SUMMARY PLANDESCRIPTIONMayo Clinic Health & WelfareBenefits PlanGeneral Information BookletJanuary 2021
fsMayo Clinic Health & Welfare Benefits PlanGeneral Information BookletJanuary 2021DM# 1362335.1
GENERAL INFORMATION BOOKLETIMPORTANT NOTICEIMPORTANT NOTICEThis General Information Booklet for the Mayo Clinic Health & Welfare Benefits Plan (the “Plan”)provides information that is applicable to all benefit programs offered under the Plan. This GeneralInformation Booklet addresses eligibility for coverage under the Plan, how to enroll, opportunities tomake mid-year changes, when coverage ends and how you and your covered family members may beable to continue coverage under certain benefit programs if it ends. It also contains information such aswho provides coverage, who administers the benefit programs offered under the Plan, who decides claimsfor benefits, ERISA rights and who has the right to amend and terminate the Plan and the benefitprograms offered under the Plan.The benefits booklets, benefits summaries, certificates of coverage and other documents provided inconnection with this General Information Booklet (collectively, the “Incorporated Documents”) describethe benefits provided by the benefit programs offered under the Plan, including deductible, co-pay and coinsurance information, as applicable, coverage levels, how to submit a claim for benefits and otherimportant information about your benefit programs.This General Information Booklet, together with the Incorporated Documents provided in connectionwith this General Information Booklet, constitutes the Summary Plan Description for the Plan as ofJanuary 1, 2021 and replaces all prior descriptions of the Plan. It is intended to provide a summary ofyour benefits available under the Plan. If there are any discrepancies between the Summary PlanDescription and the governing plan documents and insurance policies, the plan documents and insurancepolicies will control.2
GENERAL INFORMATION BOOKLETINTRODUCTIONINTRODUCTIONMayo Clinic maintains the Mayo Clinic Health & Welfare Benefits Plan (the “Plan”) for the exclusivebenefit of eligible employees of Mayo Clinic and its affiliates that participate in the Plan (collectivelyreferred to with Mayo Clinic as “Mayo”), eligible retirees and their eligible family members. The Planprovides benefits through the following benefit programs: Mayo Medical Plan Mayo Expatriate Medical Plan Mayo Dental Plan Mayo Vision Plan Health Care Flexible Spending Account Plan (offered under the Mayo Cafeteria Plan) Dependent Care Flexible Spending Account Plan (offered under the Mayo Cafeteria Plan) Pre-Tax Health Savings Account Mayo Clinic Employee Assistance Plan Group Life Insurance Plan (Employer Paid) Voluntary Group Term and Universal Life Plan Short-Term Disability Policy Mayo Paid Disability Income Plan Fellows Group Term Life Insurance & Disability Income Plan Mayo Clinic Accidental Death & Dismemberment Plan Mayo Travel Accident Plan Mayo Legal PlanAll of the above benefit programs are described in this General Information Booklet and in theIncorporated Documents provided in connection with this General Information Booklet.Note: The Dependent Care Flexible Spending Account Plan, the Pre-Tax Health Savings Account andthe Short-Term Disability Policy are not part of the Plan and are not subject to the requirements ofERISA, but information about these benefits programs is included in this General Information Bookletfor ease of reference.3
GENERAL INFORMATION BOOKLETCONTACT INFORMATIONCONTACT INFORMATIONFor enrollment or eligibility questions, please contact Mayo’s HR Connect. HR Connect is your humanresources office for the Plan and the benefit programs offered under the Plan.QUESTIONS ABOUT ENROLLMENT/ELIGIBILITYHR Connect200 First Street SWRochester, MN 55905507-266-0440 (local)1-888-266-0440 (toll free)M – F, 7 a.m. to 6 p.m CT (excluding holidays)HR Connect has access to translation services to meet the needs of non-English speaking persons.El presente Resumen del Plan de Descripción está redactado en inglés y ofrece detalles sobre sus derechosy beneficios bajo el Plan y los programas de beneficios ofrecidos bajo el Plan. Si tiene alguna dificultadpara entender cualquier parte de este documento, por favor comuníquese con el Centro para Servicios alEmpleado al número que se encuentra arriba.4
