2016 Enrollment Toolkit

Transcription

1 2016 Enrollment Toolkit Full-Time Employees For Benefits Effective January 1, 2016

2 WELCOME Welcome to the Liberty Hospital Benefits Program! This enrollment guide outlines your benefit program and what options are available to you. It is important that you review this information and understand how to use the various programs to maximize your benefits package. The programs outlined in this booklet give you a tremendous opportunity to protect you and your family. From medical benefits to voluntary benefits offering financial protection, it s all included in a comprehensive package from Liberty Hospital designed to take care of you now and in the future. NOTE The purpose of this booklet is to describe the highlights of your benefit program. Your specific rights to benefits under the Plans are governed solely, and in every respect, by the official Plan documents, insurance contracts, and Board Policy and not by this booklet. If there is any discrepancy between the descriptions of the Plans as described in this booklet and the official Plan documents and Board Policy, the language of the Plan documents shall govern. To obtain a copy of the official Plan documents, simply log on to the Liberty Hospital Intranet. Select the Human Resources link under Quick Launch. Select the Benefits tab and then select the plan you wish to obtain a document for and select Summary Plan Description. You can then either view the appropriate Plan document or print a copy for your records. 1

3 INTRODUCTION January 1, 2016 marks the renewal of our employee benefit programs. Liberty Hospital remains committed to offering a comprehensive and competitive benefits package to our employees. A comprehensive benefits package means you should have choices. Just as you bring your own unique talents to the Hospital, you have your own unique coverage needs. By offering you choices, you will be able to find the combination of coverage that s right for you, your family and your goals. We recognize the importance of medical benefits to our employees and their families. This is why the Hospital is committed to helping you manage your health care and associated costs. Every year, we thoroughly review our current medical plans and compare them to those offered by other employers in the area. It was through that review process along with the need to make sure that we continue to control escalating medical costs that we made the decision to make a change in the plans offered to our employees. Beginning January 1, 2016, we have combined the current Plans 1 and 2 in to a new plan the Traditional Plan. With this new plan, employees currently enrolled in Plan 1 will see a reduction in their monthly premium along with a slight increase in their out-of-pocket medical expenses (things such as deductibles and copayments). On the other hand, those employees who are currently enrolled in Plan 2 will not see a change in their monthly premium, but they will have lower out-of-pocket medical expenses with this new plan. Liberty Hospital will also continue to offer the current Plan 3 but have renamed it the Qualified High Deductible Plan (QHDP). There will be no benefit or premium changes for this plan. Please take the time to read this booklet thoroughly as you make your benefit selections for the 2016 plan year. Our annual enrollment period begins on November 1, 2015 and ends on November 20, You will be responsible for completing your own enrollment through our new enrollment website. Please go to when you are ready to enroll. To ensure that you have benefits for the 2016 plan year, please make sure that you complete the enrollment process by November 20, 2015! 2

4 TABLE OF CONTENTS Eligibility & Enrollment 4 Medical Benefits Blue Cross/Blue Shield Dental Benefits 15 Delta Dental of Missouri Vision Benefits 18 Vision Service Plan Flexible Spending Accounts 20 CBIZ, Inc. Group Life and AD&D Insurance 23 Lincoln Financial Group Long Term Disability Insurance 24 Lincoln Financial Voluntary Insurance 25 Important Contacts

5 ELIGIBILITY & ENROLLMENT date. WHO IS ELIGIBLE? All full-time employees working 60 hours or more biweekly and parttime employees working at least 30 hours biweekly are considered eligible to participate. Please discuss with Human Resources your employment status to determine eligibility and your benefit effective Dependents of eligible employees may also be eligible for coverage under many of these benefits plans. Eligible dependents include: Your spouse; Dependent children through the age noted for each plan; Dependent children over each plan s noted age limit who are incapable of supporting themselves because of mental or physical handicaps (upon approval). You will be required to enter the actual date of birth (DOB) and accurate social security number (SSN) of all dependents (spouse and children) in order to complete the enrollment process. You will not be able to enter default numbers (ex: ). Please have the DOBs and SSNs of your insured dependents available before you begin the enrollment process. If you do not complete this process, you will not have any benefits for the 2016 plan year. OPEN ENROLLMENT Each year during Open Enrollment, you have the opportunity to re-evaluate your benefit needs and adjust your coverage for the upcoming plan year. Even if you are not making any changes, you must re-enroll every year if you wish to maintain benefits. This year, you will complete the enrollment process yourself through our new on-line enrollment website. To enroll in your 2016 benefits, go to On the homepage, you ll be asked to provide a username, password, and company name. Your default username will be your (first initial)(last name)(employee ID) o Example: tsmith1234 Your default password will be your date of birth (no dashes or slashes) o Example- if your DOB is 1/1/1970, your password will be: Company Name: Liberty Hospital Once logged in, you will be able to change your password, and you will be guided through the enrollment process. Remember, your enrollment is not complete until you click Finish after viewing your confirmation statement. If you have any issues with the enrollment website, please call Cool Creek directly at (913) or them at ccsinfo@coolcreek.com. 4

