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2015 Open Enrollment
Deadline November 6
Retirees and Surviving Spouses Under Age 65
Welcome
This is your open enrollment guide designed to assist you through
the open enrollment process for electing your 2015 benefits.
Getting started
This guide describes each of your 2015 benefit options and includes important details to help you make informed
elections for you and your family.
Your benefits will roll over into 2015
If you are satisfied with your medical and dental options indicated on your Confirmation Statement, you do not
need to do anything else. Your benefits will remain as they were for 2014 and will automatically adjust to 2015 rates.
When is my enrollment deadline?
You have until November 6, 2014 to enroll for benefit elections effective January 1, 2015.
Can I change my elections at any other time during the year?
Once enrolled, your benefits will be effective January 1, 2015 and remain in effect until December 31, 2015.
Annual open enrollment is the only time during the year that you can make changes to your benefit elections
unless you experience a qualifying life event or HIPAA special enrollment event. If you experience a qualifying life
event, you must notify the HR Service Center within 31 days of the event.
Will you be eligible for Medicare in 2015?
You can find the Notice of Creditable Coverage with information about your Northeast Utilities prescription drug
coverage and Medicare Part D, the prescription drug coverage available through Medicare, within a separate Legal
Notices brochure included with this enrollment guide.
What if I have questions?
More than likely your questions can be answered within this guide. This is a comprehensive review of your benefit
options intended to provide you with enough information to make informed enrollment decisions. If you find
you need additional information, NU’s HR Service Center can help answer your questions. Call the HR Service
Center at 860-665-5660 or toll-free at 1-800-841-8684 Monday through Friday, 8 a.m. to 4:30 p.m.
Your enrollment guide
This open enrollment guide serves as your summary of 2015 material
modifications (SMM) to the summary plan description for the NUSCO Retiree
Health Plan for NU retirees and surviving spouses under the age of 65. Please
retain a copy of this guide for your records so you can read it together with your
summary plan description (as formally amended by this SMM) in order to fully
understand your benefits.
2015 Retiree and Surviving Spouse Enrollment Guide | 1
Step 1
LEARN ABOUT THE CHANGES
Every year, as a result of new health care reform requirements, IRS limits, or adjustments to
benefit administration, your benefits will undergo change. This year you have very little change
to your benefits. Please note the changes for 2015 below.
Saver Medical Option
Re-Enrolling in the Plan
Beginning in 2015, the deductibles in the Saver medical
option will increase from $1,250 to $1,300 for single
(retiree only) coverage, and from $2,500 to $2,600 for
family (retiree plus one or more dependent) coverage in
accordance with IRS requirements for high-deductible
plans. The out-of-pocket maximums for the Saver option
are not changing.
The NUSCO Retiree Health Plan allows you to opt out
or re-enroll in the Plan during an annual open enrollment
period or if you experience a qualifying event. If you wish
to re-enroll or change your elections during this open
enrollment period, please complete the enclosed NUSCO
Retiree Health Plan form and return it in the selfaddressed envelope.
Health Savings Account (HSA)
The IRS has also increased the limit on contributions
to the Health Savings Account (HSA) for 2015. The
maximum amount you can contribute to the HSA in 2015
is $3,350 if you enroll as a retiree only; or $6,650 if you
enroll as a retiree plus one or more dependent. The IRS
also allows participants age 55 or older to contribute an
additional $1,000 to their HSA account.
Enrollment Instructions
If you want to make changes…
If you DO NOT want to make changes…
1. Review your Confirmation Statement included with this
guide.
2. Make any desired changes on the enclosed NUSCO
Retiree Health Plan form.
3. Mail your completed NUSCO Retiree Health Plan
form to the HR Service Center in the enclosed, selfaddressed envelope included with your materials. (Please
affix appropriate postage.)
1. If you are satisfied with your medical and dental options
indicated on your Confirmation Statement, you do not
have to do anything else. Your benefits (indicated on
your Confirmation Statement) will automatically adjust
to 2015 rates.
2. Retain your Confirmation Statement and this
enrollment guide for your records.
You will receive a new Confirmation Statement in the
mail once enrollment closes. Please review your statement
carefully to confirm your elections for 2015 benefits.
You should retain your Confirmation Statement with
your NUSCO Retiree Health Plan Summary Plan
Description (SPD).
2
Step 2
ADD OR REMOVE DEPENDENTS
The annual open enrollment period allows you the opportunity to add or remove a dependent
from health care coverage. The benefits described in this guide are available to Northeast
Utilities retirees under age 65 and their eligible dependents.
Eligible Dependents
Verification Documents
:: Your legal spouse (same sex or opposite sex);
If you wish to enroll a dependent, please indicate the
dependent information on the NUSCO Retiree Health
Plan form and forward the required documentation to the
HR Service Center.
:: Your child under age 26 who is a natural child or legally
adopted child (or a child for whom you have entered into
a formal order of adoption), stepchild, foster child, or a
child for whom you are legal guardian;
:: Your unmarried child (as described above) will continue
to be eligible after his or her 26th birthday if deemed
mentally or physically incapable of self support (subject
to annual certification once the child reaches age 26)
and covered under the Plan immediately prior to the
attainment of age 26.
If you are adding a dependent, you must provide the
dependent’s Social Security number and legible copies of
the appropriate documents to verify dependent eligibility.
Coverage will not be continued in 2015 for any dependents
over six months old if they do not have a Social Security
number. If you have a dependent who does not have a
Social Security number, contact the HR Service Center.
