Regularly scheduled full- or part-time colleague with 40 or more budgeted hours per pay period

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1 Welcome to Open Enrollment Saint Agnes Medical Center! CHE Trinity Health and Saint Agnes Medical Center are pleased to provide you with the information you will need to enroll in benefits for next year. Throughout the rest of this communication, you will see CHE Trinity Health and Saint Agnes Medical Center referred to as simply CHE Trinity Health. If you have more questions after reviewing this guide, refer to the For More Information section to learn where you can get answers. What s Inside What s New for Other Information About 3 Enrolling Health Care Reform Update 4 Medical Coverage 5 Medical Plan Highlights 6 More About the Health 8 Savings PPO Take the Health 9 Assessment Dental Coverage 11 Vision Care Coverage 12 Flexible Spending 13 Accounts Life Insurance 14 Time Away from Work 15 Voluntary Benefits 16 How to Enroll 17 For More Information 18 Who Is Eligible Benefit Hours Requirement Dependents Other Medical, dental and vision coverage Regularly scheduled full- or part-time colleague with 40 or more budgeted hours per pay period Eligible adult: You may cover your spouse or Eligible Adult. An Eligible Adult is an adult who resides and has financial interdependence with the colleague, and is not a tax-qualified dependent or related by blood, adoption or marriage to the colleague. Flexible spending accounts Life insurance Long-term disability Regularly scheduled full- or part-time colleague with 40 or more budgeted hours per pay Dependent children are eligible for coverage through the end of the Plan Year in which they turn age 26, regardless of marital status, student status, residency, financial dependency or other requirements provided they meet both of the following criteria: They are: Your or your eligible adult s natural children; Your or your eligible adult s legally adopted children or children placed with you or your eligible adult for adoption; or Children for whom you or your eligible adult are the court-appointed legal guardian. They are not otherwise covered under the Plan or any other group health plan offered by the Employer Can submit claims for eligible dependents period Regularly scheduled full- or Can elect coverage for your spouse or part-time colleague with 40 or eligible children more budgeted hours per pay period Regularly scheduled full- or Not applicable part-time colleaguewith 40 or more budgeted hours per pay period New hires must satisfy the required waiting period New hires must satisfy the required waiting period New hires must satisfy the required waiting period Verifying your dependents If you add a new dependent, you must show the appropriate documents to your Human Resources department by Nov. 19, To obtain a full list of documentation requirements and resources available to obtain this documentation, visit your benefits website. Important Reminders 19 Saint Agnes Medical Center 1

2 What s New for 2015 If you enroll in the Health Care Flexible Spending Account (HCSA), you will receive a new debit card from WageWorks, called the WageWorks Health Card. Watch for your new card in the mail before Jan. 1, Your 2015 debit card will have the CHE TrinityHealthlogoonit.Ifyoumadea2014HCSA contribution, be sure to hold onto your current WageWorks debit card because it will be the card you need to use to access your 2014 HCSA through March Also, remember to create a new online account at CHE Trinity Health is offering two new dental plan options this year administered by Delta Dental the High Plan and the Standard Plan. If you are currently enrolled in today s Preferred High plan, you will automatically be moved to the 2015 High plan. If you are enrolled in today s Preferred Standard plan, you will be moved to the 2015 Standard plan. You may elect to change your dental plan during Open Enrollment. CHE Trinity Health is offering two new vision plan options this year administered by United Health Care the High Plan and the Standard Plan. If you are currently enrolled in today s Saint Agnes Vision plan, you will automatically be moved to the 2015 Standard UHC Vision. You may elect to move to the High UHC Vision plan during Open Enrollment. We are changing our life insurance program to harmonize across the system. These changes include an increase in the colleague supplemental life election, addition of colleague supplemental AD&D coverage as well as a new coverage amount for spouse supplemental life. 2 Saint Agnes Medical Center

3 Other Information About Enrolling If you don t enroll If you don t make benefit elections on or before Nov. 12, 2014, you will automatically receive a default package of benefits, which includes the same elections you have in 2014 for medical, life insurance, and disability benefits. In addition, if you are currently enrolled in today s Delta Dental Preferred High plan, you will automatically be moved to the 2015 Delta Dental High plan. If you are in today s Delta Dental Preferred Standard plan, you will be moved to the 2015 Delta Dental Standard plan. If you are currently enrolled in today s Saint Agnes Vision plan, you will automatically be moved to the 2015 Standard UHC Vision. Your current election for the health care and dependent care flexible spending accounts and Vacation cash-out will not carry over. If your wish to participate in these programs next year you must complete your enrollment by Nov. 12, 2014 at 12 midnight EST. Benefit elections are effective for the entire year Remember, the benefits you elect during open enrollment will be in effect from Jan. 1 through Dec. 31, Open enrollment is your only opportunity during the year to make elections for your 2015 benefits unless you experience a qualified family status change. If you experience a qualified family status change or certain employment status changes and provide any required documentation to your Human Resources representative within 30 days of the event, you will be allowed to make certain benefit changes as long as they are consistent with the status change. For example, if you get married during the plan year, you ll be able to add your spouse/eligible adult to your coverage within 30 days of the marriage. For more information on qualified family status changes, visit Adding family members If you re adding family members to your benefitplanforthefirst time during this year s open enrollment, you re required to provide written documentation (for example, marriage certificate or birth certificate) verifying their dependent status to Human Resources no later than Nov. 19, If you don t submit the required documentation by the deadline, your dependents will not be enrolled for coverage for 2015, and you ll be required to wait until next year s open enrollment period to add them to the plan provided they remain eligible, and you provide written documentation verifying their dependent status at that time. You are required to provide a Social Security number for each of your dependents over the age of one in order for them to be covered. Please provide any missing Social Security numbers to Human Resources. Please note, you have the option to purchase coverage for your spouse/eligible adult and dependents. If you and your spouse/eligible adult both work for CHE Trinity Health, and are benefits eligible, you cannot elect dual coverage (enrolled as a colleague and a dependent). In addition, only one of you will be able to elect coverage for your child(ren). To view the complete eligibility rules and documentation requirements for you and your family members, visit Choose your Primary Care Physician (PCP) Maintaining a relationship with your PCP is important because they are trained to recognize any health problems you may have. A PCP is the doctor you see for most services, including annual check-ups. Your PCP can also help you identify and meet your health goals and help you prevent serious, long-term health conditions. And, by following their preventive recommendations, they can help keep your health care costs low. CHE Trinity Health encourages you to select a PCP and develop a relationship with them. To find an in-network physician and provider, visit your benefits website. Saint Agnes Medical Center 3

