Employee Benefits

Transcription

Employee Benefits

Employee
Benefits
2014 OPEN ENROLLMENT
Welcome
Dear Mercy Health Employee (and Family),
It is time to focus on your own health and medical needs. We spend each day taking care of our
patients, visitors, residents, clients and one another — providing exceptional, quality care with
compassion. Now it is your turn to make sure you and your family has the same care.
We continue to be committed to providing each and every Mercy Health employee with options
to support your overall health and well-being. For 2014, we are introducing three new, plans that
continue to support healthy behaviors and prevention, while encouraging our employees to use
Mercy Health facilities and services — building relationships with our own providers.
I want to stress that our benefits are not just for times when we are ill, but are here to support us
as we strive for overall health and well-being.
New highlights for 2014 include:
•Three medical plan options. Two plans (Choice and Traditional) are similar to Plan A and Plan B
offered in 2013. We are introducing a new Exclusive plan featuring a single network (only one tier),
with discounted premiums for those at lower wage levels.
•All three health plans will include health reimbursement accounts (HRA), and you earn a
portion of the annual account contribution by completing the My Health Journey wellness
incentive requirements.
•The Tobacco-Free discount on the medical plan premium will increase to $30 per pay if you qualify.
•Generic prescriptions filled at Riverfront Pharmacy will have a maximum $10 co-pay for a 30-day
supply. Effective July 1, 2014, maintenance medications must be filled with Riverfront Pharmacy
starting with the first refill.
•We’ve updated dental benefits, including an increased annual maximum benefit of $1,250, with
major services covered at 50%.
•Enhanced tuition reimbursement benefits will be available for nursing degrees; for other degree
programs, the maximum benefit will be $5,250 (full-time) or $3,150 (part-time). A three-year work
commitment will be required.
There are some great reasons to choose our new Exclusive Plan this year. As a pioneer in
establishing Accountable Care Organizations (ACO), we are forging the journey to value-driven
healthcare delivery. This plan has lower premiums and encourages you to access Mercy Health
providers who deliver high quality, clinically-integrated, appropriate care to us and our families.
2 Mercy Health — Open Enrollment 2014
Mercy Health provides you with a variety of wellness programs and benefits to help you maintain
and improve your health. Healthy employees make healthy communities. Who we are to the
community starts with how we are as employees — healthy role models. Care for yourself as much
as you care for each other and our patients. Optimal health means different things to each of us,
and one size doesn’t fit all. That’s why you have a wide range of health and wellness programs
available, including:
• 100% in-network preventive care under any of our medical plans
•HealthPlex memberships and discounts to area fitness centers
•Programs to help you be active, manage your weight, quit tobacco use and manage
chronic conditions
•My Health First wellness tools, resources and information, including
My Health Assessment screenings and My Health Journey incentives
As you read through this book and consider the offerings, support and
encouragement we are providing you, our employee, please know that
we truly have your best health and wellness in mind. We have tried to
make this book and the open enrollment process easy to understand,
follow and execute.
On behalf of Mercy Health and the Executive Management Team,
I encourage you to take full advantage of the benefit offerings and
to continue to strive to achieve good health and well-being.
We want you and your family to be well — in mind, body and spirit.
Yousuf J. Ahmad, DrPH, FACHE
President & CEO, Mercy Health
Employee Benefits 2014
3
Table of Contents
5ELIGIBILITY
45RETIREMENT
6
7
8
9
Eligibility Chart
Dependent Eligibility and Verification
Qualified Medical Child Support Orders
Spousal Eligibility
10 ENROLLMENT PROCESS
12 MY HEALTH FIRST
13 Program Eligibility
14 Program Descriptions
16MEDICAL
17 Medical Plans Summary of Coverage
20 Preventive Care and Premiums
21 Prescription Drug Program
23 Health Reimbursement Account
25Benefit Information Center and
Benefit Cost Estimator
26 Networks and Out-of-Area Networks
28 DENTAL, VISION AND HEARING
29 Dental Plan Summary
30 Vision Plan Summary
31 Hearing Services Plan
32 FLEXIBLE SPENDING ACCOUNTS
33Healthcare and Dependent Day Care
Flexible Spending Accounts
35PREMIUMS
36Medical Plans Premium Chart
and Discounts
37 Dental Plan Premium Chart
37 Vision Plan Premium Chart
38 LIFE INSURANCE
39 Term Life Insurance
39Supplemental Life and
Accidental Death and Dismemberment
40 Cost Per Pay Chart and Calculation Table
41 Conversion and Continuation
42DISABILITY
43 Disability Management
43 Short Term Disability
43 Long Term Disability
43 Family and Medical Leave Act (FMLA)
44 Workers Compensation
44 Continuation Coverage
4
Mercy Health — Open Enrollment 2014
46 CHP Retirement Savings Plan
48 Cash Balance Plan
49 CONTINUATION COVERAGE
52 TIME OFF BENEFITS
53 Paid Time Off (PTO)
53Holidays
53 Jury Duty
53Bereavement
53 Military Leave
53 Educational Leave
53 Personal Leave
54 Paid Time Off/PTO Accrual Charts
55 OTHER BENEFITS
56EAP
56 Employee Emergency Fund
56Adoption
56 Spiritual Support/RISEN
56 Employee Recognition
57 Critical Illness/Universal Life Insurance
58Educational Benefits and
Tuition Reimbursement
58
iLearn
59 THE FINE PRINT
60HIPAA
64 Special Notices
65 Women’s Health and Cancer Rights
65 Newborn Coverage
66 Appeals Process
68CONTACTS, GLOSSARY AND FREQUENTLY
ASKED QUESTIONS
69 Benefits Contact List
72Glossary
74 Benefits — Frequently Asked Questions
77Guide to Mercy Health Services
and Locations
81 SUMMARY OF BENEFITS AND COVERAGE
ELIGIBILITY
Eligibility
Pamina Kim, MD
ANDERSON DERMATOLOGY
“We strive to provide the best
dermatology care close to
where you live and work.
As part of the Mercy Health
integrated care network, we
are able to communicate and
provide seamless care with
your primary care physicians
and other specialists.”
5
ELIGIBILITY
Eligibility 2014
Eligibility to participate in benefits and services is based
on an employee’s classification, or status. There are four
primary status levels within the organization:
• FULL-TIME: An employee who works in a permanent
position and whose budgeted work hours are at
least 30 hours per week (60 hours per pay period).
•P
ART-TIME, BENEFIT ELIGIBLE: An employee who
works in a permanent position and whose budgeted
work hours every pay period are between 32 hours
and 59 hours.
• PART-TIME, NON-BENEFIT ELIGIBLE (NBE): An
employee who works in a permanent position and
whose budgeted work hours every pay period are
less than 32 hours.
• PER DIEM (PRN): Employees who are designated as
per diem (PRN) employees may work any number of
hours/shifts/days, are not regularly scheduled, and
are called upon as needed. PRN employees have no
set or budgeted hours.
In addition, iFlex nurses are eligible for certain benefits.
For employees with multiple positions, the employee’s
total number of combined budgeted hours will be used
to determine benefit eligibility status. Benefits and
services are available to employees as follows:
BENEFITSCLASSIFICATION
This is summary information only.
Full-Time
Part-Time
Please see plan materials for more details. Part-Time
NBE*
Bereavement
l
l
l
Dental Insurance
l
l
Employee Recognition
l
l l
PRN
l
l
l
l
Hearing Services Plan
l
l
l
l
Holiday Premium Pay
l
l
l
l
l
Jury Duty
l
l
Life Insurance (basic, supplemental and universal)
l
l
Long Term Disability
l
iFlex
Medical Insurance
l
ll
Paid Time Off (PTO)
l
l
Short Term Disability
l
l
CHP Retirement Savings Plan
l
l
l
Tuition Reimbursement l
l
l
l
l
l
l
Unemployment
l
l
Vision Insurance
l
ll
Worker’s Compensation
l
l
l
l
l
SERVICESCLASSIFICATION
Full-Time Part-Time
Part-Time
NBE*
PRN
iFlex
Credit Union
l
l
l
l
l
Discount Pharmacy
l
l
l
l
l
Employee Assistance Program (EAP)
l
l
l
l
l
Educational Training (other than tuition reimbursement)
l
l
l
l
l
Employee Emergency Fund
l
l
l
Employee Health/Wellness Support
l
l
l
l
l
Meal Discounts (where available)
l
l
l
l
l
Non-Mandatory Employee Health
l
l
l
l
l
Parking (FREE)
l
l
l
l
l
Payroll Deduction in Gift Shop
l
l
ll
Vendor Discounts to Employees (i.e., Verizon, Dell)
l
l
l
*NBE — Non Benefits Eligible
6
l
l
ELIGIBILITY
Dependent Eligibility and
Verification 2014
Participants in Medical, Dental, Vision and Life Insurance Benefits Plans may enroll qualified family members for
coverage. Dependent eligibility requirements must be met before coverage can begin in the plans.
FAMILY MEMBER
ELIGIBILITY
AGE
ELIGIBILITY
CRITERIA
(meets all)
DOCUMENTATION FOR
MEDICAL, DENTAL OR
VISION COVERAGE
(provide one from list below)
DOCUMENTATION
FOR SUPPLEMENTAL
LIFE COVERAGE
None
• Legally married,
Spousal eligibility certification (see
•E
vidence of Insurability
Spouse
(Medical Dental,
Vision and
opposite gender
below for more information*) and
form if election exceeds
Supplemental Life
spouse
one of these documents:
guaranteed coverage
• Copy of most recent tax return
amount or past initial
• If both you and your
Coverage)
spouse are employed
(page 1 of the Federal 1040 form,
enrollment period.
by any CHP affiliate,
showing dependent with SS#)
See page 40 for more
you cannot be
covered as both an
• Other documents as approved in
information
•S
pousal coverage to
a case-by-case basis
age 70 only
employee and a
dependent under any
CHP plans.
Children
Employee’s
Up to age 26
•C
opy of birth or adoption
certificate
Natural-Born Child,
•C
opy of most recent tax return
Adopted Child or
Step-Child
(Medical, Dental
•P
roof of legal guardianship/
and Vision
custody
coverage)
•O
ther documents as approved
on a case-by-case basis
Legal Guardian Child
(Medical, Dental
Up to age 26
• Legal guardianship
and Vision
granted to employee
coverage)
or employee’s spouse
or child support order
requiring employee to
maintain coverage
(see page 8)
•C
opy of most recent tax return
•P
roof of legal guardianship/
custody
•O
ther documents as approved
on a case-by-case basis
Disabled Child
(Medical, Dental,
Older than
Vision and
age 26
Supplemental Life
coverage)
•P
roof of total disability, subject
•P
roof of total disability,
to review and approval by the
subject to review and
• Incapable of
plan supervisor. Contact Human
approval by the insurance
self-support
Resources for more information.
carrier
• Totally disabled prior
to age 26
• Principally supported
by employee
• Continuously totally
disabled and covered
thereafter
• Unmarried
• Coverage subject to
plan approval
Continued
7
ELIGIBILITY
FAMILY MEMBER
ELIGIBILITY
AGE
ELIGIBILITY
CRITERIA
(meets all)
DOCUMENTATION FOR
MEDICAL, DENTAL OR
VISION COVERAGE
(provide one from list below)
DOCUMENTATION
FOR SUPPLEMENTAL
LIFE COVERAGE
Employee’s
From age 14
•D
ependent of parent
Natural-Born Child,
days to age
insurance benefit for a
Adopted Child or
19 years
child 14 days to less than
Children 0-19
• The maximum life
6 months old is $500
Step-Child
(Supplemental Life
Coverage)
Children 19-25
Employee’s
From age 19
• Full-time student
Natural-Born Child,
years to age
• Not in the military
Adopted Child or
25 years
• Not married
Step-Child
(Supplemental Life
Coverage)
• Copy of birth certificate or
approved document
• Full-time student schedule
• Not employed
full-time
• Dependent on parent
for financial support
*SPOUSE ELIGIBILITY: If you elect medical coverage
for your spouse, you must complete the annual Spousal
Eligibility certification. If your spouse is eligible for
coverage through his or her own employer and does
not meet certain criteria, he/she may only enroll in
Mercy Health coverage if also enrolled in his/her
employer’s coverage.
8
QUALIFIED MEDICAL CHILD SUPPORT ORDERS
(QMCSO): If you are eligible to participate in the medical
plan, you may be obligated to provide medical insurance
for any child for whom the court deems you to be
responsible. A QMCSO may be enforced whether or
not you are enrolled in the medical plan at the time the
QMCSO is issued. If a QMCSO is issued, the Plan
Supervisor will determine if the QMCSO is qualified and
will notify you and the covered child(ren). Coverage will
generally be effective on the date specified in the order.
Coverage will continue for as long as the child is eligible
to be covered in accordance with the medical plan’s
dependent eligibility guidelines, the length of the order
or for as long as you are eligible to participate in the
medical plan. Children covered by a QMCSO are also
eligible for coverage under Mercy Health’s Continuation
Coverage plan (see pages 50 - 51 for more information).
Mercy Health has special eligibility requirements for
your covered spouse and you must recertify every year.
This provision is commonly used by employers to help
keep medical plan costs lower for all. If your spouse is
eligible under another employer’s plan at a cost of $160
per month or less for single coverage, your spouse must
enroll in coverage through his/her employer in order to
be eligible for coverage under the Mercy Health plan.
If your spouse is covered under his/her employer’s
plan, and is also covered under our medical plan, our
medical plan will provide secondary coverage and the
spouse’s plan will be primary. The primary plan is the
plan which pays benefits first. The secondary plan can
then consider the claim for any additional payments.
Be sure to check with your spouse’s employer, as its
plan may not allow your spouse to carry Mercy Health
coverage as secondary insurance (for example, if
enrolled in a Health Savings Account).
You may enroll your spouse without restriction
if you certify that:
•Your spouse does not work, is self-employed
or is employed by any Catholic Health Partners
(CHP) entity, OR
•Your spouse is covered by both the Mercy
Health Medical Plan and his/her employer’s
medical plan, OR
•Your spouse’s individual premium contribution
through his/her employer’s medical plan is more
than $160 per month.
Otherwise, to enroll your spouse in Mercy Health
coverage, you must certify that he/she has enrolled in
his/her employer-provided coverage, and you may be
required to provide documentation upon request for
audit purposes. You must complete the Spousal
Eligibility certification when required — upon initial
enrollment, annually during Open Enrollment, and
after any loss, gain or change to your spouse’s
medical coverage.
ELIGIBILITY
Spousal Eligibility for Mercy Health
Medical Coverage
EXAMPLE 1: Mary’s spouse, Tom, is eligible for his
employer’s health insurance at a cost of $35 per month
for single coverage. To be eligible for coverage under
the Mercy Health plan, Tom must enroll in coverage
through his employer. Tom’s employer-provided
coverage will be primary for him and our coverage will
be secondary. If he does not enroll in his employer’s plan,
he cannot be covered under the Mercy Health plan.
EXAMPLE 2: Bill’s spouse, Beth, is eligible for two
different health insurance plans. One plan is at a cost of
$40 per month and the other plan is at a cost of $180
per month. To be eligible for coverage under the Mercy
Health plan, Beth is required to enroll in coverage
through her employer under one of the plans her
employer offers because one of the plans costs $160
or less per month for single coverage. Beth’s employerprovided plan will be primary for her and the Mercy
Health plan will be secondary.
EXAMPLE 3: Maria’s spouse, Louis, is eligible for
health insurance at a cost of $185 per month for single
coverage. Louis is not required to enroll in insurance
under his employer plan in order to be eligible for
coverage under the Mercy Health plan. However, if he
does enroll under his employer’s plan, that plan will be
primary and the Mercy Health plan will be secondary.
CERTIFICATION DEADLINES
Spousal Eligibility certification must be completed
annually and can be completed online during the annual
Open Enrollment period. The Spousal Eligibility Form
must be completed upon initial enrollment, or within 31
days of a qualified event. Failure to complete the online
certification or to complete the form and return it to
Mercy Health will result in loss of coverage for your
spouse under the Mercy Health Medical Plan. Periodic
audits will be conducted to verify eligibility with the
spouse’s employer. Failure to provide documentation
when requested for audit purposes will also result in
loss of coverage for your spouse.
TIP: If you want to cover your spouse on your health insurance, you must return the Spousal
Eligibility form. This form can be completed online during open enrollment, or on paper for new
hires. If you do not complete the online certification or return this completed form by the deadline,
your spouse will not be covered under your plan.
9
ENROLLMENT PROCESS
Enrollment
Process
Hilary Shapiro-Wright, DO
KENWOOD BREAST SURGERY
“I encourage patients to stay
within the Mercy Health system
for their healthcare. I believe
Mercy Health employs high quality
healthcare professionals who
treat their patient’s like family.”
Enrollment Process
PEOPLESOFT SELF-SERVICE
REFER TO ENROLLMENT INSTRUCTIONS
FOR MORE DETAILS.
CONFIRMATION AND CORRECTIONS
Please review your benefits summary after entering
your benefits elections to ensure they are correct.
If you find an error on your summary, please print out
the summary, write your changes on the page, sign,
date and fax the form to the HRMS Department at
513-981-6156 or scan and email the form to
HRMSREQUESTS@health-partners.org. Verify
your changes have been made by rechecking your
Benefits Summary three business days after you
fax the corrections to the number above. Certain
deadlines may apply to making changes to your
elections. Please ask your Human Resources
Department for more information.
CHANGING YOUR BENEFITS ELECTIONS
DURING THE YEAR
You can change your elections during the year based
on these guidelines below:
a. Change in marital status
b. Birth or adoption of a child
c. Death of spouse or child
d.Change in spouse’s employment that
affects benefits
e.Change in employment status (i.e., to/from
full-time to/from part-time status)
f.Change in spouse’s employment status that affects
benefits (i.e., to/from full-time to/from part-time
status)
g.Call to active military duty and military leave
of absence or
h. Reduction in force
Any mid-year change must be consistent with the
qualifying event, but you cannot change from one
medical plan to another.
To comply with IRS requirements, you may make
changes in medical, dental, vision and flexible spending
account elections if you have one of these qualifying
events. You must complete and submit the appropriate
Benefits Change form within 31 days of the date of the
qualifying events listed above. If changes are not
requested in a timely manner, you must wait until the
next open enrollment period or another qualifying event
to make changes. Any change in benefits eligibility will
become effective on the date of the status change. Any
waiting periods and/or other specific eligibility terms,
conditions or requirements will still apply. You are
responsible for verifying that any changes to benefits
premiums, if applicable, are reflected on your paycheck.
If you have a change of status and need to make
changes in your benefits elections, complete and
submit the Benefits Enrollment/Change Form
found on the Mercy Health intranet or in your site
Human Resources department.
NOTE: Instructions for how to enroll online in PeopleSoft
and print a summary of your benefits elections will be
provided online on the Mercy Health intranet.
TIP: If you have a change in status and need to make changes in your benefits elections, complete
and submit the Benefits Enrollment/Change Form found on the Mercy Health Intranet or in your
site Human Resources department.
11
ENROLLMENT PROCESS
PeopleSoft Self-Service provides a convenient way to
access information about you, your pay and your
benefits. With PeopleSoft, you can:
•View online paychecks
•Update tax withholding
•Review and change your address, phone number,
emergency contact and email address information
•Complete your Benefits Open Enrollment each year
•View your current benefits
•Review and correct dependent
personal information
•Print a Benefits Summary
•Enter Performance Notes
•Request an Internal Transfer
MY HEALTH FIRST
My Health
First
Michael Yi, MD
BLUE ASH PRIMARY CARE
“Our employees should choose
Mercy Health Physicians
because we, as physicians and
as a health system, are focused
on delivering the highest
quality of care for our patients
and their families in patientcentered medical homes.”
My Health First
Your health is important for so many reasons — to you,
your family and friends, and to our patients and residents.
Mercy Health provides a variety of wellness programs
and benefits through My Health First to help you maintain
and improve your health. There’s something for everyone
in My Health First. Find something that works for you and
invest in your health!
BENEFITS
All
Employees
Benefits
Eligible
Employees
Employees
Enrolled in
Medical Plan
Employee, Spouse
and 18 year+
Dependents
Enrolled in
Medical Plan
Employee, Spouse
and Dependents
Enrolled in
Medical Plan
Health Improvement Programs
My Health Journey
s
My Health Assessment Screening
●
●
● Wellness Coaches
●
●
●
Employee Assistance Program (EAP)
●
●
●
s (spouse only)
● (spouse only)
●
Diabetes Management
●
●
Preventive Services
●
●
s
s
s
Nicotine Replacement Therapy (free)
●
● ● ●
●
●
●
●
●
●
●
Riverfront Pharmacy Discount
●
●
●
Wellness Events
●
●
●
Nutrition and Healthy Weight Programs
Nutritional Counseling
Diabetes Self Management Education
Weight Loss at Work Program
●
●
●
●
●
●
●
●
●
●
Fitness and Exercise Programs
Virgin Pulse
Free HealthPlex Membership
Discounted HealthPlex Membership
●
Group Personal Training — 3 sessions free
●
●
●
● (spouse only)
●
●
●
●
●
●
●
●
●
●
Will Preparation Services/Funeral Planning
●
●
● (spouse only)
Identity Theft Program
●
●
● (spouse only)
Discount on Local Fitness Centers
Financial Wellness Programs
Credit Union
s = New for 2014
Employee Benefits 2014 13
MY HEALTH FIRST
Tobacco Cessation Quit For Life
●
MY HEALTH JOURNEY
This 2014 wellness incentive requires two levels of actions
in order to earn the full employer contribution to your
2014 medical plan Health Reimbursement Account
(HRA) dollars. Level 1 requires completion of My Health
Assessment (you and your covered spouse, if applicable),
selection of a primary care physician (PCP) and setting a
wellness goal with either your PCP or Wellness Coach.
Level 2 requires you to complete one of eight activities
to help further your goal. For more details, see My Health
Journey information on the Mercy Health intranet.
Once enrolled and active in the plan, you will
benefit from $0 co-pay and 0% coinsurance on
diabetes medications and supplies from Riverfront
Pharmacy. This benefit will be provided in “real time”
once program enrollment has been established and
communicated to all parties. After 12 months of active
program participation, you will be reimbursed for all
co-pays or coinsurance for office visits which were
coded by your doctor with a primary diagnosis of
diabetes. See the intranet for full details and program
incentive requirements.
MY HEALTH ASSESSMENT
PREVENTIVE CARE
MY HEALTH FIRST
Participate in this free annual screening through an online
questionnaire and measures of your blood pressure,
weight, body mass index, waist circumference, blood
sugar and cholesterol levels. Know your numbers and
get advice on goal-setting and coaching opportunities.
If you enroll in medical coverage and completed the My
Health Assessment in 2013 (or within 60 days of hire),
you will qualify for certain Health Reimbursement
Account dollars in 2014. Your spouse, if enrolled in
Mercy Health medical coverage, will also be eligible
for My Health Assessment.
WELLNESS COACHES
You can work with a Wellness Coach at your worksite,
over the phone or through eCoaching. Set goals and
work towards that healthier you! For information,
contact HealthSpan at 1-888-914-7726 or
www.healthspannetwork.com.
EMPLOYEE ASSISTANCE PROGRAM (EAP)
You and other members of your household have access
to confidential counseling and referral services that can
assist you with personal and family issues. An EAP
clinician will assess your situation and determine if
counseling through the EAP is appropriate or if longer
term care is warranted. If care beyond the scope of what
can be provided through the EAP is warranted, the EAP
will work with you to make a referral to an appropriate
level of care. Contact HealthSpan EAP, formerly called
Life Management Systems, Mercy Health EAP provider,
at 513-551-1500 or 1-800-733-0257. See page 56 for
more details.
DIABETES MANAGEMENT PROGRAM
This program encourages partnership with your doctor
and adherence to evidence-based care for diabetes. The
program reduces the costs and barriers associated with
good care of your diabetes, and shows measurable
results in terms of glucose control, member satisfaction
and reduces out of pocket expenses for the participant.
Employees, spouses and dependents 18 years and
older, who are covered by the medical plan, with a
diagnosis of Type I, Type II or Gestational Diabetes
are eligible to participate.
A full menu of preventive services, covered under our
medical plan at no cost to you, can be found on page 20.
RIVERFRONT PHARMACY
With discounts, home delivery and guidance by a
pharmacist on all your prescription needs, Riverfront
Pharmacy provides a great value for you and your
family. See page 21 for more details.
TOBACCO CESSATION SUPPORT
Mercy Health provides a Tobacco-Free Campus
environment, and does not hire or rehire tobacco
users, unless prohibited by law. For you and your family
members ready to stop using tobacco products, our
medical plans provide no-cost access to prescription
drugs designed to help you quit. In addition, you can
qualify for medical plan premium discounts if you are
tobacco-free. We also offer the Quit For Life program,
with telephonic coaching support and free nicotine
replacement therapy. Enroll by calling 1-866-QUIT-4-LIFE
(1-866-784-8454).
WELLNESS EVENTS
Join your coworkers in sponsored walks and runs,
fitness programs and other events at your facility and in
the community.
NUTRITIONAL COUNSELING
Meet one-on-one with a Mercy Health dietitian and
create a nutritional plan that’s right for you. Your medical
plan will cover up to three visits per year. Contact Mercy
Health Central Scheduling at 513-95-MERCY.
HEALTHY EATING
Your local cafeteria provides healthy fare to help you eat
right. Look for healthy choices labeled with nutritional
information for your convenience.
WEIGHT LOSS AT WORK PROGRAM
CREDIT UNION
This program is led by a registered dietitian from
Mercy Health — Weight Management Solutions, who can
help you achieve and maintain a healthier weight. The
eight-week program sessions can be scheduled at your
facility based on interest and commitment. At least 10
participants are needed in order to conduct a session.
Call 513-686-6820 for more information.
All Mercy Health employees and immediate family
members can use the services of General Electric
Credit Union with convenient on-site branches or ATMs
at some Mercy Health locations. Products and services
include free checking, direct deposit, safe deposit box,
Christmas and Vacation club accounts, car loans and
mortgages. Contact www.gecreditunion.org or
1-800-542-7093 or on the Mercy Health home page
under Benefits for more information.
VIRGIN PULSE,
FORMERLY CALLED VIRGIN HEALTHMILES
This fun program helps you track your activity levels and
turns your steps into “healthmiles” and your “healthmiles”
into cash rewards. Participate in challenges with your
coworkers and improve your fitness level. Enroll at
www.join.VirginPulse.com/MercyHealthBeWell and earn
up to $300 per year.
HEALTHPLEX MEMBERSHIP
GROUP PERSONAL TRAINING
Mercy Health will cover up to three, one-hour,
small group, personal training sessions per year
at the HealthPlex. Contact the HealthPlex to
schedule your sessions at 513-942-PLEX.
All benefits eligible employees and their spouses are
eligible to access an online will preparation service
provided by CIGNA at no cost. Services include last
will and testament, healthcare power of attorney, living
will and durable/financial power of attorney. In addition,
you and your spouse can also use an online tool to help
with funeral planning. Go to CIGNAWillCenter.com to
access the program.
IDENTITY THEFT PROGRAM
CIGNA provides this valuable program at no cost if
you are benefit eligible, protecting your identity and
resolving issues if you or your spouse become a victim
of identity theft. Dealing with credit card fraud, financial
or medical identity theft, assistance with replacement
of lost or stolen documentation, accessing free credit
reports, help with reporting theft to credit reporting
agencies, emergency cash advance and help with travel
arrangements and translation services are just a few of
the plan benefits. If you suspect you might be a victim
of identity theft, call 1-888-226-4567. Please indicate
you are a member of CIGNA’s Identity Theft Program
and Group #57.
DISCOUNTS ON LOCAL FITNESS CENTERS
You can enjoy a corporate discount to the Greater
Cincinnati YMCA (including Clermont Family YMCA),
Countryside YMCA, Greater Miami Valley YMCA, and
the Mayerson Jewish Community Center. Visit the
Mercy Health intranet for discount information.
MY HEALTH FIRST
As a benefits eligible employee, you can enjoy a
free HealthPlex membership. You only pay income
taxes on the value of the membership. If you’d like
a family membership, you simply pay the discounted
additional fee.
If you are not eligible for Mercy Health benefits,
you can join the HealthPlex at a deeply-discounted
membership rate. With three conveniently-located
facilities (Anderson, Fairfield and Western Hills) and
memberships for you and your family, you can access
state-of-the-art fitness equipment, pools, classes
and other amenities. Contact the HealthPlex at
513-942-PLEX for more information.
WILL PREPARATION SERVICES
AND FUNERAL PLANNING
MEDICAL
Medical
Mateen Hotiana, MD
KENWOOD ENDOCRINOLOGY
AND DIABETES (ALSO SEEING
PATIENTS IN ANDERSON)
“At Mercy Health —
Endocrinology, we pride
ourselves in providing
compassionate care and offer
the latest tools available in
managing diabetes and a wide
range of endocrine disorders.”
Traditional Plan
TIER 1 — MERCY
SELECT NETWORK
Health Reimbursement Account
Wellness Incentive
TIER 2 — HEALTHSPAN
NETWORK
TIER 3 —
OUT-OF-NETWORK
$500 employee / $1,000 all other levels of coverage
Your Deductible
Employee
All Other Levels of Coverage
$800
$1,600
$1,700
$3,400
$5,500
$11,000
Your Out of Pocket Maximum*
Employee
$3,000
$6,000
$5,000
$10,000
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
member pays 10%
after deductible
member pays 30%
after deductible
member pays 60%
after deductible
Facility Charges — Inpatient
Admission, Outpatient Endoscopy,
Cystoscopy, Colonoscopy, Heart
Catheterization, CT, PET, MRI
member pays 10%
after deductible
member pays $500 co-pay,
then 30% of remaining;
not subject to deductible
member pays 60%
after deductible
Facility Charges — Routine Lab,
X-Ray and Other Outpatient
Services, Durable Med. Equip.
member pays 10%
after deductible
member pays 30%
after deductible
member pays 60%
after deductible
Emergency Department Co-Pay**
member pays $200,
then 10% of remaining
member pays $200,
member pays $200,
Emergency Department
Physician Services
member pays 10%
member pays 10%
member pays 10%
member pays $10 co-pay***
member pays 10%
after deductible
member pays 30%
after deductible
member pays 60%
after deductible
member pays 10%
after deductible
member pays 30%
after deductible***
member pays $35 co-pay
member pays 10%
after deductible
member pays 30%
after deductible
N/A
member pays 30%
after deductible
member pays 60%
after deductible
Preventive Care
member pays 0%
member pays 0%
not covered
Bariatric Surgery — Approved
Programs Only (Facility and
Physician) Employee and Spouse only
member pays 10%
after deductible
not covered
not covered
Mercy Health Weight Management
Programs Facility Fees Employee
and Spouse only
member pays 10%
after deductible
not covered
not covered
Therapy includes Physical,
Occupational, Speech & Cardiac
(Cardiac maximum is 36 visits per
year; PT, OT, Speech maximum
30 visits per year)
member pays 10%
after deductible
member pays 30%
after deductible
member pays 60%
after deductible
member pays 0%
after deductible
(max benefit $70/visit)
member pays 0%
after deductible
not covered
Lifetime Maximum
Amount of Coverage
Coinsurance
Physicians — Primary Care
Office Visit (includes Mental Health)
Other Services
Physicians — Specialists
Office Visits Co-Pay
Other Services
Urgent Care
Visit Co-Pay
Other Services
Mini Clinics
member pays 60%
after deductible
* Includes deductible
** Emergency Room Co-pay is waived if admitted and the service is paid under the inpatient benefit.
*** Co-pays reimbursed after 12 months for office visits related to diabetic conditions if participating in Diabetes Management program.
MEDICAL
Chiropractic (limit 15 visits per year)
member pays 60%
after deductible
Choice Plan
TIER 1 — MERCY
SELECT NETWORK
Automatic Contribution
Wellness Incentive
Total Possible Employer Contribution
TIER 2 — HEALTHSPAN
NETWORK
TIER 3 —
OUT-OF-NETWORK
$1,000 employee / $2,000 all other levels of coverage
Your Deductible
Employee
$1,200
$2,400
$2,000
$4,000
$5,000
$10,000
Employee
$3,000
$6,000
$5,000
$10,000
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
member pays 10%
after deductible
member pays additional
$500 co-pay, then 30%
of remaining, not subject
to deductible
member pays 60%
after deductible
member pays $200,
member pays $200,
member pays $200,
Emergency Department Physician
Services
member pays 10%
member pays 10%
member pays 10%
member pays 30%;
not subject to deductible***
member pays 10%
after deductible
member pays 30%
after deductible
Lifetime Maximum
Amount of Coverage
Coinsurance
Office Visit
(includes Mental Health)
Other Services
Office Visits
member pays 30%
after deductible***
member pays 60%
after deductible
member pays 10%
after deductible
member pays 30%
after deductible
member pays 60%
after deductible
N/A
member pays 30%
after deductible
member pays 60%
after deductible
Preventive Care
member pays 0%
member pays 0%
not covered
member pays 10%
after deductible
not covered
not covered
and Spouse only
member pays 10%
after deductible
not covered
not covered
year; PT, OT, Speech maximum 30
visits per year)
member pays 10%
after deductible
member pays 30%
after deductible
member pays 60%
after deductible
member pays 0%
after deductible
member pays 0% after deductible
not covered
Other Services
Urgent Care
Visit Co-Pay
Other Services
MEDICAL
member pays 60%
after deductible
member pays 10%
after deductible
Mini Clinics
Chiropractic
(limit 15 visits per year)
Exclusive Plan
HEALTHSPAN SELECT NETWORK
Wellness Incentive
Your Deductible
Employee
$500
$1,000
Employee
$2,000
$4,000
Lifetime Maximum
Amount of Coverage
OUT-OF-NETWORK
Unlimited
No coverage except for
Emergency or services
authorized in advance
by HealthSpan. Services
authorized in advance by
HealthSpan covered at
80% after deductible.)
Coinsurance
(member pays 20% after deductible at Cincinnati Children’s
Hospital Medical Center, Dayton Children’s Hospital, Nationwide
Children’s Hospital, Rainbow Babies and Children’s Hospital,
and any other non-CHP-owned network partners)
see above
see above
member pays $200, then 10% of remaining
see above
member pays 10% not subject to deductible
see above
Emergency Department
Physician Services
Office Visit (includes Mental Health)
Other Services
Office Visits Co-Pay
Other Services
Urgent Care
Visit Co-Pay
see above
see above
see above
Mini Clinics
N/A
see above
member pays 0%
see above
see above
and Spouse only
see above
year; PT, OT, Speech maximum
30 visits per year)
see above
member pays 0% after deductible (max benefit $70/visit)
see above
Preventive Care
Chiropractic
(limit 15 visits per year)
MEDICAL
Other Services
PREVENTIVE CARE COVERAGE
For the most current offerings, please visit www.ngs.com
or call NGS CoreSource at 1-800-647-1761.
Eligible preventive services are based on guidelines
