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2017 Employee Benefits GuideJanuary 1, 2017 - December 31, 2017

2 Leech Lake Band of Ojibwe 2017 Benefits... choices that work for you

Table of Contents

A Message from Human Resources at Leech Lake Band of Ojibwe ................................................................... 3

Eligibility.............................................................................................................................................................. 4

Medical ............................................................................................................................................................... 5

Dental Insurance ................................................................................................................................................. 6

Employee Contributions (Medical and Dental) .................................................................................................. 7

Basic Life and AD&D ........................................................................................................................................... 8

Supplemental Life Insurance and Voluntary AD&D ........................................................................................... 8

Short-Term Disability Coverage .......................................................................................................................... 9

Voluntary Benefits .............................................................................................................................................. 9

How to Find Providers ...................................................................................................................................... 11

Customer Service Information ......................................................................................................................... 13

3Leech Lake Band of Ojibwe 2017 Benefits... choices that work for you

A Message from Human Resources at Leech Lake Band of OjibweAt Leech Lake Band of Ojibwe we recognize our ultimate success depends on our talented and dedicated workforce. We understand the contribution each and every employee makes to our accomplishments and so our goal is to provide a comprehensive program of competitive benefits to attract and retain the best employees available. Through our benefits programs we strive to support the needs of our employees and their dependents by providing a benefit package that is easy to understand, easy to access and affordable for all of our employees. This brochure will help you choose the type of plan and level of coverage that is right for you.

You can also view overviews of our benefit plans by accessing mybenergy.com.

Welcome aboard!{


EligibilityEligible Employees and when Coverage begins:

All elections are in effect for the entire plan year and can only be changed during Open Enrollment, unless you experience a family status event. You may enroll in the Leech Lake Band of Ojibwe Employee Benefits Program if you are in one of the following Employee Groups working the required amount of hours.

Gaming Employees

■ Eligibility: Full-time employees working a minimum of 30 hours per week

■ Effective: First of the month following completion of the 60 day waiting period

Department of Public Safety and Resource Management Employees


■ Effective: First of the month following the date full-time employment begins

Government and Housing Division employees



Bug-o-nay-ge-shig, Head Start Program or Heritage Site Program Employees

■ Eligibility, Medical: Full-time employees working a minimum of 30 hours per week

■ Eligibility, Basic Life and Short Term Disability: Full-time employees working a minimum of 37 hours per week

■ Effective: First day of the school year if working full-time on that date, or the first of the month following the date full-time employment begins

Tribal College Employees

■ Eligibility: A faculty member who is regularly scheduled to teach a minimum of eight (8) credits per week per quarter; or administrative staff scheduled to work a minimum of 30 hours per week.


Reservation Tribal Council Members

■ Eligibility: No hour requirements


Family Status Change:A change in family status is a change in your personal life that may impact your eligibility or dependent’s eligibility for benefits. Examples of some family status changes include:

■ Change of legal marital status (i.e. marriage, divorce, death of spouse, legal separation)

■ Change in number of dependents (i.e. birth, adoption, death of dependent, ineligibility due to age)

■ Change in employment or job status (spouse loses job, etc.)

If such a change occurs, you must make the changes to your benefits within 30 days of the event date. Documentation may be required to verify your change of status. Failure to request a change of status within 30 days of the event may result in your having to wait until the next open enrollment period to make your change. Please contact HR to make these changes.

Eligible Dependents:If you are eligible for our benefits, then your dependents are too. Eligible dependents include your spouse and children up to age 26. If your child is mentally or physically disabled, coverage may continue beyond age 26 once proof of the ongoing disability is provided. Children may include natural, adopted, step-children and children obtained through court-appointed legal guardianship.


Medical Plan Overview Administered by PreferredOne

$400 Deductible PlanThis is a Traditional Health Plan with a Deductible of $400 and co-pays for Prescription Drugs and Emergency Room visits. Members pay the first $400 individual / $1,000 family coverage for services such as Physician visits and in or out patient hospital services.

$6,350 High Deductible Health Plan (HSA eligible) This is a High Deductible Health Plan (HDHP) that is HSA qualified. Members pay the first $6,350 individual / $12,700 family coverage for all services. Once the deductible has been met, all eligible services are covered at 100% for that plan year.