6 All benefit elections will be made through the online enrollment system this year with one exception. If you want to enroll in or make changes to a current policy with Boston Mutual whole life insurance, you will need to schedule an appointment with a benefit counselor at WBA. There are two options available to you to schedule this appointment: You may call and a counselor will schedule the appointment for you. As you complete your online enrollment at the Cool Creek website, click on the link on the Boston Mutual page to schedule an appointment online. If you do not complete the enrollment process by the enrollment deadline of November 20, 2015, your benefits will be waived effective January 1, Remember, once you make selections, you may not change your benefits until the next open enrollment period unless there is a qualifying status change. All changes made during fall 2015 Open Enrollment are effective January 1 - December 31, New Hires The following pages contain benefit summaries which outline the coverage provided and payroll deductions required for each benefit option. We have included brief benefit summaries, but please refer to the Summary Plan Description for more detailed information on each option. Please note that your benefits will be effective on the first of the month following your date of hire. After you review the material, you should mark your selection for each benefit option in this workbook. During orientation you will complete an on-line benefit enrollment election. You may retain this workbook as a record of your choices. Active Employees Active employees select benefits during the open enrollment period held each November. The following pages contain benefit summaries which outline the coverage provided and payroll deductions required for each benefit option. We have included brief benefit summaries, but please refer to the Summary Plan Description or Certificate of Coverage for more detailed information on each option. COBRA Participants You will receive a paper enrollment form in the mail that you will need to complete and send back by the deadline listed on the form. IMPORTANT: It is very important that you complete your enrollment by the deadline listed on your enrollment worksheet. If you do not complete your enrollment by the deadline, you will have no coverage for the plan year. 5

7 QUALIFYING STATUS CHANGES As an active employee, if you experience a qualifying status change during the plan year, you may make changes to some benefits within 31 days of the event. The changes you request must be consistent with the status change event. Qualifying Status Changes Include: Marriage Birth or adoption of your child Death of your spouse or child Divorce, legal separation or annulment Change in your child s dependent status (age requirement, obtaining other coverage, marriage) Change in your or your spouse s employment status (part-time to full-time, commence new job or gain coverage availability) You must notify the Benefit Specialist in Human Resources within 31 days of a qualifying status change to adjust benefits. If the Benefit Specialist in Human Resources is not notified within this time frame, you must wait until the next Open Enrollment period to adjust your benefits. If you or your dependents become ineligible for Medicaid or CHIP, you may be able to enroll in Liberty Hospital s plan; you must request enrollment within 60 days. Additionally, if you or your dependents become eligible for premium assistance from Medicaid or CHIP, you may be able to enroll yourself and your dependents in Liberty Hospital s plan; you must request enrollment within 60 days. 6

8 MEDICAL BENEFITS When it comes to benefits, we recognize that one size doesn t fit all. We understand that people are different with different lifestyles and needs. Situations change. That s why the Liberty Hospital plan offers you two different plan options that are all insured through Blue Cross Blue Shield (BCBS), including one PPO plan and a Qualified High Deductible Health Plan with H.S.A (Health Savings Account). The difference in each plan is the out-of-pocket cost to you and the premium you pay. On each plan, you have the option to choose between four levels of coverage: Employee Only, Employee & Spouse, Employee & Child (ren), or Employee & Family. Dependent children are covered to age 26 regardless of student status, residency or marital status. WEIGH YOUR OPTIONS When choosing a health benefits plan, the most important question is: Will it provide the right amount of coverage for you and your family? After deciding how much coverage you need, consider the costs and when you pay them. There are two ways you contribute to the cost of a health plan: 1. Up-front costs. This is the part of the health insurance premium you pay. If you re an employee, up-front costs are deducted from your paycheck. If you re on a nonemployee plan like COBRA, you write a check or bank draft for the premium. Either way, you pay premium costs regularly, like any bill, no matter how often or how seldom you need health care. 2. Pay-as-you-go costs. These are the out-of-pocket dollars you pay when you see a doctor, go to a hospital or outpatient clinic, or have a prescription filled. Pay-as-yougo costs include copayments, deductibles, and coinsurance. If you need medical care often, you might want to pay more up-front and less as-you-go costs. Budgeting is easier because your premium costs are always the same, and you won t have huge expenses for any major, unexpected medical treatment. If you see a doctor or need prescriptions only two or three times a year, it might make more sense to pay less up-front and more as-you-go. This way, you can save the premiums and avoid paying for more coverage than you might use. 7

9 BCBS CHOICES Making the right choices and becoming more knowledgeable about your plan options helps you be a better health care consumer. The plan you choose should simply be the one you re most comfortable with a plan that fits your health needs, budget, and personal preferences. No matter which plan you enroll in, you ll have the assurance of some financial protection against any major, unexpected medical expenses that are covered by your plan. Your choices include the plans briefly described below. For more details, refer to the plan descriptions on the following pages. PPO. A PPO (Preferred Provider Organization) allows you to see participating and non-participating providers. o The PPO plan utilizes the Preferred-Care Blue Network. o In-network preventative care covered at 100%. o The hospital offers you one PPO plan the Traditional Plan. Qualified High Deductible PPO. A QHDP (Qualified High Deductible Plan) PPO allows you to see participating and non-participating providers. This medical plan option consists of two parts the QHDP which provides health insurance coverage through BCBS and the Health Savings Account (HSA). o The QHDP plan utilizes the Preferred-Care Blue Network. o In-network preventative care covered at 100%. o Lower premium/higher deductible. o The hospital offers you one QHDP. Are Your Medical Providers In the BCBS Network? To obtain a list of providers participating in network, visit Select Find a Doctor in Kansas City to link directly to the Preferred-Care Blue KC network. Select Find a Provider to search for providers outside of the KC service area. You will need to enter the 3 letter alpha prefix LHA in the field labeled First 3 letters. Providers are subject to change at any time. 8