described in regulations issued by the Department of
Health and Human Services. Services that fall outside the
preventive care benefit and other services performed
during a preventive care visit will be considered for
coverage under other plan provisions.
All three medical plans provide coverage for preventive
care and many eligible preventive care services are
covered at 100%. This means you will pay nothing for
those eligible preventive care services as long as you
use a Mercy Select Network, HealthSpan Select Network
or HealthSpan Network doctor. The list of eligible
preventive care services may change from time to time.
PREVENTIVE CARE
TRADITIONAL AND CHOICE PLANS
EXCLUSIVE PLAN
Out-of-Network
HealthSpan Select
Network
Out-of-Network
100%
not covered
100%
not covered
100%
not covered
100%
not covered
100%
100%
not covered
100%
not covered
Annual Physical
100%
100%
not covered
100%
not covered
Prostate Exam
100%
100%
not covered
100%
not covered
OB/GYN Exam
100%
100%
not covered
100%
not covered
Mammograms
100%
100%
not covered
100%
not covered
Colonoscopy
100%
100%
not covered
100%
not covered
Routine Hearing
100%
100%
not covered
100%
not covered
Mercy Select
Network
HealthSpan
Network
Immunization
100%
Pap Smear
100%
Well/Baby Care
Subject to Accepted Guidelines for Frequency of Service
ADDITIONAL SCREENINGS
TRADITIONAL AND CHOICE PLANS
Mercy Select
Network
HealthSpan
Network
Out-of-Network
EXCLUSIVE PLAN
HealthSpan
Select Network
Out-of-Network
Heart and Vascular Disease Screening
100%
100%
not covered
100%
not covered
Infectious Disease Screening
Screenings for Mental Health Conditions
and Substance Abuse — Dementia,
Depression, Drug Abuse
100%
100%
100%
100%
not covered
not covered
100%
100%
not covered
not covered
See page 36 for medical plan premiums and Tobacco-Free discount. See page 14 for details on wellness incentive (My Health Journey).
MEDICAL
TOBACCO-FREE DISCOUNT
If you and any covered family members do not use
tobacco products, you can receive a $30 per pay
discount on your medical premium in 2014. You must
complete and return the Tobacco-Free Certification
(either online during open enrollment or using the paper
form available on the intranet). This certification must
be completed annually. If you do not meet the deadline
for completing the certification, you may still complete
the certification and receive the full discount, but the
premium discount will be applied and any retroactive
premium provided in the pay period following the
beginning of the next calendar quarter.
You may also qualify for the discount if all covered
adult family members who are not tobacco-free
complete a Catholic Health Partners-sponsored
tobacco cessation program. See page 14 for details on
available programs.
If it is medically inadvisable for you or any covered
family members to achieve the standards necessary to
meet the tobacco-free requirements, or it is
unreasonably difficult to do so due to a medical
condition, you must complete the Tobacco-Free
Discount Waiver Form and return it for consideration
to the address on the form by the stated deadline.
Your 2014 medical deductions will appear on your
paycheck as the full benefit premium cost without
discount (for example, $89.26 for employee only
coverage under the Exclusive Plan if you are full-time
and earn between $40,000 and $150,000 annually).
The Tobacco-Free Discount will show as earnings,
resulting in a reduction in your per pay cost for medical
coverage. This allows you to see both the deduction
and the cost separately, so you can be sure when your
Tobacco-Free Discount has been applied.
Prescription Drug Program
Mercy Health’s prescription drug program provides you and your family with excellent coverage at the lowest
possible costs when you enroll in any medical plan option.
EFFECTIVE JANUARY 1, 2014, Mercy Health Riverfront
Pharmacy will deliver all prescriptions via mail order to
your home unless picked up in person at Mercy Health
Riverfront Pharmacy. Mercy Health Riverfront Pharmacy
will be relocating from the Mercy Health — Mt. Airy
Hospital campus to the Mercy Health — Fairfield
HealthPlex in late 2013. If your doctor orders a new
maintenance medication for you, please request a 30day prescription to be filled at a Retail Pharmacy, as well
as a 90-day prescription to send to Riverfront Pharmacy.
EFFECTIVE JULY 1, 2014, our medical plan will permit
one (first) fill at any retail pharmacy within the
Catamaran network, for a maximum of 30 days’ supply
of maintenance medications. (Currently two fills are
permitted at retail.) While you may use any Retail
Pharmacy or Mercy Health Riverfront Pharmacy for initial
fills of maintenance medication, to manage costs and
improve quality, it is important to have a single
pharmacy handle your medication needs.
NOTE that prescriptions for antibiotics, pain
management, steroids and ADD/ADHD medications
requiring a hard copy prescription are exempt from the
maintenance medication policy. These items can be filled
either through Mercy Health Riverfront Pharmacy or any
Retail Pharmacy. This will minimize delays in obtaining
these medications. A detailed list of exempted
medication classes can be found on the Mercy Health
intranet under the Benefits tab.
PHARMACY BENEFITS
30-Day Supply at any Retail Pharmacy or Mercy Health Riverfront Pharmacy
Generic
Formulary, Preferred
Non-Formulary, Non-Preferred
You pay up to $10
You pay $25 or 20% co-pay, whichever is greater, up to a maximum of $100
90-Day Supply at any Mercy Health Riverfront Pharmacy or Mail Order Pharmacy
Generic
Formulary, Preferred
Non-Formulary
You pay up to $25
In the event that Mercy Health Riverfront Pharmacy cannot supply a particular maintenance or specialty medication, you may obtain it
from the Catamaran Mail Program* (drug mail order service) at the same co-pay that would apply at Mercy Health Riverfront.
If your prescription costs less than the stated minimum co-payment, you pay no more than the actual cost of the prescription.
Fertility drugs — You pay 50% and the plan pays 50% up to an annual maximum of $2,500.
As part of the Mercy Health healthcare delivery
network, we strive to provide value for employees by
filling prescriptions at reduced co-pay, as well as a
reduced cost to our benefit plan.
TO USE MERCY HEALTH RIVERFRONT
PHARMACY:
FIRST-TIME CUSTOMERS need to fill out a “New
Customer Information” form and mail or fax to Mercy
Health Riverfront Pharmacy to enroll. These forms are
located on the intranet under the Benefits tab, outside
of your Human Resources Department or call Riverfront
Pharmacy at 1-866-775-5767 to have a form faxed or
emailed to you.
GETTING YOUR NEW PRESCRIPTION TO MERCY
HEALTH RIVERFRONT PHARMACY:
•For maintenance medications, request a 90-day
supply from your physician.
•Your physician can ePrescribe, phone or fax your
prescription directly to Mercy Health Riverfront
Pharmacy.
•If your physician gives you a hard copy prescription,
you will need to mail that prescription to Mercy Health
Riverfront Pharmacy. Please fill out a New Prescription
Order Form when mailing in a new prescription. This
form can be found on the intranet under the Benefits
tab, outside of your Human Resources Department or
call Riverfront Pharmacy at 1-866-775-5767 to have a
form faxed or emailed to you.
•NOTE: Under federal law, prescriptions faxed from
patients are not valid and will not be filled.
TRANSFERRING AN EXISTING PRESCRIPTION FROM
ANOTHER RETAIL PHARMACY TO MERCY HEALTH
RIVERFRONT PHARMACY. Please call the Mercy Health
Riverfront Pharmacy staff to assist you with the transfer.
MEDICAL
MERCY HEALTH RIVERFRONT PHARMACY
MAIL ORDER
Please have available:
•Name and phone number of pharmacy the
prescription is at currently.
•Prescription number needing to be transferred.
•Name of the drug needing to be transferred.
•Note that if the original prescription was written only
for a 30-day supply, Mercy Health Riverfront
Pharmacy is legally not allowed to increase your
quantity to a 90-day supply. Your physician must
phone, fax or ePrescribe in a new prescription for
a 90-day supply.
REFILLING EXISTING PRESCRIPTIONS AT MERCY
HEALTH RIVERFRONT PHARMACY. Mercy Health
Riverfront Pharmacy utilizes an automated refill ordering
system. For your convenience, you can call 1-866-7755767 to order your refill requests 24 hours a day, seven
days a week. The system will ask for your prescription
number and your phone number should there be any
questions. You will also have an option to leave a
message with any specific instructions.
VALID PRESCRIPTIONS, BOTH NEW AND REFILLS,
WILL GENERALLY BE MAILED OUT WITHIN 3 BUSINESS
DAYS OF RECEIVING. Actual delivery times are
dependent on the US Postal Service, so we recommend
that you place your order 7-to-10 days before it will be
needed. If your doctor needs to authorize more refills,
this will take additional time.
•If we have a valid email address on file, an email will
be sent to the customer with a tracking number.
•If at any time you need information on a
prescription, please call Mercy Health Riverfront
Pharmacy at 1-866-775-5767.
ALL PRESCRIPTIONS THAT ARE ePRESCRIBED, PHONED OR
FAXED TO MERCY HEALTH RIVERFRONT PHARMACY FROM
A PHYSICIAN OFFICE WILL BE FILLED, CHARGED AND
MAILED TO CUSTOMER ADDRESS ON FILE UNLESS
EXAMPLES OF SPECIALTY DRUGS:
TEMODARCOPAXONE
OTHERWISE NOTED FROM THE PHYSICIAN OFFICE.
HUMATROPEAVANEX
Please work with your doctor on any special instructions.
REBIFLETAIRIS
CATAMARAN MAIL PROGRAM
MEDICAL
QUANTITY LIMITS: The plan limits the amount of
certain medication you can receive based on clinical
guidelines and other best practices.
PROTON PUMP INHIBITORS: These are drugs such as
Nexium and Prilosec used to treat disorders of the
stomach. Mercy Health will provide the generic
equivalent drug, Omeprazole, until or unless the member
obtains a prior authorization. You will be notified if this
applies to you and your current medications.
FORMULARY UPDATES: Each year, the plan may move
certain brand medications from preferred to non-preferred
to encourage use of cost-effective equivalent medications.
STATINS: These are drugs used to manage cholesterol.
Members will be expected to use the generic equivalent
until or unless they have obtained a prior authorization.
You will be notified if this applies to you and your current
medications.
DISPENSE AS WRITTEN: When a doctor writes you a
prescription for a brand name drug and there is a 1-for-1
generic equivalent drug available, the plan will apply the
flat dollar generic co-pay and you will be responsible for
the remaining difference in cost between the generic
and the brand. This will not apply where there is not a
1-for-1 generic alternative.
SPECIALTY DRUGS: These are costly, uncommon
drugs with special formulations, storage requirements,
and often with no generic alternatives. Specialty drugs
require prior authorization. You will be notified if this
applies to you and your current medications. Please
start the process immediately to obtain your prior
authorization to ensure there is no interruption of your
therapy. See below for examples of specialty drugs to
which this process applies. A complete list is available
from Catamaran.
If Mercy Health Riverfront Pharmacy cannot fill your
maintenance or specialty prescription, you will be
referred to the Catamaran Mail Program. Follow the
enrollment instructions provided by the Mercy Health
Riverfront Pharmacy staff. If you need assistance you
may also contact Catamaran Mail Program at 1-877-2322017 Mon. – Fri. from 8 a.m. – 10 p.m. (Eastern Time) or
Sat. from 9 a.m. – 5 p.m. (Eastern Time).
CLINICAL PROGRAMS
There are a number of clinical programs in place for
2014. These programs are to help you get the proper
medications, in the appropriate amounts, and to
promote the use of generic alternatives.
STEP THERAPY: You will be asked to utilize a generic
or other equivalent drug when available. Non-generic
drugs will not be dispensed until or unless the generic
has proven to be ineffective.
GENOTROPINTARCEVA
REMICADEENBREL
HUMIRABETASERON
REVATIO
HUMIRA PEN
TYSABRIPEGASYS
LUPRON DEPOT
RIBAVIRIN
OCTREOTIDE ACETATE
FOLLISTIM AQ
EUFLEXXAARIXTRA
OVIDREL
PREGNYL W/DILUENT BENZYL ALCOHOL/NAC
PRIOR AUTHORIZATION: You are required to obtain
medical justification from your doctor to override any of
the clinical edits within the Pharmacy benefit program.
Contact Mercy Health Riverfront Pharmacy at 1-866775-5767 to begin the prior authorization process.
Prior authorizations do require additional time in order
to coordinate between your doctor and the pharmacy.
Frequently Asked Questions
HEALTH REIMBURSEMENT ACCOUNT (HRA)
All three medical plans include a Health Reimbursement
Account (HRA). Funds are contributed by Mercy Health
into the HRA on your behalf, based on plan provisions
and any wellness incentive for which you have qualified.
The plan will automatically use these funds to cover
expenses applied to your plan deductible. You may also
use the debit card you’ll receive, called a Benny Card, to
access these funds for any flat-dollar co-pays, such as
for prescription drugs and office visits. Any unused
funds roll over for use in a future plan year.
HRA BASICS
3. WHAT ARE THE TAX ADVANTAGES OF AN HRA?
• M
ercy Health funds your HRA with tax free dollars.
The amount funded is based on the plan you select
and whether you complete the wellness incentive
requirements. If you enroll in any of the medical
plans, and you complete the My Health Journey
wellness incentive requirements, Mercy Health will
fund your HRA with $500 if you enroll in coverage
for yourself only, or $1,000 if you enroll in any level
of dependent coverage. In addition, if you enroll in
the Choice plan (which has a higher deductible), the
employer will fund an additional $500 if you enroll in
coverage for yourself only or and additional $1,000
if you enroll in any level of dependent coverage.
4. CAN MY HRA BE USED FOR DEPENDENTS NOT
COVERED BY MY MEDICAL INSURANCE? No. It can only
be used for family members covered under your medical
plan election.
5. WHY DOES THE CHOICE PLAN HAVE A HIGHER
DEDUCTIBLE? The Choice plan is designed to allow you
to take charge of your healthcare spending through a
higher deductible coupled with an automatic employer
contribution to a Health Reimbursement Account. This
account can be used to pay out-of-pocket expenses
under the plan, including the deductible responsibility.
The account dollars can cover most, but not all of your
plan deductible for the year.
ELIGIBLE EXPENSES
6. WHAT EXPENSES ARE ELIGIBLE UNDER THE HRA?
Medical plan expenses such as deductible, co-insurance
and pharmacy or other co-pays are eligible. Dental and
vision expenses are not eligible under the HRA.
7. WHAT TYPES OF EXPENSES CAN BE PAID FROM AN
HRA AUTOMATICALLY?
•A
ny qualified medical expenses used to meet your
plan deductible.
• Any portion of the cost of covered services
(coinsurance) you pay.
8. HOW CAN OTHER PLAN EXPENSES BE PAID FROM
AN HRA? You will also receive a Benny Card, which is a
special debit card you can use to access funds in your
HRA. Use the Benny Card for any flat-dollar
co-payments such as for:
• Office visits
• Prescription drugs
• Emergency Room
• Urgent Care
9. CAN I USE THE MONEY IN MY HRA FOR ANYTHING
OTHER THAN ELIGIBLE MEDICAL EXPENSES? No.
MANAGING YOUR HRA
10. WHO IS OUR HRA ADMINISTRATOR AND WHAT
ROLE DO THEY PLAY IN MY HRA? NGS Core Source will
administer your account and make the automatic
payments when they process your medical claims.
11. HOW WILL I KNOW HOW MUCH MONEY IS IN MY
HRA? You will have access to your account balance by
going to your account online at NGS (www.ngs.com).
You may also call NGS at 1-800-647-1761.
MEDICAL
1. WHAT IS AN HRA? An HRA is a special tax-sheltered
account that is, in some ways, similar to a traditional
Healthcare Flexible Saving Account, but is funded by the
employer and not the employee. An HRA allows you to
pay for covered medical expenses on a tax-free basis.
Contributions to and payments from the HRA (for
medical needs) all are exempt from federal income and
Social Security (FICA) taxes.
With the HRA there are no bank accounts to establish
and payment of many covered medical expenses is
automatic. In addition, there are no banking rules and
fees associated with use and maintenance of the
account. You may also enroll in the Healthcare Flexible
Spending Account (FSA).
2. HOW DOES THE HRA WORK? The HRA works in
conjunction with your medical plan to help you pay for
your healthcare expenses. The medical plan pays
covered expenses in excess of the deductible amount
and you can pay your share of costs (deductible,
co-insurance and co-pays) using available HRA funds.
Unlike a flexible spending account, unused HRA account
balances roll over from the current year to the next and
accumulate and can be used for future qualified
medical expenses.
•A
utomatic tax-free payment of qualified healthcare
expenses (amounts applied to deductible or
co-insurance) directly to providers.
• You can carry unused amounts over to future years
with no tax obligation.
12. WHEN CAN I START USING THE FUNDS IN MY HRA?
You can use the funds in your HRA as soon as your
coverage begins and you have a qualifying expense.
13. HOW DO I WITHDRAW MONEY FROM MY HRA?
Money cannot be withdrawn from your account except
to pay eligible expenses. You may not use the HRA
account for anything other than a qualified medical
expense. However, you will have a Benny Card for use in
accessing your account funds for office visit or
pharmacy co-pays.
14. IS THERE A COST TO ESTABLISH AN HRA? Mercy
Health will establish your account and pay any fees
associated with its maintenance and use.
HEALTH REIMBURSEMENT ACCOUNT (HRA)
AND THE HEALTHCARE FLEXIBLE SPENDING
ACCOUNT (HFSA)
15. CAN I CONTINUE TO HAVE AN FSA IF I HAVE AN
HRA? Yes. You can contribute up to $2,500 in your HFSA
for 2014. Your HRA is funded by Mercy Health. When
you have both the HFSA and the HRA, you will be issued
one debit card (Benny Card) to use for both accounts.
Generally speaking, you should not pay for medical
services, other than flat-dollar co-payments, with your
Benny Card. Most medical plan services are delivered
through networks which offer discounts. Claims must be
submitted to NGS and the discounts applied so you do
not overpay (see #22).
Medical plan eligible claims will be applied first to the
HRA and only to the HFSA if the HRA money is
exhausted. Claims not medical plan-eligible but HFSAeligible (such as dental or vision expenses) will flow
through to the HFSA for payment. When you use the
Benny Card, NGS will automatically charge the correct
account. Keep in mind that when the Benny Card is used
for HFSA funds, it is always using HFSA funds for the
current plan year on the date you swipe your Benny Card.
MEDICAL
16. HOW IS AN HRA DIFFERENT FROM THE HFSA?
Both HRAs and HFSAs allow you to pay medical bills
with pre-tax dollars. However, under IRS rules, there are
several key differences. HRA balances can rollover from
year to year, while HFSA money left unspent at the end
of the year must be forfeited. You can only use money
from your HRA once your coverage begins. You can use
HFSA money up to the annual amount for which you
enrolled before you have actually contributed those
dollars to your account. The company funds your HRA,
but not your HFSA. You contribute to your HFSA, but
not to your HRA. Enrollment in the HRA is automatic
when you elect any of our medical plans. However, you
must enroll separately each year in the HFSA and make
an election to contribute to have a HFSA account.
WHAT IF?
17. WHAT IF I CHANGE MEDICAL PLANS FROM YEAR
TO YEAR? The balance of HRA funds in your old account
will transfer to the HRA in your new Mercy Health or CHP
medical plan, as long as it has an HRA account feature.
18. WHAT HAPPENS TO MY HRA IF I LEAVE MERCY
HEALTH? All funds contributed to your HRA will be
forfeited unless you extend your medical coverage or
you meet the definition of an HRA Retiree (age 62 + 5
years of service). Retirees may spend down their account
after retirement on eligible medical services.
19. WHAT IF I HAVEN’T SPENT THE MONEY IN MY HRA
BY THE END OF THE YEAR? Any money left in your HRA
at the end of the year will roll over for you to use for
eligible medical expenses in the next year. There is no
limit on the amount that can be carried over.
20. WHAT IF I AM NO LONGER ENROLLED IN MERCY
HEALTH MEDICAL COVERAGE IN THE FUTURE? WHAT
WILL HAPPEN TO THE MONEY IN MY HRA? If you are no
longer enrolled in Mercy Health medical coverage, you
will forfeit any money in your HRA account.
21. WHAT IF I HAVE A MEDICAL EXPENSE THAT IS
GREATER THAN THE AMOUNT OF MONEY IN MY HRA? If
you have an expense that is greater than the balance in
your HRA, the balance of that expense can be applied to
your HFSA. If you do not have an HFSA, you must pay
your share of that balance. For example, if you are
responsible for a $500 expense, but have only $200 in
your HRA, NGS will pay only the $200 from your
account. To pay the remaining $300, you would apply
the expense to your HFSA (as long as you were enrolled
in the HFSA at the time the expense was incurred) or
pay out of pocket.
22. WHAT IF I BECOME DISABLED? THEN WHAT
HAPPENS TO THE MONEY IN MY HRA? If you become
disabled, you can continue to use your HRA as long as you
are still enrolled in one of the Mercy Health medical plans.
MEDICAL CLAIMS
23. HOW WILL THE CLAIMS PROCESS WORK? You
present your medical plan ID card to the provider at time
of service. If you owe a co-payment (such as for an office
visit, emergency room co-pay, or prescription), you will
use your Benny Card to pay the co-payment at the
time of service. Be sure to save your receipts in case
substantiation is required by NGS. You do not need to pay
deductible or co-insurance amounts at the time of service.
For medical services, the provider sends a claim to
NGS on your behalf. NGS will process your claim, make
any adjustments to reflect discounts and make payment
to your provider (including your part of the bill which
applies to deductible or co-insurance) from available
HRA funds.
Benefit Information Center
and Benefit Cost Estimator
The Benefit Information Center is hosted by NGS
CoreSource, Mercy Health’s plan supervisor. This online
resource contains comprehensive information about
benefit plans, policies and practices. You will also find
forms and contact information to help you make the
most of your Mercy Health benefits.
One of the tools you can access is the Benefit Cost
Estimator, which will allow you to estimate your medical
plan costs under each of the Mercy Health medical plan
options, based on expected services you believe you will
use during the 2014 plan year.
HOW DO I GET TO THE BENEFIT
INFORMATION CENTER?
You simply type in the following address into your
internet browser: www.benefitinfocenter.com/mhp.
Once you are there, you sign in using your NGS
CoreSource User or Unique ID or your Social Security
number and password.
WHERE DO I GET MY NGS CORESOURCE
USER OR UNIQUE ID?
Your initial NGS CoreSource User or Unique ID can be
found on your medical plan ID card issued by NGS
CoreSource. It is listed on that card as your Member ID#.
If you were not issued a medical/benefits Member ID
card by NGS CoreSource, you may use your Social
Security number for your User or Unique ID. Your
password will be the last four digits of your Social
Security number. Once you sign in for the first time you
will have an option to change your password.
HOW DO I FIND WHAT I WANT?
HOW DO I SELECT MY PRIMARY CARE
PHYSICIAN (PCP)?
You will need to select your Primary Care Physician
(PCP) online in PeopleSoft during Open Enrollment.
This function has been disabled in the Benefit
Information Center. Watch for details on the Mercy
Health intranet homepage.
Move the cursor down the left side of the page to the
listing for “Compare My Medical Plan Options with
Benefits Cost Estimator.” A listing of medical benefit
services will appear. If you are covered by a Mercy Health
medical plan, the estimator will pull in your actual claims
experience and populate the estimator with real service
costs and frequencies. Any of these values may be
changed by you to reflect your view of the next 12
months of claims. The Benefit Cost Estimator also factors
in your per pay cost for each medical plan premium.
Once you have the values you want in the estimator,
you click on the “Calculate” button to see the results.
NOTE: Benefit Cost Estimator results are only estimates
based on past claims and values changed by the user.
Results may or may not be a close estimate of future costs.
CAN I SIGN UP FOR DIRECT DEPOSIT FOR MY
FLEXIBLE SPENDING ACCOUNT (FSA)
CLAIMS?
Yes, you can receive your FSA funds faster by direct
deposit to your bank account. To sign up, select the
listing for Flexible Spending Direct Deposit. Supply the
requested information, and when you are finished, press
the “Submit” button.
WHAT ELSE WILL I FIND AT THE BENEFIT
INFORMATION CENTER?
Listed below are just a few of the plans, tools and
resources you will find on the site. We will continue
to add information and functionality to the site. There
is even an option to email your question(s) to NGS
CoreSource. We encourage you to sign in, have some
fun and explore all the Benefit Information Center
has to offer:
• Medical Plans
• Dental Plan
• Vision Plan
• My Health Journey
• Health Reimbursement Account Information
• Flexible Spending Accounts
• CHP Retirement Savings Plan
• Employee Assistance Program
• Forms
• Medical Claims History
• Flexible Spending Account Direct Deposit
MEDICAL
You simply move your cursor (the arrow on the screen)
over the menu items listed down the left side of the
page. As the cursor moves over one of the listings,
additional sub-items under that listing will appear. You
may click on any of those sub-items and walk through
the information or process associated with that subitem. If your computer is connected to a printer, you can
select items, such as forms, and print them for your use.
HOW DO I ESTIMATE MY MEDICAL COSTS?
The Mercy Select Network,
the HealthSpan Network
and the New HealthSpan Select Network
WHAT IS A NETWORK?
Health plans recognize facilities and professional
providers (doctors) in groups known as networks.
These networks are differentiated by the relationship
to the sponsor of the plan and the contracted discounts
on services they provide. The closer the relationship to
the plan sponsor and larger the contracted discounts,
the more preferred the network.
MEDICAL
WHAT ARE MY NETWORK CHOICES?
The Traditional and Choice Plans incorporate three
networks:
•Mercy Select Network (Tier 1) — This is the most
preferred network that includes Mercy Healthowned facilities and both Mercy Health employed
and affiliated doctors and other providers. They
provide discounts and support Mercy Health’s
goals to provide the highest quality of care and
services to you and your family members.
NOTE: Because of the complex nature of
healthcare, your doctor may bring in other providers
to assist in your care. The plan sponsor has made
every effort to ensure the Mercy Select Network
(Tier 1) is large and reflects a broad range of
specialties. However, Mercy Health cannot guarantee
that all specialties are included or that consulting or
assisting professional providers are part of the
Mercy Select Network. Please consult with your
primary care physician about the network
association of additional providers.
•HealthSpan (Tier 2) — This network consists of
non-Mercy Health facilities and non-affiliated, but
contracted, professional providers. Services in this
network are based on contracted discounts, but do
not offer the same alignment with Mercy Health’s
goals. It can be a broader network in terms of access,
but is not as preferred as the Mercy Select Network.
•Out-of-Network (Tier 3) — This tier is essentially all
other possible providers and may not provide any
discounts on fees charged to you or the plan.
The Exclusive Plan features a single network:
•The new HealthSpan Select Network includes not
only the Mercy Health Select providers (Tier 1 for the
Traditional and Choice Plans), but also the Tier 1
providers in each of the CHP markets in Toledo,
Youngstown, Lima, Lorain, Springfield, Cleveland,
Akron and Paducah, KY.
•The following children’s hospitals (not owned by
CHP) are also included, but at the 80% coverage
level: Cincinnati Children’s Medical Center, Nationwide
Children’s Hospital, Dayton Children’s Hospital, and
Rainbow Babies And Children’s Hospital.
•The HealthSpan Select Network is critically
important to our overall strategy of delivering
excellent, clinically integrated care, and supports of
our state-wide Accountable Care Organization.
•If you enroll in this plan, there is no “Tier 2” network
and you will be expected to receive medical services
from a HealthSpan Select Network provider. Any
services provided by out-of-network providers are
not covered by the plan, except for emergency
services. If there is a plan-eligible, medicallynecessary service which cannot be provided within
the HealthSpan Select network, coverage at the
80% level can be provided, but only if services are
approved in advance by the plan.
TIP: If you need Out-of-Area coverage and enroll in the Traditional or Choice plan, complete the
Request for Out-of-Area Medical Coverage form and submit it to NGS CoreSource. Then contact
NGS CoreSource at 1-800-647-1761 to confirm the effective date of the PHCS Network coverage.
Tier 2 benefit levels will not be provided unless you have been placed in the PHCS Network and
the services are provided by a PHCS provider on or after the effective date for that network.
There is not an out-of-area option for the Exclusive Plan.
HOW DO I KNOW WHO IS IN WHICH
NETWORK?
You can call HealthSpan at 1-888-914-7726 or visit
www.healthspannetwork.com for Mercy Select Network,
HealthSpan Network and HealthSpan Select Network
providers.
WHAT IF MY DEPENDENT LIVES OUTSIDE
THE LOCAL AREA?
If you have a dependent living outside the local area,
check first for Tier 1 coverage available in other CHP
markets for the plan you’re considering. If your
dependent lives in a state or area not served by any of
our networks, you may need to enroll in the Traditional
or Choice plan and request out-of-area coverage for
that dependent. When you arrange for out-of-area
coverage for a dependent, a different network will be
substituted for the HealthSpan Network (Tier 2). Once
in place, services are provided through this national
network — the PHCS Network — which will provide you
and the plan a contracted level of discount and Tier 2
benefits. Although the discount is not equal to
HealthSpan, it is more preferable than non-discounted,
out-of-network fees and charges. There is not an out-ofarea coverage option if you enroll in the Exclusive Plan,
but emergency services are covered.
HOW DO I FIND A PHCS PROVIDER?
Please visit www.phcs.com.
HOW DO I SIGN UP FOR
OUT-OF-AREA COVERAGE?
To request out-of-area coverage, you must be enrolled
in the Traditional or Choice plan, and complete and
return the Request for Out-of-Area Medical Coverage
form to NGS CoreSource (our claims administrator).
This form can be found on the intranet under
the Benefits tab, Medical Plan section or
www.benefitinfocenter.com/mhp.
MEDICAL
Dental, Vision
and Hearing
Michelle Federer, DO
EAST OBSTETRICS AND
GYNECOLOGY
“The best part of my job at
DENTAL, VISION
AND HEARING
Mercy Health is having the
privilege to take part in one
of the most memorable events
in a family’s life — the birth
of a child.”
Dental Plan
TYPE OF SERVICE
DELTA DENTAL PREFERRED OPTION
(DPO) OR DELTA PREMIER DENTIST
NON-PARTICIPATING DENTIST
Annual Deductible
• Employee
$50
$150
$50
$150
100%; no deductible
100%: no deductible, subject to
non participating dentist fee2
80% after deductible
80% after deductible, subject to
non-participating dentist fee2
50% after deductible
50%; no deductible
Preventive Basic and Major
$1,250 per covered person —
annual maximum
annual maximum
Orthodontia
lifetime maximum
lifetime maximum
• All Other Levels of Coverage
Class I: Diagnostic/Preventive Services
Emergency Treatment, Oral Examination,
Teeth Cleaning, X-rays
For Children:
Fluoride Treatments1
Space Maintainers1
Topical Sealants1
Class ll: Basic Services
Fillings 3, Root Canal (endodontics),
Bridgework and Denture Repairs,
Oral Surgery, Periodontics
Class lll: Major Services
Inlays/Onlays, Crowns, Dentures, Bridges
Class lV: Major Services
Orthodontic Services
Maximums
1. Some age restrictions apply.
2. The non-participating dentist fee is the maximum amount allowed per procedure for services provided by a non-participating dentist.
3. Composite resin (white) fillings are covered on both anterior and posterior teeth.
NOTE: For dental premiums, see page 37.
NETWORKS
COORDINATION OF BENEFITS
We participate in the Delta Dental plan. You can go to
any licensed dentist anywhere, and the percentage you
pay is the same whether you go to a Delta Preferred
Option (DPO) dentist, a Delta Premier dentist or a
non-participating dentist. However, your out-of-pocket
costs are likely to be lower if you go to a dentist who
participates in one of Delta’s networks because your
portion of the cost will be based on discounted fees.
You will be responsible for any co-payments and
non-covered services, but any difference between your
portion of Delta’s discounted fee and the submitted fee
cannot be charged back to you when you visit a Delta
DPO or Delta Premier dentist. The greatest discounts
have been negotiated with Delta DPO dentists, so
visiting a Delta DPO dentist will result in the lowest
out-of-pocket costs. Contact Delta Dental at
1-800-524-0149 for customer service.
Mercy Health’s Dental Plan includes a coordination of
benefits provision. When the plan is secondary to other
coverage, it will pay for covered services based on the
amount left after the primary plan has paid. It will not
pay more than that amount and will not pay more than
it would have as the primary plan.
children on their dental plans. Jim’s employer plan pays
$1,000 towards Timmy’s orthodontia. Our plan will pay
up to $1,500 additional, and Timmy’s maximum benefit
has been used up.
DENTAL, VISION
AND HEARING
EXAMPLE: Sue and her spouse, Jim, both cover their
Vision Plan
We provide a Vision Plan through EyeMed Vision Care. This plan provides both an in-network and out-of-network
benefit for vision-related services. You get a better benefit by using an EyeMed Access network provider. You can
find an EyeMed Access network provider by going to www.eyemedvisioncare.com or by calling 1-866-800-5457.
TYPE OF SERVICE
ACCESS NETWORK
YOU PAY
ACCESS NETWORK
MAXIMUM PLAN BENEFIT
OUT-OF-NETWORK
PLAN PAYS
Eye Exam
Routine
$10
Retinal Imaging
$35
Up to $39
Eyeglasses
$0
Frames
$130
Up to $35
Lenses-single vision
$20
Up to $25
Lenses-bifocal
$20
Up to $40
Lenses-trifocal
$20
Up to $55
Lenses-progressive lenses
$15
Up to $55
Contact Lenses
Up to $55
Fit and follow-up
Conventional
$0
$130
Up to $130
Disposable
$0
$130
Up to $130
Medically necessary
$0
$210
Up to $210
Additional Options
Scratch resistant coating
$15
N/A
Tinting
$15
N/A
UV coating
$15
N/A
Basic polycarbonate
$40
N/A
Standard anti-reflective coating
$45
N/A
20% off
N/A
Additional Discounts
All non-covered materials
except contact lenses
Conventional contact lenses
Lasik/PRK surgery
15% off cost over plan max of $130
N/A
Discounts offered to EyeMed
Discounts offered to EyeMed
members by US Laser Network
members by US Laser Network
Pay Limits
Eye Exam
Once every 12 months
Eyeglasses-frames
Eyeglasses-lenses
Contact lenses
•The contact lens and the frames and lens benefits cannot be claimed in the same benefit year. You must choose between benefits,
however, in-network discounts may be available by asking the provider.
•If you require services or materials over and above covered benefits of the plan, discounts are offered by network providers
to EyeMed members.
DENTAL, VISION
AND HEARING
NOTE: For vision plan premiums, see page 37.
TIP: For out-of-network services, you pay the provider at the time of service, then request
reimbursement of the allowed benefit from EyeMed. Claim forms are available on the intranet,
or from EyeMed by calling 1-866-723-0513.
Hearing Service Plan
The EPIC Hearing Service Plan is a discount plan. You
enjoy reduced rates for most fees and costs associated
with your hearing healthcare under the plan.
TO ACTIVATE YOUR HEARING SERVICE PLAN BENEFITS:
1.Call EPIC Hearing Healthcare at 1-866-956-5400.
2.EPIC will send you a card with all of the
information you will need to access your
benefits, including:
•Referrals to provider(s) located near you
•An Activation Form to access the provider(s)
•A booklet outlining all plan benefits — including
pricing — in detail
•An EPIC phone contact to answer any questions
about the plan
3.Follow through with appointment, examination
and treatment.
4.All payments are to EPIC HSP. No other billings
or payments should occur.
5.Contact EPIC at any time for assistance, advice
and information.
EPIC’S FIVE-STEP PLAN
Any symptom of hearing loss deserves expert evaluation
and treatment by a trained hearing healthcare specialist.
The EPIC Hearing Service Plan starts with a thorough
medical/audiological evaluation of your ears and
hearing. Tests and measures will determine the course
of treatment most likely to help you hear better, from
hearing aids to surgery. The EPIC Hearing Service
Plan’s basic steps to good hearing include:
1.Pure Tone Hearing Test to determine if a hearing
problem exists.
2.Functional Assessment Test to define the
magnitude of the problem and the technology
best suited to treat it.
3.Hearing Aid Evaluation to determine your ability
to wear a hearing aid and select the best model
and make.
4.Fitting and programming your hearing aid.
5.Therapy and training to fine-tune your device
and maximize the benefits you receive.
NOTE: EPIC is the company that provides our Hearing
Services Plan. It is not the same company that supports
our electronic medical records system.
DENTAL, VISION
AND HEARING
FLEXIBLE SPENDING
ACCOUNTS
Flexible
Spending
Accounts
Joseph Pflum, MD
KENWOOD INTERNAL MEDICINE
“Being one of the pioneer
practices of Patient-Centered
Medical Home has allowed our
team to give more personal,
effective and efficient care. We
are able to accomplish this by
improving access to coordinated
medical care, partnering with
patients and other members of
the medical team, using the
latest guidelines for quality and
patient safety, and using current
information technologies.”
Flexible Spending Accounts (FSA) allow you to set aside
a portion of your income on a pre-tax basis to help pay
for qualifying out-of-pocket medical, dental and vision
expenses, as well as child care and elder care costs.
These are “use it or lose it” accounts, and any amounts
not used by year-end will be forfeited, so plan your
contributions carefully.
Because the FSAs are January – December plans,
you can only enroll at the time of hire or qualified status
change (for the remainder of the year), or during
Open Enrollment.
There are two options available:
HEALTHCARE FLEXIBLE SPENDING ACCOUNT
(HFSA) — You may contribute up to $2,500 per year
to cover the costs of qualified medical, dental and
vision expenses not covered by insurance.
D
EPENDENT DAY CARE ACCOUNT (DFSA) — You may
contribute up to $5,000 per year if you file jointly to
cover the costs of day care for your child or elder
dependent. Special IRS rules apply — see below for
more information.
FOR WHAT EXPENSES CAN I USE MY FSA?
The HFSA and the DFSA work differently.
•You may use your HFSA for any qualifying
healthcare expense for you or your dependents
including medical, vision, dental, hearing and
prescriptions drugs, as long as the expense was
not covered by insurance.
•DFSAs may only be used for day care for your
children under the age of 13, for your disabled child
of any age, or for an IRS qualified dependent such as
a parent or spouse and where that care cannot be
provided by you or your spouse due to work or
attending school on a full-time basis.
HOW DOES THE PAYROLL DEDUCTION
PROCESS WORK?
When you elect either of the spending accounts, the
amount you elect is for the entire year. That amount will
be spread equally over the remaining pay periods in the
year and deducted from your paycheck on a pre-tax
basis each pay period.
WHEN CAN I USE THE MONEY IN MY
ACCOUNT(S)?
The HFSA and the DFSA work differently.
•Once activated, the full election amount of your
Healthcare Flexible Spending Account (HFSA)
can be used at any time regardless of the payroll
contributions you have made.
•The Dependent Day Care Flexible Spending Account
(DFSA) can only be used as you make contributions
and only to the extent there are funds available in
your account.
HOW DO I KNOW HOW MUCH MONEY
IS IN MY ACCOUNT?
You may visit the NGS CoreSource Benefit Information
Center at www.benefitinforcenter.com/mhp to view
your account balances at any time.
HOW DO I CLAIM FUNDS FROM
MY ACCOUNT?
•You may use your Benny Card for qualified HFSA
expenses. Although you have used the card,
you may be required to provide documentation
(substantiation) to prove the expense was an eligible
expense, so be sure to save your receipts. You may
also use a paper claim form, available from the
Mercy Health intranet or the NGS Benefit
Information Center.
•The DFSA cannot be accessed with a Benny Card.
Claims must be submitted using a paper claim form
with documentation of dates of service, dependent’s
name and age, provider’s name and Social Security
number or Tax ID and the charges for the service.
These forms are located on the Mercy Health
intranet or at www.benefitinfocenter.com/mhp.
HOW DO I RECEIVE MY FSA FUNDS?
If you file a paper claim form for either HFSA or
DFSA expenses, you will receive a check from
NGS CoreSource for your reimbursement.
TIP: : Be sure you have elected the correct FSA account (Healthcare FSA vs. Dependent Day Care
FSA) and contribution amounts. If you make a mistake in your election, you may not be able to
correct that mistake.
FLEXIBLE SPENDING
ACCOUNTS
Flexible Spending Accounts (FSA)
FLEXIBLE SPENDING
ACCOUNTS
CAN I HAVE MY FSA REIMBURSEMENTS
DIRECTLY DEPOSITED INTO MY
BANK ACCOUNT?
If you choose to file a paper claim, we offer the
convenience of having your FSA reimbursements
deposited directly into your checking or savings
account. Direct deposit will greatly speed up your
reimbursement You can sign up for direct deposit of
your FSA reimbursements by going to the NGS
CoreSource website at www.benefitinfocenter.com/mhp.
WHY AM I ASKED TO SUBSTANTIATE MY
BENNY CARD PURCHASES?
The Benny Card that comes with your HFSA provides a
certain level of convenience — you can make a payment
with just the swipe of a card. However, substantiating
that your purchase was an eligible expense will likely be
required. The IRS specifies what products and services
are eligible for payment using the HFSA. Many times it is
not possible for NGS CoreSource to make a final
determination about the eligibility of a purchase based
on the card swipe data. When this happens, they will
notify you of the need to provide documentation to
resolve this question. This ensures that both you and the
plan remain compliant with IRS regulations. Be sure to
respond promptly to such requests; if you do not
respond, your card may be deactivated.
MORE TIPS:
•Over-the-counter drugs are not eligible
for reimbursement from your HFSA or
Health Reimbursement Account (HRA)
unless prescribed by your doctor.
•If you enroll in the HFSA and Medical plan,
eligible claims will always be applied first
to the HRA and only to the HFSA, if the
HRA money is exhausted.
•You do not need to enroll in a medical
plan to open a FSA.
•The IRS does not allow you to claim the
Dependent Care Tax Credit and use the
DFSA in the same tax year.
ONCE I MAKE MY FSA ELECTION,
CAN I MAKE MID-YEAR CHANGES?
You may make mid-year changes to your FSA elections
if you have a qualifying event as explained on page 11.
Please remember, any mid-year change in your FSA
election must be consistent with the event allowing the
change. For example, having a baby would allow for a
change, however reducing the FSA election would not
be consistent with that event.
HOW LONG DO I HAVE TO FILE A CLAIM?
Active employees can file claims for eligible expenses
that were incurred up to the end of any plan year
(Dec. 31). Paper claims for services incurred no later
than Dec. 31 of any year must be filed by March 31 of the
following year. Do not use your Benny Card to pay for
prior year expenses during the Jan. 1 to March 31 claims
filing extension period. All Benny Card “swipes” will be
processed against your current year HFSA balance.
WHAT HAPPENS TO MY MONEY
IF I DON’T USE IT ALL?
If you do not use all of the money in your FSA, the IRS
requires any remaining balance to be forfeited to the
plan and used to pay plan administrative expenses.
WHAT IF I LEAVE THE COMPANY BEFORE
THE END OF THE PLAN YEAR? WILL
I LOOSE THE MONEY IN MY ACCOUNT?
Effective with the 2014 plan year, if you leave, you are
still eligible to submit reimbursement claims for
expenses you incurred up to, and including, the last day
of the month in which you terminate. In addition, you are
entitled to continue your participation in the HFSA
account (not DFSA) under Continuation of Coverage
(see page 51).
Premiums
PREMIUMS
Malia Ray, MD
EAST PULMONARY, SLEEP AND
CRITICAL CARE
“Mercy Health Physicians is a unique
group that values communication
and team work to achieve our
goal of quality patient care.”
MEDICAL PLAN PREMIUMS
FULL TIME PER PAY CONTRIBUTIONS — With Tobacco-Free Discount
Your Annual Salary
Less than
$25,000 to less
$30,000 to less
$40,000 to less
$25,000/yr
than $30,000
than $40,000
than $150,000
$150,000 or more
iFlex
$268.26
Traditional Plan
Employee Only
$63.48
$63.48
$63.48
$63.48
$73.13
Employee and Spouse
$145.26
$145.26
$145.26
$145.26
$169.53
$562.11
Employee and Child(ren)
$132.05
$132.05
$132.05
$132.05
$154.11
$510.91
Employee and Family
$204.72
$204.72
$204.72
$204.72
$238.95
$792.52
$40.67
$40.67
$40.67
$40.67
$50.32
$245.44
Choice Plan
PREMIUMS
Employee Only
Employee and Spouse
$97.46
$97.46
$97.46
$97.46
$121.73
$514.31
$88.59
$88.59
$88.59
$88.59
$110.65
$467.45
Employee and Family
$137.39
$137.39
$137.39
$137.39
$171.62
$725.19
Employee Only
$17.55
$21.94
$26.33
$29.26
$38.91
$234.04
Exclusive Plan
Employee and Spouse
$44.14
$55.17
$66.20
$73.56
$97.83
$490.41
$40.12
$50.14
$60.17
$66.86
$88.92
$445.72
Employee and Family
$62.24
$77.79
$93.35
$103.73
$137.96
$691.52
PART TIME PER PAY CONTRIBUTIONS —
With Tobacco-Free Discount
Your Annual Salary
Less than
$13,000 to less
$16,000 to less
$21,000 to less
$13,000/yr
than $16,000
than $21,000
than $80,000
$104.43
$104.43
$104.43
$80,000 or more
iFlex
$104.43
$127.60
$268.26
Traditional Plan
Employee Only
Employee and Spouse
$267.87
$267.87
$267.87
$267.87
$332.60
$562.11
$243.48
$243.48
$243.48
$243.48
$302.31
$510.91
Employee and Family
$377.60
$377.60
$377.60
$377.60
$468.88
$792.52
$81.62
$81.62
$81.62
$81.62
$104.79
$245.44
Choice Plan
Employee Only
Employee and Spouse
$220.07
$220.07
$220.07
$220.07
$284.80
$514.31
$200.02
$200.02
$200.02
$200.02
$258.85
$467.45
Employee and Family
$310.27
$310.27
$310.27
$310.27
$401.55
$725.19
$42.13
$52.66
$63.19
$70.21
$93.38
$234.04
Exclusive Plan
Employee Only
Employee and Spouse
$117.70
$147.13
$176.55
$196.17
$260.90
$490.41
$106.97
$133.72
$160.46
$178.29
$237.12
$445.72
Employee and Family
$165.97
$207.46
$248.95
$276.61
$367.89
$691.52
TOBACCO-FREE DISCOUNT: These rates reflect the $30 per pay discount on your medical plan costs provided if you
certify that you and all covered family members have been tobacco-free for the past six months. Does not apply to
iFlex employees, who pay the full cost of coverage. See page 20 for details.
JUST BENEFIT
It is a priority to make sure our employees, especially
those who earn lower wages, can afford the healthcare
we offer. Therefore, starting in 2014, Mercy Health will
offer reduced medical plan premiums for the Exclusive
medical plan to those at lower wage rates. To determine
your per pay costs, refer to the appropriate chart for
full-time or part-time employees. Your per pay cost will
be determined by your base annual earnings (your
annual salary, or your hourly rate multiplied by your
scheduled hours per year).
MEDICAL PLAN PREMIUMS
FULL TIME PER PAY CONTRIBUTIONS —
Without Tobacco-Free Discount
Your Annual Salary
Less than
$25,000 to less
$30,000 to less
$40,000 to less
$25,000/yr
than $30,000
than $40,000
than $150,000
$150,000 or more
iFlex
$268.26
Traditional Plan
Employee Only
$93.48
$93.48
$93.48
$93.48
$103.13
Employee and Spouse
$175.26
$175.26
$175.26
$175.26
$199.53
$562.11
$162.05
$162.05
$162.05
$162.05
$184.11
$510.91
Employee and Family
$234.72
$234.72
$234.72
$234.72
$268.95
$792.52
Employee Only
$70.67
$70.67
$70.67
$70.67
$80.32
$245.44
Choice Plan
$127.46
$127.46
$127.46
$127.46
$151.73
$514.31
$118.59
$118.59
$118.59
$118.59
$140.65
$467.45
Employee and Family
$167.39
$167.39
$167.39
$167.39
$201.62
$725.19
$47.55
$51.94
$56.33
$59.26
$68.91
$234.04
Exclusive Plan
Employee Only
Employee and Spouse
$74.14
$85.17
$96.20
$103.56
$127.83
$490.41
$70.12
$80.14
$90.17
$96.86
$118.92
$445.72
Employee and Family
$92.24
$107.79
$123.35
$133.73
$167.96
$691.52
PART TIME PER PAY CONTRIBUTIONS —
Without Tobacco-Free Discount
Your Annual Salary
Less than
$13,000 to less
$16,000 to less
$21,000 to less
$13,000/yr
than $16,000
than $21,000
than $80,000
$134.43
$134.43
$134.43
$80,000 or more
iFlex
$134.43
$157.60
$268.26
Traditional Plan
Employee Only
Employee and Spouse
$297.87
$297.87
$297.87
$297.87
$362.60
$562.11
$273.48
$273.48
$273.48
$273.48
$332.31
$510.91
Employee and Family
$407.60
$407.60
$407.60
$407.60
$498.88
$792.52
$111.62
$111.62
$111.62
$111.62
$134.79
$245.44
Choice Plan
Employee Only
Employee and Spouse
$250.07
$250.07
$250.07
$250.07
$314.80
$514.31
$230.02
$230.02
$230.02
$230.02
$288.85
$467.45
Employee and Family
$340.27
$340.27
$340.27
$340.27
$431.55
$725.19
$72.13
$82.66
$93.19
$100.21
$123.38
$234.04
Exclusive Plan
Employee Only
Employee and Spouse
$147.70
$177.13
$206.55
$226.17
$290.90
$490.41
$136.97
$163.72
$190.46
$208.29
$267.12
$445.72
Employee and Family
$195.97
$237.46
$278.95
$306.61
$397.89
$691.52
TOBACCO-FREE DISCOUNT: A $30 per pay discount on these medical plan costs is provided if you certify that you
and all covered family members have been tobacco-free for the past six months. Does not apply to iFlex employees,
who pay the full cost of coverage. See page 20 for details.
DENTAL PLAN PREMIUMS
Contributions
Full-Time
Part Time
Employee
Employee
VISION PLAN PREMIUMS
IFlex
Contributions
Full-Time
Part Time
Employee
Employee
IFlex
Employee Only
$4.60
$6.90
$13.80
Employee Only
$2.83
$2.83
$2.83
Employee and Spouse
$9.66
$14.49
$28.99
Employee and Spouse
$5.66
$5.66
$5.66
$8.74
$13.11
$26.23
$6.29
$6.29
$6.29
Employee and Family
$13.80
$20.70
$41.41
Employee and Family
$7.73
$7.73
$7.73
PREMIUMS
Employee and Spouse
LIFE INSURANCE
Life Insurance
John Gallagher, MD
ORTHOPAEDICS AND
SPORTS MEDICINE
“All of our Mercy Health Physicians
are compassionate, experienced
physicians who use the latest
technology to treat our patients.
You cannot go wrong by choosing
one of us. We live the Mercy
Health Mission every day.”
Term Life Insurance
Mercy Health offers life insurance coverage for you and
your family through CIGNA. This insurance is known as
“term insurance”, which is usually less expensive than
whole life or universal life insurance. This is because
term insurance does not build cash value that can be
borrowed or later cashed out.
BASIC LIFE INSURANCE AND
AD&D INSURANCE
ADDITIONAL COVERAGES YOU CAN BUY
You also have the option of purchasing insurance
coverage for yourself, your spouse and your eligible
dependents. You will pay the cost of any additional life
insurance coverage you elect. These contributions are
deducted from your pay each pay period on an after-tax
basis. If you elect additional coverage for yourself or
coverage for your spouse, you (and/or your spouse)
may be required to provide Evidence of Insurability
(EOI). Your request for such coverage must be
approved by CIGNA before it is effective.
You may elect combined additional life insurance and
AD&D insurance for yourself in amounts of 1 times, 2
times, 3 times, 4 times or 5 times your base annual
earnings. The maximum supplemental benefit available is
a $1 million combined maximum that includes your basic
life. You pay for this coverage through payroll deduction.
The cost of this coverage is shown on the next page.
If you want to elect coverage for the first time or
increase your coverage at open enrollment, you can
only elect an additional 1 times your pay without EOI, as
long as your new coverage does not exceed a total of 3
times your basic annual earnings or $250,000. You may
elect additional coverage up to the plan maximum by
providing EOI.
If you are electing this coverage for the first time as
a new hire, you can elect an amount equal to three times
your basic annual earnings (up to $250,000) without
providing EOI. Any amounts selected above this amount
will be subject to EOI. If you increase this coverage at
any time in the future, those increased amounts will be
subject to EOI.
SUPPLEMENTAL SPOUSE LIFE INSURANCE
AND AD&D
You can purchase combined life insurance and AD&D for
your spouse in $10,000 increments, up to a maximum of
$100,000. If you want to increase spouse coverage at
open enrollment, you can elect an additional $10,000
without EOI, as long as your new total spouse coverage
does not exceed $20,000. If you are electing spouse
coverage for the first time as a new hire, you can
purchase up to $20,000 without providing evidence
of insurability (EOI).
You pay for this coverage through payroll deduction.
The cost of this coverage is shown on the next page.
SUPPLEMENTAL DEPENDENT LIFE
INSURANCE AND AD&D
You can also purchase combined life insurance and
AD&D for your dependent children. You can choose
from two amounts: $5,000 or $10,000. When you
choose this coverage, it covers all of your eligible
dependent children.
You pay for this coverage through payroll deduction.
The cost of this coverage shown on the next page.
LIFE INSURANCE
Mercy Health pays the full cost of basic life insurance for
benefits-eligible employees, covering you at 1 times your
base annual earnings (2 times base annual earnings for
Directors and above), rounded to the next $1,000 up to
a maximum of $500,000. For example, if your benefit
level is one times base pay and your annual base salary
is $25,186.62, then your coverage will be $26,000. This
coverage includes an equal amount of accidental death
and dismemberment (AD&D) insurance. In the event
of accidental death, the full AD&D amount is paid
in addition to the basic amount. In the event of
dismemberment, benefits will be paid according
to the level of loss.
Under IRS rules, the value of the life insurance
coverage over $50,000 that Mercy Health provides
for you is reported as taxable income for federal, state
and FICA purpose. This amount, called imputed income,
will be taxed each pay period throughout the year and
appears on your pay stub as a taxable benefit.
SUPPLEMENTAL EMPLOYEE LIFE INSURANCE
AND AD&D
EVIDENCE OF INSURABILITY
If you elect an amount of coverage that requires
Evidence of Insurability (EOI), you will receive
information from CIGNA after you enroll explaining
the additional information that is required.
NOTE:
1.Children are covered from age 14 days until age 19;
however coverage may be extended to age 25 for
full-time students. It is your responsibility to ensure
full-time student status is maintained
by your child in order for the benefit to be paid.
2.The maximum benefit for a child who is less
than six months old is $1,000.
3.Coverage for the employee will decrease
incrementally starting at age 65. Spousal coverage
will end at spouse’s age 70.
4.It is your responsibility to notify the employer when
your child or spouse is no longer eligible.
YOUR PER PAY PERIOD COST FOR SUPPLEMENTAL LIFE AND AD&D INSURANCE
YOUR AGE
Employee Cost
per $1,000 of Coverage
Spouse Cost
per $1,000 of Coverage
Dependent Child Cost
per $1000 of Coverage
<20
$0.032
$0.032
$0.092
20-24
$0.032
$0.032
Employee’s Age as of Dec. 31
LIFE INSURANCE
YOUR COST
25-29
$0.032
$0.032
30-34
$0.040
$0.040
35-39
$0.049
$0.049
40-44
$0.061
$0.061
45-49
$0.094
$0.094
50-54
$0.140
$0.140
55-59
$0.244
$0.244
60-64
$0.415
$0.415
65-69
$0.657
$0.657
N/A
70-74
$1.011
75-79
$1.411
N/A
80+
$2.110
N/A
CALCULATING YOUR LIFE AND AD&D COSTS
Use the following calculation to determine your per pay period cost for any of the Supplemental Life Insurance
coverages.
Step 1: Enter the amount of the coverage you are purchasing:
For example:
• If you are buying Supplemental Employee Life Coverage and AD&D at 2 x pay and your pay is
$50,000, you would enter $100,000.
• If you are buying Supplemental Spouse Life Insurance and AD&D coverage, enter the amount of
coverage you are purchasing (for example, $10,000 or $20,000, etc.)
• If you are buying Supplemental Dependent Life Insurance and AD&D coverage, enter the amount of
$
coverage you are purchasing (for example, $5,000 or $10,000)
NOTE: If you are buying more than one additional coverage (for example, coverage for yourself, your
spouse and your child), you must do this calculation for each type of coverage to determine your cost
for each coverage.
Step 2: Divide the amount entered in Step 1 by $1,000 and enter the result here.
Step 3: Enter the per pay period rate for the coverage you are buying.
Rates are shown above.
Step 4: Multiply Step 2 and Step 3 together; the result is your per pay period cost for coverage.
$
$
$
NAMING BENEFICIARIES
CONVERSION AND CONTINUATION OPTIONS
Included in your enrollment packet is a beneficiary form
provided by CIGNA, or you may elect your beneficiary
on-line, if available. Be sure to complete the form and
return it to Human Resources.
You must name a beneficiary for your basic life
insurance, supplemental employee life insurance, basic
AD&D insurance and supplemental AD&D insurance. If
you want the same beneficiary for all your coverages,
just complete the section for basic life insurance and
then write “same as basic life” for all your other
coverages. Or, you can name different beneficiaries for
each coverage. The choice is yours. If you die without
naming a beneficiary, your life and AD&D insurance will
be paid to the first surviving class of the following living
relatives: spouse; child or children; mother or father;
brothers or sisters; or to the executors or administrators
of your estate.
You are automatically named the beneficiary for
supplemental spouse and dependent child life and
AD&D coverage. You do not name a beneficiary for
these coverages.
This coverage can be converted to an individual policy
if you leave the organization for any reason. Conversion
coverage is not term insurance and therefore will be
priced at a higher premium than term insurance.
Although higher, the premium is fixed and will not
change with age. It is also a guaranteed coverage
alternative and cannot be denied due to poor health
conditions. To convert, you must apply and pay your
first premium within 60 days after your coverage ends.
If you leave the organization, you may be eligible to
continue your supplemental term life coverage by paying
your premiums directly to CIGNA. With Continuation
coverage, you can only continue the supplemental
coverage amounts you had in place while at work.
The premiums for Continuation coverage will increase
with your age.
You can only choose one option — Conversion or
Continuation — not both. If you are interested in either
option, contact the Benefits department for application
information.
LIFE INSURANCE
Disability
DISABILITY
Alaba Robinson, MD
FOREST PARK INTERNAL
MEDICINE AND PEDIATRICS
“At Mercy Health — Forest Park
we are a Level 3 PatientCentered Medical Home,
board-certified pediatricians
and internal medicine
physicians. We provide
excellent, family-centered care
with a smile and treat each
patient the way we would like
our family treated.”
Disability
DISABILITY MANAGEMENT
Disability Management Services is the department of
Mercy Health that assists employees with issues relating
to short term disability, long term disability, Non-FMLA
and FMLA leaves of absence, Workers’ Compensation,
ergonomic assessments and accommodation needs
relating to disabilities.
To contact Disability Management, please call
513-981-6241 or the toll free number at 1-877-219-9947.
Follow the telephone prompts to reach the contact
person for the service needed.
SHORT TERM DISABILITY
Short term disability benefits are provided to eligible
employees who are unable to work due to their own
serious health condition. To be eligible for this benefit,
you must have worked in a benefits-eligible position for
a period of six full months plus one day in the following
month, in the time period immediately preceding the
initial day of the absence for which short term disability
benefits are sought.
There is a waiting period before benefits are paid.
For the first five days or 40 hours of time missed due
to disability, whichever is less, you must use PTO. Upon
completion of the five-day period, short term disability
benefits are paid at 60% of your base rate of pay. The
maximum period of the short term disability benefit
is 26 weeks.
To apply for short term disability, please contact
Disability Management Services at 513-981-6241 or the
toll-free number at 1-877-219-9947.
LONG TERM DISABILITY
FMLA requires covered employers to provide
up to 12 weeks of unpaid, job-protected leave to eligible
employees for certain family and medical reasons.
You are eligible if you have worked for Mercy Health
for at least one year and worked at least 1,250 hours
during the 12 months prior to the date the leave
commences and there is a serious health condition.
Please refer to the FMLA policy for definition of a
serious health condition. You may request a
continuous or intermittent leave.
FMLA leave will be approved for the following reasons:
•To care for, or for the birth of, your child or
placement of a child for adoption or
foster care with you.
•To care for your immediate family member with
a serious health condition. A family member is
defined as a child, spouse or parent (does not
include parent-in-law).
•For YOUR serious health condition.
•Service member family leave.
You must provide at least 30 days advance notice for
leave requests when the need is foreseeable. In case
of an emergency, you must give “as much notice as
practical” under the circumstances. In the case of ongoing
medical treatment requiring leave time, you must make
every effort to schedule the treatment so as to not unduly
disrupt the staffing and operations of the department.
Failure to provide notice on a timely basis may result in
the disallowance of the leave as FMLA leave.
FMLA by law is an unpaid leave of absence. You are
required to concurrently use available Paid Time Off
(PTO) for scheduled workdays during the FMLA leave
until your PTO bank is depleted to 40 hours.
During a Family Medical Leave, you may be replaced
on a temporary basis. However, if you return to work
within 12 work weeks from the beginning of a Family
Medical Leave, you will be returned to the same or
substantially-similar position with the same rate of pay,
benefits and shift. Please refer to the FMLA policy for
complete details.
To request FMLA leave of absence, please contact
Disability Management Services at 513-981-6241 or
the toll-free number at 1-877-219-9947. Follow the
telephone prompts to reach the contact person for
the service needed.
DISABILITY
Long term disability benefits are provided to full-time
employees who have been employed with Mercy
Health in a permanent position for at least one year
and are budgeted to work at least 30 hours per week.
If you are eligible and have exhausted the 26 weeks
of short term disability, you may qualify for long term
disability benefits equal to 60% of your base salary if you
become totally disabled as a result of any cause covered
by this plan. The maximum benefit payable under this
plan for Director level and below is $6,000 per month.
Additional details regarding the long term disability
benefit are contained in the Plan and Summary Plan
description. Please contact Disability Management
Services at 513-981-6241 or the toll free number at
1-877-219-9947.
FAMILY AND MEDICAL LEAVE ACT (FMLA)
LEAVE OF ABSENCE
NON-FMLA MEDICAL LEAVE OF ABSENCE
Mercy Health may grant a non-FMLA Medical Leave
of Absence without pay so that you can address
medical concerns that are not covered by the Family
and Medical Leave Act (FMLA). Non-FMLA leaves may
be requested at any time during employment but, unless
required by law, are only granted to benefits eligible
full-time and part-time employees.
Adequate staffing is a paramount consideration in
approving a non-FMLA medical leave of absence. As a
result non-FMLA medical leave requests necessitated by
an elective medical procedure must be scheduled with
consideration given to the staffing needs of the
department. Medical documentation must be submitted
to substantiate all requests for non-FMLA medical leave.
Employees returning from a non-FMLA medical leave
are not guaranteed the position and/or shift they held
prior to the leave. Please refer to the non-FMLA leave
of absence policy for complete details.
To request a non-FMLA leave of absence, please
contact Disability Management Services at 513-981-6241
or the toll free number at 1-877-219-9947. Follow the
telephone prompts to reach the contact person for
the service needed.
WORKERS’ COMPENSATION
DISABILITY
Mercy Health endeavors to provide a place of employment
free from recognized hazards and encourages employees
to participate in the responsibility for keeping the
workplace safe. In general, Workers’ Compensation
benefits are paid if you sustain an injury or contract an
occupational disease in the course of and arising out
of your employment, provided that the disability was
not self-inflicted.
If you sustain an injury or contract an illness on the
job you must report the incident to your supervisor/
manager within 24 hours from the time of the incident.
You must also complete a SafeCARE report.
Once the incident has been reported, you should then
proceed with treatment. If the incident does not require
immediate attention, you should report to the nearest
Mercy Health occupational health center for initial
treatment. If the incident occurs after the occupational
health center’s operating hours or you need immediate
medical attention, you should report to the nearest
Mercy Health emergency department.
You will need to complete all necessary Workers’
Compensation forms at the time of initial treatment.
The treating facility will forward the completed forms
to Disability Management Services. Upon receipt,
Disability Management Services will review
for claim determination.
In any case where Worker’s Compensation coverage
for the injury or illness is denied, you must make the
decision whether or not to continue to be seen for
treatment. Mercy Health will cover the charges for the
initial visit in the Mercy Health emergency department
or occupational health center. These charges will be paid
for diagnostic purposes only while the claim remains in
a denied status. If the Workers’ Compensation claim is
denied, any subsequent treatment is your responsibility.
Please refer to the Workers’ Compensation policy
for complete details.
CONTINUATION COVERAGE
Certain employee benefits may be continued for up to
26 weeks of an approved medical leave. When your
benefits terminate, you may have the option of
continuing certain benefits under the Health Benefits
Continuation Program for a maximum of 18 months.
Specific details regarding the continuation or
termination of a given benefit are included in the benefit
plans and summary plan descriptions. Please see Human
Resources or the applicable plan or policy for details.
Retirement
Zainab Contractor, MD
NEUROLOGY & HEADACHE CENTER
“When you are looking for
comprehensive and exceptional
care, you don’t have to go too far!
At Mercy Health we are keeping
up with the latest treatment and
technology and bringing it to your
neighborhood. I am proud to offer
RETIREMENT
my expertise to the community
and partner with other physicians
in taking care of my patients.”
CHP Retirement Savings Plan
As a Mercy Health employee, you are eligible to participate
in the Catholic Health Partners (CHP) Retirement Savings
Plan. CHP is the parent organization for a large health care
system that includes Mercy Health.
The CHP Retirement Savings Plan is a partnership
between you and CHP to help you plan and save so you
can be secure in retirement.
WHO IS ELIGIBLE?
You can begin contributing to the plan each pay period
as soon as you join Mercy Health. You are eligible for
CHP’s contributions to your account after completing
one year of service during which you are credited with
at least 1,000 hours of service. You must also meet the
ongoing requirement of completing 1,000 hours during
the year and being employed on the last day of the Plan
year (December 31) in order to receive CHP’s Core and
Retirement Shared Success (RSS) contributions.
HOW DOES THE PLAN WORK?
RETIREMENT
When you satisfy eligibility requirements, your savings
account will be credited with one or more of the following:
1. CHP’S CORE CONTRIBUTION : CHP will make an
automatic Core contribution of $1,400 (or 2% of eligible
compensation, if greater) each year. If you complete
fewer than 2,080 hours, the minimum $1,400 Core
contribution will be prorated.
The Core contribution will be made the following year,
based on your eligible compensation for the previous
year. For example, if you are eligible for the plan year in
2014, and employed by Mercy Health on Dec. 31, 2014,
your first Core contribution will be made in the first
quarter of 2015, based on your 2014 compensation.
You will be eligible to receive the annual Core
contribution after completing one year of service and
being credited with 1,000 hours of service. Entry dates
are either January 1 or July 1 after these service
requirements are met.
This contribution is CHP’s commitment to help
employees achieve a secure retirement.
2. CHP’S MATCHING CONTRIBUTION: When you save
through the plan, CHP will match a percentage of your
contributions on as much as 6% of eligible compensation
you save on a pre-tax basis and/or through the Roth feature.
Once you are eligible and enrolled, CHP’s matching
contributions will be deposited to your account each
pay period.
3. CHP’S RETIREMENT SHARED SUCCESS (RSS)
CONTRIBUTION: When CHP achieves annual system-
wide, mission-based goals, a Retirement Shared Success
(RSS) contribution will be made to your account equal
to as much as 3% percent of your annual eligible
compensation. In order to receive the RSS, you must
be credited with at least 1,000 hours for the year and
be employed on Dec. 31 of that plan year. The initial
eligibility requirements are the same as the initial
requirements for the Core Contribution.
The plan is designed to help you build a retirement
savings account through CHP’s Core and RSS contributions
— whether or not you contribute your own money.
Fidelity Investments provides administrative services
for this plan.
DO I HAVE TO ENROLL?
Once you are eligible, you will be automatically enrolled
for a 1% contribution deducted from your pay every pay
period. Fidelity Investments will send you information
30 days before the auto-enrollment takes place.
If you decide you want to save at a different rate (save
more than 1%), or waive participation, you must call
Fidelity’s Retirement Service Center or go online to make
the change. If you decide to waive initial participation in
the plan, you will be automatically enrolled on an annual
basis on April 1 at 1% (with the opportunity to again
change this rate or waive participation).
Your savings rate will be automatically increased by 1%
of compensation each April 1 until you reach a 6%
contribution rate. You always have the opportunity to
contact Fidelity between March 1 and March 30 each year
to avoid the automatic increase in your contributions.
Fidelity will send you information 30 days before any
automatic increase takes place.
The reason for the annual automatic increase up to 6%
is to help you benefit from the full CHP match.
You can change your rate of savings at any time —
you are never locked in at any contribution rate, even if
you are automatically enrolled.
WHAT IS VESTING AND HOW DOES IT WORK?
Vesting is a term to describe the ownership you have in
your plan account balance. You are always 100% vested
in your own contributions and earnings. If you were
employed before Sept. 28, 2012, you will be 100% vested
in employer matching contributions upon completing