4 Update on the Affordable Care Act Each year during open enrollment, CHE Trinity Health gives an update on the health care reform law, officially called the Affordable Care Act (ACA). Thelawwasputinplacetomakesure citizens have access to health insurance they can afford. Since Jan. 1, 2014, the law has required that most U.S. citizens and legal resident aliens have health insurance whether they get it from an employer, a private insurance company or from the government. If they do not have health insurance, they may have to pay a tax penalty. As a colleague at CHE Trinity Health, here is how the law may affect you: CHE Trinity Health will continue to offer health insurance for U.S. colleagues who are benefits eligible. During open enrollment, you can choose the CHE Trinity Health medical plan that works best for you and your family. Effective Jan. 1, 2015, as a result of the ACA, employers will be required to offer medical and prescription coverage to employees who work more than 30 hours a week or more than 130 hours per month. Colleagues who work an average of 30 hours a week over a rolling 12-month period will be eligible for medical coverage through CHE Trinity Health. A CHE Trinity Health medical plan may be your best option for coverage. You will probably continue to hear a lot about the health insurance marketplace that has been set up in each state to help people find health insurance for If you are benefits eligible, a CHE Trinity Health medical plan will likely be the more cost-effective option. CHE Trinity Health will continue communicating with you about your benefits coverage as we remain committed to providing you with the latest information. In the meantime, if you have questions, please contact your Human Resources representative. Women s Preventive Care under the Affordable Care Act Part of the Affordable Care Act (ACA) (also known as health care reform) requires employers to cover certain women s preventive care services, including contraception, under health insurance benefits at no charge. As a health ministry of the Catholic Church, we have engaged in extensive advocacy with the support of the Catholic Health Association, to find an acceptable resolution to this issue. The final rules from the U.S. Health and Human Services, Treasury and the Department of Labor give an accommodation to certain religious and religiously-affiliated organizations, like CHE Trinity Health, to provide an exemption from the requirement to provide contraceptive coverage to employees as preventive health services. The intent of the rules is to accommodate the moral perspectives of certain religiously-affiliated employers while also providing for the preventive health care needs of their employees who may not share the employers religious beliefs. In 2015, your medical/pharmacy benefit provider will continue to provide these benefits as mandated by the ACA. CHE Trinity Health colleagues will be provided with access to these benefits, but they will not be paid for by CHE Trinity Health or its health plans. Contact your medical/pharmacy benefit provider for further details. More about the Clinically-Integrated Network A Clinically-Integrated Network (CIN) joins local physicians and health care providers that have made a decision to partner with a Regional Health Ministry (RHM) to deliver services focused on high quality and cost-efficient care designed to improve the health of those we serve. Seeking care within the CIN can help you and your physician make health care decisions that ensure that you are accessing the right care, at the right time in the right setting. In addition, by utilizing our CIN you will pay less out of pocket for the care you receive, because all of the CIN providers are in our Tier 1 network. The Affordable Care Act is changing the way we provide care. As a result, there have been many changes designed to help increase health care quality and reduce the cost in order to make it more affordable. Our health care organization is changing in order to deliver better care at a reduced cost and with an improved, people-centered care experience. There are a lot of changes happening on the health care landscape. We believe putting them in place will better position our organization to keep our colleagues and their families healthier, fulfill our Mission, meet our nation s needs and improve the health of the millions of people and the hundreds of communities we serve. If you have questions about these changes, please contact your Human Resources representative. 4 Saint Agnes Medical Center

