20 Using Your HSA Account .. 21 Eligible HSA Expenses .. 21 Investing Your HSA Account .. 22 If You Have HSA Money Left Over .. 22 Pharmacy Benefits (for Members of BlueCross BlueShield, PPO Plus Cigna/Tufts HP Open Access with HSA and Tufts) .. 23 Prescription Drug Copays Express Scripts Plans .. 23 List of Formulary and Non-Covered Drugs .. 24 Participating Pharmacies .. 24 Specialty Drugs .. 24 For More Information about Pharmacy Benefits .. 24 Kaiser HMO and Aetna Global Medical plan Members.

5 24 For More Information .. 24 Retiree Medical and Life Insurance .. 26 Eligibility .. 26 Changing Your Elections .. 26 Coverage Ends at Age 65 .. 26 Spouse/Domestic Partner/Dependent Coverage for Retirees under Age 65 .. 26 COBRA .. 27 Cost Sharing for Retirees under Age 65 .. 27 If You Waive Medical Coverage .. 28 Retiree Health Expense Reimbursement Account Age 65 and Older .. 28 Reimbursement from Your Account .. 29 Medicare for Retirees .. 29 Spouse/Domestic Partner/Dependent Coverage for Retirees Age 65 or Older .. 30 COBRA .. 30 Other Events Death or Divorce .. 30 If You Die .. 31 Spouse/Domestic Partner .. 31 Other Covered Dependents .. 31 If You Divorce .. 31 Eligibility Chart for Retiree Medical Benefits .. 32 Retiree Life Insurance .. 37 Dental plan .. 38 Your Cost .. 38 Publication Date: October 1, 2014 iv How the Plans Work .. 38 Dental plan Comparisons .. 40 Definitions of Service Types .. 41 For More Information.

6 41 Vision plan .. 42 Vision plan summary .. 42 Your Cost .. 43 For More Information .. 43 Disability Benefits .. 44 Short-Term Disability .. 44 Long-Term Disability .. 47 Life and Accident Insurance .. 49 Coverage Overview .. 49 Eligible Dependents .. 50 Designating Your Beneficiary .. 50 Your Cost .. 50 Proof of Good Health .. 51 Changes Due to Life Events .. 51 Changes During the Year .. 52 Continuation of Life Insurance Coverage .. 52 Death in Service Benefit .. 52 Corporate Credit Card Coverage .. 53 Workers Compensation .. 53 International SOS .. 53 Employee Assistance Program .. 53 Legal and Financial Consultation .. 53 Cost .. 54 Confidential and Voluntary .. 54 In the Event of Your Death .. 54 How to Access the EAP .. 54 Hyatt Legal Plans .. 54 Continuation of Legal plan Coverage .. 54 Claims and Appeal Process .. 55 Overview .. 55 Claims Administrators .. 55 Health Care Claims (Medical and Dental Plans and Employee Assistance Program).

7 58 Health Care Claim Review Procedures .. 58 Health Care Claim Appeal Procedures .. 60 Short-Term and Long-Term Disability Claims and Appeals .. 61 Publication Date: October 1, 2014 v STD and LTD Claim Review Procedures .. 61 STD and LTD Claim Appeal Procedures .. 61 General Claims Review Procedures for Non- Health and Non-Disability Claims (such as Life Insurance , Vision and Wellness) .. 61 Claim Review Requests for Non- Health and Non-Disability Claims .. 61 Appeal Procedures for Non- Health and Non-Disability Claims .. 61 Legal Action .. 62 Your Rights and Responsibilities .. 63 Continuing Coverage under COBRA .. 63 COBRA at a Glance .. 63 COBRA and FMLA .. 64 COBRA Qualifying Events .. 65 Your Right to Privacy under HIPAA .. 68 plan Amendment and Continuation .. 68 Right of Recovery .. 68 plan Information .. 69 plan Year .. 69 Employer Identification Numbers of Participating Employers .. 69 plan Administrator .. 69 plan Sponsor.

8 69 Agent for Legal Process .. 70 plan Fiduciary Responsibility .. 70 plan Funding .. 70 Additional Employee Benefit plan Information .. 71 Your ERISA Rights .. 73 Receive Information about Your plan and Benefits .. 73 Continue Group Health plan Coverage .. 73 Prudent Actions by plan Fiduciaries .. 73 Enforce Your Rights .. 74 Assistance with Your Questions .. 74 If You Have Questions .. 75 Premium Assistance under Medicaid and the Children s Health Insurance Program (CHIP) .. 77 Appendix: summary of Benefits / plan Certificates .. 81 Publication Date: October 1, 2014 1 Highlights State Street offers a number of Benefits to help you maintain your good Health and protect your family income while you are employed at the Company. If you meet the eligibility requirements, certain plans ( , medical and life Insurance ) may be available to you when you retire from the Company. This document is a summary plan Description (SPD) for the following Benefits that are part of the State Street Corporation Employee Benefits plan , including the following: Medical (including pharmacy) Retiree Medical and Life Insurance Dental Vision Short-Term Disability Long-Term Disability Basic and Optional Life Insurance Basic and Optional Accidental Death & Dismemberment (AD&D) Business Travel Accident Insurance Employee Assistance Program Wellness MetLife Critical Illness Insurance * Hyatt Legal plan * *Note: These Benefits are described in the SPD although they are not part of the plan .

9 Also note that although the Health Care Flexible Spending Account is part of the plan , a description of that benefit can be found in the summary plan description for the State Street Health Care Flexible Spending Accounts and Dependent Care Flexible Spending Account by logging on to the NetBenefits website listed below. You can access information about your Benefits plan by logging on to NetBenefits at or by calling GHR Service Center at +1 855 447 7007, Option 1 (hours: 8:30 to 8:30 Eastern time). International callers, dial toll-free AT&T Direct access number, then enter 770 281 4858. For TDD service for the hearing impaired, call +1 888 343 0860. Publication Date: October 1, 2014 2 Eligibility, Enrollment and Participation This section provides introductory information such as eligibility, enrollment, when coverage for each benefit begins and ends, and how your coverage is affected by certain life or work events.

10 For more details about each benefit, see that benefit s section of this SPD. Benefits are not available to interns, contractors or temporary employees. You must reside in the applicable program s service area to be eligible for coverage under that p rogram. Eligibility Active Employees Full-T ime Employees If you are regularly scheduled to work at least 29 hours per week, you are eligible to participate in the following Benefits at State Street in accordance with the eligibility and enrollment requirements for each program: Medical (including pharmacy) Dental Vision Short-Term Disability (STD) Insurance Long-Term Disability (LTD) Insurance Life and Accident Insurance Business Travel Accident Insurance MetLife Critical Illness Insurance Employee Assistance Program (EAP) Hyatt Legal plan Wellness Part-T ime Employees If you are regularly scheduled to work at least 20 but less than 29 hours per week, you are eligible to participate in the following Benefits in accordance with the eligibility and enrollment requirements for each program.


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