one year of service. If you were employed on or after
Sept. 28, 2012, you must have three plan years (January –
December) of service during which you are paid for
1,000 hours to be 100% vested in the employer
matching contributions, CHP Core contributions and
RSS contributions.
HOW DOES YOUR MONEY GROW?
With the CHP Retirement Savings Plan, you are in
control of how your account is invested. This includes
your own contributions, as well as those made by CHP.
Fidelity Investments provides administrative services
for the CHP Retirement Savings Plan, and you can take
advantage of its tools, resources and investment funds.
CHP works with financial experts to offer you a wide
range of investment options through Fidelity. These
investment options fit into three categories:
1. “DO IT FOR ME.” Based on your birth date and
estimated retirement date, lifecycle funds automatically
provide an investment mix of stocks, bonds and shortterm investments that are gradually adjusted to become
more and more conservative as the fund approaches its
target date and beyond.
2. “GIVE ME SOME HELP.” Through a choice of funds,
you may invest in diverse asset classes. By selecting
these investments, you take on more responsibility for
the investment risk in your account.
3. “I’LL DO IT MYSELF.” This self-directed investment
option gives you broad investment choices and ultimate
control. Transaction fees and brokerage commissions
apply for some transactions.
If you don’t make any investment election for your
CHP Retirement Savings Plan account, your money will
be invested in a lifecycle fund that is closest to your
age 65 retirement date.
HOW MUCH CAN YOU PUT IN THE PLAN?
You can contribute as much as 75% of your eligible
compensation on a pre-tax basis and/or Roth
alternative. Saving on a pre-tax basis allows you to defer
Federal taxes (however, you may be subject to local
taxes). Contact the Fidelity Retirement Service Center
for more information about Roth contributions. Your
pre-tax and Roth contributions are subject to the same
maximum amount allowed by the IRS (which is $17,500
for 2013; $23,000 if you are age 50 or older during the
year). You also have an after-tax option. The Internal
Revenue Code states that the combined annual limit for
all plan contributions (combined pre-tax, Roth and/or
after tax) other than age 50 catch-up contributions is
100% of your total compensation or $51,000 (in 2013),
whichever is less.
CAN YOU ROLL OVER MONEY FROM
ANOTHER PLAN INTO THIS PLAN?
Yes, distributions from other qualified plans may be
eligible for rollover into this plan. However, those
distributions must meet certain criteria to be eligible.
Contact the Fidelity Retirement Service Center at
1-800-343-0860 to discuss these requirements.
WHEN CAN YOU TAKE YOUR MONEY
FROM THE PLAN?
Generally, you can take the vested portion of your account
balance whenever your employment ends with Mercy
Health and all other Catholic Health Partners entities.
There are other times you may withdrawal funds from
your account if you meet the plan requirements for
a distribution:
•Y
ou may borrow a portion of your account for any
reason, but you must repay your account.
•Y
ou may take hardship withdrawals for limited
reasons. (There are additional plan requirements
which must be met to take a hardship withdrawal).
•Y
ou become age 59 1/2.
•Y
ou become totally disabled (as determined by the
plan administrator).
• You withdraw funds rolled over from another plan.
•Y
ou withdraw your non-Roth, after-tax
contributions.
CAN YOU ROLL OVER YOUR ACCOUNT?
Distributions from this plan are eligible for rollover into
another qualified plan which is structured to accept the
types of assets (pre-tax, Roth and after-tax) being
distributed from our plan. Example: If the new plan does
not provide for after-tax contributions, you would not
be able to roll over your after-tax account assets.
HOW SAFE IS YOUR MONEY?
Once vested, you own your account balance. CHP
reviews the performance of the investment options on
a regular basis in order to provide a strong and stable
lineup from which to choose. However, your money is
always subject to the market risks associated with your
chosen investments.
WHAT HAPPENS TO YOUR MONEY
IF YOU DIE?
You should complete a Beneficiary Designation
Form online at http://plan.Fidelity.com/chpsavings.
A beneficiary form allows you to identify who you want
to receive your account balance in the event of your
death. Spousal consent is required to name anyone
other than your spouse as primary beneficiary.
RETIREMENT
Cash Balance Plan
WHAT IS THE CASH BALANCE PLAN?
RETIREMENT
The Cash Balance Plan, also known as the Mercy Health
Partners of Greater Cincinnati Retirement Plan, is a
retirement benefit that is similar to a traditional pension
plan. The Cash Balance Plan is entirely paid by
Mercy Health.
Employees of Mercy Health employed before Jan. 1,
2014 may have qualified for participation in the Mercy
Health Partners of Greater Cincinnati Retirement Plan.
Those who met the eligibility requirements before the
plan freeze date (Dec. 31, 2013) were advised of the cash
balance plan change. Employees who are/were not
eligible by Dec. 31, 2013 cannot participate.
For more information about the Cash Balance Plan,
you can call the Catholic Health Partners Pension
Services Center at 1-877-783-1282.
CONTINUATION
COVERAGE
Continuation
Coverage
Mohamed Dahman, MD
FAIRFIELD GENERAL AND
LAPAROSCOPIC SURGERY
AND BARIATRICS
“As a fellowship-trained
advanced laparoscopic surgeon,
I can minimize the chance of an
open procedure which will allow
for a faster recovery, less pain,
less scarring and get you back to
your daily life quicker. With several
office locations and hours, we will
accommodate your schedule and
evaluate you promptly.”
CONTINUATION
COVERAGE
Continuation Coverage
Mercy Health offers the opportunity to continue most
benefit plan coverage after you have left the company
or are no longer eligible. In order to continue plan
coverage you must follow certain procedures and may
be required to pay a higher premium. There are also
limits on how long you may continue the coverage.
CONTINUING MEDICAL, DENTAL AND
VISION COVERAGE
HOW CAN I ELECT
CONTINUATION COVERAGE?
You or the individual losing coverage will be notified of
the right to continue coverage and provided an election
form. You or the individual losing coverage must elect
Continuation Coverage within 60 days of the date the
notice was sent. Each covered member of the family may
individually decide whether or not to continue coverage.
Our health plans, which include medical, dental and vision
plans, are what are known as “church” plans. These plans
are not subject to the Consolidated Omnibus Budget
Reconciliation Act of 1985, as amended (COBRA). Our
plans offer what is called “Continuation Coverage” rather
than COBRA, but offer similar arrangements. The
following provisions apply to Continuation Coverage
for medical, dental and vision plans.
WHAT IS THE COST FOR
WHEN WOULD I OR MY DEPENDENTS
QUALIFY FOR CONTINUATION COVERAGE?
For coverage to continue, the first premium must be
received by the date stated in the notice. Normally this
date will be 45 days after the Continuation Coverage is
elected. Premiums for every following month of
Continuation Coverage must be paid monthly on or
before the premium due date stated in the notice. There
is a 30-day grace period for these monthly premiums.
If the premium is not paid within 30 days after the due
date, Continuation Coverage will end on the first day of
that period of coverage. Coverage cannot be reinstated.
Continuation Coverage is available if coverage would
otherwise end due to:
•Termination of your employment for reasons other
than gross misconduct OR
•Reduction in your work hours OR
•Divorce or legal separation from your dependent
spouse OR
•Your death, for your dependent spouse and for
child(ren) OR
•Loss of eligibility as a covered dependent for your
dependent child(ren) (for example, because he or
she reaches the maximum age provided by the plan).
WHAT MUST I DO TO NOTIFY MY EMPLOYER
OF AN EVENT THAT WOULD TRIGGER
If coverage would end because of divorce or legal
separation, or because a child is no longer eligible to be
a dependent, you will need to notify Mercy Health within
31 days of this change in status, using the Benefits
Enrollment/Change Form, available on the Mercy Health
intranet. Once you have completed the form it should be
submitted to the Human Resources Department along
with the required supporting documentation. An offer to
continue coverage will be mailed to the individual losing
coverage at the address Mercy Health has on file.
Usually, this is your home address. If your coverage
changes and you lose eligibility, the continuation offer
paperwork will be sent automatically to your home
address. The continuation offer paperwork includes all
the information you need to take advantage of
Continuation Coverage.
You pay the full cost of Continuation Coverage.
The monthly cost of Continuation Coverage will be
included in the notice. Continuation Coverage costs
are adjusted annually.
WHEN MUST I MAKE MY
MONTHLY PREMIUM PAYMENTS?
HOW LONG CAN I CONTINUE COVERAGE?
If coverage would otherwise end because employment
ends or hours are reduced so you are no longer eligible
for group benefits, Continuation Coverage may continue
until the earliest of the following:
•1 8 months from the date that the coverage ended
due to a reduction in hours or the end of
employment
•The date on which a premium payment was due,
but not paid
•The date the person continuing the coverage
becomes covered by another employer’s group
health plan and that plan does not contain any
exclusion or limitation that affects a covered
individual’s pre-existing condition
•The date, after continuation coverage has been
elected, the person becomes eligible for Medicare
•The date the employer terminates all of its group
health plans
If your spouse lost coverage because of divorce or
legal separation, or your child lost eligibility under the
plans, their Continuation Coverage may continue until
the earliest of the following:
CAN THE LENGTH OF MY CONTINUATION
COVERAGE BE EXTENDED?
SECOND QUALIFYING EVENT: If Continuation Coverage
was elected by a covered dependent because your
employment ended or your hours were reduced and, if
during the period of continued coverage, another event
occurs which is itself an event which would permit
Continuation Coverage to be offered, the maximum
period of continued coverage for the dependent can
be extended for 18 months to a maximum of 36 months
from the date of the initial event. (Coverage will still end
for any of the other reasons listed previously, such as
failure to pay premiums when due, etc.)
SPOUSE AND DEPENDENTS OF MEDICARE — ELIGIBLE
EMPLOYEES: If Continuation Coverage was elected by
your spouse or dependent child because you became
entitled to Medicare and dropped our coverage while
an employee, the maximum period of Continuation
Coverage for a spouse or child is the later of 36 months
from the date you became entitled to Medicare. If you
maintain Mercy Health coverage, then later drop that
coverage and enroll in Medicare, the maximum period
of continuation is 18 months from the date you dropped
coverage. (Coverage will still end for any of the other
reasons listed previously, such as failure to pay
premiums when due, etc.)
DISABLED INDIVIDUALS: If a covered individual is
disabled, according to the Social Security Act, at the
time he or she first becomes eligible for Continuation
Coverage, or within 60 days of that date, the maximum
period of Continuation Coverage is extended to 29
months. (Coverage will still end for any other reason
listed previously, such as failure to pay premiums when
due, etc.) The covered individual must notify the
employer within 60 days of the date he or she is
determined to be disabled under the Social Security
Act and within 30 days of the date he or she is finally
determined not to be disabled. (Coverage will end on
the first day of the month beginning 30 days after the
covered individual is determined not to be disabled.)
The cost of Continuation Coverage may increase after
the 18th month of Continuation Coverage, and may be
adjusted annually when group rates are adjusted.
WHAT ELSE SHOULD I KNOW ABOUT MY
In order to protect your family’s rights, you should keep
your employer informed of any changes in the addresses
of family members who are or may become eligible for
Continuation Coverage. You should also keep a copy
of any notices you send to the Plan Administrator for
your records.
WHO IS MY CONTACT FOR
If you need more information regarding Continuation of
Coverage, please feel free to contact NGS CoreSource
at 1-800-647-1761 or contact Human Resources. Mercy
Health is responsible for administering Continuation
Coverage and has contracted with NGS CoreSource, to
perform certain administrative functions on its behalf.
These functions may include mailing of notices, collection
of premium payments and reporting eligibility to
applicable vendors.
CONTINUING HEALTHCARE FLEXIBLE
SPENDING ACCOUNT COVERAGE
You may also continue your Healthcare Flexible
Spending Account Coverage at your expense, but only
until the end of the calendar year in which you lose
eligibility. You will automatically receive the continuation
offer paperwork for your Healthcare Flexible Spending
Account if you lose eligibility because your employment
ends or your hours are reduced. Full details of the cost
of this coverage will be included in your continuation
offer and you must elect this coverage if desired.
CONTINUING COVERAGE
FOR OTHER BENEFIT PLANS
If your employment ends or your hours are reduced and
you lose eligibility, you can also maintain your basic life
insurance, supplemental life insurance, universal life
insurance and critical illness coverage. Maintaining
coverage is at your cost, and each plan has its own options
and requirements for maintaining coverage, as well as
for payment arrangements. For these benefits plans,
you are responsible for initiating the request to maintain
coverage within 31 days of your status change. Here are
the contacts for maintaining coverage in these plans:
BASIC TERM LIFE AND SUPPLEMENTAL TERM LIFE
INSURANCE: Contact Benefits at 513-981-6225 to request
the necessary documents. You will need to complete and
submit your application to the insurance company within
31 days of your status change, so call Benefits as soon as
possible to make sure you meet the deadline.
UNIVERSAL LIFE AND CRITICAL ILLNESS INSURANCE:
Contact ING at 1-800-537-5024 to arrange for
home billing.
CONTINUATION
COVERAGE
•36 months from the date the dependent’s
coverage ended
•The date on which the premium payment was due,
but not paid
•The date the person continuing coverage becomes
covered by another employer’s group health plan
and that plan does not contain any exclusion or
limitation that affects a covered individual’s preexisting condition
•The date, after Continuation Coverage has been
elected, the person continuing coverage becomes
eligible for Medicare
•The date the employer terminates all of its group
health plans
TIME OFF BENEFITS
Time Off
Benefits
Anil Verma, MD
THE HEART INSTITUTE,
WESTERN HILLS
“I encourage my patients
to eat healthy, sleep well,
breathe deeply and move
through life in rhythm.”
Time Off Benefits
JURY DUTY
Everyone uses their time off differently. Experience
shows that employees like having the flexibility to
decide how they use their time away from work. PTO
is a benefit that Mercy Health gives you to provide pay
at your regular base rate while taking time off. Time off
includes vacation, holiday and sick days.
You decide how to use your time as long as you have
approval from your manager for vacation and holidays.
You accrue PTO for all paid hours up to 80 hours per
pay period. You do not accrue PTO for on-call hours. See
page 54 to determine how many hours you can accrue.
ELIGIBILITY: You are eligible for PTO if you are budgeted
to work at least 32 hours per pay period. If eligible, you
begin accruing on your first day of employment.
USING YOUR PTO: You can start using PTO after
successfully completing your introductory period.
However, if any of Mercy Health’s recognized holidays
fall within your introductory period, you may be paid
for the holiday with PTO hours being deducted from
your PTO bank, which may result in a negative balance.
IF YOU DO NOT USE YOUR PTO: Mercy Health wants
you to use your PTO and take a break from work. We
understand that scheduling can sometimes make it hard
to take time off when you want to use it. That’s why you
can carry over your balance from year to year. The
maximum amount of hours you can have in your PTO
bank is 288 hours. If your bank reaches this Total
Maximum Accrual, you will no longer accrue PTO until
you take some time off. For more information, please
see the Paid Time Off policy.
Mercy Health balances its needs for quality service
with your responsibilities and obligations as a citizen to
serve local government when called for jury duty. Mercy
Health will compensate you at your regular base rate
of pay for the time you would normally be scheduled
to work during the jury duty period. Only in extreme
circumstances can Human Resources be asked to send
a letter requesting a jury duty exemption. For more
information, please refer to the Jury Duty policy.
HOLIDAYS
Although the care of the sick requires work to be
performed seven days a week, 365 days a year, Mercy
Health recognizes that observation of holidays is
important to our employees. Non-exempt employees
who must work on a recognized holiday are paid 1 1/2
times the base rate of pay, to recognize the commitment
made to our patients.
Mercy Health recognizes seven nationally-observed
holidays: New Year’s Day, Martin Luther King, Jr. Day,
Memorial Day, Fourth of July, Labor Day, Thanksgiving
Day and Christmas Day. For more information, please
refer to the Holiday Premium policy.
BEREAVEMENT
Mercy Health recognizes and respects its employees
who suffer the death of a relative and allows employees
to take paid time off from their job. Employees receive
base pay during Bereavement Leave. For a complete list
of included relatives and applicable Bereavement pay,
please refer to the Bereavement policy.
MILITARY LEAVE
Mercy Health provides military leaves of absence
to employees who leave active employment for the
purpose of serving in the nation’s Armed Forces, with
a Reserve or National Guard component, with the
commissioned corps of the Public Health Service, or
with some other category designated by the President
of the United States, in accordance with applicable law.
In these situations, every effort is made to hold your
position open during service. For more information,
please refer to the Military Leave of Absence policy.
PERSONAL AND EDUCATIONAL
LEAVES OF ABSENCE
Mercy Health may grant you an unpaid leave of absence
up to a maximum of one year to attend an approved,
accredited educational program relevant to Mercy
Health’s needs.
You may request a personal leave for events such
as unusual family needs (not including medical or
FMLA), hardship situations or other unique personal
needs requiring a temporary absence. Personal leaves
of absence may be granted for periods up to 30 days.
Extensions may be granted for special circumstances
with approval of your facility’s Human Resources
Director. Generally not more than one personal leave
in a calendar year will be granted to an employee.
Factors considered when Mercy Health reviews an
educational or personal leave request include: adequate
available staffing, performance and absence record, your
role in the organization, future potential roles, length of
service and intent to return to work after the leave.
TIME OFF BENEFITS
PAID TIME OFF (PTO)
Both of these leaves are non-benefits eligible with
benefits ending the last day of the month in which the
leave begins. Upon return to a benefits-eligible position,
you must elect benefits again within 31 days by
completing the Benefits Enrollment/Change Form found
on the intranet or in the Human Resources department.
NOTE: All Mercy Health policies are located on the
Mercy Health Intranet under Policy & Procedures.
PAID TIME OFF / PTO ACCRUAL
TIME OFF BENEFITS
Your PTO Factor (per hour you work)
This is the amount you will accrue each hour you are paid, based on
the amount of time you’ve been employed with Mercy Health
If you are Non-Exempt (hourly) & work at:
0 to 24 months
25 to 60 months
61 to 120 months
over 120 months
Mercy Health — Anderson Hospital,
Clermont Hospital, Fairfield Hospital,
West Hospital, The Jewish Hospital,
0.0731
0.0924
0.1077
0.1231
0.0731
0.0731
0.0924
0.1039
0 to 60 months
61 to 120 months
over 120 months
0.1116
0.1231
0.1424
0.0924
0.1116
0.1231
0 to 60 months
61 to 120 months
over 120 months
0.1116
0.1231
0.1424
0.0924
0.1116
0.1231
Mercy Health Medical Imaging, Blue Ash
Regional Office, St. John and St. Raphael
West Park and Mercy Health Physicians
RN, technical and professional positions
may accrue at a different rate.*
If you are Exempt/Non-Management (Salaried) & work at:
Mercy Health — Anderson Hospital, Clermont Hospital,
Fairfield Hospital, West Hospital, The Jewish Hospital,
Mercy Health Medical Imaging, Blue Ash Regional Office,
St. John and St. Raphael
If you are Exempt/Management (Salaried) up to Regional
Director level & work at:
Mercy Health — Anderson Hospital, Clermont Hospital,
Fairfield Hospital, West Hospital, The Jewish Hospital,
Mercy Health Medical Imaging, Blue Ash Regional Office,
St. John and St. Raphael
* All RN/Technical/Professional class employees are assigned a minimum 25 months service status. Because Mercy Health is a network
and some employees work at one location, but are paid through a separate Cost Center, your PTO factor may be different than on this
chart. Ask your manager about your Job Code — which indicates your correct PTO factor.
EXAMPLE 1: Molly is a full-time, non-exempt (hourly) employee at Mercy Health — Fairfield Hospital. She has been with Mercy Health
more than 120 months so her PTO factor is 0.1231. To determine how much PTO she can accrue in 2014:
0.1231 x 40 hours
= 4.924 x
52
=
256
PTO
(Her hours
(# of
(the amount of
(factor)
per week pay)
weeks
PTO hours Molly
per year)
can accrue)
Other
Benefits
OTHER BENEFITS
John Adler, MD
KENWOOD GYNECOLOGY
“My patients love our central
location in Kenwood, and
they really appreciate being
seen in a quiet, dignified,
spa-like office setting. Our
daily office schedule and
MyChart utilization allow
employees easy access for
questions, problems and
appointments, thereby
maximizing their Mercy
Health insurance benefits.”
Other Benefits
EMPLOYEE ASSISTANCE PROGRAM (EAP)
SPIRITUAL SUPPORT/RISEN
This confidential program includes family and individual
services by HealthSpan Employee Assistance Program.
The licensed staff includes psychologists, social workers
and counselors.
For information or to use these benefits, please
call 513-551-1500 for assistance. EAP services are
available for concerns such as:
•Work-related stress/Stress management
•Marital challenges/Divorce
•Family conflicts
•Parenting issues
•Substance abuse
•Financial or Legal referrals
•Spouse/Child abuse
•Aging-related concerns
Reflective of Mercy Health’s faith-based Mission and
Core Values is its commitment to foster a workplace that
encourages and embraces expressions of spirituality.
Mission Integration and Spiritual Care Services provide
opportunities for service, mission-centered activities and
spiritual growth throughout the year. Many Mercy Health
facilities have chaplains on staff, and offer designated
chapels or quiet rooms for prayer and reflection.
As part of this commitment, the RISEN program
— Re-Investing Spirituality and Ethics in our Network —
is presented twice annually by Spiritual Care Services
and is available to all employees. The program
approaches the spiritual as a universal aspect of every
human, including the potential for a relationship with
the Divine. Each person’s distinct expression of the
spiritual is honored through this experience.
RISEN participants attend four eight-hour sessions
and six one-hour sessions over the course of three
months. Periodic RISEN Reconnections are also
coordinated by Spiritual Care to provide ongoing
spiritual support to participants.
OTHER BENEFITS
EMPLOYEE EMERGENCY FUND
Mercy Health makes emergency financial assistance
available to employees who experience emergent
circumstances such as a fire, natural disaster, sudden
death or illness, or other financially-stressful events.
You must meet certain eligibility criteria to participate.
The confidential administration of this fund is managed
by Mission Integration and requests for assistance can
be directed to Human Resources or Mission Integration.
The Employee Emergency Fund is funded by the
employees and Auxiliaries at Mercy Health and relies on
voluntary contributions and approved fundraising events.
ADOPTION ASSISTANCE
Benefits-eligible employees are offered financial
assistance in completing the adoption process. Qualified
families can receive up to 50% of the amount allowed by
Section 137 of the Internal Revenue Code for qualified
and documented adoption expenses (visit www.irs.gov
for the current IRS allowance). Qualifying expenses
include agency fees, court costs, legal fees and
transportation directly related to the adoption.
In addition, adoptive parents employed by Mercy
Health can qualify for FMLA (see page 43) for up
to 12 weeks of unpaid leave to be with their new child.
To apply for adoption assistance, please visit the
intranet or Human Resources.
EMPLOYEE RECOGNITION
At Mercy Health, recognizing your accomplishments and
service is a major part of fostering a culture of employee
engagement. Managers are encouraged to regularly
recognize staff for their achievements, and you are
encouraged to recognize your peers for the work they
do to support our Mission and Core Values.
When you achieve career milestones, you will receive
special recognition from the organization and your
manager. Employees with five years of service or more
receive special acknowledgement from Mercy Health on
each milestone year (5, 10, 15, etc.) and can select a free
gift to commemorate the anniversary.
PREMIER CRITICAL ILLNESS/PREMIER
UNIVERSAL LIFE INSURANCE
OTHER BENEFITS
This is a brief summary of coverage and is not a
contract. Read your policy and riders carefully for
exact terms and conditions. This policy has exclusions
and terms under which the policy may be continued
in force or discontinued. For costs and complete
details of the coverage, call ING Employee Benefits
at 1-800-537-5024.
PREMIER CRITICAL ILLNESS INSURANCE: Premier
Critical Illness Insurance pays a lump sum benefit in
the event of a diagnosis of a covered critical illness.
It is supplemental coverage and does not replace
or in any way affect any medical, life and/or disability
insurance coverage provided by Mercy Health. This
is a limited benefit policy. There is no coverage for
hospital, medical-surgical or major medical expenses.
If you are benefits eligible, coverage is available
for you, your spouse and your children. Coverage is
available in amounts of $5,000 up to $50,000 for an
employee and up to $25,000 for a spouse. Covered
illnesses include: cancer (optional coverage), heart
attack, stroke, major organ failure, end stage renal
(kidney) failure, permanent paralysis and coma.
A $10,000 Occupational HIV Benefit Rider is
automatically included on employee coverage for no
additional premium. A rider is additional insurance
coverage to the policy that is only available if the
primary insurance is elected. Sometimes a rider
requires you to make an election and other times it is
automatically included by the insurance company.
•RESTORATION BENEFIT RIDER: This rider is available
for an additional premium if you elect it. Following
payment of 100% of the base plan benefits, this rider
will restore the maximum benefit amount one time
for a future occurrence or reoccurrence of any
covered critical illness except for cancer and
carcinoma in situ.
•EASY TO APPLY: Employees ages 18 – 69 may apply
for up to $24,000 on a simplified issue basis by
answering three health questions satisfactorily to
the insurer. Additional health questions will be asked
for amounts from $25,000 to $50,000. Benefits will
be reduced by 50% on the anniversary of the
coverage effective date following the insured’s
70th birthday.
PREMIER UNIVERSAL LIFE INSURANCE: This is a life
insurance policy that offers a variety of options. You
own the policy, which means you choose the premium
amount that fits your budget and your needs. If you
qualify, you can purchase coverage for yourself, your
spouse, children and even grandchildren. Because the
coverage is portable, if you leave Mercy Health, you can
keep it at the same rates. The insurance company will
bill you directly.
•ACCELERATED DEATH BENEFIT RIDER: This rider
allows the insured to access up to 50% of the eligible
death benefits upon diagnosis of a terminal illness.
The minimum amount to include the rider is $50,000
and it is available with no additional premium.
•E ASY TO APPLY: Employees ages 15 – 70 may apply
for up to three times their annual salary with a
maximum of $100,000 in coverage by answering
two health questions satisfactorily to the insurer.
Additional coverage may be available up to a
maximum of $500,000 for non-tobacco users or
$250,000 for tobacco users.
Educational Benefits
INTEGRATED LEARNING
CLASSROOM — INSTRUCTOR LED TRAINING
Integrated learning is the learning and development
function of Human Resources, which includes Talent
and Performance, iLearn and Grow, and Engagement.
Mercy Health has many opportunities to help you
learn and grow:
Mercy Health provides a Divisional Training Schedule
annually with instructor-led classes related to employee
and leadership development. Courses are mapped to
Key Result Areas, as well as our organizational goals and
include topics such as project management, finance,
communication, leadership, team-building, influencing
behaviors, and diversity. The Divisional Training
Schedule is available through the intranet.
OTHER BENEFITS
CONTINUING EDUCATION —
TUITION REIMBURSEMENT
Mercy Health is committed to helping you begin, continue
or further your education. Tuition reimbursement is
available if you are taking a course related to your job
or other jobs in the organization and if the coursework
is of clear value to Mercy Health.
To qualify, you must be in good standing and in a
benefits-eligible position budgeted for at least 32 hours
per pay period at the time the Tuition Reimbursement
application is submitted, when the course begins and
throughout the duration of the course. You will not be
reimbursed for classes attended, in whole or in part,
while on leave of absence.
The Tuition Reimbursement benefit covers tuition
costs after any grants/scholarships are subtracted. Books
and fees are the responsibility of the student. Courses
must be for academic credit and carry a letter grade or a
pass/fail provided on a formal grade report to be eligible.
The maximum annual benefit for non-nursing coursework
is $5,250 if you are benefit-eligible and budgeted to work
at least 30 hours per week ($3,150 if benefit-eligible and
budgeted to work 16 – 29 hours per week, with a lifetime
benefit limit of $21,000.) An enhanced benefit is available
for nursing degree coursework, with an annual and
lifetime benefit of $17,500.
To be reimbursed, you must submit a clear copy
of the grade report showing a “C” or better, or a “Pass”
for a Pass/Fail course; an itemized statement of tuition
costs and proof of payment. In exchange for receiving
reimbursement, you agree to repay this benefit if
you leave Mercy Health within three years. For more
information, please refer to the Tuition Reimbursement
policy, available on the intranet.
iLEARN — LEARNING MANAGEMENT SYSTEM
Mercy Health provides web-based training (WBTs)
through our internal learning management system. While
some WBTs are mandatory for employees to complete
for compliance purposes, our iLearn system also
includes a wide variety of training modules for personal
development, such as training in spreadsheets, word
processing, personal development, and more. The iLearn
System is available through the Mercy Health intranet.
CERTIFICATE PROGRAMS
Mercy Health has a strong partnership with area colleges
and universities and leverages these relationships to
provide certificate programs for groups of employees
at different times. Many times these programs are held
on site, in cohort type settings, which enhances your
learning experience.
The Fine Print
THE FINE PRINT
Charlene Cureton, CNP
DRY RIDGE FAMILY MEDICINE
“As a Nurse Practitioner I strive
to provide quality medical
care at a reasonable cost.”
Health Insurance Portability And
Accountability Act (HIPAA) Privacy Rules
THE FINE PRINT
EFFECTIVE DATE: MAY, 2013. This notice describes how
medical information about you may be used and
disclosed and how you can get access to this
information. Please review it carefully.
This Notice of Privacy Practices describes how we
may use and disclose your protected health information
to carry out treatment, payment or healthcare operations
and for other purposes that are permitted or required by
law. It applies to the benefits in the group health plans
sponsored by Mercy Health that pay for the cost of, or
provide, health, prescription drug, dental or medical
flexible spending benefits. We will refer to these benefits
in this Notice as “the Plan.” It does not apply to other
benefits such as life insurance, disability benefits, or
accidental death and dismemberment insurance. If you
receive health benefits through an insurance company
through the Plan, you may also receive a notice from the
insurer. That notice will describe how the insurer will use
your health information and provide your rights.
This notice also describes your rights to access and
control your protected health information, as well as
certain obligations we have regarding the use and
disclosure of your protected health information.
“Protected health information” PHI is medical information
about you, including demographic information, that may
identify you and that relates to your past, present or
future physical or mental health or condition and related
healthcare services. It also includes information related
to the payment for these services such as claims,
eligibility and enrollment for benefits.
We are required by law to maintain the privacy of
your PHI and to provide you with notice of our legal
duties and privacy practices with respect to your PHI.
We are also required to abide by the terms of this Notice
as currently in effect.
This notice will be followed by the Plan and all of the
employees, staff and other individuals who assist in the
administration of the Plan. This notice also covers our
third party “business associates” who perform various
activities for us to provide you benefits and to administer
the Plan. Before we disclose any of your PHI to one of
our business associates, we will enter into a written
contract with them that contains terms to protect the
privacy of your PHI.
USES AND DISCLOSURES OF YOUR
PROTECTED HEALTH INFORMATION
This notice sets forth different reasons for which we
may use and disclose your PHI. The Notice does not list
every possible use and disclosure; however, all of our
uses and disclosures of your PHI will fall into one of the
following general categories:
FOR TREATMENT. We may disclose your PHI to
healthcare providers who treat you.
FOR PAYMENT. We will use your PHI for “payment”
purposes. For example, we may use and disclose your
PHI to the Plan Administrator so that we may provide
reimbursement for healthcare services you received. We
may also use or disclose your PHI to obtain premiums for
insurance coverage, to determine whether you are eligible
for health benefits or coverage, or to make determinations
whether treatment is medically necessary for you.
FOR HEALTHCARE OPERATIONS. We may use and
disclose your PHI for purposes of healthcare operations.
These uses and disclosures are necessary to manage the
plan and to make sure that all of its participants receive
quality healthcare. Your PHI may be used to assess the
quality of service our staff has provided to you or to
help us evaluate the benefits of the plan.
TREATMENT ALTERNATIVES AND HEALTH-RELATED
BENEFITS. We may use and disclose your PHI to inform