Legal Spouse (same sex or opposite sex) – marriage
certificate
Children – birth certificate, adoption certificate,
guardianship papers, or foster care agreement
Mail copies of your documents
Make legible copies of the required
documents and send them within
31 days of enrollment to:
HR Service Center
Benefits Section BMNG
Northeast Utilities Service Company
P.O. Box 270
Hartford, CT 06141-0270
You must call the HR Service Center at 860-665-5660 or toll-free at 800-841-8684
within 60 days of your dependent losing eligibility for coverage. Dependents who
are no longer eligible for coverage as defined above may be eligible to continue
medical and dental benefits under COBRA continuation coverage.
2015 Retiree and Surviving Spouse Enrollment Guide | 3
Step 3
COMPARE AND ELECT A MEDICAL OPTION
Compare medical options and choose one that best fits your needs and those of your family.
Your Medical Options
Coverage Levels
You have the following three medical options from which
to choose in addition to the option to waive medical
coverage if you have coverage elsewhere:
You also have the choice of whom, in addition to yourself,
you want to cover under medical benefits. You will have
the choice of covering just yourself, you and your spouse,
you and your children, or you, your spouse and children.
And the coverage level you choose for medical does not
have to match that for dental.
Saver Medical Option
PPO 90 Medical Option
PPO 100 Medical Option
Medicare Supplement Plan Option for
Participants Age 65 and Over or Disabled
Waive medical coverage
Coverage details are outlined on the following pages.
Consult the Medical Option Comparison charts to view a
side-by-side comparison on pages 6 through 9 to help you
determine which option is most appropriate.
Retirees under age 65 and/or their eligible dependents
who are disabled and eligible for Medicare have an option
to participate in the same Medicare Supplement coverage
under the NUSCO Retiree Health Plan that is offered
to participants age 65 and older. Interested participants
should contact the HR Service Center at 860-665-5660 or
toll-free at 1-800-841-8684 for enrollment details.
Prescription Drugs
Prescription drug copays for participants enrolled in a medical option are not changing for 2015. If you enroll in the PPO
100 or PPO 90 medical option, your prescription drug coverage will be administered by Express Scripts and you will have a
copay and coinsurance for non-formulary retail pharmacy benefits as indicated below. It will also be mandatory for you to
fill your maintenance medications through the Home Delivery pharmacy.
If you enroll in the Saver medical option, your prescription drug coverage will be administered by Cigna and you will have
to first satisfy a deductible and then the prescription drug copays, as indicated below, will apply.
Type of Drug
Retail Pharmacy
(Up to a 34-day supply)
Generic
$6
$12
Brand (Formulary)
$25
$50
Non-Formulary
50% coinsurance
(up to an annual $1,000
maximum/person)
$97
Medical Option
Type of Drug
Retail Pharmacy
(Up to a 30-day supply)
Saver Option (Cigna)
Generic
$0
$12
Brand (Formulary)
$25
$50
Non-Formulary
$50
$97
Medical Option
PPO 100 and PPO 90
(Express Scripts)
(copays apply once the
annual deductible is met;
no copays or deductible
for generic medication
considered preventive)
4
Mail Order
(Up to a 90-day supply)
Mail order is
mandatory for
maintenance
medications
Mail Order
(Up to a 90-day supply)
Mail order is
NOT mandatory
for maintenance
medications
Glossary of Health Care Terms
Coinsurance
Out-of-Pocket Costs
The percentage of allowed charges for covered services
that you are required to pay. For example, your benefits
plan may cover 90 percent of charges for a covered
hospitalization, leaving you responsible for the other 10
percent up to your maximum out-of-pocket limits. This 10
percent cost is known as the coinsurance.
Your expenses for medical care that are incurred when
you seek care and are not reimbursed by insurance. Outof-pocket costs include deductibles, coinsurance, and
copays for covered services plus all costs for services that
aren’t covered—including amounts above the maximum
reimbursable fees.
Copayment (Copay)
Out-of-Pocket Limit
A flat dollar amount you must pay for a covered service.
For example, you may have to pay a copayment for each
covered visit to a primary care or specialist doctor. Copays
are not always subject to the out-of-pocket limit.
The most you can pay for certain copays and any
deductibles and coinsurance amounts. Once you pay
this amount out of your pocket during the year, your
benefits plan usually pays 100 percent of covered services,
excluding your contributions. If you elect medical options
PPO 100 or PPO 90, you will continue to pay for provider
office visit and prescription drug copays. If you elect the
Saver medical option, all in-network covered expenses—
including copays—are limited to the total out-of-pocket
maximum limit. Your monthly contributions, however, are
not included in this limit.
Deductible
The amount you pay each year before your benefits plan
shares in the cost of certain services. The deductible may
not apply to all services. For example, preventive care is
always covered and no deductible will be required before
your preventive services are paid.
Formulary
A list of approved prescription drug medications that your
benefits plan will cover. Your formulary includes both
generic and brand-name drugs and categorizes them into
different coverage tiers.
In no event will out-of-pocket costs in any medical option
plan design exceed the maximum limits established under
Affordable Care Act regulations. In 2015, the limits are
$6,600 for individual coverage and $13,200 for family
coverage. Limits under each option will be significantly
lower for some services. Lower limits are imposed by Plan
rules and may not apply to all services.
In-network preventive care is covered at 100 percent
Preventive care includes periodic well visits, routine immunizations, and routine screenings
provided on an age-based schedule. Preventive care is covered at 100 percent no matter
which medical option you elect. Preventive care determination is generally made by your
physician based on your age, gender and family history.