10 Qualified High Deductible Health Plan with Health Savings Account This medical plan consists of two parts: 1. Qualified High Deductible Health Plan (QHDP): provides health insurance coverage through BCBS. 2. Health Savings Account (H.S.A.): a special, tax exempt account used in conjunction with the high deductible health plan. This account provides funding to pay for qualified medical expenses NOT covered by the insurance. The H.S.A. account is provided by HSA Bank. o The QHDP/H.S.A. plan utilizes the Preferred-Care Blue Network. o In-network preventative care is covered at 100% with no deductible or copayment. o Includes an in-network deductible of $2,600 individual /$5,200 Family. o Health Savings Account is owned by YOU and is portable in the event you change employers. o Funds contributed to your H.S.A are not subject to federal income tax at the time of deposit. o H.S.A has no use it or lose it rule. o Interest or earnings that accumulate in your H.S.A are not subject to federal income tax. o Funds withdrawn from your H.S.A to pay for qualified medical expenses-at any time- are not subject to federal income tax. o In the event of disability or at the age of 65, H.S.A funds can be withdrawn for any purpose without penalty. o H.S.A funds can be used to help meet and pay for your deductible. o If you open up an H.S.A., your account will be charged a monthly administrative fee of $2.25. This fee will be waived once your H.S.A. balance exceeds $3,000 for one full month. If you enroll in the QHDP for the first time in 2016 and are eligible to contribute to an H.S.A., Liberty Hospital will make a contribution to your H.S.A.! The contribution depends on the level of coverage that you have under the medical plan (see below) and will be made in one lump-sum payment in either mid-january, mid-april or as soon as administratively possible after your enrollment in the plan. (Please note that you must open an H.S.A. through HSA Bank in order to receive this contribution.) If my level of coverage on the QHDP is The one-time H.S.A. contribution made by Liberty Hospital is Employee Only $100 Employee & Spouse or Employee & Child(ren) $250 Family $350 9

11 How Much Can I Contribute? The IRS limits the annual maximum contribution. The maximum annual contribution for 2016 is: $3,350 individual / $6,750 family Catch-up contributions of $1,000 are available for employees 55 and over. What Are the Eligibility Requirements to enroll in an H.S.A? Cannot be enrolled in Medicare, Medicaid, Tricare or VA benefits. Cannot be covered by any other Traditional health plan. (Spouse s FSA or Spouse s Non-HDHP will make you ineligible for HSA.) Traditional Flexible Spending Accounts (FSAs) and Health Reimbursement Arrangements (HRAs) will make you INELIGIBLE for an HSA. Must be enrolled in a Qualified High Deductible Plan (QHDP). Liberty Hospital s QHDP is a qualified plan. What If I. Use my funds for non-qualified expenses, such as a new TV? There is a 20% penalty assessed for non-qualified expenses, plus taxes. Keep your receipts in case of an audit! Turn age 65? You can spend funds on non-qualified expenses with no penalty. Would pay normal income tax. Change to a Traditional plan next year? What happens to the funds in the account? It s your money, so you can continue to spend the funds on qualified medical expenses; you just can t contribute to the H.S.A. Don t have enough funds in my HSA to cover my service or prescription? You pay out of pocket and can reimburse yourself once your funds are available. Am currently participating in the 2015 plan year Liberty Hospital Section 125 Flexible Spending Account? In order to open up an HSA and begin contributions on 1/1/16, your Flexible Spending Account must have a $0 balance as of 12/31/15. If your Flexible Spending Account does not have a $0 balance as of 12/31/15, then the following will apply: 10

12 Your HSA will be frozen until April 1, This means that you cannot make any contributions to or withdrawals from your HSA until April 1 st. You can contribute the entire annual maximum contribution specified on page 10, as long as you remain enrolled in a qualified high deductible plan for the remainder of the 2016 plan year as well as the 2017 plan year. Otherwise, your annual maximum contribution for 2016 would be limited to $2,511 individual / $4,986 family. Where can I find more information about the medical plans? You can access a variety of helpful information by going to the Liberty Hospital Intranet. Select the Human Resources link under Quick Launch, and then select the Benefits tab. There you will find such things as the BCBS Prescription Drug List, mail order prescription brochures and specialty drug information. 11