you of or recommend possible treatment alternatives or
health-related benefits or services that may be available
to you.
PLAN SPONSOR. The plan may use and disclose your
PHI, as needed, to employees of Mercy Health who have
a need to know your PHI to help administer the plan and
answer your questions about your benefits. Your PHI
cannot be used for employment purposes other than
purposes related to the plan without your authorization.
INDIVIDUALS INVOLVED IN YOUR HEALTHCARE OR
PAYMENT FOR YOUR HEALTHCARE. We may disclose
your PHI to a family member or friend who is involved in
your medical treatment or care. We may also disclose
this information to a person who is responsible for your
medical bills or otherwise involved in paying for your
healthcare. The Plan will generally try to obtain your
written authorization before it releases your PHI to your
spouse or your parent (if you are over age 18). However,
if you are not present or are incapacitated, the plan may
still release your PHI if a disclosure is in your best
interest and directly relevant to the inquiring person’s
involvement in your healthcare. In addition, we may use
and disclose PHI so that your family can be notified as
to your condition, location, or death, or so that care or
rescue efforts can be coordinated.
AS REQUIRED BY LAW. We will use and disclose your
PHI when required to do so by federal, state or local law,
to the extent that such use and disclosure is limited to
the relevant requirements of such law.
JUDICIAL AND ADMINISTRATIVE PROCEEDINGS.
CORONERS, MEDICAL EXAMINERS AND FUNERAL
DIRECTORS. We may disclose your PHI to a coroner or
medical examiner as necessary to identify a deceased
person or determine a cause of death. We may also
disclose your PHI, as necessary, in order for the funeral
directors to carry out their duties.
ORGAN, EYE AND TISSUE DONATION. We may disclose
your PHI to an organ procurement organization or other
entity involved in the procurement, banking or
TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY.
We may use and disclose your PHI when we believe in
good faith it is necessary to prevent a serious threat to
your health and safety or the health and safety of
another person or the public. Any disclosure, however,
would only be to a person able to help prevent the threat.
GOVERNMENTAL FUNCTIONS. We may disclose the PHI
of individuals who are members of the Armed Forces, as
required by appropriate military command authorities.
PHI may be disclosed for purposes of determining an
individual’s eligibility for or entitlement to benefits under
appropriate military laws. We may also disclose the PHI
of foreign military personnel to the appropriate foreign
military authority. We may disclose your PHI to
authorized federal officials for lawful intelligence,
counterintelligence, and other national security activities
as authorized by law. We may disclose your PHI to
authorized federal officials, so they may adequately
provide protection to the President of the United States,
other authorized persons, or foreign heads of state. PHI
may also be disclosed to conduct special investigations.
INMATES. We may disclose your PHI, as long as you are
an inmate of a correctional institution or under the
custody of a law enforcement official, to the correctional
institution or law enforcement official. The disclosure
must be necessary: (1) for the institution or law
enforcement official to provide you with healthcare;
(2) to protect your health and safety or the health and
safety of others in connection with the correctional
institution; and (3) for the safety and security of the
correctional institution.
WORKERS’ COMPENSATION. We may disclose your
PHI for workers’ compensation or similar programs.
These programs provide benefits for work-related
injuries or illness.
BUSINESS ASSOCIATES. We may disclose information
to business associates to carry out our activities
provided the business associates agree to protect
your information in the same manner as we would.
OTHER USES AND DISCLOSURES OF YOUR
PROTECTED HEALTH INFORMATION
Psychotherapy Notes. Most uses and disclosures of
psychotherapy notes require an authorization. We must
obtain an authorization from you for any use or
disclosure of PHI in the form of psychotherapy notes,
unless such a use or disclosure is: (1) to defend against
a legal action or other proceeding brought by you; (2)
to demonstrate compliance with the HIPAA privacy
THE FINE PRINT
We may disclose your PHI in response to a court or
administrative order. We may also disclose your PHI
in response to a subpoena, discovery request or other
lawful process by another person involved in the
dispute, but only if we believe that the party seeking
the PHI has made reasonable efforts to tell you about
the request or to obtain an order protecting the
information requested.
PUBLIC HEALTH ACTIVITIES. We may disclose your PHI
for purposes of public health activities. These activities
generally include activities such as: preventing or
controlling disease, injury, or disability; reporting the
conduct of public health surveillance, investigations,
and interventions; reporting adverse events relating to
product defects, problems, or biological deviations;
and notifying people to enable product recalls, repairs,
and replacement.
ABUSE, NEGLECT, OR DOMESTIC VIOLENCE. We may
disclose PHI to notify an appropriate government
authority if we reasonably believe an individual has been
the victim of abuse, neglect or domestic violence. We
will only make this disclosure if you agree or when
required or authorized by law.
HEALTH OVERSIGHT ACTIVITIES. We may disclose your
PHI to a health oversight agency for activities that are
necessary for the government to monitor the healthcare
system, government benefit programs, compliance with
program standards, and compliance with civil rights
laws. These activities might include: civil, administrative
or criminal investigations, proceedings, and prosecutions
and audits of the plan by governmental agencies.
LAW ENFORCEMENT. We may disclose your PHI, within
limitations, if asked to do so by a law enforcement
official for a law enforcement purpose, if it is: (1) to
identify or locate a suspect, fugitive, material witness
or missing person; (2) about the victim of a crime if the
individual agrees to the disclosure, or due to incapacity
or emergency, we are unable to obtain the individual’s
agreement; (3) about a death we suspect may have
resulted from criminal conduct; and (4) about criminal
conduct we believe in good faith to have occurred on
our premises.
transplantation of organs, eyes or tissue to facilitate the
donation and transplantation process.
RESEARCH. We may use and disclose your PHI for
certain limited research purposes. Generally, the
research project must be approved through a special
committee that reviews the research proposal and
ensures that the PHI is necessary for research purposes.
THE FINE PRINT
standards upon investigation by the Secretary of the
U.S. Department of Health and Human Services; (3)
permitted by law; (4) permitted as described above for
Health Oversight Activities with respect to the oversight
of the originator of the psychotherapy notes; (5) to a
coroner or medical examiner for the purpose of
identifying a deceased person, determining cause of
death, or other duties as authorized by law; or (6) made
upon our good faith belief that it is necessary to prevent
or lessen a serious or imminent threat to the health or
safety of a person or the public, and is made to a person
able to help prevent or lessen that threat.
MARKETING. Most uses and disclosures of PHI for
marketing purposes require an authorization. We must
obtain an authorization from you for any use or disclosure
of your PHI for marketing, unless the communication is in
the form of: (1) a face-to-face communication; or (2) a
promotional gift of nominal value. This authorization will
state whether the marketing involves direct or indirect
remuneration to us from a third party.
SALE OF PHI. We must obtain an authorization from you
for any use or disclosure of your PHI that we exchange
for direct or indirect remuneration from, or on behalf of,
the recipient of the PHI, unless provided for purposes of:
(1) public health activities described above; (2) research
described above, provided individual identifiers are
removed, and the only remuneration received is a
reasonable cost-based fee to cover the cost to prepare
and transmit the PHI for that purpose; (3) your treatment
or payment of your treatment; (4) disclosures related to
the sale, transfer, merger or consolidation of all or part of
the Plan to another entity or plan and related due
diligence; (5) services rendered by a business associate
pursuant to a business associate agreement at our
request, provided the only remuneration provided is for
the performance of activities specified in the business
associate agreement; (6) providing you access to your
PHI and the only remuneration received is a reasonable
cost-based fee for providing such access; or (7) any
other purpose required or permitted by law.
GENETIC INFORMATION. We will not use genetic
information for underwriting purposes.
ALL OTHER USES AND DISCLOSURES OF PHI . All other
uses and disclosures of your PHI not covered by this
notice or the laws that apply to us, will be made only
with your written authorization. If you have given us
your authorization, you may revoke that authorization,
in writing, at any time. If you revoke your authorization,
we will no longer use or disclose the PHI for the reasons
covered by your written authorization, except to the
extent that we have taken action in reliance on your
authorization. Please note that we are unable to
withdraw any disclosures we have already made with
your written authorization, and that we are required by
law to maintain our records as to the healthcare benefits
that we have provided to you.
YOUR RIGHTS REGARDING YOUR PROTECTED
HEALTH INFORMATION.
You have the following rights regarding your PHI which
we maintain, as required by law. To exercise any of the
following rights, you must make your request in writing
by filling out the appropriate form provided by the Plan
and submitting it to the Plan’s Privacy Officer, Mercy
Health, 4600 McAuley Place, 6th Floor, Cincinnati, OH
45242, (513) 981-6000.
RIGHT TO NOTIFICATION OF BREACH. You have the
right to be notified of any breach of protected health
information in which the information disclosed was
compromised.
RIGHT TO REQUEST RESTRICTIONS. You have the right
to request a restriction or limitation on the use or
disclosure of your PHI for purposes of treatment,
payment or healthcare operations. You also have the
right to request that we restrict the disclosure of your
PHI from those involved in your healthcare or the
payment for your healthcare, such as with a family
member or friend. For example, you may request that
we not use or disclose your PHI relating to a procedure
you may have had. We are not generally required to
agree with your request for restrictions. However, if we
do agree, we will comply with your request unless the
information is needed to provide you with emergency
treatment. If we agree to your request, either you or we
may revoke the restriction; however, if we revoke it, it
will only apply to PHI that we obtain after the revocation.
In your request, you must tell us: (1) what information
you want to limit; (2) whether you want to limit our use,
disclosure or both; and (3) to whom you want the limits to
apply, for example, disclosures to your spouse or children.
RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS.
You have the right to request that we communicate with
you about your personal health matters in a particular
way or at a particular location. For example, you can
request that we only contact you at work or at a friend’s
house. We may require that your request contain a
statement that the disclosure of all or part of the PHI for
which you are requesting a restriction could harm you if
disclosed. We will accommodate all reasonable requests.
However, we may condition granting your request on
receiving appropriate information regarding payment,
as well as you specifying how or where you would like
us to contact you.
RIGHT TO INSPECT AND COPY. You have the right to
inspect and copy your PHI that is kept in a designated
record set. This may include medical and billing records,
but does not include: (1) psychotherapy notes; (2)
information compiled in anticipation of or for use in legal
actions or proceedings; or (3) PHI that is maintained by the
plan to which access is prohibited by law. If you request a
copy of the information, we may charge a fee for the costs
of copying, mailing or preparing the requested documents.
You have the right to an electronic copy of your
health information that exists in an electronic format
within a 12-month period will be free. For additional
accountings, we may charge you for the costs of
providing the accounting.
We will notify you of the costs involved and give you an
opportunity to withdraw or modify your request, before
any costs have been incurred. You have a right to
receive a written access report that indicates who has
accessed your protected health information in an
electronic designated record set maintained by us or
our business associate for up to three years prior to the
date on which the access report is requested. You may
limit the access report to a specific date, time period or
person or to a specific organization or a specific
business associate. The first disclosure list request in a
12-month period is free; other requests will be charged
according to our cost of producing the list. We will
inform you of the cost before you incur any costs.
RIGHT TO A PAPER COPY OF THIS NOTICE. You have the
right to receive a paper copy of this Notice. You may
request that we give you a copy of this Notice at any
time. Even if you have agreed to receive this Notice
electronically, you are still entitled to receive a paper copy.
CHANGES TO THIS NOTICE
We reserve the right to change the terms of this Notice.
We reserve the right to make the new Notice provisions
effective for all PHI we currently maintain, as well as any
information we receive in the future. Please note, in the
first paragraph of the Notice, you will find the effective
date. A Notice with a more recent date supersedes a
Notice with an older date.
FUND RAISING
You have the right to opt out of receiving
communications for fund-raising purposes.
COMPLAINTS
If you believe your privacy rights have been violated,
you may file a complaint with the plan or with the Office
for Civil Rights in the United States Department of
Health and Human Services. You will not be retaliated
against or penalized for filing the complaint. To file a
complaint with the Plan, contact our Privacy Officer at
513-981-6000. You may also contact Catholic Health
Partners Report Line, a 24-hour hotline, at
1-888-302-9224.
REQUEST FOR FORMS/SUBMISSION OF
FORMS/QUESTIONS
To request a form and/or to submit a form, or if you
have any questions about this Notice, please contact the
Privacy Officer.
Date:
May 2013
Name of Entity/Sender:
Mercy Health
Address:4600 McAuley Place
Cincinnati, OH 45242
Phone Number:513-981-6000
THE FINE PRINT
and you may direct that the copy be transmitted directly
to an entity or person designated by you provided that
any such designation is clear, conspicuous and specific
with complete name and mailing address or other
identifying information.
We may provide you with a written denial of your
request to inspect and copy in certain very limited
circumstances: (1) the PHI you are requesting to inspect
is specifically prohibited by law; or (2) the information
you are requesting was confidentially obtained from a
source other than a healthcare provider and if you were
granted access you could find out the identity of the
source. If you are denied access to your PHI, for reasons
other than those listed above, you may request that the
denial be reviewed. A licensed healthcare professional
chosen by the Plan will review your request, as well as the
basis for the denial. The person conducting the review
will not be the person who denied your request the first
time. The outcome of the review will be the final decision.
RIGHT TO AMEND. You have the right to request that we
amend your PHI in a designated record set if it is
incorrect or incomplete. You have the right to request
an amendment for as long as the information is kept by
or for the plan within a designated record set. You must
be prepared to provide a reason to support your request
for an amendment. We may deny your request for an
amendment if the request does not include a reason to
support the request for an amendment. Furthermore, we
may deny your request for an amendment if you request
that we amend PHI that: (1) was not created by us, unless
the person or covered entity that created the PHI is no
longer available to make the amendment; (2) is not part
of the health information kept by or for the Plan within
the designated record set; (3) is not part of the
information that you would be permitted to inspect
and copy by law; or (4) is accurate and complete.
RIGHT TO AN ACCOUNTING OF DISCLOSURES. You
have the right to a written accounting of the following
disclosures of protected health information about you
that we or our business associate made in the three
years prior to the date on which you request an
accounting:
•Disclosures not permitted by HIPAA law, unless you
have received notification from us of the impermissible
disclosure;
•For public health activities, except disclosures to
report child abuse or neglect;
•For judicial and administrative proceedings:
•For law enforcement purposes as provided in
§164.512(f) of the HIPAA regulations;
•To avert a serious threat to health or safety;
•For military and veterans activities, the Department of
State’s medical suitability determinations and
government programs providing public benefits; and
•For disclosures for workers’ compensation. You may
receive the accounting of disclosures in paper or
electronic form. The first accounting you request
Special Notices 2014
NOTICE TO PLAN PARTICIPANTS
The federal government has issued regulations that
require virtually all group health plans to cover
contraceptive services, starting January 1, 2014. Because
some employers, including Catholic Health Partners,
object to the regulation because contraception goes
against its organization’s tenets, these final regulations
include an accommodation for third party administrators
to provide coverage and pay for contraceptive services.
CHP will not be involved in paying for or providing this
separate coverage. Unless this requirement is delayed,
amended or repealed, NGS CoreSource, a company
independent of CHP, will provide separate coverage for
contraceptive services, along with information about this
coverage, for employees/family members enrolled in a
CHP group health plan.
NOTWITHSTANDING THE ABOVE PARAGRAPH,
THE PLAN WILL CONTINUE TO PROVIDE SERVICES
CONSISTENT WITH PLAN PROVISIONS WITH THE
DIAGNOSIS OF MEDICAL NECESSITY.
THE FINE PRINT
IMPORTANT NOTICE FROM MERCY HEALTH
ABOUT YOUR PRESCRIPTION DRUG
COVERAGE AND MEDICARE
Please read this notice carefully and keep it where you
can find it. This notice has information about your
current prescription drug coverage with Mercy Health
and about your options under Medicare’s prescription
drug coverage. This information can help you decide
whether or not you may want to join a Medicare Drug
Plan. If you are considering joining, you should compare
your current coverage, including which drugs are
covered at what cost, with the coverage and costs of
the plans offering Medicare prescription drug coverage
in your area. At the end of this notice is information
about where you can get help to make decisions about
your prescription drug coverage.
There are two important things you need to know
about your coverage and Medicare’s prescription
drug coverage:
1.Medicare prescription drug coverage became
available in 2006 to everyone with Medicare.
You can get this coverage if you join a Medicare
Prescription Drug Plan or join a Medicare Advantage
Plan (like an HMO or PPO) that offers prescription
drug coverage. All Medicare prescription drug plans
provide at least a standard level of coverage set by
Medicare. Some plans may also offer more coverage
for a higher monthly premium.
2.Mercy Health has determined that the prescription
drug coverage offered by Mercy Health is, on
average for all plan participants, expected to payout
as much as the standard Medicare prescription drug
coverage will pay and is considered Creditable
Coverage. Because your existing coverage is
Creditable Coverage, you can keep this coverage
and not pay a higher premium (a penalty) if you later
decide to enroll in Medicare prescription drug plan.
WHEN CAN YOU JOIN A MEDICARE
DRUG PLAN?
You can join a Medicare Drug Plan when you first
become eligible for Medicare and each year from Oct. 15
to Dec. 7. However, if you lose your current creditable
prescription drug coverage, through no fault of your
own, you will also be eligible for a two-month Special
Enrollment Period (SEP) to join a Medicare Drug Plan.
What Happens To Your Current Coverage If You Decide
To Join A Medicare Drug Plan? If you decide to join a
Medicare Drug Plan, your Mercy Health coverage will
not be affected. If you do decide to join a Medicare Drug
Plan and drop your current employer coverage, be
aware that you and your dependents may not be able
to get the coverage back.
WHEN WILL YOU PAY A HIGHER PREMIUM
(PENALTY) TO JOIN A MEDICARE
DRUG PLAN?
You should also know that if you drop or lose your
coverage with Mercy Health and don’t join a Medicare
Drug Plan within 63 continuous days after your current
coverage ends, you may pay a higher premium (a
penalty) to join a Medicare Drug Plan later. If you go
63 continuous days or longer without creditable
prescription drug coverage, your monthly premium
will go up at least 1% of the Medicare base beneficiary
premium for every month that you did not have that
coverage. For example, if you go 19 months without
creditable coverage, your premium may consistently be
at least 19% higher than the Medicare Base beneficiary
premium. You may have to pay this higher premium (a
penalty) as long as you have Medicare prescription drug
coverage. In addition, you may have to wait until the
following October to join.
FOR MORE INFORMATION ABOUT
THIS NOTICE OR YOUR CURRENT
PRESCRIPTION DRUG COVERAGE
WOMEN’S HEALTH & CANCER RIGHTS ACT
OF 1998 (WHCRA)
As part of the Women’s Health and Cancer Right’s Act,
the coverage described below must be made available
under our health plan. Notice provisions in the law
require written notification to plan participants on an
annual basis.
The following coverage will be provided to plan
participants having breast reconstruction in connection
with mastectomy:
1. Reconstruction of the breast on which the
mastectomy was performed
2.Surgery and reconstruction of the other breast
to produce a symmetrical appearance, and
NOTICE OF SPECIAL ENROLLMENT RIGHTS
If you are declining enrollment for yourself or your
dependents (including your spouse) because of other
health insurance coverage, you may, in the future, be
able to enroll yourself or your dependents in this plan,
provided that you request enrollment within 31 days
after your other coverage ends. In addition, if you have
a new dependent as a result of marriage, birth,
adoption, or placement for adoption, you may be able
to enroll yourself and your dependents, provided that
you request enrollment within 31 days after the
marriage, birth, adoption, or placement for adoption.
NEWBORN’S AND MOTHER’S HEALTH
PROTECTION ACT OF 1996 (NMHPA) NOTICE
Group health plans and health insurance issuers
generally may not, under Federal law, restrict benefits
for any hospital length of stay in connection with
childbirth for the mother or newborn child to less than
48 hours following a vaginal delivery, or less than 96
hours following a cesarean section. However, Federal law
generally does not prohibit the mother’s or newborn’s
attending provider, after consulting with the mother,
from discharging the mother or her newborn earlier than
48 hours (or 96 hours, as applicable). In any case, plans
and issuers may not, under Federal law, require that a
provider obtain authorization from the plan or the
insurance issuer for prescribing a length of stay less
than 48 hours (or 96 hours following cesarean section).
THIS GUIDE IS ONLY A SUMMARY
This Guide is only a summary of the main features of
these plans and programs. The terms and conditions of
the benefits described will be determined solely by the
applicable plan documents, and such plan documents
will govern in the event of any discrepancies or
omissions. As in the past, Mercy Health reserves the
right to change, amend or terminate these plans and
programs at any time. The benefits described herein
may not automatically apply to employees at all locations
or employees covered under a labor agreement.
Mercy Health’s benefits practices are separate from its
employment practices. Your participation in a Mercy
Health plan is not a contract or guarantee of employment.
No statement in this document is an offer or
contractual commitment by Mercy Health to any
participant. Mercy Health reviews its benefits plans
regularly and reserves the right to change, or end any
plan at any time.
THE FINE PRINT
For further information contact the Mercy Health
Compensation and Benefits Department at
513-981-6000.
NOTE: You’ll get this notice each year. You will also
get it before the next period you can join a Medicare
Drug Plan, and if this coverage through Mercy Health
changes, you also may request a copy of this notice at
any time. For More Information About Your Options
Under Medicare Prescription Drug Coverage More
detailed information about Medicare plans that offer
prescription drug coverage is in the “Medicare & You”
handbook. You’ll get a copy of the handbook in the mail
every year from Medicare. You may also be contacted
directly by Medicare prescription drug plans. For more
information about Medicare prescription drug coverage:
•Visit www.medicare.gov.
•C all your State Health Insurance Assistance Program
(see the inside back cover of your copy of the
“Medicare & You” handbook for their telephone
number) for personalized help.
•C all 1-800-MEDICARE (1-800-633-4227). TTY users
should call 1-877-486-2048.
If you have limited income and resources, extra help
paying for Medicare prescription drug coverage is
available. For more information about this extra help, visit
Social Security on the web at www.socialsecurity.gov
or call them at 1-800-772-1213 (TTY 1-800-325-0778).
REMEMBER: Keep this Creditable Coverage notice. If
you decide to join one of the Medicare drug plans, you
may be required to provide a copy of this notice when
you join to show whether or not you have maintained
creditable coverage and, therefore, whether or not you
are required to pay a higher premium (a penalty).
Date:8/2/2013
Name of Entity/Sender:
Mercy Health
Contact-Position/Office:Compensation & Benefits
Address:4600 McAuley Place
Phone Number:513-981-6000
3.Coverage for prosthesis and physical
complications.
This coverage will be subject to all deductible,
co-payment and other plan provisions in effect at the
time of claim for the type of service provided.
Should you have any questions or concerns, please
feel free to contact NGS American at 1-800-647-1761.
Benefits and Administrative Appeals
There are two types of appeals available under the
medical plan.
•B
ENEFITS APPEAL You may appeal a denial of
benefits or a reduced payment of services for you
or your covered family member has received or are
planning to receive. Benefits Appeals should be sent
to NGS Core Source, our Plan Supervisor, for review
and determination.
• ADMINISTRATIVE APPEAL You may also appeal an
administrative decision that results in loss of
eligibility for you or a family member. Administrative
Appeals should be sent to the Catholic Health
Partners Benefits Appeals Committee for review
and determination.
THE FINE PRINT
BENEFITS APPEALS PROCESS
You can file a Benefits Appeal when benefits have been
denied, either on a pre-service or post-service basis,
such as denials for medical necessity, failure to precertify, or experimental treatment.
WHAT IF YOUR CLAIM IS DENIED? Except with Urgent
Care Claims, when the notification may be given orally
followed by written or electronic notification within three
days of the oral notification, the Plan Supervisor shall
provide written or electronic notification of any adverse
benefit determination. The notice will state, in a manner
calculated to be understood by the claimant:
1.The specific reason or reasons for the adverse
benefit determination.
2.Reference to the specific plan provisions on which
the determination was based.
3.A description of any additional material or
information necessary for the claimant to perfect
the claim and an explanation of why such material
or information is necessary.
4.A description of the plan’s review procedures and
the time limits applicable to such procedures.
5.A statement that the claimant is entitled to receive,
upon request and free of charge, reasonable access
to, and copies of, all documents, records, and other
information relevant to the claim.
6.If the adverse benefit determination was based on
an internal rule, guideline, protocol, or other similar
criterion, the specific rule, guideline, protocol, or
criterion which was relied on will be provided free
of charge to the claimant upon request.
7.If the adverse benefit determination is based on
medical necessity or experimental or
investigational treatment or a similar exclusion or
limitation, an explanation of the scientific or clinical
judgment for the determination, applying the terms
of the plan to the claimant’s medical circumstances,
will be provided free of charge to the claimant
upon request.
HOW DO YOU FILE AN APPEAL? If a claimant receives
an adverse benefit determination for a non-urgent,
pre-service claim or a post-service claim, you or your
covered dependent may appeal the decision in writing
within 180 days of the date of the adverse benefit
determination. You or your covered dependent may
submit written comments, documents, records, and
other information relating to the claim.
The appeal and all supporting documentation should
be submitted to the Plan Supervisor, NGS Core Source,
at P.O. Box 2310, Mt. Clemens, MI 48046. It is your
responsibility to submit proof that the claim for benefits
is covered and payable under the provisions of the plan.
Any appeal must include:
•The employee name/plan participant
•The employee/plan participant identification number
•The group name or identification number
•All of the facts and theories supporting the claim for
benefits. Failure to include any theories or facts in the
appeal could result in losing a right to raise additional
factual arguments and theories at a later date.
•A statement from the plan participant in clear and
concise terms of the reason or reasons for
disagreement with the original benefits
determination
•Any materials or information the plan participant has
which indicates the plan participant is entitled to
benefits under the plan.
Generally, a decision on your appeal will be made
within 72 hours for an urgent, pre-service claim, 30 days
for a non-urgent, pre-service claim and 60 days from
receipt of the appeal for a post-service claim. The period
of time within which a benefit determination on review is
required to be made shall begin at the time an appeal is
filed in accordance with the procedures of the plan. This
timing is without regard to whether all the necessary
covered dependent requests, he/she will be provided,
free of charge, reasonable access to, and copies of, all
documents, records, and other information relevant to
the claim. A document, record or other information shall
be considered relevant to a claim if it:
1.Was relied upon in making the benefit determination;
2.Was submitted, considered or generated in the
course of making the benefit determination,
without regard to whether it was relied upon in
making the benefit determination;
3.Demonstrates compliance with the administrative
processes and safeguards designed to ensure and
ADMINISTRATIVE APPEALS PROCESS
You can file an Administrative Appeal when there has
been a denial of coverage based on a failure to comply
with an administrative plan provision, such as a missed
enrollment deadline or failure to provide timely eligibility
documentation.
WHAT IF YOUR COVERAGE IS DENIED? You will be
provided with notice of the denial and the reason for
the denial, including the plan provision at issue. You
will be given:
1.The specific reason or reasons for the adverse
administrative determination.
2.Reference to the specific plan provisions on which
the determination was based.
3.A description of any additional material or
information necessary for the claimant to compose
the appeal and an explanation of why such material
or information is necessary.
4.A description of the plan’s review procedures and
the time limits applicable to such procedures.
5.If the adverse administrative determination was
based on an internal rule, guideline, protocol, or other
similar criterion, the specific rule, guideline, protocol,
or criterion which was relied on will be provided free
of charge to the claimant upon request.
If you experience an adverse administrative
determination you may appeal the decision in writing
within 60 days of the date of the adverse administrative
determination. You may submit written comments,
documents, records, and other information relating to the
appeal. The appeal and all supporting documentation
should be submitted to Catholic Health Partners Benefits
Appeals Committee, c/o Mercy Health, 4600 McAuley
Place, Cincinnati, OH 45242. It is your responsibility to
submit proof that your request for Administrative remedy
is warranted and there are compelling circumstances
which justify waiving an administrative provision of the
plan. The appeal must include the following information,
as appeals received with missing information may not be
considered for review:
•Your name
•Your employee identification and phone number
•Name of the plan
•All of the facts and theories supporting the claim for
coverage. Your failure to include any theories or
facts in the appeal could result in losing a right to
raise additional factual arguments and theories at
a later date.
•Your statement in clear and concise terms indicating
the reason or reasons for disagreement with the
original administrative determination.
•Any materials or information you have which
indicates that you should be entitled to a remedy
under the plan.
The review shall take into account all comments,
documents, records, and other information submitted by
you relating to your appeal, without regard to whether
such information was submitted or considered in the
initial benefit determination. The review will not afford
deference to the initial adverse administrative
determination and will be conducted by individuals who
are members of the CHP Benefits Appeals Committee.
IS THE DECISION ON REVIEW FINAL?
The decision by the CHP Benefits Appeals Committee
on review will be final, binding and conclusive, and will
be afforded the maximum deference permitted by law.
THE FINE PRINT
to verify that benefit determinations are made in
accordance with Plan documents and plan
provisions have been applied consistently with
respect to all claimants; or
4.Constitutes a statement of policy or guidance with
respect to the plan concerning the denied
treatment option or benefit.
The review shall take into account all comments,
documents, records, and other information submitted by
the claimant relating to the claim, without regard to
whether such information was submitted or considered
in the initial benefit determination. The review will not
afford deference to the initial adverse benefit
determination and will be conducted by individuals who
are neither the individual who made the adverse benefit
determination nor subordinates of that individual.
If the determination was based on a medical
judgment, including determinations with regard to
whether a particular treatment, drug or other item is
experimental, investigational or not medically necessary
or appropriate, the Plan Supervisor will consult with a