2015 Retiree and Surviving Spouse Enrollment Guide | 5
Medical Option Comparison Charts
In-Network Coverage
This chart refers to benefit coverage available if you use a provider who participates in the
Cigna network.
In-Network Highlights
PPO 90
Lifetime Maximum
PPO 100
Saver Option
Unlimited
$1,300 retiree only OR
$2,600 retiree plus one or
more dependent(s)
$250 per person up to a
$500 family maximum
None
10%
None
10%
$1,500 per person up to a
$3,000 family maximum
$750 per person up to a
$1,500 family maximum
$2,500 retiree only OR
$5,000 retiree plus one or
more dependent(s)
Prescription Drug
(Retail Copays)
No deductible applies
$6 (generic)
$25 (brand)
50% of cost up to
$1,000 (non-formulary)
Express Scripts
$6 (generic)
$25 (brand)
50% of cost up to
$1,000 (non-formulary)
Express Scripts
Full cost until deductible is
met; then copays apply:
$0 (generic)
$25 (brand)
$50 (non-formulary)
Cigna
Prescription Drug
(Mail Order Copays)
No deductible applies
$12 (generic)
$50 (brand)
$97 (non-formulary)
Express Scripts
$12 (generic)
$50 (brand)
$97 (non-formulary)
Express Scripts
Full cost until deductible is
met; then copays apply:
$12 (generic)
$50 (brand)
$97 (non-formulary)
Cigna
Office Visit (PCP)
$20 copay
No deductible applies
$15 copay
Office Visit (Specialist)
$35 copay
No deductible applies
$30 copay
Preventive Care1
100% covered,
No deductible applies
100% covered
Annual Deductible
Coinsurance
Annual Out-of-Pocket
(OOP) Maximum*
(Includes Deductible)
Inpatient Hospital
Outpatient Surgery
Emergency Room
Urgent Care/Walk-In
Lab and X-Ray
Advanced Radiology
(MRI, CAT/PET Scan)
Infertility Procedures
Hearing Aid Device
10% coinsurance after
deductible
100% covered,
No deductible applies
$150 per day (not to exceed
$300 per admission)
$150 copay
$100 copay
(waived if admitted)
$100 copay
(waived if admitted)
$30 copay
$30 copay
10% coinsurance
after deductible
10% coinsurance after
meeting deductible
10% coinsurance
after deductible is met
100% covered
$150 copay
Plan pays $25,000 lifetime maximum per person for in- and out-of-network combined for
procedures related to artificial insemination, in-vitro fertilization, GIFT and ZIFT.
Up to $1,000 lifetime maximum benefit for the hearing aid device.
Preventive care is determined by your physician. Any non-preventive services provided by an In-Network provider as part of a preventive care visit will be
considered standard service and any annual deductibles, copays, and coinsurance will apply.
1
*In no event will out-of-pocket costs (excluding participant contributions) in any medical option plan design exceed the
maximum limits established under Affordable Care Act regulations. In 2015, the limits are $6,600 for individual coverage
and $13,200 for family coverage. Limits under each option will be significantly lower for some services. Lower limits are
imposed by Plan rules and may not apply to all services. See pages 8 and 9 for more information.
6
Out-of-Network Coverage
This chart refers to benefit coverage available if you use a provider who DOES NOT participate
in the Cigna network. The cost of out-of-network services is based on the carrier’s maximum
reimbursable charges (MRC), a defined fee schedule developed by the medical carrier and/
or what other doctors in your area charge. You will pay 100 percent of costs above MRC and
these amounts do not contribute to your deductible or out-of-pocket maximum.
Out-of-Network Highlights
PPO 90
Lifetime Maximum
Annual Deductible
Coinsurance
Annual Out-of-Pocket
(OOP) Maximum
(Includes Deductible)
Prescription Drug
(Retail Copays)
Prescription Drug
(Mail Order Copays)
PPO 100
Unlimited
$1,000 per person up to a
$2,000 family maximum
$400 per person up to a
$1,200 family maximum
Combined amount for In- and
Out-of-Network, see
In-Network chart
30%
30%
30%
$3,000 per person up to a
$6,000 family maximum
$3,000 per person up to a
$6,000 family maximum
Combined amount for In- and
Out-of-Network,
see In-Network chart
No Out-of-Network
coverage
No Out-of-Network coverage
Office Visit (PCP)
Office Visit (Specialist)
Preventive Care
Saver Option
30% coinsurance
after deductible is met
30% coinsurance
after deductible is met
$100 copay per visit
(waived if admitted)
$100 copay per visit
(waived if admitted)
$30 copay
$30 copay
30% coinsurance
after deductible is met
30% coinsurance
after deductible is met
30% coinsurance
after deductible is met
(No coverage for mail order
prescription drugs)
Inpatient Hospital
Outpatient Surgery
Emergency Room
Urgent Care/Walk-In
Lab and X-Ray
(at independent lab or facility)
Advanced Radiology
(MRI, CAT/PET Scan)
at outpatient facility
Infertility Procedures
Hearing Aid Device
10% coinsurance
after deductible is met
30% coinsurance
after deductible is met
Plan pays $25,000 lifetime maximum per person for in- and out-of-network combined for
procedures related to artificial insemination, in-vitro fertilization, GIFT and ZIFT.
Up to $1,000 lifetime maximum benefits for the hearing aid device.
2015 Retiree and Surviving Spouse Enrollment Guide | 7
Medical Option Comparison Charts
How are the three medical options the same?