13 BCBS Plan Designs Effective January 1, 2016 (amounts shown below are member responsibility) Annual Deductibles (calendar year) Out-of-Pocket Amounts (calendar year) 1 Lifetime Maximum Benefit Preventive Care Liberty Hospital Traditional Plan Participating Preferred-Care Blue Providers 7 Non-Participating Providers Single None $1,000 $2,000 Family None $2,250 $4,000 Single $5,200 $8,000 Family $10,400 $16,000 Unlimited Adult & Child Routine Physicals Not Applicable 0% 50% after deductible Physician Services Hospital Services Routine Lab 0% 50% after deductible Routine Mammogram 0% 50% after deductible Vision Exam Not Applicable $30 co pay 50% after deductible Primary Care Physician Office Visit Not Applicable $25 co pay 50% after deductible Specialist Office Visit Not Applicable $50 co pay 50% after deductible Inpatient Care 10% 20% after deductible 50% after deductible Outpatient nonsurgical care (i.e. MRI) Additional Services 10% 20% after deductible 50% after deductible Urgent Care $45 co pay $80 co pay 50% after deductible Emergency Room 2 $125 co pay then 15% 20% after deductible & $200 co pay Chiropractic Care 3 Not Applicable $50 co pay 50% after deductible Physical & Occupational 4 Not Applicable $50 co pay 50% after deductible Therapy Speech Therapy 5 Not Applicable $50 co pay 50% after deductible Durable Medical Equipment Not Applicable 20% after deductible 50% after deductible Prescription Drugs 8 Participating Pharmacy Non-Participating Pharmacy Calendar Year Deductible $100 per family N / A Tier 1 $10 co pay Not Covered Tier 2 $35 co pay Not Covered Tier 3 $55 co pay Not Covered Specialty Drugs $70 co pay Not Covered Mail Order (90 Day Supply) $25 (Tier 1) / $90 (Tier 2) / $135 (Tier 3) Not Covered 1 Out-of-pocket amount includes coinsurance, deductible, medical copays and prescription drug deductible and copays. 2 Benefit shown is for emergency services only. Emergency room co pay will be waived if admitted to the hospital. 3 Limited to 30 visits per calendar year. 4 Limited to maximum of 90 visits, combined, per calendar year. 5 Limited to maximum of 90 visits per calendar year. 6 Specialty drugs must be filled through CuraScript/Accredo Specialty Pharmacy. They are not covered if filled at a retail pharmacy. 7 Includes Liberty owned clinics. Note: This is only a summary. Please refer to the booklet/certificate for specific details. If a conflict arises, the booklet/certificate will govern in all cases. Note: This is not an offer of insurance coverage. Information on final rates, coverage s, and limitations must come from the Insurance Company. 12

14 BCBS Plan Designs Effective January 1, 2016 (amounts shown below are member responsibility) Annual Deductibles (calendar year) Out-of-Pocket Amounts (calendar year) 1 Lifetime Maximum Benefit Preventive Care Liberty Hospital Qualified High Deductible Plan Participating Preferred-Care Blue Providers 7 Non-Participating Providers Single $2,600 $5,200 Family $5,200 $10,400 Single $5,200 $10,400 Family $10,400 $20,800 Unlimited Adult & Child Routine Physicals Not Applicable 0% 50% after deductible Physician Services Hospital Services Routine Lab 0% 50% after deductible Routine Mammogram 0% 50% after deductible Vision Exam Not Applicable 20% after deductible 50% after deductible Primary Care Physician Office Visit Not Applicable 20% after deductible 50% after deductible Specialist Office Visit Not Applicable 20% after deductible 50% after deductible Inpatient Care 10% after deductible 20% after deductible 50% after deductible Outpatient nonsurgical care (i.e. MRI) Additional Services 10% after deductible 20% after deductible 50% after deductible Urgent Care 10% after deductible 20% after deductible 50% after deductible Emergency Room 2 10% after deductible 20% after deductible Chiropractic Care 3 Not Applicable 20% after deductible 50% after deductible Physical & Occupational 4 Not Applicable 20% after deductible 50% after deductible Therapy Speech Therapy 5 Not Applicable 20% after deductible 50% after deductible Durable Medical Equipment Not Applicable 20% after deductible 50% after deductible Prescription Drugs 8 Participating Pharmacy Non-Participating Pharmacy Calendar Year Deductible Subject to medical plan deductible N / A Tier 1 15% after deductible Not Covered Tier 2 15% after deductible Not Covered Tier 3 15% after deductible Not Covered Specialty Drugs 15% after deductible Not Covered Mail Order (90 Day Supply) 15% after deductible Not Covered 1 Out-of-pocket amount includes coinsurance and deductible. 2 Benefit shown is for emergency services only. 3 Limited to 30 visits per calendar year. 4 Limited to maximum of 90 visits, combined, per calendar year. 5 Limited to maximum of 90 visits per calendar year. 6 Specialty drugs must be filled through CuraScript/ Accredo Specialty Pharmacy. They are not covered if filled at a retail pharmacy. 7 Includes Liberty owned clinics. Note: This is only a summary. Please refer to the booklet/certificate for specific details. If a conflict arises, the booklet/certificate will govern in all cases. Note: This is not an offer of insurance coverage. Information on final rates, coverage s, and limitations must come from the Insurance Company. 13