healthcare professional who was not involved in the
original benefit determination. This healthcare
professional will have appropriate training and
experience in the field of medicine involved in the
medical judgment. Additionally, medical or vocational
experts whose advice was obtained on behalf of the plan
in connection with a review on appeal will be identified.
IS THE DECISION ON REVIEW FINAL? The decision by
the Plan Supervisor on review will be final, binding and
conclusive, and will be afforded the maximum deference
permitted by law.
EXTERNAL REVIEWS. A claimant may request an
external review of a denied claim by making written
request to the Plan Supervisor within four months of
receipt of notification of the final internal denial of
benefits. The plan may charge a filing fee to the covered
individual requesting an external review, subject to
applicable laws and regulations. The following are not
eligible for external review: a denial, reduction,
termination, or failure to provide payment for a benefit
based on a determination that an individual fails to meet
the requirements for eligibility under the terms of the
plan. For more detailed information, please review the
Adverse Benefit Determinations and Appeals section of
the Plan Summary Plan Description.
Contacts,
Glossary and
Frequently
Asked
Questions
Dyatra Mitchell, MD
MASON AREA MEDICAL
ASSOCIATES
“When looking for a primary
care physician you want to
choose a physician you can
communicate with and
trust. You want a physician
who provides quality and
compassionate care. You
want to choose a physician
CONTACTS, GLOSSARY
AND FAQ
who values the patient
physician relationship. At
Mercy Health we provide all
of these qualities and much
more. Choose Mercy Health
Physicians. I did.”
Benefits Contacts
MEDICAL PLAN
Plan Supervisor:
NGS CoreSource
Plan Name:
Mercy Health Plan
Group #:
MHPSWO
Member ID #:
Employee Social Security Number
Website for Claims Information:
www.ngs.com
To register, select “Plan Participants click here...”
Note: website registration cannot be completed
until enrollment is verified by NGS via US mail.
Customer Service:
1-800-647-1761 or submit your question at www.ngs.com
• Eligibility verification (contact your facility’s HR for enrollment or benefit changes)
• Benefit questions
• Medical and Benny Card replacement
• Claim inquiries
Claims Address:
NGS CoreSource
P.O. Box 2310
Mt. Clemens, MI 48046
Provider Network:
Mercy Health Select Network and HealthSpan Preferred Network
www.healthspannetwork.com
513-551-1400 or 1-888-914-7726
Benefit Information Center:
www.benefitinfocenter.com/MHP
Pre-Certification/Utilization Management:
HealthSpan: 513-551-1420 or 1-800-972-7726
Pharmacy Benefit Manager:
Catamaran (formerly Catalyst Rx)
Plan Name:
Mercy Health Plan
Member ID #:
Refer to ID card
Website for Formulary, Provider Network,
www.mycatamaranRx.com
PRESCRIPTION PLAN
Drug Pricing & Mail Order:
Catamaran RX Customer Service:
1-877-235-2017
• Eligibility verification
• Prescription benefit questions
• Mail order refills (only if not available through Mercy Health Riverfront Pharmacy)
Mercy Health Riverfront Pharmacy: 1-866-775-5767
FLEXIBLE SPENDING ACCOUNT (FSA)
NGS CoreSource
www.ngs.com (see info under Medical to register on the website)
Customer Service:
1-800-647-1761 or submit your question at www.ngs.com
CONTACTS, GLOSSARY
AND FAQ
Plan Supervisor:
Website ID#:
HEALTH REIMBURSEMENT ACCOUNT
Plan Supervisor:
NGS CoreSource
Customer Service:1-800-647-1761 or submit your question at www.ngs.com
CHP RETIREMENT SAVINGS PLAN
Administrative Service Provider:
Fidelity Investments
Website:
https://plan.Fidelity.com/chpsavings
Customer Service:
1-800-343-0860
Group ID:
95881
Member ID:
Plan Supervisor:
Delta Dental Plan of Ohio
Plan Name:
DeltaPreferred Option USA Point-of-Service (DPO)
Group #:
9950-0201
Member ID #:
www.consumertoolkit.com
Customer Service:
1-800-524-0149
DENTAL PLAN
• Locate DPO participating providers
• Plan benefit questions (customer service or instant faxed benefits)
• Claims status & processed claim inquiries (customer service or instant
faxed claims summary)
Provider Network:
DeltaPreferred and Premier Options USA — www.deltadental.com
Claims Address:
Delta Dental
P.O. Box 9085
Farmington Hills, MI 48333-9085
NOTE: ID cards are not necessary to obtain services. Your dentist can verify your eligibility 24/7 at dentalofficetoolkit.com or by calling
the Customer Service number above. If you wish to have a Dental Reference Card, you may print one from www.consumertoolkit.com.
VISION PLAN
Insurance Carrier:
EyeMed Vision Care
Group #:
9730979
Member ID #:
www.eyemedvisioncare.com
Customer Service:
1-866-800-5457
• Benefit questions
CONTACTS, GLOSSARY
AND FAQ
• Network provider information
Provider Network:
Access Network www.eyemedvisioncare.com
Claims Address:
EyeMed Vision Care
P.O. Box 429491
Changes to your benefits elections for Medical, Dental and Vision coverage must be submitted within 31 days of a qualifying status
change/event. New coverage for Medical, Dental, Vision and FSA will be effective the first of the month following hire or an eligibility event.
Changes in existing coverage will be effective the event date. Member cards for new enrollment can take 2 – 4 weeks for processing.
In the meantime, please use this sheet to supply providers with coverage information.
LIFE INSURANCE
Insurance Carrier:
CIGNA
Policy #:
FLX-980075
Customer Service:
1-800-732-1603 for claims information
Beneficiary Forms:
Available on the intranet or contact your Human Resources Department
HEARING BENEFIT SERVICES
Insurance Carrier:
EPIC Hearing Healthcare
Coverage Information:
1-866-956-5400
NOTE: This benefit is managed entirely by EPIC. Please call EPIC directly regarding this benefit.
WILL PREPARATION/FUNERAL PLANNING
Insurance Carrier:
CIGNA
Website:
www.CIGNAWillCenter.com
IDENTITY THEFT PROGRAM
Insurance Carrier:
CIGNA
Customer Service:
1-888-226-4567 (member of CIGNA Identity Theft Program)
Group #:
57
DISABILITY INSURANCE (TELEPHONIC)
Insurance Carrier:
CIGNA
Customer Service:
1-800-36-cigna (24462) or 1-866-562-8421 (Español)
Website:
myCigna.com
Policy #:
Short Term Disability — SHD 985195
between 7:00 a.m. and 7:00 p.m.
Long Term Disability — FLK 980128
EMPLOYEE ASSISTANCE PROGRAM
HealthSpan Employee Assistance Plan
Customer Service:
1-513-551-1500 or 1-800-733-0257
CONTACTS, GLOSSARY
AND FAQ
Service Provider:
Glossary
ALLOWED CHARGES: Charges billed by a provider
for services, less the network discount.
BENEFICIARY: The person(s) designated by you to
receive life insurance and/or available retirement funds
in the event of your death.
DEPENDENT: Includes your legally-married, opposite-sex
spouse, and your child(ren) under age 26 who meet plan
eligibility requirements, including any child for whom
you or your spouse serve as legal guardians. See pages
6 - 7 for eligibility guidelines.
BENNY CARD: A debit card to use to access funds
DEPENDENT DAY CARE FLEXIBLE SPENDING ACCOUNT
(DFSA): You may set aside dollars from your pre-tax
in your Healthcare FSA, if enrolled, and Health
Reimbursement Account, if enrolled in a medical plan.
earnings to reimburse daycare for dependents. See
page 33 for qualifications and dollar limits.
BRAND NAME DRUG: A drug protected by a patent
issued to the original innovator or marketer. The patent
prohibits the manufacture of the drug by any other
companies. In other words, there is no generic equivalent
until the patent expires.
EVIDENCE OF INSURABILITY: A form with a list of
questions regarding the status of your health and, if
needed, your spouse’s/dependent’s health. This applies
to Supplemental Life only. See page 39 - 40 for details.
FLEXIBLE SPENDING ACCOUNTS (FSA): Flexible
CHP RETIREMENT SAVINGS PLAN: Also known as a
403b plan. Benefit contributions come from employee
deferrals, company matching funds, Core contribution
and Retirement Shared Savings Success contribution.
CLAIMS ADMINISTRATOR/PLAN SUPERVISOR: Company
contracted by Mercy Health to process medical plan
claims and appeals (NGS CoreSource). See pages
66 – 67 for more information.
spending accounts give you the opportunity to set
aside pre-tax dollars for the reimbursement of eligible
benefits. FSA’s are funded by your payroll deduction.
To establish a Healthcare FSA as well as a Dependent
Day Care FSA. See pages 32 – 33 for qualifications and
dollar limits.
FORMULARY: The list of drugs identified by the plan as
Generic, Preferred Brand Name or Non-Preferred Brand
Name, which may determine your cost.
CO-PAY: A fixed dollar amount you pay when you receive
a specific service, for example, an office visit. Certain
co-pays, such as office visit co-pays, count toward
meeting your out of pocket maximum for the year.
GENERIC DRUG: A drug that is comparable to a brand
name drug and is usually sold at a lower price.
HEALTH BENEFITS: Generally includes medical, dental
CO-INSURANCE (EMPLOYEE): The percentage of
allowed charges you pay when you receive care after
the deductible (if any) has been satisfied. This amount
counts toward meeting your out of pocket maximum
for the year.
HEALTH BENEFITS CONTINUATION COVERAGE: If you
charges the plan pays for approved covered services.
terminate employment, exhaust your benefits on a leave
of absence, or if you or your dependents otherwise
become ineligible for benefits, you and/or they will have
the opportunity to continue health benefits through a
pay-from-home program. See pages 50 - 51 for details.
DEDUCTIBLE: The amount of money you must pay each
HEALTHCARE FLEXIBLE SPENDING ACCOUNT (HFSA):
year for covered medical services before any benefits
are covered by the plan. Certain preventive services are
covered at 100% and not subject to the deductible. See
page 19 for more information.
An account which uses pre-tax dollars set aside by
you to reimburse healthcare expenses not covered
by insurance, such as co-pays, prescription costs,
deductibles and some over-the-counter medications
(if prescribed by a doctor). See pages 32 – 33 for
qualifications and dollar limits.
CO-INSURANCE (PLAN): The percentage of allowed
CONTACTS, GLOSSARY
AND FAQ
and vision benefits.
HEALTH REIMBURSEMENT ACCOUNT (HRA): A special
account funded for you by Mercy Health when you
enroll in one of the three medical plans. These account
funds are used to cover part of your deductible or
co-insurance when you have claims under the plan.
OUT-OF-NETWORK: Physicians and facilities that are
not part of the HealthSpan Select Network, the Mercy
Select Network or HealthSpan Network. When you use a
doctor or facility that does not participate in either
network, your out-of-pocket costs are highest.
HEALTHSPAN: Sponsor of the provider networks used
OUT-OF-POCKET COST: The amount you pay when you
by Mercy Health’s medical plans. All providers defined
in the medical plan as belonging to the HealthSpan
Select Network, the Mercy Select Network or the
HealthSpan Network have contracts with HealthSpan.
HealthSpan also provides other plan services such as
provider lookup, pre-certification, Employee Assistance
Plan, disease management and wellness coaches.
receive care. These costs include deductibles, co-pays
and co-insurance.
HEALTHSPAN NETWORK: When you use this HealthSpan
network of providers you are eligible for Tier 2 coverage
under the Traditional and Choice medical plans.
HEALTHSPAN SELECT NETWORK: This is the network of
providers for the Exclusive medical plan. If you enroll in
this plan, you are expected to use these providers
except for emergency services, or unless authorized in
advance by HealthSpan.
LIFE INSURANCE CONVERSION/CONTINUATION: If you
become ineligible for benefits at a later date, terminate
employment, or exhaust one year of leave of absence,
you have the opportunity to maintain any basic and
supplemental life insurance benefits you carry through
a pay-at-home policy with CIGNA. See page 51
for more information.
LIFETIME MAXIMUM AMOUNT OF COVERAGE: There
is no lifetime limit to the amount payable for covered
expenses for each member covered under the health plan.
MERCY SELECT NETWORK: When you use this network
of Mercy Health facilities, Mercy Health Physicians and
Mercy Health-affiliated doctors, you are eligible for the
Tier 1 coverage under the Traditional and Choice
medical plans. Your out of pocket costs are lower when
you use the Mercy Select Network.
OPEN ENROLLMENT: The time period each autumn
when you can select your benefit options. Changes
you make during Open Enrollment take effect the
following Jan. 1.
OUT-OF-POCKET MAXIMUM: The maximum amount
you must pay out of pocket during the calendar year
before the plan pays for covered services at 100%.
Deductibles, co-insurance amounts and certain co-pays
count toward meeting this limit.
PRIMARY CARE PHYSICIAN (PCP): A doctor practicing in
the fields of General Medicine, Family Medicine, Internal
Medicine or Pediatrics.
PREVENTIVE SERVICES: Services and screenings
performed on a regular schedule to monitor health and
wellness (e.g., mammogram, annual physical, well child
visits). See page 20 for more information.
QUALIFYING EVENT: Family or job change that allows
you to change your benefit selections. See page 11 for
more information.
SPECIALIST OR SPECIALTY CARE PHYSICIAN: A doctor
practicing in any field of medicine not considered
Primary Care.
SUMMARY DESCRIPTION: This is a complete written
description of a benefit plan listing benefits, eligibility,
time limits, minimums and maximums, excluded
benefits, etc.
USUAL, CUSTOMARY AND REASONABLE (UCR): When
services are provided and no network discount exists on
which to base payment, a UCR amount is established for
the service and is used like allowed charges as the basis
for claim payment. If the charge billed is in excess of
UCR, you will be responsible for the remainder, in
addition to any applicable deductibles and co-insurance.
VESTING: The process by which you accrue ownership
of employer contributions that are made to your
qualified retirement plan account.
OUT-OF-AREA COVERAGE: If you are enrolled in the
CONTACTS, GLOSSARY
AND FAQ
Traditional or Choice medical plan and have a covered
family member who lives outside the area serviced by
our medical plan networks, you may request out-of-area
coverage. This will provide access to Tier 2 benefits
through a national network. This is not available under
the Exclusive plan. See page 26 for details.
Employee Benefits —
Frequently Asked Questions
ENROLLMENT
Q: I am currently enrolled in medical, dental and/or
vision coverage. What happens if I do not enroll
by the Nov. 25 open enrollment deadline?
A: If you don’t re-enroll, you will retain your current
medical, dental and vision elections (including “no
coverage” if that is your current choice), at your
current level of coverage (employee only, family,
etc.). You will not be enrolled in either flexible
spending account, because these elections do not
roll over from year to year. You will not be able to
make corrections to your benefit elections during
the correction period immediately following the
deadline, and your access to the tobacco-free
discount will be delayed.
So it is to your advantage to enroll.
Q: I am a new hire or newly eligible for benefits. What happens if I don’t enroll by the deadline
(31 days from hire date or qualifying event date)?
A:You will not be enrolled in medical, dental, vision
or flexible spending account benefits for 2014. You
will need to wait until the next open enrollment or
qualifying event to apply for enrollment in these plans.
ENROLLMENT OF SPOUSE OR
FAMILY MEMBER
Q: What if my spouse doesn’t want to take his/her
employer’s health coverage?
A: To cover your spouse on one of our medical plans,
he/she must enroll in their employer’s health plan if
one is offered at a reasonable cost, that is, not more
than $160 per month.
Q: Does my spouse have to enroll in his employer’s
dental and vision coverage to be enrolled
in my plan?
A: No. You may cover your spouse on the dental
and/or vision plans regardless of the other
employer’s offerings.
Q:
Will my spouse be covered if I haven’t completed
and submitted the Spousal Eligibility Form?
CONTACTS, GLOSSARY
AND FAQ
A: No. The plan will not pay claims if the Spousal
Eligibility form has not been completed online
during open enrollment, or completed on paper
and returned.
Q: Will Mercy Health contact my spouse’s
employer regarding his/her participation
in the employer’s plan?
A: Mercy Health reserves the right to verify the
work and benefit coverage information provided
when requesting spousal coverage.
Q: I provided dependent eligibility documentation
and spousal eligibility certification last year. Do
I have to provide this documentation each year?
A: You must provide dependent eligibility
documentation for any newly-added family member,
as well as annual spousal eligibility certification. If
you do not provide the required documentation by
the deadline, your spouse or other family member
will be dropped from the plan effective Jan. 1, 2014.
OUR MEDICAL NETWORK
Q:Why is Cincinnati Children’s Hospital Medical
enter not in the Mercy Select Network (Tier 1 for
C
the Traditional and Choice medical plans)?
A: Only our own facilities are in the Mercy Select
Network (Tier 1). We can provide a higher level
of coverage for our own facilities because our costs
are lower than those at other facilities in the
HealthSpan Network (Tier 2). However, Cincinnati
Children’s Hospital Medical Center is included in the
HealthSpan Select Network and covered at 80%
under the Exclusive plan.
Q:Why isn’t my doctor in the Mercy Select Network
or HealthSpan Select Network?
A: The Mercy Select Network and HealthSpan Select
Networks include our own Mercy Health doctors, as
well as Mercy Health-affiliated doctors. They do not
include doctors who are employed by another
health system.
MY HEALTH ASSESSMENT AND TOBACCOFREE PREMIUM DISCOUNT
Q: What if I quit using tobacco before the next
Open Enrollment?
A: You may also qualify for the discount if all covered adult family members who are not tobacco-free complete a Catholic Health Partners-sponsored tobacco cessation program. See page 14 for details on available programs.
Q: I didn’t get My Health Assessment. How can
Q:I didn’t get the My Health Assessment in 2013. If I
I get the full wellness incentive?
A: To receive the wellness incentive in 2014, you must
have completed the My Health Assessment, as well
as all Level 1 and Level 2 My Health Journey
requirements by the stated deadline in 2013. If your
spouse is enrolled in the medical plan, he/she must
also complete the My Health Assessment by the
deadline. If you (and your spouse, if applicable),
completed only the Level 1 requirements, you will
receive a portion of the wellness incentive.
participate when they are offered next summer,
can I get the wellness incentive at that time?
A: No, but participating will help you complete some
of the requirements to qualify for the wellness
incentive for 2015.
Q:As a new hire, I have 60 days to complete the My
Health Assessment but only 31 days to enroll in
benefits. Can I still receive the wellness incentive?
A: Yes, your wellness incentive will be deposited into
your Health Reimbursement Account you complete
your My Health Assessment within 60 days of hire.
Q: Will my premiums increase if something negative
is found in My Health Assessment results?
A: No. The results of your tests are not used to
determine your premiums.
Q:
What do you do with My Health Assessment results?
A:You receive a detailed report of your My Health
Assessment results available online in the
participant portal. The report helps you identify
areas to discuss with your doctor and set individual
goals to improve your health. Your results are used
by the medical plan to suggest programs and
resources that may help you with those goals.
Aggregate results (which don’t identify any
individual) are used by the organization to develop
future programs and incentives.
Q:I didn’t complete My Health Assessment and I
don’t currently have medical coverage through
Mercy Health. What if I do need to get coverage
next year? Will I be able to get a My Health
Assessment then?
A: All employees are eligible to participate in My
Health Assessment, whether they enroll in benefits
or not — it’s part of our commitment to good health.
To be sure you will qualify for a discount in 2014 if
you choose Mercy Health medical coverage later,
you should plan to complete the My Health
Assessment requirement during 2013.
HEALTH REIMBURSEMENT ACCOUNTS/
FLEXIBLE SPENDING ACCOUNTS/BENNY CARD
Q:
A: Is it true I can have my flexible spending
reimbursement direct deposited?
Yes. You can complete the paper authorization
form located on the intranet under the
Benefits/Flexible Spending and send it to NGS
or go to the Benefits Information Center and
supply the needed information.
Q: Should I use my Benny Card when I have an
office visit?
A:Yes, for all fixed dollar co-payments including
prescription drug co-pays, office visits, ER, and urgent
care, you can swipe your card at the time of service.
For any other charges, you should allow the provider
to bill the plan so the discount can be addressed
before what you owe is calculated. NGS will
automatically pay the provider what you owe from
your HRA account, other than any flat-dollar co-pays.
Q: Will I get a new Benny Card this year?
A:If your current Benny Card is set to expire soon, you
will receive a new one. If you did not previously have
a Benny Card and you enroll in any of our medical
plans or the Healthcare Flexible Spending Account,
you will get a new Benny Card. Watch for the bright
red Benny Card in the mail.
Q: How do I obtain reimbursement for 2013
Healthcare FSA claims after Dec. 31, 2013 but
before the timely filling deadline of March 31, 2014?
A:As long as the expense was incurred during 2013
(while you were covered under the plan), you can
apply for reimbursement by filing a paper claim form
with NGS. Your Benny Card cannot be used for prior
year FSA claims, because it always pulls funds for
the current year’s account on the date of the swipe.
CONTACTS, GLOSSARY
AND FAQ
Q: Will Mercy Health accept lab results obtained
outside the My Health Assessment process?
A: Yes, you or your spouse may complete the My Health
Assessment requirements by having your primary
care physician complete the required tests and
submit the form that can be found on the intranet.
Q: How do I access rollover account dollars in Plan A
after Dec. 31?
A:If you have dollars left in your Health
Reimbursement Account, these dollars will roll
forward into your 2014 HRA, regardless of which
plan you choose. You may obtain reimbursement
using these funds by filing a paper claim form with
NGS. You can also use your Benny Card for these
expenses once the account dollars have rolled over
to the new plan. You can check your HRA account
balance at the NGS Benefit Information Center at
www.benefitinfocenter.com/mhp.
Q: Since I can now cover my adult child (ages 19 – 26)
on the medical plan even if he is living
independently and has his own job, can I also
maintain the dependent life insurance?
A: No. In order to maintain dependent child life
insurance, the child must remain a full-time student
and can only be covered to age 25. It is up to you to
insure the student status is maintained or the benefit
will not be payable. If you need to remove your child
from this coverage for this reason, submit a Benefit
Enrollment/Change Form.
Q: How do I receive the wellness incentive?
A:The wellness incentive dollars are deposited in your
2014 Health Reimbursement Account, provided you
are enrolled in one of our medical plans.
Q: Are “white” composite fillings available for
LIFE INSURANCE
Q: How do I join the HealthPlex?
Q:I want to change my life insurance at open
enrollment. How can I do that?
A: Now during open enrollment, you can elect your
supplemental, spouse and dependent life insurance
options online in PeopleSoft self-service. You may
increase your current supplemental life or spouse
life coverage by one level without evidence of
insurability (EOI), as long as your new coverage
does not exceed the guaranteed issue amount. If
your new coverage does exceed the guaranteed
issue amount, you will need to provide EOI and be
approved by CIGNA before the higher coverage
takes effect. See pages 39 - 40 for more details.
You can also make changes to your term life insurance
at any time throughout the year. You will need to
complete a Supplemental Life Insurance Application
form and an Evidence of Insurability form, both of
which are available on the intranet or in the Human
Resources Department.
CONTACTS, GLOSSARY
AND FAQ
Q:
A: DENTAL INSURANCE
posterior (back) teeth?
A: Yes.
HEALTHPLEX/WELLNESS
A: Call a membership representative
at 513-942-PLEX (7539).
Q: How do I schedule a Nutritional Counseling visit?
A: Call Central Scheduling at 1-800-95-MERCY to
schedule your visit with a Mercy Health dietitian,
covered by our medical plan.
I heard that life insurance for my spouse ends
when he/she turns 70 years of age. Is that true?
Yes. This coverage is not available for a spouse after
reaching age 70. It is up to you to remove your
spouse from coverage upon reaching age 70.
TIP: Instructions for how to enroll online in PeopleSoft and print a summary of your benefit
elections will be provided online on the Mercy Health intranet.
Your Guide To Services and
Locations at Mercy Health
KEY:
North Market
Central Market
East Market
West Market
Indiana
Bariatrics and Weight Management
WEIGHT MANAGEMENT SOLUTIONS
Anderson
Fairfield
Kenwood
Behavioral Health and Mental Health
MENTAL AND BEHAVIORAL HEALTH
SERVICES FOR ADULTS
Clermont Hospital
PSYCHIATRY
Anderson
Cardiology and Heart Care
THE HEART INSTITUTE
Anderson
Bridgetown
Clermont
Fairfield
Hamilton
Harrison
Kenwood
Lawrenceburg
Liberty Falls
Mt. Orab
Oxford
Rookwood
West
HEART REHABILITATION
Anderson Hospital
Clermont Hospital
Fairfield Hospital
The Jewish Hospital
West Hospital
Anderson Hospital
Clermont Hospital
Fairfield Hospital
The Jewish Hospital Cholesterol and Metabolism Center
West Hospital
Mercy Health — Orthopaedic & Spine Specialists
Dermatology
Anderson
Kenwood
Diabetes Care & Endocrinology
Anderson
Cholesterol and Metabolism Center
Deerfield
Fairfield
The Jewish Hospital
Kenwood
West Hospital
Ear, Nose and Throat
Blue Ash Ear, Nose and Throat
Fairfield Ear, Nose and Throat
Tri-County Ear, Nose and Throat
Emergency Services
Anderson Hospital
Clermont Hospital
Fairfield Hospital
Harrison Medical Center
The Jewish Hospital
Mt. Orab Medical Center
Rookwood Medical Center
West Hospital
Western Hills Medical Center
Imaging Services
IMAGING LOCATIONS
Anderson Hospital
Anderson Imaging and Lab Services
Clermont Hospital
Fairfield Hospital
The Jewish Hospital Outpatient CT Center of Norwood
The Jewish Hospital Outpatient MRI/Women’s Center
The Jewish Hospital
Liberty Falls Imaging and Lab
Mason Imaging
Midwest Medical Associates
Milford Imaging
Tri-County Imaging
Westside Imaging
White Oak Imaging
CONTACTS, GLOSSARY
AND FAQ
NUTRITION COUNSELING
Chiropractic Care
LAB SERVICES
Anderson Hospital Anderson Imaging and Lab Services
Blue Ash Lab Services
Clermont Hospital
Deerfield Lab Services
Eastgate Occupational Health & Urgent Care
Fairfield HealthPlex Lab Services
Fairfield Hospital Finneytown
Kenwood Lab Services
Liberty Falls Imaging & Lab Services
Lindenwald Lab Services
Mt. Healthy Lab Services
Springdale Occupational Health & Urgent Care
West Hospital
Winton Lab Services
Life Management
Systems/Counseling
Anderson
Clifton
Kenwood
Springdale
Lung and Pulmonary
East Pulmonary, Sleep and Critical Care
•Anderson
•Clermont
Fairfield Pulmonary and Critical Care
Kenwood Pulmonary and Critical Care
West Pulmonary, Sleep and Critical Care
Neurology
Batavia Deerfield Fairfield
Liberty Falls
Westside
Occupational Health
Eastgate Occupation Health & Urgent Care
Oncology/Cancer Care
CONTACTS, GLOSSARY
AND FAQ
Anderson Hospital Clermont Hospital Fairfield Hospital
The Jewish Hospital
West Hospital
Orthopaedics and
Sports Medicine
Anderson
Blue Ash
Eastgate
Fairfield
Harrison
Kenwood
Oxford
Sardinia
West
West Chester
Osteoporosis and Bone Health
Kenwood Endocrinology & Osteoporosis
Pain Medicine
Fairfield
Kenwood
West
Palliative Care
Anderson Hospital
Clermont Hospital
Fairfield Hospital
The Jewish Hospital
West Hospital
Patient-Centered Medical Home
Blue Ash Family Medicine
Deerfield Family Medicine & Specialists
Dent Crossing Family Medicine
Eastgate Family Medicine
Evendale Family Medicine
Fairfield Family Medicine
Fairfield Internal Medicine and Rheumatology
Forest Park Internal Medicine and Pediatrics
Kenwood Family Medicine
Mariemont Family Medicine
Milford Family Medicine
Mt. Airy Internal Medicine
Red Bank Family Medicine
Sardinia Family Medicine
Wyoming Primary Care
Primary Care and
Family Medicine
Rehabilitation and Therapy
Addyston Family Medicine
Anderson Family Medicine
Anderson Hills Internal Medicine
Anderson Primary Care
Avondale Internal Medicine
Blue Ash Family Medicine
Blue Ash Internal Medicine
Blue Ash Primary Care
Colerain Internal Medicine
College Hill Internal Medicine
Deerfield Family Medicine & Specialists
Delhi Family Medicine
Delhi Internal Medicine
Dent Crossing Family Medicine
Downtown Medical Care
Dry Ridge Family Medicine
Eastgate Family Medicine
Evendale Family Medicine
Fairfield Family Medicine
Fairfield Internal Medicine & Rheumatology
Forest Park Internal Medicine & Pediatrics
Forest Hills Family Medicine
Georgetown Family Medicine
Glendale-Milford Internal Medicine
Goshen Family Medicine
Goshen Internal Medicine
Harrison Internal Medicine
Harrison Primary Care
Kenwood Family Medicine
Kenwood Internal Medicine
Kenwood Internal Medicine & Pulmonary
Mack Road Family Medicine
Mariemont Family Medicine
Mason Area Medical Associates
Mason Family Medicine
Midwest Primary Care
Milford Family Medicine
Monfort Heights Family Medicine
Mt. Carmel Family Medicine
Mt. Airy Internal Medicine
Mt. Airy Primary Care
Mt. Orab Family Medicine
Oak Hills Internal Medicine
Oakley Primary Care
Red Bank Family Medicine
Sardinia Family Medicine
Springdale Family Medicine
Springdale Family Medicine at Liberty Falls
State Road Internal Medicine
Westside Internal Medicine
White Oak Primary Care
Wyoming Primary Care
Anderson HealthPlex
Anderson Hospital
Bethel Outpatient Physical Therapy
Clermont Hospital
Compton Outpatient Physical Therapy
Eastgate Outpatient Rehabilitation and Therapy
Fairfield Hospital
Fairfield HealthPlex
The Jewish Hospital
West Hospital
Western Hills HealthPlex
Western Hills Medical Center (outpatient)
OCCUPATIONAL THERAPY
Eastgate Occupational Health & Urgent Care
SPEECH THERAPY
Anderson Hospital Clermont Hospital Fairfield Hospital
The Jewish Hospital
West Hospital
SENIOR REHABILITATION
Sacred Heart
West Park
PULMONARY REHABILITATION
Anderson Hospital
Clermont Hospital
Fairfield Pulmonary & Critical Care
The Jewish Hospital
West Hospital
Rheumatology
Fairfield Internal Medicine and Rheumatology
Senior Living
Sacred Heart
StoneBridge at Winton Woods
West Park
Sleep Center
Anderson Sleep Center
Clermont Pulmonary, Sleep & Critical Care
West Pulmonary, Sleep & Critical Care
CONTACTS, GLOSSARY
AND FAQ
PHYSICAL THERAPY
Social Service Agencies
St. John
St. Raphael
Women’s Health and OB/GYN
DIGITAL MOBILE MAMMOGRAPHY
GYNECOLOGY/OBSTETRICS
Anderson Hospital Family Birthing Center
Anderson Hospital Women’s Center
Anderson OB/GYN Clinic
Batavia Gynecology
Clermont Women’s Center
East OB/Gynecology
Fairfield Hospital Family Birthing Center
Georgetown Gynecology
Hillsboro Gynecology
The Jewish Hospital
The Jewish Hospital Breast Center
The Jewish Hospital Outpatient MRI/Women’s Center
Kenwood Gynecology
Kenwood Breast Surgery
Mt. Airy Gynecology
West Gynecology
West Hospital Family Birthing Center
Wound Care
CONTACTS, GLOSSARY
AND FAQ
Clermont Hospital Wound Care Center
Fairfield Hospital Wound Care Center
The Jewish Hospital Wound Care Center
Monfort Heights Wound Care Center
SUMMARY OF BENEFITS
AND COVERAGE
Appendix
SUMMARY OF BENEFITS AND COVERAGE
TRADITIONAL PLAN
CHOICE PLAN
EXCLUSIVE PLAN
The following pages are Summary
of Benefits and Coverage Notices
required by Federal Health Care
Reform. The format and content of the
notices must follow Federal guidelines.
These guidelines also selected the
examples and plan cost calculations
to be used. For example, the coverage
examples do not reflect premiums and
health reimbursement account dollars
contributed by your employer.
Please be sure to read the
disclaimers at the end of the notices.
Coverage Period: 01/01/2014 – 12/31/2014
Coverage for: Individual + Family | Plan Type: PPO
No.
Yes. Domestic Tier 1 providers $3,000 individual/$6,000
family. In-Network Tier 2 providers: $5,000
individual/$10,000 family. Out of Network Tier 3
providers Unlimited individual/ Unlimited family
Out of Network expenses, penalties, premiums, balancebilled charges, and health care this plan doesn’t cover.
No.
Answers
Domestic Tier 1= $800 individual/$1,600 family
In-Network Tier 2= $1,700 individual/$3,400 family Outof Network Tier3 =$5,500 individual/$11,000 family
Not subject to deductible: Tier 1/Tier 2 preventive care,
primary care office visits, and specialist office visits. All
Tiers: urgent care, emergency treatment, prescription
drugs, co-pays and penalties.
No. You don’t need a referral to see a specialist.
MHP, CMHP, Tiffin, Willard
1 of 12 If you use an in-network doctor or other health care provider,
this plan will pay some or all of the costs of covered services. Be
aware, your in-network doctor or hospital may use an out-ofnetwork provider for some services. Plans use the term innetwork, preferred, or participating for providers in their
network. See the chart starting on page 2 for how this plan pays
different kinds of providers.
You can see the specialist you choose without permission from
this plan.
The chart starting on page 2 describes any limits on what the plan
will pay for specific covered services, such as office visits.
You don’t have to meet deductibles for specific services, but see
the chart starting on page 2 for other costs for services this plan
covers.
The out-of-pocket limit is the most you could pay during a
coverage period (usually one year) for your share of the cost of
covered services. This limit helps you plan for health care
expenses.
Even though you pay these expenses, they don’t count toward the
out-of-pocket limit.
You must pay all the costs up to the deductible amount before
this plan begins to pay for covered services you use. Check your
policy or plan document to see when the deductible starts over
(usually, but not always, January 1st). See the chart starting on
page 2 for how much you pay for covered services after you meet
the deductible.
Why this Matters:
Questions: Call 1-800-647-1761
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call 1-800-647-1761 to request a copy.
Do I need a referral to see a
specialist?
Yes. For a list of Network providers see
Does this plan use a network of
www.healthspannetwork.com or call 1-888-914-7726
providers?
or www.phcs.com at 1-8900-914-7726
Is there an overall annual limit
on what the plan pays?
What is not included in the
out–of–pocket limit?
Is there an out–of–pocket limit
on my expenses?
Are there other deductibles for
specific services?
What is the overall deductible?
Important Questions
document by calling 1-800-647-1761
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Catholic Health Partners 3 Tier Traditional Plan
Office Visit:
$35 copay per
visit
All other
services: 10%
coinsurance
0% coinsurance
up to max of
$70 per visit
Specialist visit
Other
practitioner
office visit
Chiropractor
Primary care
visit to treat an
injury or illness
Office Visit:
$10 copay per
visit
All other
services: 10%
Domestic
Network Tier
1 Provider
Office Visit
$30 copay per
visit
All other
services: 30%
coinsurance
Office Visit:
$50 copay per
visit
All other
services: 10%
coinsurance
0%
coinsurance up
to max of $70
per visit
Not covered
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
Network Tier Non Network
2 Provider Tier 3 Provider
Your cost if you use a:
2 of 12 Chiropractic care: limited to 15 visits in a calendar year.
Bariatric surgery is only covered for approved programs under
Tier 1 Network providers or if no Tier 1 facility is available
within 200 miles.
Women’s preventive care contraceptives are excluded.
Limitations & Exceptions
If you visit a
health care
provider’s
office or clinic
Common
Medical
Event