5 Watch the Video to Learn More Scan the tag with your smartphone to download and view a video about your 2015 medical plan choices. Get the free mobile application at If you don t have a smartphone, visit your benefits website to view the video. Medical Coverage CHE Trinity Health is offering you three medical plan choices for 2015 which supports our efforts to provide a common experience for all colleagues and provide meaningful choices. All three plans are administered by BlueCross BlueShield of Michigan with a benefit incentive to use a Tier 1 provider. The three medical plan options are the Traditional PPO, the Health Savings PPO, and the Essential PPO. Each plan offers these three tiers so you can pay less by receiving care from network providers. Tier 1, or the CHE Trinity Health network providers, are facilities or physicians aligned with our organization that provide you with the most cost-effective care. Tier 2 includes all other Blue Cross and Blue Shield Providers not listed under Tier 1. Tier 2 providers can save you money, but not as much as using our Tier 1 network. Tier 3 providers are out-of-network providers and this Tier provides the lowest level of coverage. You can use these facilities and physicians for care, but you will pay the most out of your pocket when you do. How the medical plan works Traditional PPO If you elect coverage under the Traditional PPO, you pay for a portion of the medical services you receive until you meet the annual deductible. Then, coinsurance begins up to the annual out-of-pocket maximum. Health Savings PPO With the Health Savings PPO, you pay much less per pay period for coverage leaving more money in your paycheck and you have access to a Health Savings Account (HSA) to help pay for current and future medical expenses. Here s how it works: First Second Third You pay the full cost of medical and prescription expenses until you reach the annual deductible (Note: preventive care services and certain preventive 90-day generic prescriptions do not require you to pay the deductible). Once you meet the deductible, you pay coinsurance until you reach the out-of-pocket maximum. Once you reach the out-of-pocket maximum, CHE Trinity Health pays 100% of all remaining eligible expenses during the year. To learn more about the Health Savings PPO, see page 6 of this enrollment guide. If you enroll in the Health Savings PPO, you will automatically have an HSA. CHE Trinity Health and Saint Agnes Medical Center contributes to your HSA to help you pay for expenses toward your annual deductible and out-of-pocket maximum. You can also contribute to this account to build savings for current and future medical expenses. We encourage you to consult with a tax advisor for IRS rules and tax implications related to HSAs. Essential PPO The Essential PPO works the same as the Traditional PPO where you pay a portion of the medical services you receive until you meet the annual deductible. Then, coinsurance begins. If you elect the Essential PPO, you pay less in premium contributions than in the Traditional PPO, however, your out-of-pocket costs are higher. Saint Agnes Medical Center 5

6 Medical Plan Highlights For more information about your medical plan options, visit your benefits website. Medical Plan Highlights Traditional PPO Health Savings PPO Essential PPO Tier 1 Tier 2 Tier 3 Tier 1 Tier 2 Tier 3 Tier 1 Tier 2 Tier 3 CHE Trinity Health- N/A Health Savings Account (HSA) Health Reimbursement Account (HRA), funded account if you qualify Single $650 $750 Family $1,300 $1,500 Annual deductible Individual $250 $750 $1,500 $1,300 $2,500 $3,500 $1,000 $2,500 $4,000 Family $500 $1,500 $3,000 $2,600 1 $5,000 1 $7,000 1 $2,000 $5,000 $8,000 Coinsurance 10%* 20%* 40% 10%* 20%* 40% of 20%* 30%* 40% R&C* R&C* R&C* Preventive care 0% no 0% no 40% 0% no 0% no 40% 0% no 0% no 40% deductible deductible R&C* deductible deductible R&C* deductible deductible R&C* Office visit PCP: $20 PCP: $30 40% 10%* 20%* 40% 20%* 30%* 40% Specialist: Specialist: R&C* R&C* R&C* $30 $40 bug Urgent care visit 0% after $35 copay 10%* 0% after $40 copay Emergency room 0% after $100 copay 10%* 0% after $100 copay Inpatient None** $500** $1,000** None** $500** $1,000** None** $750** $1,000** admission Outpatient $50** $100** $200** None** $100** $200** $50** $100** $200** admission Out-of-pocket maximum (includes deductible, copayments, and coinsurance) Individual $2,500 $4,750 $9,500 $2,600 $5,000 $7,000 $3,500 $5,500 $9,000 Family $5,000 $9,500 $19,000 $5,200 $10,000 $14,000 $7,000 $11,000 $18,000 Prescription drug Retail/In-house pharmacy (34-day supply) Generic $10 $10 Brand formulary 20% ($30 min., $80 max.) 20%, 0% after out-of-pocket max. 25% ($30 min., $80 max.) Brand non-formulary 40% ($60 min., $100 max.) (Deductible and out-of-pocket max. 50% ($60 min., $120 max.) (90-day supply) based on Tier 1) Generic Mail $25 / In-house $30 Mail $25 / In-house $30 Brand formulary 20% 25% Mail ($75 min., $200 max.) 20%, 0% after out-of-pocket max. Mail ($75 min., $200 max.) In-house ($90 min., $240 max.) In-house ($90 min., $240 max.) Brand non-formulary 40% 50% Mail ($150 min., $250 max.) (Deductible and out-of-pocket max. Mail ($150 min., $300 max.) In-house ($180 min., $300 max.) basedontier1) In-house ($120 min., $360 max.) 1 The full family deductible must be met even if only one person in the family is receiving care. * Subject to deductible. ** Subject to deductible and coinsurance. Select, generic preventive drugs are covered at 100% and are not subject to the annual deductible. See My Benefits for the complete list of eligible drugs. 6 Saint Agnes Medical Center

7 Paying for medical coverage Contribution levels for the medical plans are based on the Social Security taxable wage base ($117,000 for 2014, indexed annually) to ensure our benefit plan cost-sharing model is appropriately aligned with our colleagues income levels. The amount you pay for medical coverage is based on your annual base salary (your base rate of pay times your budgeted hours) and your participation in the Health Assessment (HA). If at any time during the 2015 plan year, you earn $117,000 or more, you will pay a higher premium contribution per pay period for your medical insurance. Traditional PPO Health Savings PPO Essential PPO Full-time Part-time Full-time Part-time Full-time Part-time Your per pay With Without With Without With Without With Without With Without With bug Without period cost HA HA HA HA HA HA HA HA HA HA HA HA Colleague only Colleague plus spouse/eligible bug adult Please contact your Human Resources representative for medical plan rates. Colleague plus child(ren) Colleague plus family Need help with your health care costs? You may be eligible for the Essential PPO Assist plan if you meet certain income requirements. It is the same as the Essential PPO, but includes a CHE Trinity Health-funded Health Reimbursement Account (HRA), to help you pay for your health care costs at the time of service. You do not make contributions to the HRA under the Essential PPO Assist plan. To participate in the Essential PPO Assist, you must apply for and meet specific income and eligibility guidelines. To learn more about the qualifications please see the applicationform on My Benefits. You can apply for the Essential PPO Assist by completing an application form and submitting it with a copy of your most recent Federal Income Tax Form 1040 or 1040EZ to Human Resources by Nov. 19, NOTE: Even if you think you qualify for the Essential PPO Assist, you should elect the medical plan you think will be best for you and your family which could be the Traditional PPO, the Health Savings PPO, or the Essential PPO. If you qualify for the Essential PPO Assist plan, you will be moved to the Essential PPO Assist plan. Otherwise, you will remain in the plan you elected during open enrollment. Saint Agnes Medical Center 7