15 MAINTENANCE PRESCRIPTION DRUG OPTIONS If you are taking prescription medications on a regular, on-going basis, you can save money in one of two ways. You can either obtain a 90-day supply at certain retail pharmacies through the Retail 90 plan or by ordering them through the Caremark Home Delivery program. If you plan to participate in either program, make sure to ask your doctor to write your long-term medication prescription for a 90-day supply. The biggest benefit of the Retail 90 plan is convenience. You can get a three-month supply of your long-term, maintenance medication at one time instead of a 31-day supply, reducing your trips to the pharmacy from 12 to just 4 trips a year. With the high price of gas, you ll save more than time! The Retail 90 Network is a subset of the BCBS National Retail Network and includes most major and regional chains plus thousands of independent pharmacies. Ask your pharmacist if your pharmacy participates in this program or call BCBS at the phone number on the back of your ID card. The Caremark Home Delivery program offers the following benefits: Prescriptions are delivered directly to your home with free standard shipping. You get up to a 90-day supply of your medications for reduced co pays. You can speak with a pharmacist anytime, day or night. Once you begin using Home Delivery, you can order refills by phone or online. Availability of Summary Health Information Your plan offers a series of health coverage options. Choosing a health coverage option is an important decision. To help you make an informed choice, your plan makes available a Summary of Benefits and Coverage (SBC), which summarizes important information about your medical plan options in a standard format. The SBC is available on the Liberty Hospital Intranet under the Human Resources link and the Benefits tab. A paper copy is also available, free of charge, by ing Cynthia Benz at cbenz@libertyhospital.org. 14

16 DENTAL BENEFITS Maintaining good oral health is very important to the overall well-being of employees and their families. That is why Liberty Hospital offers you the choice between two dental plans that are flexible enough to respond to a variety of dental care needs. Whether you need a check-up, a filling, or major dental work, the Delta Dental plans cover you. YOUR CHOICES The Delta Dental plans allow you to receive services from any dentist. But, for maximum cost savings, you should choose a dentist who participates in either the Delta Dental PPO or Delta Dental Premier network. Delta PPO dentists typically offer the greatest discounts. Participating network dentists cannot bill you for any charges that are in excess of Delta s PPO or Premier maximum plan allowances, and they have discounted the fees that they do charge. Participating dentists will also file your claims directly with Delta, so you won t have to file any paperwork. If your dentist participates in both networks, you will receive the best level of coverage and discounts available which are typically found in the PPO network. Please note that the highest level of coverage available through the plans requires that you utilize a Delta Dental PPO dentist. You do have the option of going outside the Delta Dental networks for services. Should you choose to do so, you may have to pay up front and file your own claim. Delta Dental will make payment directly to you based on the maximum plan allowance for non-participating dentists. In addition, non-participating dentists may balance bill you up to their entire billed charge. To obtain a list of dentists participating in the network, visit and select Looking for a Dentist? Select either Delta PPO or Delta Premier depending on which network you are interested in. You may also call Delta s Customer Service team at Predetermination A predetermination of benefits is simply a notification to you and your dentist as to whether the procedures recommended are within the services covered by the Delta contract. By obtaining a predetermination from Delta prior to receiving dental services, you have the security of knowing in advance the percentage Delta will pay, how much you will be responsible for out of pocket and whether the services recommended by your dentist fall within the benefit maximums and procedure limitations. Delta suggests having a predetermination for all services that exceed $200. You or your dental provider can submit the predetermination by sending Delta an itemized bill or a completed claim form. 15

17 Non-Orthodontic Plan Dental Plan Features (Your Insurance Pays) Delta Dental PPO Network Delta Dental Premier Network or Out-of-Network Preventive Services (not subject to the deductible) Oral Exams (all types) twice per calendar year Cleanings (all types) twice per calendar year Bitewing x-rays twice per calendar year Periapical x-rays as required 100% 100% Full Mouth x-rays once every 36 months Fluoride Treatments once per calendar year for dependents under age 19 Space Maintainers for dependents to age 16, limited to initial appliance only Basic Services Pallative emergency treatment Consultation (by other than Dental Practitioner providing treatment) Sealants for dependent children to age 19, limited to non-decayed, non-restored 1 st and 2 nd permanent molars, once in 5 years Fillings Amalgam (silver) and composite (white) fillings when 85% after 80% after composite fillings are placed in molar teeth, benefits are based on deductible deductible that of an amalgam filling Oral Surgery including simple and surgical extractions Periodontics treatment for the diseases of the gums and bone supporting the teeth Endodontics includes pulpal therapy and root canal filling Denture Relines Major Services Crowns, jackets, labial veneers, inlays and onlays when required for restorative purposes once every 5 years 55% after 50% after Prosthodontics (partial or complete dentures and fixed bridges) if deductible deductible an existing bridge or denture cannot be made serviceable, a replacement will be covered once every 5 years but not during the first year of coverage. Orthodontic Services Not Covered Not Covered Calendar Year Deductible $50 individual / $150 family unit Calendar Year Annual Maximum (per person) $1,500 Late Entrants For the first 12 months a late entrant is covered under the policy, benefits will be limited to preventive dental procedures & accidental injuries only 19/24 if full-time student Dependent Age Limit This is intended to be a summary only. Please refer to your Summary Plan Description (SPD) for a more complete listing of services including plan limitations and exclusions. 16