General Plan Information PreferredOne $400 Plan PreferredOne $6,350 HDHP

Annual Deductible (In-Network Benefits)

■ Individual $400 $6,350

■ Family $1,000 $12,700

Coinsurance 20% 100%

Annual Out-of-Pocket Limit

■ Individual $2,000 $6,350

■ Family $4,500 $12,700

Lifetime Plan Maximum Unlimited Unlimited

Preventive Care/Screening/Immunizations No charge No charge

Office Visits – Primary or Specialist Deductible, then 20% Deductible, then $0

In and Out Patient Hospital Services Deductible, then 20% Deductible, then $0

X-Rays and other Imaging Services Deductible, then 20% Deductible, then $0

Lab Tests Deductible, then 20% Deductible, then $0

Emergency Room $100 copay, then 20% after deductible Deductible, then $0

Ambulance Deductible, then 20% Deductible, then $0

Urgent Care Deductible, then 20% Deductible, then $0

Substance Abuse or Mental Health – In or Out Patient Deductible, then 20% Deductible, then $0

Vision

Exam No Charge N/A

Eyeglasses Up to $300 per calendar year N/A

Pharmacy

Retail (30-day supply)

Deductible, then $0

■ Generic $10 copay

■ Preferred Brand $25 copay

■ Non-Preferred Brand $35 copay

■ Specialty $35 copay

Mail Order (90-day supply)

Deductible, then $0

■ Generic $20 copay

■ Preferred Brand $50 copay

■ Non-Preferred Brand $70 copay

■ Specialty Not Covered

This is merely a summary of benefits for comparison purposes only. Please refer to the Summary Plan Description (SPD) booklets and carrier benefit summaries for complete details. In the event of discrepancies between this summary and the official SPD, the SPD will prevail.


Dental Insurance Administered by Delta Dental

Delta Dental Plan The Delta Dental PPO gives you access to a network of dentists that have agreed to a discount payment schedule. You are not required to designate a Primary Care Dentist, and you have the choice to select any participating Delta PPO or Premier dentist. You may choose to obtain services from a non-network provider; however, your out-of-pocket costs will be higher. To locate a participating dental care provider, go to www.DeltaDentalMN.com.

Plan Benefit Highlights

Network(s) Delta Dental PPO℠ Delta Dental Premier® Non‐Participating*

Calendar Year Plan MaximumPer person

$1,500 $1,500 $1,500

Lifetime Ortho MaximumPer eligible covered person

$1,500 $1,500 $1,500

DeductiblePer person / per family per calendar yearNo deductible for diagnostic and preventive services or orthodontics

$50/person$150/family



Eligible Dependents Spouse, dependent children to age 18 and full-time students until age 25

Covered Services Dental Benefit Plan Coverage

Diagnostic & Preventive Services ■ Exams ■ Cleanings ■ X-rays ■ Fluoride treatments Space Maintainers

100% 100% 100%

Basic Services ■ Emergency treatment for relief of pain ■ Sealants ■ Amalgam restorations (silver fillings) ■ Composite resin restorations (white fillings) on anterior (front) teeth

80% 80% 80%

Endodontics ■ Root canal therapy on permanent teeth ■ Pulpotomies on primary teeth for dependent children

80% 80% 80%

Periodontics ■ Surgical/Nonsurgical periodontics

80% 80% 80%

Oral Surgery ■ Surgical/Nonsurgical extractions

80% 80% 80%

Major Restorative ■ Crowns ■ Composite resin restorations (white fillings) on posterior (back) teeth

70% 70% 70%

Prosthetic Repairs and Adjustments ■ Denture adjustments, repairs, and bridge repair

70% 70% 70%

Prosthetics ■ Dentures (full and partial) ■ Bridges ■ Limited implant coverage

70% 70% 70%

Orthodontics ■ Treatment for the prevention/ correction of malocclusion

Available for dependent children through age 1850% 50% 50%

This is a summary of benefits only and does not guarantee coverage. For a complete list of covered services and limitations/exclusions, please refer to the Dental Benefit Plan Summary.

* Dentists who have signed a participating network agreement with Delta Dental have agreed to accept the maximum allowable fee as payment in full. Non-participating dentists have not signed an agreement and are not obligated to limit the amount they charge; the member is responsible for paying any difference to the non-participating dentists.


Dental

Employee Monthly Contribution Per paycheck (24 pay periods)

Dental Plan

Single $8.49 $4.25

Family $23.46 $11.73

Employee Contributions (Medical and Dental Rates)

Medical

Employee Monthly Contribution Per paycheck (24 pay periods)

$400 Deductible Plan With Wellness Incentive

No Wellness Incentive

With Wellness Incentive

No Wellness Incentive

Single $132.42 $158.90 $66.21 $79.45

Family $380.96 $457.16 $190.48 $228.58

$6,350 HDHP with HSA

Single $94.20 $47.10

Family $270.82 $135.41

Leech Lake Band of Ojibwe The share of premiums that you pay for coverage is deducted on a pre-tax basis through payroll deductions.

Leech Lake Gaming OperationsThe share of premiums that you pay for coverage is deducted on a pre-tax basis through payroll deductions.