8 More about the Health Savings PPO TheHealthSavingsPPO is a consumer-driven health plan which gives you the opportunity to participate in a plan where your health care costs are more closely determined by your decisions. Here are some reasons to consider choosing the Health Savings PPO in 2015: IlikedthatIsaved money in premium contributions spending money only when I used medical care. I can really save for my health care expenses when I use the HSA. It s great that CHE Trinity Health makes its full contribution to my HSA in January. For certain generic preventive drugs, I didn t have to pay my deductible before the plan started paying those expenses. How the deductible works TheHealthSavings PPO Plan includes a combined deductible. A combined deductible means the full family deductible must be met even if only one person in the family is receiving care. Coinsurance begins once the combined deductible has been met. How the Health Savings Account (HSA) works When you enroll in the Health Savings PPO plan, you automatically have a Health Savings Account (HSA) through Health Equity to help you pay for current or future health care costs. CHE Trinity Health will make a full contribution to your account in January based on the coverage level you elect. In addition, you can also contribute to this account up to IRS limits: Coverage Level CHE Trinity Health Your Voluntary Total IRS Allowed Saint Agnes Medical Center Contributions* HSA Contributions Contributions Colleague only $650 $2,700 $3,350 All other coverage levels $1,300 $5,350 $6,650 *If you are 55 or older, you can contribute an additional $1,000 in catch-up contributions to your HSA. May be subject to state taxation. Questions about the HSA How do I get an HSA? To be eligible for the HSA, you must enroll in the Health Savings PPO. In addition, you cannot have coverage under any other medical plan, such as Medicare, TRICARE, or coverage through a spouse s health plan. Who can use funds in my HSA? You and your dependents can pay for medical, dental and vision expenses with funds in your HSA. Dependents must be claimed on your tax return. Why would I contribute to my HSA? Contributions to the HSA are a great way to save on taxes. With the HSA, you do not pay taxes on the amount you contribute through payroll deductions, the amount you withdraw for medical expenses, and the interest you earn in the account (up to amounts set by federal law). Keep in mind that you can change the amount you contribute to your HSA at any time during the plan year. How can I use the money in my HSA? You may use the HSA to pay for qualified medical expenses now and during retirement for you and your qualified dependents. How do I pay for medical expenses with my HSA? When you receive eligible health care services, you can pay for those services with your HSA debit card, or through several online and smartphone app options. You ll receive more information about your payment options if you enroll in the Health Savings PPO with the HSA. What happens if I don t use all the money in my HSA each year? Any money you do not use during the year is carried over, without any limits. Remember, you own the money in your HSA and it is yours to keep even when you change jobs or retire. Can I enroll in the Health Care Spending Account (HCSA) if I have an HSA? When you enroll in the Health Savings PPO which includes the HSA, you will not have access to the health care spending account (HCSA). However, the HSA may be seen as having more advantages over the HCSA including: The opportunity to carry over savings from year to year you do not forfeit any amount in your HSA at the end of the plan year (if you are currently enrolled in the HCSA, you must utilize your account funds by Dec. 31, 2014); Contributions of up to $6,650 in tax-free HSA dollars each year (the HCSA maximum is $2,500); Your HSA dollars are saved in a bank account that may earn interest. How do I know if the Health Savings PPO, including an HSA, is right for me? Your medical plan choice depends on your personal situation. If you answer yes to some of these questions, the Health Savings PPO plan is right for you: Would you like to have lower per pay period contributions deducted from your paycheck? Do you want to save on taxes by contributing to the HSA for your health care costs?! For more information about the Do you need a way to pay for future health care costs? Health Savings PPO, including the Can you see your HSA balance growing as you keep Health Savings Account (HSA), visit or making contributions each year? We encourage you to consult with a tax advisor for IRS rules and tax implications related to an HSA. 8 Saint Agnes Medical Center