No matter which medical option you elect, your medical benefits will be administered by Cigna and the Open Access
Plus/Tufts/Carelink network and the same network discounts apply. All preventive care is covered at 100 percent and you
will have no lifetime maximums or pre-existing limitations on essential health services to worry about.
In-Network Services
PPO 100
PPO 90
Saver
3
3
3
:: Annual physicals, routine, age-based screenings,
3
3
3
:: No lifetime maximums or pre-existing condition limits
:: No annual limits on essential health services
:: Protection against catastrophic cost through out-of-
3
3
3
:: Cigna Open Access Plus/Tufts/Carelink network
:: Same carrier discounts for in-network services :: Out-of-network coverage
:: No referrals for specialty care
:: No PCP designation required
:: Same coverage rules for all services
100% Coverage for Preventive Care
immunizations, etc.
:: Preventive care is generally determined by your doctor
pocket maximums
Saver Medical Option
The Saver option has the lowest fixed premium cost but also has the least predictable out-ofpocket costs.
All services other than preventive care are subject to a deductible. After the deductible is satisfied, coinsurance and copays
apply. One hundred percent of costs are subject to the annual out-of-pocket limits. Limits under the Saver Plan are based on
the level of coverage you elect. If you elect “retiree only” coverage, the annual deductible is $1,300 and your out-of-pocket
maximum amount is $2,500. If you elect “retiree plus one or more dependent(s),” the annual deductible is $2,600 and
the out-of-pocket maximum is $5,000—and limits for this coverage level can be met by one individual or by all family
members combined.
Saver Medical Option
Service (In Network Only)
Preventive Care
Prescription Drugs
8
You Pay
Is there a Deductible?
Does Out-of-Pocket Limit Apply?
$0
NO
NO
YES - all services
$1,300 retiree only
OR
$2,600 retiree plus one
or more dependent(s)
YES - all services
$2,500 retiree only
OR
$5,000 retiree
plus one or more
dependent(s)
(Includes deductible)
Cigna Copays
(after deductible)
PCP Office Visit
10%
Specialist Office Visit
10%
Urgent Care/Walk-in Clinic
10%
Lab & X-Ray
10%
Advanced Imaging (MRI, CT, PET)
10%
Emergency Room
10%
Outpatient Surgery
10%
In Patient Hospitalization
10%
PPO 90 Medical Option
PPO 90 has a lower fixed premium cost than PPO 100 and more predictable out-of-pocket costs
than Saver.
Although fixed copays apply for basic services, other services are subject to a deductible and coinsurance. All copays of $100
or more plus deductibles and coinsurance are subject to annual out-of-pocket maximum limits. Copays under $100 are not
limited, which means that once you reach the out-of-pocket maximum amount, you will continue to pay these copays.
PPO 90 Medical Option
Service (In Network Only)
You Pay
Preventive Care
Prescription Drugs
Does Out-of-Pocket Limit Apply?*
$0
Express Scripts
Copays
PCP Office Visit
$20
Specialist Office Visit
$35
Urgent Care/Walk-in Clinic
$30
Emergency Room
Is there a Deductible?
NO
NO
$100 (waived if
admitted)
Lab & X-Ray
10%
Advanced Imaging (MRI, CT, PET)
10%
Outpatient Surgery
10%
In Patient Hospitalization
10%
YES
$250/person up to a
$500 family maximum
YES
$1,500/person up to
$3,000/family
(Includes deductible)
PPO 100 Medical Option
PPO 100 has the highest fixed premium cost and the most predictable out-of-pocket costs.
All charges are subject to a fixed copay amount and no deductibles apply. Only copays of $100 or more are subject to
an annual out-of-pocket limit. Other services, such as office visit and prescription drug copays, are not limited.
PPO 100 Medical Option
Service (In Network Only)
Preventive Care
Prescription Drugs
You Pay
Express Scripts
Copays
$15
Specialist Office Visit
$30
Urgent Care/Walk-in Clinic
$30
Lab & X-Ray
$0
Emergency Room
Outpatient Surgery
In Patient Hospitalization
Does Out-of-Pocket Limit Apply?*
$0
PCP Office Visit
Advanced Imaging (MRI, CT, PET)
Is there a Deductible?
NO
NO
$150
$100 (waived if
admitted)
$150
YES
$750/person up to $1,500/family
$150/day up to
$300/admission
*In no event will out-of-pocket costs in any medical option plan design exceed the maximum limits established under Affordable
Care Act regulations. In 2015, the limits are $6,600 for individual coverage and $13,200 for family coverage. Limits under each
option will be significantly lower for some services. Lower limits are imposed by Plan rules and may not apply to all services.
2015 Retiree and Surviving Spouse Enrollment Guide | 9
Step 4
CONSIDER A HEALTH SAVINGS ACCOUNT
If you enroll in the Saver medical option, you have the opportunity to contribute to a taxadvantaged Health Savings Account (HSA) to pay for your eligible health care expenses.
The Internal Revenue Service (IRS) allows you to use your HSA to set aside tax-free dollars to help you save and pay for
your eligible health care expenses. The maximum amount you can contribute to the HSA in 2015 (as determined by
the IRS) is $3,350 if you are single; or $6,650 if you are enrolled in family coverage. Also, if you are 55 or older and not
enrolled in Medicare, you can make an additional contribution of up to $1,000 in 2015.
What is a high-deductible health plan (HDHP)?