GENERAL INFORMATION BOOKLETTABLE OF CONTENTSTABLE OF CONTENTSIMPORTANT NOTICE . 2INTRODUCTION . 3CONTACT INFORMATION . 4OVERVIEW OF THE PLAN’S BENEFIT PROGRAMS . 7ELIGIBILITY AND PARTICIPATION. 11Who is Eligible . 11Eligible Family Members . 13When You Can Enroll . 15Who Pays the Costs of the Plan . 16How You Pay for Coverage and Pre-Tax Premium Payment Program . 17Mid-Year Election Changes . 18Permitted Mid-Year Election Change Events . 18Special Enrollment Rights . 25When Coverage Becomes Effective . 26WHEN COVERAGE ENDS . 28When Employee Coverage Ends . 28When Retiree Coverage Ends . 28When Eligible Family Member Coverage Ends . 29Additional Termination of Coverage Rules . 30Rescission. 30CONTINUATION OF HEALTH CARE COVERAGE UNDER COBRA . 32COBRA Eligibility. 32Notification of COBRA Continuation Coverage Election . 33Who May Elect COBRA Continuation Coverage . 33How to Elect COBRA Continuation Coverage . 34Special Considerations in Deciding Whether to Elect COBRA . 34Duration of COBRA Continuation Coverage . 34Cost of COBRA Continuation Coverage . 36Termination of COBRA Continuation Coverage before the End of the Maximum Coverage Period . 37Enrolling in Medicare in Lieu of Electing COBRA Continuation Coverage . 37Keep Your Plan Informed of Address Changes . 38Continuation of Health Coverage under USERRA . 38BENEFIT RESOURCES . 39CLAIM AND APPEAL PROCEDURES. 41General Rules Applicable to All Claim Procedures . 41Timeline and Notification Requirements . 42CONTRIBUTIONS AND FUNDING. 43Allocation of Plan Cost . 43Employee Contributions. 43Operating Expenses for the Plan. 43Plan Assets . 43No Trust . 435
GENERAL INFORMATION BOOKLETTABLE OF CONTENTSGENERAL PROVISIONS. 44Applicable Law and Venue for Legal Action . 44Conformity with Governing Law . 44Construction of Terms . 44HIPAA Privacy Rules. 44No Guarantee of Employment . 44Non-Discrimination Policy . 44Maternity Length of Stay . 45Plan Provisions Binding . 45Erroneous Payments . 45Women’s Health and Cancer Rights Act . 45PLAN ADMINISTRATION . 46Powers and Duties of the Plan Administrator . 46Delegation of Authority . 46Records . 46Release of Medical Information . 47Assignment of Benefits . 47Amendment and Termination of Plan . 47Payment of Benefits after Plan Termination . 47ERISA STATEMENT OF RIGHTS . 48Receive Information about Your Plan and Benefits . 48Continue Group Health Plan Coverage . 48Prudent Action by Plan Fiduciaries. 48Enforce Your Rights . 48Assistance with Your Questions . 49PLAN ADMINISTRATIVE INFORMATION . 50Incorporated Documents . 51Employers Participating in the Plan . 526
OVERVIEW OF THE PLAN’S BENEFIT PROGRAMSGENERAL INFORMATION BOOKLETOVERVIEW OF THE PLAN’S BENEFIT PROGRAMSThe following is a brief description of the benefit programs offered to eligible employees, eligible retirees andtheir eligible family members under the Plan.DescriptionBenefitMayo Medical Plan (the“Medical Plan”)Mayo Dental Plan (the“Dental Plan”)Mayo Vision Plan (the“Vision Plan”) Provides medical, prescription drug, mental health and chemicaldependency benefits The Medical Plan includes a high deductible health plan (“HDHP”)coverage option - the Mayo Basic option - and two non-HDHP coverageoptions - the Mayo Select and Mayo Premier options The Medical Plan also includes the Mayo Medicare Supplement optionfor Medicare-eligible individuals on LTD, eligible retirees who areMedicare-eligible and their Medicare-eligible family members All Medical Plan options are designed to help you pay for eligiblehealth care expenses You must enroll in the Medical Plan to participate Eligible retirees and their eligible family members also can enroll inaccordance with and subject to the Medical Plan’s retiree coverage rules Provides coverage for diagnostic and preventive services, basic dentalservices and major restorative dental services The Dental Plan is designed to encourage regular checkups andpreventive care to correct minor dental problems before they becomeserious, and to help cover the cost of more expensive dental procedures The Dental Plan includes two Delta Dental of Minnesota coverageoptions - the Standard Option and the Deluxe Option - and a MayoReimbursement Account coverage option The Dental Plan also includes a Retiree Mayo Reimbursement Accountcoverage option and a Dental Assistance Plan coverage option foreligible retirees and their eligible family members Coverage is provided for orthodontia only once per person per lifetimeunder all of the Dental Plan’s coverage options combined You must enroll in the Dental Plan to participate Provides vision benefits for vision examinations, contact lenses,eyeglass lenses and frames for eligible employees and their eligibledependents The Vision Plan is designed to help you pay for eligible vision expenses You must enroll in the Vision Plan to participate7