9 Take the Health Assessment The Health Assessment (HA) asks about your health habits and lifestyle to help identify some of your health needs. Your answers are kept secure and confidential; summary data is used to identify areas of focus for future wellness and prevention programs. When you and your covered spouse/eligible adult take the HA you will maintain your 30 percent premium contribution discount for the rest of For current BlueCross BlueShield users, you and your covered spouse/eligible adult can take the HA from Oct. 1, 2014 through Jan. 31, Your covered spouse/eligible adult must register separately using their BlueCross BlueShield ID card. New BlueCross BlueShield users will be able to take the HA from Jan. 1 through Jan. 31, 2015 because your BlueCross BlueShield benefit will not be available until Jan. 1, Information collected in this assessment will not affect your participation in the plan or negatively impact your health care costs. It will be kept confidential and shared only with those who will help colleagues make choices that improve health and quality of life, and may be used to develop future health and wellness programs for colleagues. To continue receiving the per pay period discounted premium contributions for the remainder of the year, both you and your covered spouse/eligible adult will need to complete an online Health Assessment at BCBSM.com by Jan. 31, NOTE: Remember to retain proof of completion for your records. Here s how to complete the HA: 1 Log on to 2 Under Health and Wellness tab, click on BlueHealthConnection. NOTE: You will receive a screen that indicates you are leaving this website. Thisiscorrect,clickOK. 3 Answer the questions on the screens and click Continue on each screen. If updating a current HA, be sure to update at least one field in the assessment so it will reflect the most recent date. 4 Once you are finished answering the questions, you will be provided an overall risk score. The following screens have information for you to take better control of your health risks and lifestyle behaviors. 5 Caution the assessment is not complete until you see your certificate on the screen. Print this and keep it for your records. 6 If you have questions regarding your health assessment or are experiencing difficulties logging into BCBS, contact BCBS Web support at Remember, if you do not complete the HA by Jan. 31, 2015, your per pay period premium contributions will increase beginning with the first pay that includes Mar. 1, 2015, and continue through the remainder of the 2015 plan year. You will not have the option to lower your premium contributions until the 2016 plan year. Saint Agnes Medical Center 9

10 Be a smart health care consumer As you know, the cost of high-quality health care continues to increase each year. Being a smart consumer means getting the best price on something you need, whether it s a new car or health care. Being a smart health care consumer doesn t mean you should avoid trips to the doctor it means making the best decisions about when to go to the doctor. Regular checkups can improve your health and extend your life. By getting the recommended exams and tests, you increase your chances of discovering problems before an illness significantly affects your health. Plus, preventive care is beneficial not only to your physical well-being, it also makes sense for your financial health because generally, it s covered by your medical plan. For more information on preventive care benefits, visit An easy way to be a smart health care consumer is to choose a CHE Trinity Health Tier 1 provider when you or a family member needs medical care. Besides receiving excellent care at our own facilities, you receive the highest level of benefits while paying the lowest available copayment and coinsurance amounts. Maintenance Choice program for your maintenance medications Our prescription drug plan requires that you receive your maintenance medications* in 90-day supplies through the CVS Caremark Mail Service Pharmacy or a local CVS Pharmacy. Once you reach your plan limit (initial fill and 2 refills) for filling 30-day supplies at a retail pharmacy, you will pay the full cost of your medications if you do not move your prescription to one of the long-term options listed here. *A maintenance medication is a long-term medication taken regularly for chronic conditions or long-term therapy. 10 Saint Agnes Medical Center

11 Dental Coverage You have a choice between two new Delta Dental plan options: the High plan and the Standard plan. Visit for providers in your area. Dental Plan Highlights High Plan Standard Plan Participating Dentist Nonparticipating Dentist Participating Dentist Nonparticipating Dentist Annual deductible Individual $25 $50 $50 $100 Family $50 $100 $100 $150 Class I - Preventive services 100% covered 100% covered 100% covered 100% covered ($0 colleague cost) (Usual and Customary ($0 colleague cost) (Usual and Customary rates apply) rates apply) Class II - Basic services 20% after deductible 20% after deductible 40% after deductible 40% after deductible Class III - Major restorative services 40% after deductible 40% after deductible 50% after deductible 50% after deductible Class IV - Orthodontics 50% after deductible 50% after deductible Not covered Maximums Per person annual (non-orthodontics) $1,750 $1,250 $1,500 $1,000 Per person lifetime (orthodontics) $1,500 $1,500 Not applicable Not applicable Your per pay period cost Colleague only Colleague plus spouse/eligible adult Colleague plus child(ren) Colleague plus family Please contact your Human Resources representative for dental plan rates. NOTES: When you receive services from a non-participating dentist, you will be responsible for the difference between what your dentist charges and the non-participating dentist fee. Fluoride treatments are covered once every 12 months to age 14. Bitewing x-rays are covered once every 12 months.! For more information about your dental plan options or about Delta Dental, visit Saint Agnes Medical Center 11

12 Vision Care Coverage You have a choice between two new United Health Care vision plan options: the High plan and the Standard plan. Visit for providers in your area. UHC Vision Plan Highlights High Plan Standard Plan In-network Out-of-network In-network Out-of-network (reimbursement schedule) (reimbursement schedule) Benefit frequency Calendar year Calendar year Calendar year Calendar year Vision exam Covered in full Up to $40 $10 copayment Up to $40 Pair of lenses Single vision Up to $40 Up to $40 Bifocal $0 copayment Up to $60 $0 copayment Up to $60 Trifocal Up to $80 Up to $80 Lenticular Up to $80 Up to $80 Frames The preferred price is a The preferred price is a Covered frame $50 wholesale allowance $50 wholesale allowance Non-covered frame at independent locations Up to $45 at independent locations Up to $45 or a maximum of $150 or a maximum of $150 of retail allowance at retail locations of retail allowance at retail locations Contact lenses $0 copay $0 copay (in lieu of eyeglasses) $200 allowance toward $175 allowance toward Elective contact lenses, fitting/ Up to $200 contact lenses, fitting/ Up to $175 Necessary evaluation fees and two Up to $210 evaluation fees and two Up to $210 follow-up visits instead follow-up visits instead of glasses once every 12 of glasses once every 12 months.upto8boxes of contact lenses are included. months.upto6boxes of contact lenses are included. Additional pair of eyeglasses 20% discount 20% discount 20% discount 20% discount or contact lenses Additional lense options Your per pay period cost Colleague only Colleague plus spouse/eligible adult Colleague plus child(ren) Colleague plus family The following lens options are covered in full: standard scratchresistant coating, standard basic and high-end progressive lenses, standard polycarbonate lenses, standard antireflective coating, UV, tints, photochromic, Transitions, edge coating The following lens options are covered in full: standard scratch-resistant coating, standard polycarbonate lenses. Please contact your Human Resources representative for vision plan rates.! For more information about your vision care plan options, visit 12 Saint Agnes Medical Center