An HDHP, such as the Saver option, is a health plan with
unique features defined by the IRS and designed to give
you more control over your health care dollars. An HDHP,
in conjunction with a health savings account (HSA), gives
you greater flexibility and discretion over how you use your
health care dollars. In-network preventive care is covered
at 100 percent with no out-of-pocket costs to you—such
as a copayment or coinsurance. You “pay as you go” for
medical care beyond preventive care, instead of paying
high monthly contributions in exchange for coverage you
may not need.
How do I open an HSA?
Many national banks and some regional banks and credit
unions offer HSAs. Check with your banking institution
to find out if an HSA is available.
What happens to my HSA if I switch medical
options next year or transition to Medicare?
eligible to contribute to your HSA. If you terminate your
participation in the Saver option, the amount you are
allowed to contribute to your HSA will be limited based on
when you terminate participation. For more information,
go to www.irs.gov or your tax advisor.
What happens to the HSA funds I contribute?
The amount you contribute is nontaxable, within limits,
under federal law and in most states. Most HSA vendors
offer the opportunity to invest the funds you contribute
in a number of market securities. Earnings on funds in
the account are also tax-free as long as they are used for
reimbursement of qualified expenses. Qualified expenses
are defined under Internal Revenue Code Sec. 213 (d),
and currently include qualified medical expenses such as
copays and coinsurance, prescription drugs, long-term care
insurance premiums, COBRA premiums, and—for those
age 65 and older—premiums for retiree health through
Medicare Part B.
If you are not participating in a qualified high-deductible
health plan, like the Saver option, you will not be
You are encouraged to consult a tax advisor
This information, although not complete, can help you understand the basics of Health
Savings Account (HSA) investing. The choice to participate in an HSA is up to you and
NU does not sponsor or control your investment or spending elections in this account in
any way. The information provided is not intended to be tax advice and you are strongly
encouraged to consult a tax advisor with questions.
10
Who is considered a “qualified dependent”
for purposes of tax-free HSA distributions?
Qualified medical expenses for the HSA are those incurred
by the following:
:: You and your spouse
:: All dependents you claim on your tax return
:: Any person you could have claimed as a dependent on your return except that:
– The person filed a joint return,
– The person had gross income over the limit described in
IRS Publication 969, or
– You (or your spouse if filing jointly) could be claimed as a dependent on someone else’s tax return.
Is there a time limit for taking a distribution
from the HSA to pay for an eligible health
care expense?
No. The HSA is not subject to a “use it or lose it” rule.
There is no time limit for taking a distribution from an
HSA for the eligible health care expenses you have during
any year after the HSA is established. However, you must
keep sufficient documentation to later show that amounts
distributed were used for eligible health care expenses, and
that those expenses were not previously paid or reimbursed
from another source or claimed as an itemized deduction
on your tax return.
Can I use HSA distributions to pay for my
spouse’s and/or children’s eligible health care
expenses if they are not covered under the
Saver Option?
Yes. You can take tax-free distributions for eligible health
care expenses for yourself, your legal spouse and any
qualified dependents, as defined by the IRS (even if not
covered by the Saver option).
Can I use the funds in my HSA for something
other than medical expenses?
Yes. However, HSA funds disbursed for anything other
than certain eligible health insurance premiums and
eligible health care expenses, as defined by the IRS, will
be subject to income tax and a 20 percent additional
tax penalty. The 20 percent penalty will not apply if the
distribution is taken after the individual dies, becomes
disabled, or turns age 65.
2015 Retiree and Surviving Spouse Enrollment Guide | 11
Step 5
CONSIDER ELECTING DENTAL
Your dental carrier is Delta Dental of Massachusetts.
Your out-of-pocket cost is based on the type of provider you choose:
The coverage level you
choose for medical does
NOT need to match
the coverage level you
choose for dental.
1. If you choose a dentist in the Delta Dental Preferred national
network, you will be charged a discounted rate (below what is
determined to be reasonable and customary).
2. If you choose a dentist in the Delta Dental Premier national
network, you will be charged no more than reasonable and
customary limits as determined by Delta Dental.
If you waive dental
coverage, you cannot
re-enroll in dental coverage
for two-years unless you
have a qualifying life event.
3. If you choose a dentist that does not participate in a Delta Dental
network, you are responsible for any charges beyond Delta
Dental’s reasonable and customary limits.
Your 2015 Monthly Retiree Dental Contributions
Retiree
Only
Child(ren)
Only
Surviving
Spouse
Only
Retiree +
Child(ren)
Retiree +
Spouse
Child(ren)
+ Spouse
Retiree +
Child(ren) +
Spouse
$20.31
$20.31
$20.31
$40.63
$40.63
$40.63
$60.93
Dental Benefit Chart
Dental Benefit Highlights
Your Annual Deductible
Your Costs under Dental 1000
$50 per person to a
family maximum of $150
Preventive and Diagnostic Treatment
(exams, x-rays and cleanings)
20% after deductible
Restorative and other Basic Services
(standard amalgam and composite fillings, dentures, denture repair,
simple extractions and root canals)
20% after deductible
Oral and Periodontal Surgery
(not subject to the calendar year maximum) Please note that Delta
Dental of MA is the primary insurance carrier when submitting oral or
periodontal surgery claims.
20% after deductible
Prosthodontics and other Services
(bridges and crowns; implants allowed once per 60 months per implant)
50% after deductible
TMJ Appliance
(subject to deductible and calendar year maximum)
50% after deductible
Maximums Paid by the Plan
Calendar Year Maximum for Covered Services
Lifetime Maximum for Orthodontia
(for adults and children)
Plan Pays
$1,000 per person* (includes orthodontia)
100% up to $750 lifetime maximum*; included
in calendar year maximum; not subject to
deductible
*You pay 100 percent of services once calendar and lifetime maximums have been paid by the Plan.