18 Orthodontic Plan Dental Plan Features (Your Insurance Pays) Delta Dental PPO Network Delta Dental Premier Network or Out-of- Network Preventive Services (not subject to the deductible) Oral Exams (all types) twice per calendar year Cleanings (all types) twice per calendar year Bitewing x-rays twice per calendar year Periapical x-rays as required 100% 100% Full Mouth x-rays once every 36 months Fluoride Treatments once per calendar year for dependents under age 19 Space Maintainers for dependents to age 16, limited to initial appliance only Basic Services Pallative emergency treatment Consultation (by other than Dental Practitioner providing treatment) Sealants for dependent children to age 19, limited to non-decayed, nonrestored 1 st and 2 nd permanent molars, once in 5 years Fillings Amalgam (silver) and composite (white) fillings when composite 85% after 80% after fillings are placed in molar teeth, benefits are based on that of an amalgam filling deductible deductible Oral Surgery including simple and surgical extractions Periodontics treatment for the diseases of the gums and bone supporting the teeth Endodontics includes pulpal therapy and root canal filling Denture Relines Major Services Crowns, jackets, labial veneers, inlays and onlays when required for restorative purposes once every 5 years 55% after 50% after Prosthodontics (partial or complete dentures and fixed bridges) if an deductible deductible existing bridge or denture cannot be made serviceable, a replacement will be covered once every 5 years but not during the first year of coverage. Orthodontic Services Coverage is available to all eligible members who satisfy 12 consecutive 50% after 50% after months of enrollment in the Orthodontic Plan. Benefits are limited to deductible deductible treatment that begins after the 12 month waiting period has been satisfied. Calendar Year Deductible $50 individual / $150 family unit Calendar Year Annual Maximum (per person) $1,500 Orthodontic Lifetime Maximum (per person) $1,500 Late Entrants For the first 12 months a late entrant is covered under the policy, benefits will be limited to preventive dental procedures & accidental injuries only Dependent Age Limit 19/24 if full-time student This is intended to be a summary only. Please refer to your Summary Plan Description (SPD) for a more complete listing of services including plan limitations and exclusions. 17

19 VISION BENEFITS Also, keep in mind that you automatically get an extra $20 to spend when you choose a featured frame brand like bebe, ck Calvin Klein, Flexon, Lacoste, Michael Kors, Nike, Nine West, and more. Visit to find a doctor who carries these brands. Vision Highlights In-Network Benefits Benefit Frequency Exam Lenses Frames Copayments Exam Lenses Covered in full Covered Lens Options Frames Elective Contact Lenses* (material co pay does not apply. Allowance is applied to materials) Liberty Hospital offers you an affordable, simple-to-use plan to keep your eyes healthy. By enrolling in this plan, you will have coverage for annual routine eye exams, materials and contact lenses. You can use any provider; however, you will receive a higher level of benefits should you receive your care from a participating Vision Service Plan provider. To locate a provider participating in the Vision Service Plan network, simply visit and select Find a VSP Doctor. Once every 12 months Once every 12 months Once every 24 months $15 Exam $25 Materials $60 maximum copay for Contact Lens Fitting & Evaluation Covered in full Single, Lined Bifocals, Lined Trifocals, Lenticular Progressives/blended bifocals Photochromic lenses Tints/dyes $130 allowance for a wide selection of frames; $150 allowance for featured frame brands Out-of-Network Reimbursement Exam Up to $50 Single Vision Up to $50 Bifocal Up to $75 Trifocal Up to $100 Frame Up to $70 Elective Contact Lenses* Up to $105 (for fitting, evaluation & materials) *Contact lenses in lieu of eyeglasses $130 18

20 Vision Highlights (continued) Discounts Add-ons to covered pair of lenses Average of 35 40% Additional purchases of eyeglasses Refractive surgery (RK, PRK, LASIK) Miscellaneous Plan Provisions Dependent Age Limit 30% off additional glasses and sunglasses, including lens options, from the same VSP doctor on the same day as your WellVision Exam. Or get 20% off from any VSP doctor within 12 months of your last WellVision Exam. Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities. After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor. The day the dependent turns age 26, regardless of student status. This is only a summary of your vision benefit plan. Please refer to the certificate of coverage for plan details. 19

21 FLEXIBLE SPENDING ACCOUNTS A great way to plan ahead and save money over the course of a year is to participate in the Flexible Spending Account (FSA) programs. These accounts allow you to redirect a portion of your salary on a pre-tax basis into reimbursement accounts. Money from these accounts is then used to pay medical expenses which are not reimbursed by your insurance plan or to pay for dependent care expenses. Pre-tax means the dollars you use for eligible expenses are not subject to social security tax, federal income tax, and state and local income tax. Money you would have paid in taxes can be used to pay for qualified expenses. There are three ways to maximize your pre-tax savings: The Healthcare Account The Limited Flexible Spending Account The Dependent Care Account Don t Forget the *Use it or Lose it Rule!* HEALTHCARE ACCOUNT (Not Available to HSA Participants) You may elect to contribute up to $2,500 each plan year. Eligible expenses that can be paid from this account are those not covered by your medical, dental, and/or vision plans. Some examples include: Plan deductibles, copayments, and other out-of-pocket costs Vision services, such as contact lenses, eye exams, eyeglasses and laser eye surgery Prescription expenses The IRS does not allow the following expenses to be reimbursed under the Healthcare Account: (the list below includes some of the more common items and is not meant to be allinclusive): Cosmetic surgery/procedures Electrolysis Hair loss medication Health club dues Herbs & herbal medicines Teeth whitening/bleaching 20