13 Health Care and Dependent Care Flexible Spending Accounts You have the opportunity to set aside before-tax money to offset eligible health care or dependent care expenses. There are two different types of Flexible Spending Accounts a Health Care Spending Account and a Dependent Care Spending Account. How much can I contribute? What expenses will it cover? When do I have to spend the money? How do I access my FSA savings? Health Care Spending Account (HCSA) Before-tax dollars in any amount between $130 and $2,500 Eligible health care products and services used by you and/or your eligible dependents. Examples include: Vision care, including eyeglasses, contact lenses and saline solution Dental care, both preventive and restorative Orthodontia Physical therapy, counseling, or psychological services Chiropractic care and acupuncture Copayments, coinsurance and deductibles Prescribed Over-the-Counter (OTC) medications For a list of expenses that are eligible for HCSA reimbursement, visit Contributions made to the HCSA during the 2015 calendar year can be used for claims with dates of service between Jan. 1, 2015 and Mar. 15, You can use a variety of payment options to access your FSA savings. These include the WageWorks Health Card; Pay my Provider, Pay me Back; or the Mobile application. Dependent Care Spending Account (DCSA) Before-tax dollars in any amount between $130 and $5,000 Expenses for the care of your eligible dependents (child under age 13 or qualifying adult incapable of self-care) while you work: Babysitting or au pair services Before and after-school programs Day care and nursery school Pre-school programs Elder care services Contributions made to the DCSA during the 2015 calendar year can be used for claims with dates of services between Jan. 1 and Dec. 31, You can use a variety of payment options to access your FSA savings. These include Pay my Provider, Pay me Back; or the Mobile application. Reminders: If you choose to enroll in the Health Savings PPO medical plan option, you cannot enroll in the HCSA. The Health Savings Account works just like the HCSA but offers additional benefits, such as the opportunity to carry over unused funds, contribute up to $2,700/individual ($5,350/family), plus an additional $1,000 in catch-up contributions if you are age 55 or over, and earn interest on your savings. You must make health care and/or dependent care spending account elections for 2015 during open enrollment. Your prior year elections will NOT carry forward. Health Care Spending Account and Dependent Care Spending Account claims for the 2015 plan year must be postmarked on or before Mar. 31, All colleagues electing the Health Care Spending Account for 2015 will receive a new debit card to use for expenses in 2015 and beyond.! For more information about your FSA benefits and to obtain a list of eligible expenses, visit Take advantage of WageWorks mobile site As the nation s largest independent provider of consumer-directed benefit solutions, WageWorks offers FSA participants the latest technology to make it easier to manage your savings. Their mobile site and new EZ Receipts app offer the following features: Check your current HCSA and DCSA account balances Submit HCSA and DCSA claims Submit WageWorks Health Care card receipts Learn more at or contact your Human Resources representative. Saint Agnes Medical Center 13

14 Life Insurance Colleague life insurance options If eligible, you receive employer-provided basic life/ad&d insurance at 1 times your annual base salary. In addition, you have the option to purchase supplemental coverage for yourself in the increments shown in the table below. If you purchase colleague supplemental life insurance and you re approved, the premium contributions will be deducted from your paycheck on an after-tax basis. If you elect supplemental life insurance and you re approved, you will be eligible for will preparation services through ComPsych Legal Plans at no charge. To get started, access ComPsych at and enter the CHE Trinity Health Web ID THWILL in the Promotional Code box. Basic life/ad&d (employer-paid) Supplemental life Supplemental AD&D Maximum amounts Evidence of Insurability Colleague Life Insurance Plan Highlights (full- and part-time) 1 x annual base salary One to eight x annual base salary One to eight x annual base salary Basic life: $1.5 million Supplemental life: $1.5 million (Combined: $3 million) You can increase your Supplemental life election by 1x without Evidence of Insurability. If you waived Supplemental life in the past, you can elect 1x annual pay without Evidence of Insurability. Any other increase in colleague Supplemental life coverage will require you to complete Evidence of Insurability. NOTE: Evidence of Insurability forms should be sent to Prudential Life Insurance by Jan. 9, Costs for colleague supplemental life insurance coverage are based on your age as of Jan. 1, 2015 and will be available when you enroll online. Are your beneficiaries up-to-date? You may want to take a moment to review the beneficiary(ies) you have on file for your basic life coverage. If you haven t yet designated beneficiaries, your life insurance benefits will be paid according to the plan provisions as outlined in the Summary Plan Description. You ll have an opportunity to review (and change, if you wish) your life insurance beneficiary(ies) during the open enrollment process. Spouse and/or child life insurance options You have the option to purchase coverage for your dependents. You may elect coverage for your dependents without electing coverage for yourself. If you and your spouse both work for CHE Trinity Health, you cannot elect both Colleague Supplemental Life and Spouse Life coverage for the same person. Also, only one of you will be able to elect coverage for your child(ren). Evidence of Insurability Dependent Life Insurance Plan Highlights (full- and part-time) Spouse life 1 Child(ren) life 2 Coverage amount Coverage amount* $10,000 $5,000* $20,000 $50,000 $80,000 $100,000 $10,000 $20,000 Any increase in spouse supplemental life coverage will require you to complete an Evidence of Insurability. NOTE: Evidence of Insurability forms should be sent to Prudential Life Insurance by Jan. 9, Costs for spouse life insurance coverage are based on your age, and will be available when you enroll online. 2 Child(ren) life insurance costs per pay period cover all of your eligible children, and will be available when you enroll online. * The $2,000 child(ren) life insurance coverage amount is no longer offered. If you enrolled in that coverage for 2014, you will be moved to the $5,000 coverage amount for 2015 unless you make a new election.! For more information about your life insurance benefits or to obtain an Evidence of Insurability form, visit 14 Saint Agnes Medical Center