12
Calculating Your Rates
The total cost of coverage is determined annually. The company contributes a fixed amount
toward the total cost and you pay the rest. The company’s contribution is further reduced by
your Retirement Health Contribution Factor. The example below describes how cost sharing is
calculated. To determine your actual cost of coverage for 2015, please refer to the charts on the
following pages.
Medical Benefits Cost Sharing Equation
1
SUBTRACT
2
MULTIPLY
3
ADD
{
{
A
} {
} {
}
}
Monthly Company
Cap for Medical Option
and Coverage Tier
FROM
Total Monthly Plan
cost for Medical Option
and Coverage Tier
=
A
Monthly Company
Cap for Medical Option
and Coverage Tier
BY
Cost Sharing Factor
(Retirement Health
Contribution Factor)
=
B
TO
B
= MONTHLY PARTICIPANT COST
Medical Benefits Cost Sharing Example
Joe retires at age 58 with 17 years of service and enrolls in the PPO 90 medical option for himself only.
His Retirement Health Contribution Factor is 20 percent. The company contributes a maximum of
$508.42 towards individual coverage and calculates his total monthly cost for medical coverage
as $954.33.* How much will Joe pay?
1
SUBTRACT
2
MULTIPLY
3
ADD
A
{ } { }
{ } { }
$508.42
FROM
$954.33.*
=
A
$445.91
20%
BY
$508.42
=
B
$101.68
$445.91 TO
B
$101.68 = $547.59
MONTHLY PARTICIPANT COST
In this example, Joe will pay $547.59 each month for the Plan year.
*Cost for the PPO 100 and Saver medical options would be different.
2015 Retiree and Surviving Spouse Enrollment Guide | 13
Medical Contributions
Company contributions toward your coverage are reduced based on your Retirement Health
Contribution Factor (RHCF).
Your 2015 medical plan monthly contributions are based on your Retirement Health Contribution Factor, as shown in the
charts below. To be eligible for retiree medical coverage, you must have been at least age 55 and have had 10 years of service
when you retired (or you must have been terminated when eligible for the 50-54 benefits).
Retirement Health Contribution Factor
Your
completed
years of
service…
And your age when you retired…
55
56
57
58
59
60
61
62
63
64
65+
10
40
38
36
34
32
30
28
26
24
22
20
11
38
36
34
32
30
28
26
24
22
20
18
12
36
34
32
30
28
26
24
22
20
18
16
13
34
32
30
28
26
24
22
20
18
16
14
14
32
30
28
26
24
22
20
18
16
14
12
15
30
28
26
24
22
20
18
16
14
12
10
16
28
26
24
22
20
18
16
14
12
10
8
17
26
24
22
20
18
16
14
12
10
8
6
18
24
22
20
18
16
14
12
10
8
6
4
19
22
20
18
16
14
12
10
8
6
4
2
20+
20
18
16
14
12
10
8
6
4
2
0
Your Retirement Health
Contribution Factor
can be found on your
Confirmation Statement.
14
2015 Retiree and Surviving Spouse Enrollment Guide | 15
$929.39
$939.05
$548.25
6
$958.37
$558.41
8
$977.69
$568.58
10
$588.92
14
$594.00
15
$599.09
16
$609.26
18
$619.42
20
$997.01 $1,016.33 $1,025.99 $1,035.65 $1,054.97 $1,074.29
$578.75
12
$932.86
Child(ren) + Spouse
$953.20
$580.70
$372.50
$957.75
$771.11
$456.08
$979.11
$790.43
$466.25
$973.53
$591.88
$381.65
$614.25
$399.96
$625.44
$409.11
$636.62
$418.26
$305.88
$490.49
$796.37
Child(ren) Only
Spouse Only
Child(ren) + Spouse
$816.71
$501.68
$315.03
$837.04
$512.86
$324.18
$647.81
$427.41
$653.40
$431.99
$658.99
$436.56
$670.18
$445.71
$681.36
$454.87
$809.75
$476.42
$829.07
$486.58
$848.39
$496.75
$867.71
$506.92
$887.03
$517.09
$896.69
$522.17
$906.35
$527.26
$925.67
$537.43
$944.99
$547.59
$993.87 $1,014.21 $1,034.54 $1,054.88 $1,075.22 $1,085.39 $1,095.55 $1,115.89 $1,136.23
$603.07
$390.80
$847.21
$518.45
$328.76
$857.38
$524.05
$333.33
$877.72
$535.23
$342.49
$898.05
$546.42
$351.64
$918.39
$557.60
$360.79
$938.73
$568.79
$369.94
$948.90
$574.38
$374.52
$959.06
$579.97
$379.09
$979.40
$591.16
$388.24
$999.74
$602.34
$397.40
$1,646.69 $1,661.94 $1,677.19 $1,707.70 $1,738.20
$989.78 $1,000.46 $1,021.81 $1,043.17 $1,064.52 $1,085.88 $1,096.55 $1,107.23 $1,128.58 $1,149.94
$800.09
$471.33
$983.70
$597.47
$386.23
$1,433.15 $1,463.66 $1,494.16 $1,509.41 $1,524.67 $1,555.17 $1,585.68 $1,616.18
$936.40
Retiree + Spouse
Retiree + Child(ren)
+ Spouse
$751.79
$445.91
Retiree + Child(ren)
Retiree Only
Pre-65 PPO 90 Medical Option
$569.51
$363.35
Spouse Only
Child(ren) Only
$1,869.37 $1,884.62 $1,899.87 $1,930.38 $1,960.88
$1,655.83 $1,686.34 $1,716.84 $1,732.09 $1,747.35 $1,777.85 $1,808.36 $1,838.86
$919.73
$543.16
5
Retiree + Child(ren)
+ Spouse
$900.41
$538.08
4
$1,087.25 $1,108.60 $1,129.96 $1,140.63 $1,151.31 $1,172.66 $1,194.02 $1,215.37 $1,236.73 $1,247.40 $1,258.08 $1,279.43 $1,300.79
$881.09