Services You
May Need
Are there services this plan
doesn’t cover?


Coverage Period: 01/01/2014 – 12/31/2014
Some of the services this plan doesn’t cover are listed on page 13.
Yes.
See your policy or plan document for additional information
about excluded services.
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if
you haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use Tier 1 and Tier 2 providers by charging you lower deductibles, copayments and coinsurance
amounts.
Imaging
(CT/PET scans,
MRIs)
Physician
charge: 10%
coinsurance
Facility charge:
10%
coinsurance
Facility charge:
10%
coinsurance
No charge
Facility charge:
$500 copay per
visit then 30%
coinsurance
30%
coinsurance
No charge
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
Not Covered
3 of 12 Precertification and copay applies for , virtual colonoscopy,
and PET scan.
Failure to comply with precertification requirements will result
in a $500 penalty for inpatient services and $250 penalty for
outpatient services.
Precertification required for any genetic testing covered by the
plan. Failure to comply with precertification requirements will
result in a $500 penalty for inpatient services and $250 penalty
for outpatient services.
Women’s preventive care contraceptives are excluded
Coverage Period: 01/01/2014 – 12/31/2014
If you have a
test
Diagnostic test
(x-ray, blood
work)
Preventive
care/screening/
immunization
Non-Formulary
Formulary
30 day supply
Retail pharmacy or In-house pharmacy:
30% coinsurance with a $40 minimum and $150
maximum
90 day supply
Mail order pharmacy or In-house pharmacy:
maximum
4 of 12 Effective July 1, Tiffin, and Willard employees must obtain
maintenance medications (multiple fills) in excess of 1 fill at
(1) their market’s In-House Pharmacy, (2) Riverfront mail
order pharmacy, or (3) Catamaran mail order pharmacy.
SWO and Springfield employees: Mail order is through
Riverfront Pharmacy unless prior authorization is obtained.
Maintenance medications (multiple fills) in excess of 2 fills
must be obtained at Riverfront Pharmacy in order to be
covered. Effective July 1, 2014 maintenance medications
(multiple fills) in excess of 1 fill must be obtained at
Riverfront Pharmacy in order to be covered.
Fertility drugs will be paid at 50% with a $2,500 maximum
Request for brand medication when generic is available, will
require you to pay the applicable brand co-pay plus the
difference in cost between generic and brand.
Women’s preventive care services are offered, except for
contraceptives.
Preventive drugs mandated by PPACA=No Charge.
Coverage Period: 01/01/2014 – 12/31/2014
More
information
about
prescription
drug coverage
is available at
www.mycatama
ranrx.com
If you need
drugs to treat
your illness or
condition
Generic drugs
30 day supply
0% coinsurance up to a $10 maximum
90 day supply
0% coinsurance with up to a $25 max
30 day supply
maximum
90 day supply
maximum
10%
coinsurance
Urgent care
20%
coinsurance
$200 copay per
visit, then 10%
Emergency
room services
Emergency
medical
transportation
Office Visit:
Office Visit: $50
$35 copay per
copay per visit
visit
All other
All other
services: 30%
services: 10%
coinsurance
coinsurance
(no deductible)
(no deductible)
$200 copay per
visit, then 10%
10%
coinsurance
30%
coinsurance
30%
coinsurance
Physician/surge
on fees
10%
coinsurance
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
(no deductible)
20%
coinsurance
$200 copay per
visit, then 10%
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
5 of 12 Bariatric surgery is only covered for approved programs under
Tier 1 Network providers or if no Tier 1 facility is available
within 200 miles.
Precertification required for: Blepharoplasty, Rhinoplasty,
Sclerotherapy for varicose veins, Septoplasty, Vein surgery,
Scar revisions, TMJ treatment, Breast reconstruction (other
than following a surgery to treat cancer), any covered cosmetic
services, prophylactic mastectomies and oophorectomies,
covered oral surgery procedures, chemo therapy, radiation
therapy dental procedures (including confinements for
concurrent medical conditions, sleep disorder treatment,
transplant evaluation and surgery. Failure to comply with
precertification requirements will result in a $500 penalty for
inpatient services and $250 penalty for outpatient services.
contraceptives.
Coverage Period: 01/01/2014 – 12/31/2014
If you need
immediate
medical
attention
If you have
outpatient
surgery
Facility fee (e.g.,
ambulatory
surgery center)
Physician/
surgeon fee
10%
coinsurance
10%
coinsurance
30%
coinsurance
$500 copay per
visit, then 30%
coinsurance
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
6 of 12 Precertification required for all inpatient hospitals
confinements Failure to comply with precertification
requirements will result in a $500 penalty for inpatient services
and $250 penalty for outpatient services. This provision does
not apply to childbirth admissions less than 48 hours for
vaginal delivery or 96 hours for cesarean delivery.
Precertification required for all inpatient hospitals
confinements. Failure to comply with precertification
and $250 penalty for outpatient services. This provision does
not apply to childbirth admissions less than 48 hours for
Coverage Period: 01/01/2014 – 12/31/2014
If you have a
hospital stay
Facility fee (e.g.,
hospital room)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
Delivery and all
inpatient
services
Prenatal and
postnatal care
Substance use
disorder
inpatient
services
Substance use
disorder
outpatient
services
10%
coinsurance
No charge
Office Visit:
$10 copay per
visit
All other
services: 10%
Office Visit:
$10 copay per
visit
All other
services: 10%
coinsurance
Facility: 10%
coinsurance
Physician: 10%
coinsurance
Mental/
Behavioral
health inpatient
services
30%
coinsurance
No charge
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
Office Visit $30
copay per visit
All other
services: 30%
coinsurance
30%
coinsurance
Office Visit $30
copay per visit
All other
services: 30%
coinsurance
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
Office Visit $30
copay per visit
All other
services: 30%
coinsurance
7 of 12 Precertification required for all inpatient and intensive
outpatient programs. Failure to comply with precertification
and $250 penalty for outpatient services.
Coverage Period: 01/01/2014 – 12/31/2014
If you are
pregnant
If you have
mental health,
behavioral
health, or
substance
abuse needs
Office Visit:
$10 copay per
visit
All other
services: 10%
coinsurance
Mental/
Behavioral
health
outpatient
services
30%
coinsurance
30%
coinsurance
Not Covered
Facility
10%
coinsurance
Physician: 10%
coinsurance
10%
coinsurance
Not Covered
Skilled nursing
care
Durable medical
equipment
Hospice service
Eye exam
30%
coinsurance
Facility:
10%
coinsurance
Physician: 10%
coinsurance
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
Not Covered
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
8 of 12 ----------------------------------none---------------------------------
Services by a Tier 3 provider will only be covered up to the
approved amount (UCR) You may be responsible for the
difference between the billed amount and the approved
amount in addition to your coinsurance
Cardiac Therapy maximum 36 visits per year.
Physical therapy, occupational therapy and speech therapy
maximum for each = 30 visits per calendar year.
Precertification required for extracorporeal shock wave
therapy for muscular skeletal treatment
therapy for muscular skeletal treatment
All inpatient hospitals confinements (including rehab stays,
LTAC - if covered, skilled nursing facility stays, and
confinements for the treatment of mental disorders and /or
substance abuse). This provision does not apply to childbirth
admissions less than 48 hours for vaginal delivery or 96 hours
for cesarean delivery.
Precertification required for: durable medical equipment
purchase cost or aggregate rental cost greater than $500, bone
growth stimulators, neuromuscular stimulators, Orthotics over
$200 prosthetics over $1000, and dual chamber defibrillator
pacemaker.
Precertification required for all home health care. Failure to
comply with precertification requirements will result in a $500
penalty for inpatient services and $250 penalty for outpatient
services.
Coverage Period: 01/01/2014 – 12/31/2014
If your child
If you need
help
recovering or
have other
special health
needs
30%
coinsurance
10%
coinsurance
Habilitation
services
30%
coinsurance
10%
coinsurance
Rehabilitation
services
30%
coinsurance
10%
coinsurance
Home health
care
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
Dental check-up
Glasses
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
----------------------------------none---------------------------------
----------------------------------none---------------------------------
Coverage Period: 01/01/2014 – 12/31/2014
Cosmetic surgery
Dental care (Adult)