15 Time Away From Work At CHE Trinity Health, we are working to harmonize time off benefits across the enterprise. Our goal is to help strengthen and enhance the enterprise and provide our colleagues with meaningful benefits that are competitive and sustainable. Here are some of the benefits you receive as you need time away from work. Long-term disability Long-term disability (LTD) pays a benefit if you are unable to work for a long period of time because of a qualified injury or illness. You have the option to elect more LTD coverage through a buy-up election during open enrollment. Amount of employer-provided benefit Amount of available buy-up coverage Cost for buy-up coverage When benefits may begin How long benefits continue 60% of base pay 66 2/3% of base pay Based on your income level Available when you enroll online After 180 days of disability Benefits continue until you are able to return to work, are deemed no longer disabled, or until age 65 or older, depending on when the disability begins.! For more information about your disability benefits, visit Vacation cash-out Under the Vacation program, you earn Vacation based on your hours worked. You are able to cash out a certain amount of your unused Vacation each year. Howmuchtimecan you cash out Electing to cash out Payment date for cash-out You can cash out a minimum of 4 hours, provided you maintain a minimum Vacation balance of 24 hours Election for 2015 may only be made during open enrollment to avoid taxation on the value of your Vacation bank. Your election is irrevocable and cannot be changed. You may elect to cash-out eligible vacation hours on any of the three cash-out dates in April, August or December. You may cash out only hours you will accrue during the calendar year in which you plan to receive payment. Consequently, you may not cash out Vacation hours carried over from previous years. For example, Jane has a Vacation balance of 100 hours as of Dec. 31, During open enrollment, she elects to cash out 40 hours in Jane cannot cash out any of the 100 hours she earned in 2014 or earlier. She must plan her 2015 cash-out amount on only the hours she will accrue in REMINDER: If you want to cash out Vacation in 2015, you must make a new Vacation cash-out election. Your prior year election will NOT carry forward.! For more information about the program, visit Saint Agnes Medical Center 15

16 Voluntary Benefits In addition to your group benefits, CHE Trinity Health has partnered with the Farmington Company to provide eligible colleagues the opportunity to elect personal insurance plans. Individual policy options include: Life insurance Accidental Death and Dismemberment (AD&D) Insurance Cancer insurance Critical illness insurance Auto/home insurance Pet insurance Identity theft insurance For more information, call Be sure to tell the representative that you are a member of CHE Trinity Health and Saint Agnes Medical Center. 16 Saint Agnes Medical Center

17 How to Enroll Annual enrollment is conducted using our web-based tool which you access through your benefits website. It takes only about 10 minutes to make your benefit elections online, and you may not need to fill out any forms. If you don t have a computer with Internet access in your workplace or your home, you can enroll at computer stations provided by your Human Resources department or at your local public library. You can enroll any time that s convenient to you during the open enrollment period 24 hours a day, seven days a week. During the two-week open enrollment period, you can make as many changes to your benefit elections as you wish. The last day to modify your choices is Nov. 12, Be sure that your personal information is secure on the enrollment website. CHE Trinity Health has taken extra precautions to ensure the integrity of all confidential records. Step-by-step instructions 1. Access the CHE Trinity Health My Benefits website through the Internet at 2. Click on the section titled My Health & Welfare. 3. Click on the Name/Location of your CHE Trinity Health Regional Health Ministry. 4. Select 2015 Open Enrollment. 5. Click on Enroll Now. 6. Enter your user ID, password and the unique code shown on the screen: PeopleSoft ID: Your employee ID (if you don t remember your employee ID number, refer to your pay advice). Password: Enter your existing password. If you forgot your password and have set up your two security questions, click the Forgot Password link for a new password to be generated. Unique Code: Enter the combination of random letters and numbers shown on the screen. Click on Sign In. You may be prompted to change your password. 7. Under Benefits, click Benefits Home TH. The e-benefits home page is the starting point for enrolling in your benefits. You may choose from the following options/links: Benefits Summary: Review your current coverage. Benefits Enrollment: Review detailed information on coverage and dependents and make any open enrollment changes for 2015 by Nov. 12, 2014 at 12 midnight EST. Remember, if you enroll in the Health Savings PPO, you cannot enroll in the Health Care Spending Account (HCSA). 8. Follow the instructions on the online enrollment system. 9. Be sure to print the enrollment page for your records by clicking on the printer icon located at the top of the screen. If the confirmation statement that you receive in your home mail does not match the benefits that you elected, contact your Human Resources representative immediately to make the necessary corrections to your benefit enrollment record. If you do not change or correct your benefit elections by Nov. 12, 2014 at 12 midnight EST, IRS regulations require you to remain in your elections throughout 2015 or until you experience a qualified status change. For more information on qualified status changes, visit Saint Agnes Medical Center 17