Retiree + Child(ren)
$527.91
2
Retiree + Spouse
$517.74
Retiree Only
Pre-65 PPO 100 Medical Option
0
Retiree Monthly Contributions at Retirement Health Contribution Factor
16
$1,156.56
$1,020.07
$613.53
Spouse Only
Child(ren) + Spouse
$406.55
$1,768.71
Retiree + Child(ren)
+ Spouse
Child(ren) Only
$1,171.29
$964.31
Retiree + Child(ren)
Retiree + Spouse
$557.76
Retiree Only
$639.76
24
$1,040.41
$624.71
$415.70
$1,799.21
$1,192.64
$983.63
$567.93
$1,176.90
$703.73
$473.17
$2,021.89
$1,343.49
$1,112.93
Pre-65 PPO 90 Medical Option
Child(ren) + Spouse
$692.55
Spouse Only
$1,991.39
Retiree + Child(ren)
+ Spouse
$464.02
$1,322.14
Retiree + Spouse
Child(ren) Only
$1,093.61
$629.59
Retiree + Child(ren)
Retiree Only
Pre-65 PPO 100 Medical Option
22
$1,050.58
$630.31
$420.28
$1,814.47
$1,203.32
$993.29
$573.02
$1,187.07
$709.33
$477.75
$2,037.15
$1,354.17
$1,122.59
$644.85
25
$660.10
28
$726.10
$491.47
$2,082.90
$588.27
$647.08
$434.00
$1,060.75 $1,081.09
$635.90
$424.85
$1,829.72 $1,860.22
$1,214.00 $1,235.35
$1,002.95 $1,022.27
$578.10
$1,197.24 $1,217.58
$714.92
$482.32
$2,052.40
$1,364.85 $1,386.20
$1,132.25 $1,151.57
$649.93
26
$1,101.42
$658.27
$443.15
$1,890.73
$1,256.70
$1,041.59
$598.44
$1,237.91
$737.29
$500.62
$2,113.41
$1,407.55
$1,170.89
$670.27
30
$1,121.76
$669.45
$452.31
$1,921.23
$1,278.06
$1,060.91
$608.60
$1,258.25
$748.47
$509.78
$2,143.91
$1,428.91
$1,190.21
$680.43
32
$1,142.10
$680.64
$461.46
$1,951.74
$1,299.41
$1,080.23
$618.77
$1,278.59
$759.66
$518.93
$2,174.42
$1,450.26
$1,209.53
$690.60
34
$700.77
36
$710.94
38
$721.11
40
$770.84
$528.08
$782.03
$537.23
$2,204.92 $2,235.43
$793.21
$546.38
$2,265.93
$628.94
$639.11
$649.28
$691.82
$470.61
$1,982.24
$703.01
$479.76
$2,012.75
$714.19
$488.91
$2,043.25
$1,152.26 $1,162.43 $1,182.77 $1,203.11
$686.23
$466.03
$1,966.99
$1,310.09 $1,320.76 $1,342.12 $1,363.47
$1,089.89 $1,099.55 $1,118.87 $1,138.19
$623.86
$1,288.75 $1,298.92 $1,319.26 $1,339.60
$765.25
$523.50
$2,189.67
$1,460.94 $1,471.61 $1,492.97 $1,514.32
$1,219.19 $1,228.85 $1,248.17 $1,267.49
$695.69
35
Retiree Monthly Contributions at Retirement Health Contribution Factor
2015 Retiree and Surviving Spouse Enrollment Guide | 17
$505.42
$796.93
Retiree + Spouse
Retiree + Child(ren)
+ Spouse
$406.42
Child(ren) + Spouse
$740.31
Retiree + Spouse
$242.35
$387.78
$630.12
Child(ren) Only
Spouse Only
Child(ren) + Spouse
$1,132.49
$594.88
Retiree + Child(ren)
Retiree + Child(ren)
+ Spouse
$352.53
Retiree Only
Pre-65 Saver Medical Option
22
$264.74
Spouse Only
$141.68
$382.36
Retiree + Child(ren)
Child(ren) Only
$240.68
Retiree Only
Pre-65 Saver Medical Option
0
$650.46
$398.96
$251.50
$1,162.99
$761.66
$614.20
$362.70
24
$426.76
$275.93
$150.83
$827.44
$526.77
$401.68
$250.85
2
5
$660.63
$404.56
$256.08
$1,178.25
$772.34
$623.86
6
$670.80
$410.15
$260.65
$1,193.50
$783.02
$633.52
8
$691.14
$421.33
$269.80
$1,224.00
$804.37
$652.84
30
$711.47
$432.52
$278.95
$1,254.51
$825.72
$672.16
$654.90
$517.60
$311.86
14
$665.57
$527.26
$316.94
15
$676.25
$536.92
$322.03
16
$847.08
$691.48
$403.37
32
$528.44
$331.85
$196.59
$731.81
$443.70
$288.11
$752.15
$454.89
$297.26
$1,315.52
$868.43
$710.80
$413.54
34
$548.78
$343.04
$205.74
$762.31
$460.48
$301.83
$1,330.77
$879.11
$720.46
$418.63
35
$558.95
$348.63
$210.32
$772.48
$466.07
$306.41
$1,346.02
$889.78
$730.12
$423.71
36
$569.11
$354.22
$214.89
$979.96 $1,010.47 $1,025.72 $1,040.97
$633.54
$498.28
$301.69
12
$1,285.01
$508.10
$320.67
$187.44
$949.46
$612.19
$478.96
$291.52
10
$393.21
$487.77
$309.48
$178.29
$918.95
$590.83
$459.64
$281.35
$383.04
28
$467.43
$298.30
$169.13
$888.45
$569.48
$440.32
$271.19
$372.87
26
$457.26
$292.70
$164.56
$873.19
$558.80
$430.66
$266.10
$367.79
25
$447.09
$287.11
$159.98
$857.94
$548.13
$421.00
$261.02
4
Retiree Monthly Contributions at Retirement Health Contribution Factor
$718.96
$575.56
$342.36
20
$792.82
$477.26
$315.56
$1,376.53
$911.14
$749.44
$433.88
38
$589.45
$365.41
$224.04
$813.16
$488.44
$324.71
$1,407.03
$932.49
$768.76
$444.05
40
$609.79
$376.59
$233.20
$1,071.48 $1,101.98
$697.60
$556.24
$332.20
18
Changing Your Elections
Benefits will be effective on January 1, 2015 and will remain in effect through December 31,
2015 unless you do not pay the required cost for coverage. You can change your benefits
during the year only if you have a qualifying change in status (described in your SPD) or
experience a special enrollment event.
When a Participant Becomes Medicare
Eligible