22 Limited Flexible Spending Account For those who enroll in the Qualified High Deductible Health Plan with H.S.A, IRS rules state you are not eligible to participate in the traditional healthcare spending account described above. You are, however, eligible to participate in the Limited Flexible Spending Account, allowing you to pay for any post-deductible medical expenses as well as your dental and vision care expenses. All rules that apply to the traditional healthcare spending account also apply to the Limited FSA, i.e. once you make your annual election your contributions will remain unchanged unless you experience a qualifying event; you can file claims for any amount up to your total annual contribution at any time, even if you have not yet had the amount withheld from your pay and any unused amounts at the end of the plan year and grace period are forfeited. DEPENDENT CARE ACCOUNT You may contribute up to $5,000 annually (or up to $2,500 annually if you are married and file separate tax returns). Eligible dependent care expenses are for the care of children under age 13 or dependents of any age that are unable to care for themselves because of mental or physical handicap. The services must be necessary to allow you, or you and your spouse if you are married, to work or attend full-time school. REIMBURSEMENTS Some important things to remember about flexible spending accounts: You are responsible for filing claims for reimbursement. You may elect to have reimbursements mailed to your home or deposited directly in your personal account. You may access the website myplans.cbiz.com at any time for current account information. You may elect to use the free debit card for healthcare reimbursement, which may allow you to avoid filing claims. It is important that you keep your receipts on file. Your debit card is accepted only at qualified locations, such as pharmacies, doctor s offices, vision care centers, and hospitals. These IRS-imposed limitations help to insure that the card is used only when paying qualified expenses. You can avoid having to verify card purchases by using a retail partner such as CVS, Wal-Mart, Walgreens or Drugstore.com. Only retail partner systems allow qualified purchases to be charged on the debit card. Certain card swipes can be automatically verified. However, if the total amount of a card swipe cannot be matched with your co pays, the IRS requires that all details be verified. Failure to send in requested documentation could result in suspension of your debit card and you may be required to pay-back the plan. 21

23 IMPORTANT NOTES In exchange for the tax advantages, the IRS has strict rules about how these accounts must work. You may not stop or change your contribution amounts until the next Open Enrollment, unless you have a qualifying status change. Any funds remaining in the accounts at the end of the plan year grace period are forfeited. Use it or lose it. The Healthcare Account, Limited Flexible Spending Account and the Dependent Care Account function separately; funds may not be transferred from one to the other. The money you contribute to each account for the plan year can only be used for eligible expenses you incur during that same plan year. You may not roll over funds from one year to the next. Expenses for the January 1 December 31, 2016 plan year must be incurred by March 15, 2017 and submitted by March 31,

24 GROUP LIFE, AD&D & DEPENDENT LIFE INSURANCE Group term life and AD&D insurance protects your family or beneficiary(s) in the event of your death. Your coverage amount will be paid to the beneficiary(s) of your choice in the event of your death while you are still actively employed at Liberty Hospital. If your death is due to accidental causes (as defined by the plan), your beneficiary(s) will receive an additional amount through the Accidental Death and Dismemberment (AD&D) coverage. The AD&D coverage is equal to your life insurance coverage amount. AD&D coverage also provides a portion of the benefit in the event of certain accidental injuries not resulting in death. To help protect your financial security, you will automatically receive group term life insurance coverage equal to $50,000 at no cost to you. Your amount of life insurance will decrease by 50% on the plan anniversary date which occurs on or next follows the date you attain age 70. This coverage is insured through Lincoln Financial Group. Liberty Hospital also provides each eligible employee with term life insurance for your eligible dependents at no cost to you. Eligible dependents are your spouse and unmarried children from birth to age 26. Coverage is provided in the amount of $2,000 for your spouse and $500 per child from birth to age 6 months and $1,000 per child from 6 months to age 26. If you are interested in purchasing additional life insurance, please refer to pages 25 and 27 of this enrollment booklet for information on the voluntary supplemental life insurance and voluntary permanent life insurance products that are also available to you. 23

25 GROUP LONG TERM DISABILITY INSURANCE One of the most important items to insure is your ability to earn a living. Many times this area is overlooked. However, Liberty Hospital provides you with a core disability plan through Lincoln Financial Group to continue a portion of your income if you become unable to perform your regular job duties due to illness or injury. Liberty Hospital provides long term disability protection equal to 50% of your monthly income up to a $1,000 maximum monthly benefit payment. The first benefit payment will be made to you as soon as possible after the 90 day elimination period and claim approval. Liberty Hospital will pay the total cost of this 50% plan for each full-time employee. You also have the option to increase your coverage to 60% of your monthly salary, up to a maximum monthly benefit of $7,500. You will be responsible for paying the premium should you choose elect this option. If you have previously declined participation in this buy-up plan when you were first eligible but would like to purchase the coverage now, you may do so during the online enrollment process. Please note that you may also be required to complete an evidence of insurability form. Your additional coverage is then subject to approval by Lincoln Financial. You will be able to see the cost of the additional benefit as you complete your online enrollment. For new hires with effective dates after January 1, 2016, please note that if you elect not to purchase the 60% plan when first eligible, evidence of insurability may be required at future enrollment dates. 24