18 For More Information We hope this enrollment guide has provided you and your family with all of the information you need to make your benefit elections for In addition to Open Enrollment, please remember to review and update your personal information, such as your address, phone number, and emergency contacts as necessary. You may update your personal information at any time throughout the year. If you still have questions about your options or the open enrollment process, you can: Contact your Human Resources representatives: Brittany Orr at or Amy Taglione at or Jason Samnang at or Attend a Benefits Fair session to learn more about your benefits and visit with benefit vendor representatives. This is the best opportunity to ask your questions and get the information you need to make the best decisions for you and your family during Open Enrollment. Day Time(s) Room Wednesday, Oct :30 a.m. 1:00 p.m. OneMainCaféAnnex 3:00 p.m. 5:00 p.m. OneMainCaféAnnex 9:30 p.m. 11:30 p.m. OneMainCaféAnnex Thursday, Oct. 30 8:00 a.m. 9:30 a.m. OneMainCaféAnnex 11:00 a.m. 2:00 p.m. OneMainCaféAnnex Get assistance with enrollment. A Human Resources representative will be available. Day Time(s) Room Monday, Nov. 3 10:30 a.m. 1:30 p.m. OneMainCaféAnnex 9:00 p.m. 10:30 p.m. OneMainCaféAnnex Tuesday, Nov. 4 10:30 a.m. 12:00 p.m. OneMainCaféAnnex 3:00 p.m. 5:00 p.m. OneMainCaféAnnex Wednesday, Nov. 5 7:30 a.m. 9:30 a.m. Plaza IS Training Room 11:00 a.m. 1:00 p.m. OneMainCaféAnnex Thursday, Nov. 6 9:00 a.m. 11:00 a.m. OneMainCaféAnnex Saturday, Nov. 8 10:30 a.m. 1:00 p.m. OneMainCaféAnnex Monday, Nov. 10 3:00 p.m. 5:00 p.m. OneMainCaféAnnex Tuesday, Nov :30 a.m. 1:00 p.m. OneMainCaféAnnex 4:00 p.m. 7:00 p.m. OneMainCaféAnnex Wednesday, Nov. 12 7:30 a.m. 9:30 a.m. OneMainCaféAnnex 11:00 a.m. 2:00 p.m. OneMainCaféAnnex Visit the Open Enrollment page on InTouch under Human Resources > Staff > 2015 Open Enrollment. Visit 18 Saint Agnes Medical Center

19 Important Reminders Benefit elections are final for 2015 Remember, the benefits you elect during open enrollment will be in effect from Jan. 1 through Dec. 31, The choices you make now are final for 2015, because open enrollment is your only opportunity during the year to switch medical, dental or vision plan coverage. If you experience a qualified family status change or certain employment status changes and provide any required documentation to your! For more information on qualified family status changes, visit Human Resources representative within 30 days of the event, you will be allowed to make certain benefit changes that are consistent with the status change. For example, getting married is considered a family status change. If you get married during the plan year you ll be able to add your spouse/eligible adult to your coverage within 30 days of the marriage. HIPAA privacy notice is available online CHE Trinity Health takes the security of its colleagues and family members Personal Health Information (PHI) very seriously. To access a copy of the Health Information Portability and Accountability Act (HIPAA) Privacy Notification, visit If you are unable to access the HIPAA notice online, contact your Human Resources representative to request a paper copy by mail. Medical plan election notification When you enroll in a CHE Trinity Health medical plan, the medical plan coverage provides benefits through a clinically integrated network (CIN) of hospitals, physicians, and other health care providers and professionals, including care coordinators and case managers that monitor and coordinate all aspects of your medical care. CHE Trinity Health and Saint Agnes Medical Center participate in the CIN. When you and your covered dependents receive health care services at facilities or by the colleagues of your employer or a health care provider or professional affiliated with your employer, colleagues of your employer or a health care provider or professional affiliated with your employer will have access to and may use and disclose your and your covered dependents personal health information to manage and coordinate your care. Any access to and use and disclosure of protected health information will comply with the privacy and security regulations under HIPAA and any applicable state privacy and security laws. Plan documents and Summary of Benefits and Coverage (SBC) are available online Health Care Reform legislation requires all employers to provide an easy-to-read summary of their medical plan options called the Summary of Benefits and Coverage (SBC). The SBC provides basic information about your medical plan options, comparison examples, and a glossary of terms. To access a copy of the SBC, visit If you are unable to access the SBC online, contact your Human Resources representative to request a paper copy by mail. Notice: Women s Health and Cancer Rights Act of 1998 The Women s Health and Cancer Rights Act of 1998 requires all employers who provide a medical benefit plantoits employees to communicate the coverage provisions established under the Act. CHE Trinity Health s medical benefit plan provisions are as follows: The CHE Trinity Health medical benefit plan will not restrict benefits if you or your eligible dependent receives benefits for a mastectomy and elects breast reconstruction in connection with the mastectomy. Benefits will not be restricted provided that the breast reconstruction is performed in a manner determined in consultation with your (or your eligible dependent s) physician, and may include: Reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; and Prostheses and treatment of physical complications of all stages of mastectomy, including lymphedemas. Benefits for breast reconstruction may be subject to appropriate plan coverage provisions and limitations, including annual deductible, copayment and coinsurance provisions that are consistent with those established for other benefits under the plan. If you have any questions about your medical plan provisions relating to the Women s Health and Cancer Rights Act of 1998, contact your Human Resources representative. Saint Agnes Medical Center 19