When a participant turns age 65 or becomes eligible for
Medicare coverage at an earlier date because of a disability,
the available options for that participant change as he or
she becomes eligible for NUSCO’s Medicare Supplement
coverage (including Express Scripts Medicare prescription
drug coverage), which is secondary to Medicare. In the
case of a participant turning age 65, the change is initiated
automatically—whether or not the participant enrolls in
Medicare Part B. You will receive more information prior
to your 65th birthday.
For disabled participants under age 65, the change only
becomes effective at the election of the participant and
upon provision of documentation of his or her Medicare
enrollment to the HR Service Center.
In the Event of Your Death
Surviving spouses and their dependents are eligible for
coverage until the earliest of any of the following events:
:: Surviving spouse or dependent child becomes eligible
for coverage under another group plan (other than a
plan sponsored by NU) or government sponsored plan
with no pre-existing condition limitation (except for
eligibility for Medicare Parts A and B).
:: Dependent child no longer meets eligibility
requirements. (Upon the death of a surviving spouse,
dependent children are no longer eligible.)
:: Surviving spouse or dependent does not pay required
cost for coverage.
Did you know?
If you decide not to enroll in the NUSCO Retiree Health Plan during this open
enrollment, and instead enroll in your spouse’s health care coverage, you
have the option to come back to the NUSCO Retiree Health Plan if you have a
qualifying event (such as losing your spouse’s health coverage) or at a future
annual open enrollment opportunity.
18
Information Resources
For information regarding your benefits, call your benefit carriers. If your question is NU policyspecific, please call the HR Service Center at (860) 665-5660 or toll-free at 1-800-841-8684.
Medical
Cigna
800-244-6224www.mycigna.com
Dental
Delta Dental of Massachusetts 800-872-0500 Prescription Drugs
Express Scripts (PPO 100 and PPO 90)
Cigna (Saver) 800-351-0509 800-244-6224
Call for qualifying life events
If you experience a qualifying
change during the year, please
call the HR Service Center. All
benefit changes must be made
within 31 days of the event to
be retroactive to the date of the
event; otherwise the change will be prospective.
If you need to make a change during the year,
the type of change must be consistent with your
status change.
www.deltadentalma.com
www.express-scripts.com
www.mycigna.com
Legal Notices
A collection of legal notices is
included with this enrollment
guide. Keep this collection
of notices with your NUSCO
Retiree Health Plan Summary
Plan Description and other
benefit materials.
2015 Employee Enrollment Guide | 19
Notes
Information contained in this brochure applies only to eligible retirees of Northeast Utilities Service Company and certain properly designated affiliates
(the “Company”), and eligible dependents of such retirees. This guide serves as your summary of 2015 material modifications (SMM) to the summary plan
description for the NUSCO Retiree Health Plan for NU retirees and surviving spouses under the age of 65. All Company benefits are governed by the official
plan documents, summary plan descriptions, insurance contracts, or personnel policy statements (“Documents”). While we have made every attempt to
ensure the accuracy of the information here, if there is any discrepancy between this brochure and the Documents, the Documents will govern and control.
This brochure does not constitute or imply a contract of employment, nor does it guarantee the continuation of any benefit plan or program. As in the past,
the Company reserves the right to modify, amend, suspend, or terminate any of its benefit plans or programs and any provisions thereof at any time and for
any reason with respect to any current or former employee, dependent, or beneficiary, with or without notice, on either a retrospective or prospective basis,
and the Company will continue to review all of its benefit plans and programs and make such changes as it determines appropriate in its sole discretion. Your
chosen elections (and their associated cost as they appear on your Confirmation Statement or NUSCO Retiree Health Plan Form) in addition to this guide, are
considered a part of your NUSCO Retiree Health Plan Summary Plan Description (SPD).
20
NU 10/2014
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