Non-emergency care when traveling outside the 
U.S.
Most coverage provided outside the United States. 


Long-term care

Routine foot care
Routine eye care (Adult)
Private-duty nursing
Bariatric surgery (limitations apply)

Chiropractic care (limitations apply
Weight loss programs (limitations apply)

9 of 12 MHP, CMHP, Tiffin, Willard
Infertility treatment (limitations apply)


 Hearing aids
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
Acupuncture (if prescribed for rehabilitation
purposes)

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
Excluded Services & Other Covered Services:
needs dental
or eye care
Coverage Period: 01/01/2014 – 12/31/2014
10 of 12 ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-647-1761.
Chinese (中⽂): 如果需要中⽂的帮助，请拨打这个号码 1-800-647-1761.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-647-1761.
Spanish (Español): Para obtener asistencia en Español, llame al 1-800-647-1761.
Language Access Services:
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage does meet the minimum value standard for the benefits it provides.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does
provide minimum essential coverage.
Does this Coverage Provide Minimum Essential Coverage?
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions
about your rights, this notice, or assistance, you can contact: NGS CoreSource, PO Box 2310, Mt. Clemens, MI 48046, 1-800-647-1761 or the Department of
Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
Your Grievance and Appeals Rights:
For more information on your rights to continue coverage, contact the plan at 1-800-647-1761. You may also contact your state insurance department, the U.S.
Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human
Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay
while covered under the plan. Other limitations on your rights to continue coverage may also apply.
Your Rights to Continue Coverage:
$2,900
$1,300
$700
$300
$100
$100
$5,400
$800
$90
$110
$80
$1,080
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
$800
$0
$650
$150
$1,600
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Total
Patient pays:
Deductibles
Copays
Coinsurance
Total
11 of 12  Amount owed to providers: $5,400
 Plan pays $4,320
 Patient pays $1,080
(routine maintenance of
a well-controlled condition)
(normal delivery)
 Amount owed to providers: $7,540
Managing type 2 diabetes
Having a baby
Coverage Period: 01/01/2014 – 12/31/2014
See the next page for
important information about
these examples. Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
This is
not a cost
estimator.
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
About these Coverage
Examples:
Coverage Examples
Coverage Period: 01/01/2014 – 12/31/2014
Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
No. Coverage Examples are not cost
Does the Coverage Example
predict my future expenses?
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
 No. Treatments shown are just examples.
predict my own care needs?
Yes. When you look at the Summary of
For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments, and coinsurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
12 of 12 you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket costs, such as copayments,
deductibles, and coinsurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.
Yes. An important cost is the premium
Are there other costs I should
consider when comparing
plans?
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Can I use Coverage Examples
to compare plans?
What does a Coverage Example
show?







What are some of the
assumptions behind the
Coverage Examples?
Questions and answers about the Coverage Examples:
Coverage Examples
Yes. Domestic Tier 1 providers: $3,000 individual/$6,000
family. In-Network Tier 2 providers: $5,000
individual/$10,000 family. Out of Network Tier 3 providers
Unlimited individual/ Unlimited family
Out of Network expenses, penalties, premiums, balancebilled charges, and health care this plan doesn’t cover.
No.
Yes.
specialist?
doesn’t cover?
1 of 13 You don’t have to meet deductibles for specific services, but see
the chart starting on page 2 for other costs for services this plan
covers.
covered services. This limit helps you plan for health care
expenses.
The chart starting on page 2 describes any limits on what the plan
If you use an in-network doctor or other health care provider,
this plan will pay some or all of the costs of covered services. Be
aware, your in-network doctor or hospital may use an out-ofnetwork provider for some services. Plans use the term innetwork, preferred, or participating for providers in their
network. See the chart starting on page 2 for how this plan pays
different kinds of providers.
You can see the specialist you choose without permission from
this plan.
See your policy or plan document for additional information
about excluded services.
You must pay all the costs up to the deductible amount before
this plan begins to pay for covered services you use. Check your
policy or plan document to see when the deductible starts over
(usually, but not always, January 1st). See the chart starting on
page 2 for how much you pay for covered services after you meet
the deductible.
Why this Matters:
Questions: Call Questions: Call 1-800-647-1761
www.healthspannetwork.com or call 1-888-914-7726 or
www.phcs.com or call 1-800-785-3602.
Does this plan use a
network of providers?
Is there an overall annual
No.
limit on what the plan pays?
Is there an out–of–pocket
limit on my expenses?
Are there other deductibles
for specific services?
What is the overall
deductible?
Answers
Domestic Tier 1:= $1,200 individual/$2,400 family
In-Network Tier 2= $2,000 individual/$4,000 family
Out-of Network Tier3 =$5,000 individual/$10,000 family
Not subject to deductible: Tier 1/Tier 2 preventive care, and
primary care office visits. Tier 1 specialist office visits. All
Tiers: urgent care, emergency treatment, prescription drugs,
co-pays and penalties.
Important Questions
Coverage Period: 01/01/2014 – 12/31/2014
Coverage for: Individual & Family | Plan Type: HRA
Catholic Health Partners 3 Tier Choice Plan
Coverage Period: 01/01/2014 – 12/31/2014
Other
practitioner
office visit
Chiropractor
Preventive
care/screening/
immunization
Specialist visit
No charge
No charge
Not Covered
Not covered
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
Office Visit 30%
coinsurance
(no deductible)
All other services:
30% coinsurance
Office Visit 30%
coinsurance
(no deductible)
All other services:
30% coinsurance
0% coinsurance up
to max of $70 per
visit
Non Network
Tier 3 Provider
Network Tier 2
Provider
0% coinsurance up
to max of $70 per
visit
Office Visit: $35
copay
All other services:
10% coinsurance
Office Visit: $10
copay per visit
All other services:
10%
Domestic
Network Tier 1
Provider
2 of 13 Women’s preventive care contraceptives are excluded
Chiropractic care: limited to 15 visits in a calendar year.
Bariatric surgery is only covered under Tier 1 Network
providers.
If you visit a
health care
provider’s
office or clinic
Primary care visit
to treat an injury
or illness
Services You
May Need
plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you
haven’t met your deductible.
 The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the
allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
 This plan may encourage you to use Tier 1 and Tier 2 providers by charging you lower deductibles, copayments and coinsurance amounts.
 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
 Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the
Common
Medical
Event
Imaging
(CT/PET scans,
MRIs)
Diagnostic test
(x-ray, blood
work)
Services You
May Need
Facility charge:
10% coinsurance
10% coinsurance
Domestic
Network Tier 1
Provider
Failure to comply with precertification requirements will
result in a $500 penalty for inpatient services and $250
penalty for outpatient (not considered eligible expense
nor applied to your deductible or out-of pocket
maximum.)
Precertification and copay applies for , virtual
colonoscopy, and PET scan. Failure to comply with
precertification requirements will result in a $500 penalty
for inpatient services and $250 penalty for outpatient (not
considered eligible expense nor applied to your deductible
or out-of pocket maximum.)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
30% coinsurance
Facility charge:
$500 copay then
30% coinsurance
(no deductible)
3 of 13 Limitations & Exceptions
Non Network
Tier 3 Provider
Network Tier 2
Provider
Coverage Period: 01/01/2014 – 12/31/2014
If you have a
test
Common
Medical
Event
Formulary
Generic drugs
Services You
May Need
Network Tier 2
Provider
Non Network
Tier 3 Provider
30 day supply
30% coinsurance with a $40 minimum and $150 maximum
90 day supply
maximum
30 day supply
90 day supply
0% coinsurance with up to a $25 max
30 day supply
90 day supply
Domestic
Network Tier 1
Provider
4 of 13 Preventive drugs mandated by PPACA=No Charge.
contraceptives.
Request for brand medication when generic is available,
will require you to pay the applicable brand co-pay plus
the difference in cost between generic and brand.
Fertility drugs will be paid at 50% with a $2,500
maximum.
Riverfront Pharmacy unless prior authorization is
obtained. Maintenance medications (multiple fills) in
excess of 2 fills must be obtained at Riverfront Pharmacy
in order to be covered. Effective July 1, 2014,
maintenance medications (multiple fills) in excess of 1 fill
covered.
Effective July 1, Tiffin and Willard employees must
obtain maintenance medications (multiple fills) in excess
of 1 fill at (1) their market’s In-House Pharmacy, (2)
Riverfront mail order pharmacy, or (3) Catamaran mail
order pharmacy.
Coverage Period: 01/01/2014 – 12/31/2014
More
information
about
prescription
drug coverage
is available at
www.mycatamar
anrx.com
Non-Formulary
If you need
drugs to treat
your illness or
condition
Common
Medical
Event
Urgent care
Emergency
room services
Emergency
medical
transportation
Physician/
surgeon fees
Facility fee (e.g.,
ambulatory
surgery center)
Services You
May Need
$200 copay per
visit, then 10%
20% coinsurance
Office Visit: $50
copay per visit
All other services:
30% coinsurance
(no deductible)
10% coinsurance
Office Visit: $35
copay per visit
All other services:
10% coinsurance
(no deductible)
30% coinsurance
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
$500 copay per
visit, then 30%
coinsurance (no
deductible)
-------------------------------None-------------------------------
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
(no deductible)
5 of 13 -------------------------------None-------------------------------
-------------------------------None-------------------------------
Precertification required for: Blepharoplasty, Rhinoplasty,
Sclerotherapy for varicose veins, Septoplasty, Vein
surgery, Scar revisions, TMJ treatment, Breast
reconstruction (other than following a surgery to treat
cancer), any covered cosmetic services, prophylactic
mastectomies and oophorectomies, covered oral surgery
procedures, chemo therapy, radiation therapy dental
procedures (including confinements for concurrent
medical conditions, sleep disorder treatment, transplant
evaluation and surgery.
Failure to comply with
or out-of pocket maximum).
contraceptives.
Bariatric surgery is only covered under Tier 1 Network
providers or if no Tier 1 facility is available within 200
miles.
20% coinsurance
$200 copay per
visit, then 10%
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
Non Network
Tier 3 Provider
Network Tier 2
Provider
$200 copay per
visit, then 10%
10% coinsurance
10% coinsurance
Domestic
Network Tier 1
Provider
Coverage Period: 01/01/2014 – 12/31/2014
If you need
immediate
medical
attention
If you have
outpatient
surgery
Common
Medical
Event
Facility: 10%
coinsurance
Physician: 10%
coinsurance
Office Visit: $10
copay per visit
All other services:
10%
Substance use
disorder
outpatient
services
Office Visit: $10
copay per visit
All other services:
10% coinsurance
Mental/
Behavioral health
outpatient
services
Mental/
Behavioral health
inpatient services
10% coinsurance
10% coinsurance
Domestic
Network Tier 1
Provider
Physician/
surgeon fee
Facility fee (e.g.,
hospital room)
Services You
May Need
Office Visit $30
copay per visit
All other services:
30% coinsurance
30% coinsurance
30% coinsurance
no deductible
30% coinsurance
$500 copay per
visit, then 30%
coinsurance
Network Tier 2
Provider
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
Non Network
Tier 3 Provider
6 of 13 Precertification required for intensive outpatient program.
penalty for outpatient (not considered eligible expense nor
applied to your deductible or out-of pocket maximum).
requirements will result in a $500 penalty for inpatient
services and $250 penalty for outpatient (not considered
eligible expense nor applied to your deductible or out-of
pocket maximum).
Precertification required for intensive outpatient program.
applied to your deductible or out-of pocket maximum).
pocket maximum). This provision does not apply to
childbirth admissions less than 48 hours for vaginal
delivery or 96 hours for cesarean delivery.
Coverage Period: 01/01/2014 – 12/31/2014
If you have
mental health,
behavioral
health, or
substance
abuse needs
If you have a
hospital stay
Common
Medical
Event
Delivery and all
inpatient services
Prenatal and
postnatal care
Substance use
disorder
inpatient services
Services You
May Need
10% coinsurance
30% coinsurance
No charge
Office Visit
$30 copay per visit
All other services:
30% coinsurance
Office Visit: $10
copay per visit
All other services:
10% coinsurance
No charge
Network Tier 2
Provider
Domestic
Network Tier 1
Provider
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
Non Network
Tier 3 Provider
7 of 13 Precertification provision does not apply to childbirth
admissions less than 48 hours for vaginal delivery or 96
hours for cesarean delivery.
-------------------------------None-------------------------------
pocket maximum).
Coverage Period: 01/01/2014 – 12/31/2014
If you are
pregnant
Common
Medical
Event
30% coinsurance
30% coinsurance
Facility:
10% coinsurance
Physician: 10%
coinsurance
Skilled nursing
care
30% coinsurance
10% coinsurance
10% coinsurance
Rehabilitation
services
30% coinsurance
Network Tier 2
Provider
Habilitation
services
10% coinsurance
Domestic
Network Tier 1
Provider
Home health
care
Services You
May Need
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
8 of 13 All inpatient hospitals confinements (including rehab
stays, LTAC - if covered, skilled nursing facility stays, and
confinements for the treatment of mental disorders and
/or substance abuse).
Failure to comply with
or out-of pocket maximum). This provision does not
apply to childbirth admissions less than 48 hours for
therapy for muscular skeletal treatment. Failure to
comply with precertification requirements will result in a
$500 penalty for inpatient services and $250 penalty for
outpatient (not considered eligible expense nor applied to
your deductible or out-of pocket maximum).
Precertification required for all home health care. Failure
to comply with precertification requirements will result in
a $500 penalty for inpatient services and $250 penalty for
outpatient (not considered eligible expense nor applied to
your deductible or out-of pocket maximum).
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
Non Network
Tier 3 Provider
Coverage Period: 01/01/2014 – 12/31/2014
If you need
help
recovering or
have other
special health
needs
Common
Medical
Event
10% coinsurance
Durable medical
equipment
Hospice service
Not Covered
Not Covered
Not Covered
60% coinsurance
(plus difference
between charged
amount and
allowed amount)
Not Covered Not Covered Not Covered 60% coinsurance
(plus difference
between charged
amount and
allowed amount)
Non Network
Tier 3 Provider
9 of 13 -------------------------------None-------------------------------------------------------------None-------------------------------------------------------------None-------------------------------
Services by a Tier 3 provider will only be covered up to
the approved amount (UCR) You may be responsible for
the difference between the billed amount and the
approved amount in addition to your coinsurance
Precertification required for: durable medical equipment
purchase cost or aggregate rental cost greater than $500,
bone growth stimulators, neuromuscular stimulators,
Orthotics over $200 prosthetics over $1000, and dual
chamber defibrillator pacemaker. Failure to comply with
or out-of pocket maximum).
Coverage Period: 01/01/2014 – 12/31/2014
Not Covered
Not Covered
Not Covered
30% coinsurance
Facility
10% coinsurance
Physician: 10%
coinsurance
30% coinsurance
Network Tier 2
Provider
Domestic
Network Tier 1
Provider
Services You
May Need
Eye exam
If your child
needs dental or Glasses
eye care
Dental check-up
Common
Medical
Event
Coverage Period: 01/01/2014 – 12/31/2014
Cosmetic surgery
Dental care (Adult)



U.S.


Long-term care

Routine foot care



10 of 13 If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions

 Hearing aids
services.)
purposes)

Coverage Period: 01/01/2014 – 12/31/2014
$2,900
$1,300
$700
$300
$100
$100
$5,400
$1,200
$60
$110
$80
$1,450
Sample care costs:
Prescriptions
Education
Laboratory tests
Total
Patient pays:
Deductibles
Copays
Coinsurance
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
$1,200
$0
$610
$150
$1,960
Sample care costs:
Anesthesia
Laboratory tests
Prescriptions
Radiology
Total
Patient pays:
Deductibles
Copays
Coinsurance
Total
12 of 13  Amount owed to providers: $5,400
(normal delivery)
Having a baby
Coverage Period: 01/01/2014 – 12/31/2014
different.
This is
not a cost
estimator.
Examples:
Coverage Examples
Coverage Period: 01/01/2014 – 12/31/2014
expenses.
plans?
the plan provides.
to compare plans?
show?







Coverage Examples?
Coverage Examples
Coverage Period: 01/01/2014 – 12/31/2014
Coverage for: Individual & Family | Plan Type: EPO
$2,000 individual/$4,000 family.
Out of Network expenses, penalties, premiums,
balance-billed charges, and health care this plan doesn’t
cover.
No.
www.healthspannetwork.com or call 1-888-914-7726.
Is there an out–of–pocket
limit on my expenses?
Is there an overall annual
limit on what the plan pays?
Does this plan use a
network of providers?
specialist?
1 of 16 The chart starting on page 2 describes any limits on what the plan
If you use an in-network doctor or other health care provider, this
plan will pay some or all of the costs of covered services. Be aware,
your in-network doctor or hospital may use an out-of-network
provider for some services. Plans use the term in-network,
preferred, or participating for providers in their network. See the
chart starting on page 2 for how this plan pays different kinds of
providers.
You can see the specialist you choose without permission from this
plan.
You don’t have to meet deductibles for specific services, but see the
chart starting on page 2 for other costs for services this plan covers.
covered services. This limit helps you plan for health care expenses.
You must pay all the costs up to the deductible amount before this
plan begins to pay for covered services you use. Check your policy
or plan document to see when the deductible starts over (usually,
but not always, January 1st). See the chart starting on page 2 for how
much you pay for covered services after you meet the deductible.
Why this Matters:
No.
Answers
$500 individual/$1,000 family
Not subject to deductible:
Domestic Network and Professional charges Billed by
Non-CHP-Owned Network Facility: primary care,
specialist and urgent care, emergency treatment,
preventive care, prescription drugs, co-pays and
penalties.
Non-CHP-Owned Network Facility: urgent care,
emergency treatment, co-pays and penalties.
Out of Network is not covered.
Are there other deductibles
for specific services?
What is the overall
deductible?
Important Questions
Catholic Health Partners Exclusive Plan
Specialist visit
2 of 16 Bariatric surgery is only covered for approved programs under
Network providers or if no Network facility is available within
200 miles.
Services from providers other than HealthSpan Select Network
providers or Non-CHP-Owned Network Partner providers
require an approved authorization through HealthSpan. The
20% Coinsurance will be subject to the deductible.
If you visit a
health care
provider’s
office or clinic
Primary care visit
to treat an injury
or illness
Services You
May Need
Non-CHPOwned
HealthSpan
Network
Select
Facility
Network
Non Network
(Includes
Provider or
Provider
Professional
Domestic
Charges
Facility
Billed by
Facility)
Office Visit: $10
copay per visit
20% Coinsurance
Not Covered
All other
services: 10%
Office Visit: $35
copay per visit
All other
20% Coinsurance
Not Covered services: 10%
coinsurance
allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met
your deductible.
 The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed
amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed
amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
 This plan may encourage you to use Domestic Network providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical
Event
Why this Matters:
See your policy or plan document for additional information about
excluded services.
Coverage Period: 01/01/2014 – 12/31/2014
 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
 Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s
Yes.
doesn’t cover?
Answers
Important Questions
Preventive care/
screening/
immunization
Other
practitioner
office visit
Chiropractor
Services You
May Need
No charge
No Charge
0% coinsurance
up to max of $70 20% Coinsurance
per visit
Not Covered Not Covered Women’s preventive care contraceptives are excluded.
3 of 16 Chiropractic care: limited to 15 visits in a calendar year.
Coverage Period: 01/01/2014 – 12/31/2014
Common
Medical
Event
Non-CHPOwned
HealthSpan
Network
Select
Facility
Network
Non Network
(Includes
Provider or
Provider
Professional
Domestic
Charges
Facility
Billed by
Facility)
Imaging
(CT/PET scans,
MRIs)
Diagnostic test
(x-ray, blood
work)
Services You
May Need
Facility charge:
10% coinsurance
Physician charge:
10% coinsurance
Facility charge:
0% coinsurance
20% Coinsurance
20% Coinsurance
Not Covered
Not Covered Your cost if you use a:
Non-CHPOwned
HealthSpan
Network
Select
Facility
Network
Non Network
(Includes
Provider or
Provider
Professional
Domestic
Charges
Facility
Billed by
Facility)
4 of 16 Precertification required for any genetic testing covered by the
plan. Failure to comply with precertification requirements will
result in a $500 penalty for inpatient services and $250 penalty
for outpatient (not considered eligible expense nor applied to
your deductible or out-of pocket maximum.)
Precertification required for virtual colonoscopy, and PET
scan.
outpatient (not considered eligible expense nor applied to your
deductible or out-of pocket maximum.)
Coverage Period: 01/01/2014 – 12/31/2014
If you have a
test
Common
Medical
Event
Non-Formulary
More
information
about
prescription
drug coverage
is available at
www.mycatamar
anrx.com
5 of 16 Women’s preventive care services are offered, except for
contraceptives.
Request for brand medication when generic is available, will
require you to pay the applicable brand co-pay plus the
difference in cost between generic and brand.
Fertility drugs will be paid at 50% with a $2,500 maximum.
Riverfront Pharmacy unless prior authorization is obtained.
Maintenance medications (multiple fills) in excess of 2 fills
covered. Effective July 1, maintenance medications (multiple
fills) in excess of 1 fill must be obtained at Riverfront
Pharmacy in order to be covered.
30 day supply
HMHP and Lourdes employees: Maintenance medications
30% coinsurance with a $40 minimum and $150 maximum (multiple fills) in excess of 1 fill must be obtained at the In90 day supply
House Pharmacy in order to be covered.
Effective July 1, home office, St. Rita’s, Lorain, Defiance,
Tiffin, Willard, and Marcum & Wallace employees must obtain
maximum
maintenance medications (multiple fills) in excess of 1 fill at (1)
their market’s In-House Pharmacy, (2) Riverfront mail order
pharmacy, or (3) Catamaran mail order pharmacy.
Preventive drugs mandated by PPACA=No Charge.
Coverage Period: 01/01/2014 – 12/31/2014
Formulary
Generic drugs
Services You
May Need
If you need
drugs to treat
your illness or
condition
Common
Medical
Event
Non-CHPOwned
HealthSpan
Network
Select
Facility
Network
Non Network
(Includes
Provider or
Provider
Professional
Domestic
Charges
Facility
Billed by
Facility)
30 day supply
90 day supply
0% coinsurance with up to a $25 maximum
30 day supply
90 day supply
Facility fee (e.g.,
ambulatory
surgery center)
If you have
outpatient
surgery
10% coinsurance
20% Coinsurance
Not Covered
6 of 16 Precertification required for: Blepharoplasty, Rhinoplasty,
Sclerotherapy for varicose veins, Septoplasty, Vein surgery,
Scar revisions, TMJ treatment, Breast reconstruction (other
than following a surgery to treat cancer), any covered cosmetic
services, prophylactic mastectomies and oophorectomies,
covered oral surgery procedures, chemo therapy, radiation
therapy dental procedures (including confinements for
concurrent medical conditions, sleep disorder treatment,
transplant evaluation and surgery. Failure to comply with
inpatient services and $250 penalty for outpatient (not
considered eligible expense nor applied to your deductible or
out-of pocket maximum.)
contraceptives.
Bariatric surgery is only covered for approved programs under
Network providers or if no Network facility is available within
200 miles.
Coverage Period: 01/01/2014 – 12/31/2014
Services You
May Need
Common
Medical
Event
Non-CHPOwned
HealthSpan
Network
Select
Facility
Network
Non Network
(Includes
Provider or
Provider
Professional
Domestic
Charges
Facility
Billed by
Facility)
10% Coinsurance
20% Coinsurance
(no deductible)
10% coinsurance
Office Visit: $35
copay per visit
All other
services: 10%
coinsurance
(no deductible)
Emergency
medical
transportation
Urgent care
$200 copay per
visit, then 10%
$200 copay per
visit, then 10%
Emergency room
services
20% Coinsurance
10% coinsurance
Physician/
surgeon fees
Services You
May Need
--------------------------------None---------------------------------------
Not Covered 7 of 16 Services from providers other than HealthSpan Select Network
20% Coinsurance will be subject to the deductible
10% coinsurance --------------------------------None---------------------------------------
$200 copay per
visit, then 10%
Not Covered Services from providers other than HealthSpan Select
Network providers or Non-CHP-Owned Network Partners
Coverage Period: 01/01/2014 – 12/31/2014
If you need
immediate
medical
attention
Common
Medical
Event
Non-CHPOwned
HealthSpan
Network
Select
Facility
Network
Non Network
(Includes
Provider or
Provider
Professional
Domestic
Charges
Facility
Billed by
Facility)
Physician/
surgeon fee
Facility fee (e.g.,
hospital room)
Services You
May Need
10% coinsurance
10% coinsurance
20% Coinsurance
20% Coinsurance
Not Covered Not Covered 8 of 16 Precertification required for all inpatient hospitals
confinements.
Failure to comply with precertification
and $250 penalty for outpatient (not considered eligible
expense nor applied to your deductible or out-of pocket
maximum.) This provision does not apply to childbirth
Precertification required for all inpatient hospitals confinements
outpatient (not considered eligible expense nor applied to your
deductible or out-of pocket maximum.)
This provision does not apply to childbirth admissions less than
48 hours for vaginal delivery or 96 hours for cesarean delivery.
Coverage Period: 01/01/2014 – 12/31/2014
If you have a
hospital stay
Common
Medical
Event
Non-CHPOwned
HealthSpan
Network
Select
Facility
Network
Non Network
(Includes
Provider or
Provider
Professional
Domestic
Charges
Facility
Billed by
Facility)
Substance use
disorder inpatient
services
Substance use
disorder
outpatient
services
Mental/
Behavioral health
inpatient services
Mental/
Behavioral health
outpatient
services
Services You
May Need
Office Visit: $10
copay per visit
All other
services: 10%
Office Visit: $10
copay per visit
All other
services: 10%
coinsurance
Facility: 10%
coinsurance
Physician: 10%
coinsurance
20% Coinsurance
20% Coinsurance
20% Coinsurance
Not Covered Not Covered Not Covered 9 of 16 Precertification required for all inpatient and intensive outpatient
programs. Failure to comply with precertification requirements
will result in a $500 penalty for inpatient services and $250
applied to your deductible or out-of pocket maximum.)
Coverage Period: 01/01/2014 – 12/31/2014
If you have
mental health,
behavioral
health, or
substance
abuse needs
Common
Medical
Event
Non-CHPOwned
HealthSpan
Network
Select
Facility
Network
Non Network
(Includes
Provider or
Provider
Professional
Domestic
Charges
Facility
Billed by
Facility)
Office Visit: $10 Office Visit: $10
copay per visit
copay per visit
All other
All other
Not Covered services: 10%
services: 20%
coinsurance
Coinsurance
Home health
care
Delivery and all
inpatient services
Prenatal and
postnatal care
Services You
May Need
10% coinsurance
10% coinsurance
No charge
20% Coinsurance
20% Coinsurance
No Charge
Not Covered Not Covered Not Covered Your cost if you use a:
Non-CHPOwned
HealthSpan
Network
Select
Facility
Network
Non Network
(Includes
Provider or
Provider
Professional
Domestic
Charges
Facility
Billed by
Facility)
10 of 16 Services from providers other than HealthSpan Select Network
Precertification required for all home health care. Failure to
(not considered eligible expense nor applied to your deductible
Coverage Period: 01/01/2014 – 12/31/2014
If you need
help
recovering or
have other
special health
needs
If you are
pregnant
Common
Medical
Event
20% Coinsurance
20% Coinsurance
10% coinsurance
Facility:
10% coinsurance
Physician: 10%
coinsurance
Habilitation
services
Skilled nursing
care
20% Coinsurance
10% coinsurance
Rehabilitation
services
Services You
May Need
Not Covered Not Covered Not Covered 11 of 16 Cardiac Therapy maximum 36 visits per year.
Precertification required for extracorporeal shock wave therapy
for muscular skeletal treatment. Failure to comply with
inpatient services and $250 penalty for outpatient (not
considered eligible expense nor applied to your deductible or
out-of pocket maximum.)
All inpatient hospitals confinements (including rehab stays,
LTAC - if covered, skilled nursing facility stays, and
confinements for the treatment of mental disorders and /or
substance abuse). This provision does not apply to childbirth
Coverage Period: 01/01/2014 – 12/31/2014
Common
Medical
Event
Non-CHPOwned
HealthSpan
Network
Select
Facility
Network
Non Network
(Includes
Provider or
Provider
Professional
Domestic
Charges
Facility
Billed by
Facility)
Facility
10% coinsurance
Physician: 10%
coinsurance
10% coinsurance
Not Covered Not Covered Not Covered Durable medical
equipment
Hospice service
Eye exam
Glasses
Dental check-up
Services You
May Need
Not Covered
Not Covered
Not Covered
20% Coinsurance
20% Coinsurance
Not Covered Not Covered Not Covered Not Covered Not Covered 12 of 16 Precertification required for: durable medical equipment
purchase cost or aggregate rental cost greater than $500, bone
growth stimulators, neuromuscular stimulators, Orthotics over
$200 prosthetics over $1000, and dual chamber defibrillator
pacemaker. Precertification required for extracorporeal shock
wave therapy for muscular skeletal treatment. Failure to
(not considered eligible expense nor applied to your deductible
--------------------------------None----------------------------------------------------------------------None----------------------------------------------------------------------None---------------------------------------
Coverage Period: 01/01/2014 – 12/31/2014
If your child
needs dental or
eye care
Common
Medical
Event
Non-CHPOwned
HealthSpan
Network
Select
Facility
Network
Non Network
(Includes
Provider or
Provider
Professional
Domestic
Charges
Facility
Billed by
Facility)
Coverage Period: 01/01/2014 – 12/31/2014
Cosmetic surgery
Dental care (Adult)
Hearing aids




U.S.


Long-term care

Routine foot care



13 of 16 If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions

services.)
purposes)

Coverage Period: 01/01/2014 – 12/31/2014
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
$500
$0
$680
$150
$1,330
Patient pays:
Deductibles
Copays
Coinsurance
Total
Patient pays:
Deductibles
Copays
Coinsurance
Total
Sample care costs:
Prescriptions
Education
Laboratory tests
Total
Sample care costs:
Anesthesia
Laboratory tests
Prescriptions
Radiology
Total
15 of 16 $500
$100
$120
$80
$800
$2,900
$1,300
$700
$300
$100
$100
$5,400
 Patient pays $800
(normal delivery)
Having a baby
Coverage Period: 01/01/2014 – 12/31/2014
different.
This is
not a cost
estimator.
Examples:
Coverage Examples
Coverage Period: 01/01/2014 – 12/31/2014
expenses.
plans?
the plan provides.
to compare plans?
show?







Coverage Examples?
Coverage Examples
4600 McAuley Place
Cincinnati, Ohio 45242
www.e-mercy.com
11/2013–SWO

Employee Benefits

Transcription

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