Dental

Employee Weekly Contribution

Dental Plan

Single $1.96

Family $5.41

Medical

Employee Weekly Contribution

$400 Deductible Plan With Wellness Incentive No Wellness Incentive

Single $30.56 $36.67

Family $80.99 $105.50

$6,350 HDHP with HSA

Single $21.74

Family $62.50


Supplemental Life Insurance and Voluntary AD&D Administered by The Hartford

You may purchase additional life insurance and/or voluntary accidental death and dismemberment insurance for you and your eligible dependents through The Hartford in the amounts shown below. Your cost for supplemental life insurance is based on your age and the amount of coverage requested. The rates for employee and dependent coverage are outlined below. Payroll deductions for voluntary coverages are deducted on an after-tax basis.

Benefits The Hartford

Benefit Amount

Employee Increments of $10,000, up to $300,000

Spouse Increments of $5,000 up to $50,000

Child(ren) Up to $10,000, depending on your child’s age

Guaranteed Issue*

Employee $100,000

Spouse $50,000

Child(ren) $10,000

Reduction of Benefits

At age 65 65%

At age 70 50%

* Newly eligible employees may elect supplemental life insurance in amounts up to the Guarantee Issue (GI) as listed in the table above. Any elected amounts exceeding the GI will require Evidence of Insurability (EOI). The EOI is a medical questionnaire which may also include a blood test. If you (and/or your dependents) do not elect supplemental life insurance coverage when first eligible, the entire amount of life insurance elected will require EOI. Coverage will not be effective until the insurance company agrees in writing to cover you. Voluntary AD&D amounts do not require EOI and all amounts are guaranteed. In addition, Child Life does not require EOI and all amounts are guaranteed.

Age < 30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+ (Employee Only)

Rate per $1,000 $0.06 $0.07 $0.09 $0.14 $0.23 $0.36 $0.57 $0.90 $1.41 $2.88

Child Life Rate $0.20 per $1,000

Important Note: You must purchase coverage for yourself in order to purchase for your dependents.


Benefit Amount

■ Employees working 30 or more hours per week $30,000 benefit - Employer Paid

■ Optional Dependent Life Spouse: $5,000; Child(ren): $2,500; $1.11 per month, per family

Reduction of Benefits

■ At age 65 65%

■ At age 70 50%

Important Reminder! Be sure to assign a beneficiary or living trust to ensure your assets are distributed according to your wishes.

Basic Life and AD&D Administered by The Hartford

Leech Lake Band of Ojibwe provides company-paid Basic Life/Accidental Death & Dismemberment (AD&D) Insurance through The Hartford to assist you and your family in the event of a loss. The life insurance policy will pay as follows:


Short-Term Disability Coverage Administered by The Hartford

In the event you are unable to work as a result of an illness or injury, Leech Lake Band of Ojibwe provides disability insurance through The Hartford. The plans offer income protection and will replace a portion of your earnings while you are unable to work.


Elimination Period Zero (0) days - Injury; Seven (7) days - Sickness

Benefit Percentage 67%

Maximum Weekly Benefit up to $450 per week

Maximum Period of Payment 26 weeks

Definition of Earnings Date of pay immediately prior to the date of disability

Voluntary Benefits Administered by Unum

Long-Term Disability Long Term Disability (LTD) Insurance is available for employees to purchase on a voluntary basis.

Benefits Unum

Elimination Period 180 days or the date your Short Term Disability payments end

Benefit Percentage 60%

Maximum Monthly Benefit $5,000

Pre‐existing Conditions Limitation 12/12/24Pre-existing condition means any sickness or injury for which you have received medical

treatment, consultation, care or services during the 12 months prior to the coverage effective date. A disability arising from any such sickness or injury will be covered only if it

begins after you have performed your regular occupation on a full-time basis for 24 months following the coverage effective date, unless no treatment was received for 12 consecutive

months after the coverage effective date.

Maximum Benefit Period If under age 60, pays to age 65. If over the age of 60, see Summary Plan Description for details.

This voluntary benefit also comes with an Employee Assistance Program (EAP). Work-life balance provides professional assistance for a wide range of personal and work-related issues. The service is available to you and your family members 24 hours a day, 365 days a year, and provides resources to help employees find solutions to everyday issues, such as financing a car or selecting child care, as well as more serious problems, such as alcohol or drug addiction, divorce or relationship problems. There is no charge for using the program.

Age < 24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-99

Rate per $100 of covered payroll $0.210 $0.290 $0.400 $0.520 $0.620 $0.800 $1.030 $1.130 $1.200 $1.500 $1.860


Voluntary Benefits Administered by Unum

You have the option to purchase additional voluntary benefits via post-tax payroll deductions through Unum.Benefits you may purchase includes Critical Illness, Group Accident and Whole Life Insurance.