26 VOLUNTARY INSURANCE Liberty Hospital offers a wide variety of voluntary insurance programs for you and your family. Please take some time to review all of these products which include supplemental life insurance, short term disability insurance, permanent life insurance, accident insurance and critical illness to determine which plans best suit your needs. GROUP SUPPLEMENTAL LIFE INSURANCE For your peace of mind and the financial protection of your family, Liberty Hospital offers you the opportunity to purchase group supplemental life coverage on yourself, your spouse and your children through Lincoln Financial. During open enrollment, if you want to make a change in the coverage level you elected last year, you may do so during the online enrollment process. Please note that there may be limited opportunities for you to increase coverage on yourself or your spouse without providing evidence of insurability. For new hires with effective dates after January 1, 2016, please note that if you decline voluntary life insurance when first eligible, or if you elect coverage and wish to increase your benefit amount at a later date, evidence of insurability may be required. FOR YOURSELF Choose an amount from $50,000 to the lesser of 5x your annual salary or $200,000 (if you are less than age 70) in increments of $50,000 (maximum for those age 70 and over is $50,000). FOR YOUR SPOUSE Coverage is available in amounts of $10,000, $15,000 or $25,000 and cannot exceed half the amount of supplemental life insurance you purchase for yourself. FOR CHILDREN Choose either $5,000 or $10,000 of coverage for your unmarried dependent children up to the day they turn age 26. (Coverage for children from birth to 6 months of age is $500.) GUARANTEE ISSUE LIMITS For any new hire during the 2015 plan year, the guarantee issue limits are as follows: Employee $200,000 Spouse $25,000 Children $10,000 25

27 This means that you can purchase up to this amount of coverage with no medical underwriting required. Amounts over these limits require completion of an Evidence of Insurability form and are subject to approval by Lincoln Financial. VOLUNTARY GROUP SHORT TERM DISABILITY Should a sickness or injury strike, your out-of-pocket expenses not to mention lost time on the job can impact the financial well-being of you and your family. Lincoln Financial s voluntary group short-term disability insurance can help replace a portion of your salary in the event of a covered sickness or off-the job accident. Secures up to 60% of your gross salary (not to exceed $1,000 weekly). You choose how much weekly coverage you want in increments of $50 between $100 and $1,000. Your premiums are based on the amount of coverage that you purchase. Benefits are payable after the later of a 14-day elimination period or the exhaustion of your Extended Illness Bank and you can receive benefits for up to 13 weeks. (Liberty Hospital s group long term disability plan begins after 13 weeks.) No evidence of insurability is required. Your coverage is automatically approved (although subject to the pre-existing condition limitation described below)! During the online enrollment process, you will be able to see the cost for this coverage and enroll in the plan. PRE-EXISTING CONDITION LIMITATION A pre-existing condition is defined in your policy as any sickness or injury for which you received treatment within 3 months before your coverage effective date. A disability arising from any such sickness or injury will be covered only if it begins after an employee has performed his/her regular occupation on a full-time basis for 12 months following the coverage effective date, unless the employee received no treatment for the condition for 6 months in a row after his/her effective date. Pregnancy, at the time coverage is effective, is considered a pre-existing condition. 26

28 VOLUNTARY CRITICAL ILLNESS INSURANCE The critical illness plan pays a lump sum benefit upon the initial diagnosis of a covered illness such as heart attack, cancer, or End Stage Renal Disease. Plan benefits may be used for any purpose you choose. You may elect to use these benefits to help pay the non-medical costs associated with catastrophic illnesses such as lost wages, rehabilitations, family care and transportation. You may purchase coverage for yourself and your family and may choose an amount from $5,000 to $30,000. You may be required to complete Evidence of Insurability if you elect coverage after your initial eligibility period has expired or if you purchase coverage over the guarantee issue limit. VOLUNTARY PERMANENT LIFE INSURANCE You also have the opportunity to purchase voluntary permanent life insurance through Boston Mutual. This is permanent life coverage if you terminate or change your employment, you may take this benefit with you at the same cost! This benefit allows you to pre-fund a post-retirement life benefit. Benefits and costs are guaranteed as long as you keep the policy in force. This plan allows you to choose the amount of insurance or premium that best suits your budget and needs. The benefit has a cash accumulation feature the rate is guaranteed to be no less than 3%. At age 65, Boston Mutual offers the option of converting to a paid up policy which is a specified benefit with no premiums due! For more information on this coverage, including premium costs, please refer to the Employee Life Option (ELO) brochure available on the Liberty Hospital Intranet. Select the Human Resources link under Quick Launch, and then select the Benefits tab. 27

29 VOLUNTARY ACCIDENT INSURANCE You may choose to enroll in the voluntary accident insurance through UNUM that will pay cash benefits to you for medical treatment(s) if you experience an off-the-job accident. This coverage is available to you, as well as your family. Employees are eligible to enroll if they are actively at work for at least 20 hours per week. Spouses age 17 through 64 are eligible for coverage. Dependent children of the employee between birth and 26 years of age are also eligible if they are dependent upon the employee for support and are not married. Once you enroll, the coverage is individually owned which means you own your policy and can take it with you if you leave Liberty Hospital. For detailed information on this plan, please refer to the flyer which can be found on the Liberty Hospital Intranet. Select the Human Resources link under Quick Launch, and then select the Benefits tab. Please note that all voluntary benefit elections will be made through the online enrollment system this year with one exception. If you want to enroll in or make changes to a current policy with Boston Mutual whole life insurance, you will need to schedule an appointment with a benefit counselor at WBA. There are two options available to you to schedule this appointment: You may call and a counselor will schedule the appointment for you. As you complete your online enrollment at the Cool Creek website, click on the link on the Boston Mutual page to schedule an appointment online. 28