OVERVIEW OF THE PLAN’S BENEFIT PROGRAMSGENERAL INFORMATION BOOKLETDescriptionBenefitHealth Care FlexibleSpending Account Plan(the “Health FSA”)Dependent CareFlexible SpendingAccount Plan (the“Dependent Care FSA”)Pre-Tax Health SavingsAccount (the “Pre-TaxHSA”)Mayo Clinic EmployeeAssistance Plan(“EAP”)Group Life InsurancePlan (Employer Paid)(the “Basic LifeInsurance Plan”)Voluntary Group Termand Universal Life Plan(the “Voluntary LifeInsurance Plan”) You may elect to contribute, on a pre-tax basis through payrolldeductions, to the Health FSA to help pay for eligible health careexpenses for you and your eligible family members You must be enrolled in the Mayo Select or Mayo Premier option underthe Medical Plan, or not enrolled in the Medical Plan at all, to contributeto the Health FSA Each year, you may contribute up to the annual limit communicated toyou in open enrollment materials ( 2,750 for 2021) You may elect to contribute, on a pre-tax basis through payrolldeductions, to the Dependent Care FSA to help pay for eligibledependent care expenses to allow you and your spouse to work or attendschool full-time You may contribute up to 5,000 per year per household (or up to 2,500 if you are married and file separate tax returns) If you are enrolled in the Mayo Basic option under the Medical Plan andsatisfy all other applicable requirements, you may elect to contribute, ona pre-tax basis through payroll deductions, to the Pre-Tax HSA You may contribute up to the annual limit communicated to you in openenrollment materials (for 2021, 3,600 for single coverage and 7,200for family coverage under the Mayo Basic option) Provides employees and eligible family members help to address andmanage life issues and concerns Mayo automatically provides EAP coverage at no cost to you Provides a monetary benefit to your beneficiaries if you die equal tothree times your annual salary, up to the maximum salary limit specifiedin the applicable Incorporated Documents Mayo automatically provides Basic Life Insurance Plan coverage at nocost to you Eligible retirees also are provided with coverage in accordance with andsubject to the Basic Life Insurance Plan’s retiree coverage rules You may choose to pay for supplemental (voluntary) life insurance,which provides an additional monetary benefit to your beneficiaries ifyou die and/or a monetary benefit to you if an enrolled eligible familymember dies You must enroll in the Voluntary Life Insurance Plan to participate Refer to the applicable Incorporated Documents for information aboutthe amount of coverage available8
OVERVIEW OF THE PLAN’S BENEFIT PROGRAMSGENERAL INFORMATION BOOKLETDescriptionBenefitShort-Term DisabilityPolicy (the “STDPolicy”)Mayo Paid DisabilityIncome Plan (the “LTDPlan”)Fellows Group TermLife Insurance &Disability Income Plan(the “Fellows Life <D Plan”)Mayo Clinic AccidentalDeath &Dismemberment Plan(the “AD&D Plan”)Mayo Travel AccidentPlan (the “MTA Plan”) Provides short term income replacement benefits in the event you aredisabled from illness or injury for up to 13 weeks for eligible AlliedHealth Staff or for up to 26 weeks for eligible Consultants/Voting Staff Mayo automatically provides shor
Mayo Clinic maintains the Mayo Clinic Health & Welfare Benefits Plan (the “Plan”) for the exclusive benefit of eligible employees of Mayo Clinic and its affiliates that participate in the Plan (collectively referred to with Mayo Clinic as “Mayo”), elig
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4 Mayo Clinic New Staff Guide 2021 Mayo Medical Plan Premiums for 2021 Mayo Clinic reviews the costs of Mayo Medical Plan options annually. Medical premiums are outlined in the table below with both pre-tax monthly and per-pay-period amounts. If you choose benefit coverage, the appropriate
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