Critical IllnessThe Unum Critical Illness plan is designed to help employees and their families with the out-of-pocket costs associated with a critical illness.

Critical illnesses include: Heart Attack, Stroke, Major Organ Transplant, End-State Kidney Failure, Coronary Artery Bypass Graft and Cancer.

■ Select a benefit amount:

◊ Employees $5,000 to $50,000, in $1,000 increments

◊ Spouse $5,000 to $30,000, in $1,000 increments

◊ Dependent Children $2,500 or $5,000

■ Benefits are paid directly to the insured on a post-tax basis.

■ This plan is portable, so you may continue coverage if you leave the company for any reason.

■ Health Screening Benefit; this benefit pays $50 per calendar year, per insured individual, if a covered health-screening test is performed.

■ The policy amount reduces by 50% at age 70.

■ No benefits will be paid for cancer or carcinoma in situ if the date of diagnosis occurs during the first 30 days from the effective date.

Please see your Human Resources Representative for rates.

Accident Insurance PlanThe Unum Accident plan is designed to help employees and their families with the out-of-pocket costs associated with an accident.

This coverage pays a lump sum benefit based on the type of injury you sustain or the type of treatment you need. Examples of covered injuries and expenses include:

■ Broken Bones ■ Eye injuries ■ Emergency Room Treatment

■ Burns ■ Ruptured discs ■ Hospitalization

■ Torn ligaments ■ Cuts repaired by stitches ■ Physical Therapy

■ Concussion ■ Fractures

See schedule of benefits for full list of covered injuries and expenses

■ Coverage is available to actively at work Employees, Spouses ages 17-80 if not disabled and Children ages 14 days through 24 years old who are not disabled and/or married. You have the option to add a Hospital Sickness Confinement Rider, which would pay if in the hospital for a covered illness.

■ Coverage is Guarantee Issue, no medical questions are asked

■ The plan is portable, so you may continue coverage if you leave the company

Family Coverage Options

Employee Employee + Spouse Employee + Child(ren) Family

$3.78 $5.40 $7.20 $8.82

Sickness Hospital Confinement Rider, total weekly rate

Employee Employee + Spouse Employee + Child(ren) Family

$4.59 $7.02 $8.58 $11.01

Weekly Rates

Whole LifeWhole Life Insurance offers “living benefits” you can use when you need them, as well as a death benefit. How does it work:

■ Your premiums are level for life

■ Your death benefit is level for life also

■ You own the policy. If you leave your company or retire, you’ll pay the same premium.

Rates vary based on age, coverage amount and tobacco use. Please see your HR Representative for details.


How to Find Providers

You have access to find providers by contacting the member services center for the carrier or by visiting their website. Remember, using network providers will lower your out-of-pocket cost.

To Find an PreferredOne Medical Provider

1. Contact member services at 1-800-997-1750

2. Go to www.preferredone.com

To Find a Delta Dental Provider

1. Contact Delta’s member services at 1-800-553-9536

2. Go to www.deltadentalmn.com

a. Navigate to “Find a Dentist” on the right side of the Welcome Page.

b. Network Name is “Delta Dental PPO”, then enter your zip code, and click “Search”.

c. Additional information can be found by registering and logging in to your personalized account.


Notes


Customer Service InformationCarrier Phone Website

Medical PreferredOnePolicy #PKA20386

1-800-997-1750 www.preferredone.com

Dental Delta Dental of Minnesota 1-800-553-9536 www.deltadentalmn.org

Short Term Disability The Hartford 1-800-421-0344 www.thehartford.com

Long Term Disability Income Unum 1-800-421-0344 services.unum.com

Basic Life, AD&D, Supplemental Life & Voluntary AD&D Insurance

The Hartford 1-800-421-0344 www.thehartford.com

Critical Illness, Accident Unum 1-800-635-5597 services.unum.com

401(k) Ascensus 1-866-809-8146 https://www.planservices.com/rplink

Benefits Portalmybenergy.comLogin: leech; Password: lake

This summary is not a legal document and does not replace or supersede the “Evidence of Coverage”, policy or the Summary Plan Description. Please refer to the Evidence of Coverage / Insurance Policy / Summary Plan for a complete description of the coverage, eligibility criteria, controlling terms, exclusions, limitations and conditions of coverage.

Leech Lake Band of Ojibwe reserves the right to terminate, suspend, withdraw, reduce or modify the benefits described in the Evidence of Coverage / Insurance Policy / Summary Plan Description in whole or in part, at any time. No statement in this or any other document and no oral representation should be construed as a waiver of this right. This summary is the confidential property of Leech Lake Band of Ojibwe.

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