DEACONESS HEALTH SYSTEM

Transcription

Benefits
Enrollment Guide
2014 – 2015
1
2
Introduction
DEACONESS HEALTH SYSTEM
TOTAL COMPENSATION PROGRAM
Deaconess Health System offers a total compensation program to employees. Below is a summary of the
compensation currently offered to NON SUPERVISORY EMPLOYEES. Coverage for benefits begins on
the first of the month, following one full month of employment, unless otherwise noted (for example, an
employee becomes benefit eligible on August 2nd, coverage will begin on October 1st).
*DSS Employees are eligible for the items marked with an asterisk
BENEFIT OPTIONS
Benefit
Features and Eligibility
Who Pays
Medical Insurance
2 Plans (Pre-Tax)
Coverage for employees (and dependents) authorized to
work at least 40 hours per two week pay period. A
health screening is required annually each Fall for all
covered employees and spouses.
Deaconess
and employee
Dental Insurance
(Pre-Tax)
Coverage for employees (and dependents) authorized to
work at least 40 hours per two week pay period.
Deaconess
and employee
Short Term
Disability
Receive 60% of base salary when disabled for more than
8 days for employees authorized to work at least 40
hours per two week pay period. 90 day waiting period
from hire date.
Deaconess
Long Term
Disability
Receive 60% of base salary when disabled for more than
180 days for employees authorized to work at least 40
hours per two week period. 90 day waiting period
from hire date.
Deaconess
Basic Life
Insurance
One times your annual base salary with a $20,000
minimum up to certain limits for employees authorized to
work at least 40 hours per two week pay period.
Deaconess
Optional Life
Insurance
Additional coverage available at 100%, 200% or 300%
your annual base salary with a $500,000 max for
employees authorized to work at least 40 hours per two
week pay period.
Employee
Dependent Life
Insurance
Employee may purchase coverage for spouse and eligible
dependent children if employee is authorized to work at
least 40 hours per two week pay period.
Employee
Health Care
Flexible Spending
Account
(Pre-Tax)
Employee may elect to direct from $5 to $96 per two
week pay period into a non-taxable reimbursement
account for eligible medical expenses. Debit Card
available.
Employee
Dependent Care
Flexible Spending
Account
(Pre-Tax)
Employee may elect to direct from $5 to $190 per two
week pay period into a non-taxable reimbursement
account for eligible dependent care expenses.
Employee
October 2014
3
Introduction
Benefit
OTHER BENEFITS
Who Pays
Business Travel
Accident
Insurance
Accidental death benefit while traveling on hospital salary if employee is
authorized to work at least 40 hours per two week pay period.
Deaconess
*Christmas Club
Payroll deduction plus interest available through the Credit Union.
Employee
*Credit Union
Payroll deduction for savings, checking, and loan services. Loans
available after 12 months of employment.
Employee
*Concern
Employee
Assistance
Program
Short-term counseling and referral for employees and members of their
household.
Deaconess
*Continuing
Education
Several courses & conferences offered with CE available.
Deaconess
*Children’s
Enrichment
Center
On-site day care center for infants through Pre-Kindergarten.
*Fitness Center
Exercise equipment and classes for employees, spouses, and dependent
children over the age of 18.
*Health Services
Pre-employment physical exam, health screenings, immunizations, and
Wellness Program
Deaconess
*Leave of
Absence
Available for Medical, Family, Military, and Educational purposes.
Deaconess
Military 2-Week
Leave
Difference in military pay and regular base rate if authorized 60-80
hours in a two week pay period.
Deaconess
*Parking
Gratis parking privileges
Deaconess
*Pay Check
Deposit
Pay check automatically deposited in a check account as authorized
Deaconess
*Rest Period
Fifteen minute rest period during each shift of at least 8 hours
Deaconess
*Social Security
Monthly retirement/disability benefits
Deaconess
and
employee
*Retirement
Savings Plan
Deaconess contributes a base contribution of 2% - 5% of your eligible
pay based on years of service to your 401(k) plan.
Employee
Deaconess
(Employee pays for
spouse, dependents,
& classes)
Employee/
Deaconess
for the Match
Employees may direct salary up to the federal maximum contribution
limits into a 401(k). Deaconess will match a percent of the first 6% of
contributions when meeting all criteria. Deaconess match is guaranteed
at 25% of first 6%. Additional match may occur if Deaconess meets or
exceeds its financial targets.
4
October 2014
Introduction
OTHER BENEFITS
Benefit
Who Pays
*Transfer
Opportunity for advancement after introductory period of six months
Deaconess
Educational
Assistance
Financial assistance for educational training if authorized at least 40
hours per two week pay period
Deaconess
*Unemployment
Compensation
Coverage as determined by the State for loss of income when out of
work
Deaconess
*Uniforms
Uniforms furnished for designated positions
Deaconess
*Worker’s
Compensation
On-the-job accident/illness coverage for loss of income and medical
expenses according to State Law
Deaconess
COMPENSATION
Benefit
Who Pays
Bereavement Pay
Up to 24 hours paid for death in immediate family if authorized at least
60-80 hours per two week pay period. Up to 24 hours of excused
unpaid time for death of immediate family if authorized 40-59 hours per
two week pay period. Immediate family is defined as: Spouse, Parent,
Son/Daughter, Mother- and Father-in-law, Sibling, Grandparent,
Grandchild, stillbirth or miscarriage. Must use time within 2 weeks of
the date of death.
Deaconess
Jury Duty
Difference in jury duty pay and regular base pay if authorized 60-80
hours per two week pay period.
Deaconess
*Call In Pay
Time and one-half base rate + applicable shift premium with a
minimum of 2 hours pay
Deaconess
*On Call Pay
Premium for designated positions
Deaconess
*Overtime Pay
Time and one-half average rate for hourly employees
Deaconess
Holiday Hourly
Rate
Hourly employees receive time and one-half base rate for hours worked
on the following nationally recognized holidays: New Year’s Day,
Memorial Day, Fourth of July, Labor Day, Thanksgiving Day, and
Christmas Day
Deaconess
Wage and Salary
Increases
Eligibility for annual merit increases based on job performance as
measured against criteria-based job performance standards
Deaconess
*PERCS
The PERCS Program (Positive Employee Rewards for Compassion) is
designed to reward hospital employees based on patient satisfaction
results. For each performance period in which departments either meet
or exceed predetermined goals, the cash payouts will be shared with
eligible employees.
Deaconess
*Shift
Differential Pay
$1.00 per hour for hours worked between 1700 (5:00 P.M.) and 0500
(5:00 A.M.) for hourly employees
Deaconess
5
October 2014
Introduction
COMPENSATION
Benefit
Paid Time Off
(PTO)
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
Who Pays
Employees accrue PTO based on hours paid and length of service.
Employees must use PTO for a scheduled or non-scheduled
absence.
Employees authorized 40 or more hours a pay period must use PTO
during the first seven days before Short-Term Disability will begin
to pay.
All unused hours are paid out upon termination.
An employee reducing authorized hours from Full time (>60 hours)
to Part time will be paid out available PTO in excess of their part
time annual authorized hours accrual.
Deaconess
See chart below.
Years of Service:
Accrual Rate Per Hour:
Max. Bank Accrual:
Paid Hours

80
72
64
56
48
40
0 – 4 years
0.0885
368
4 – 14 years
0.1078
448
14+ years
0.1269
528
Accrual per Pay Period* (Annual Accrual)



7.08 (184)
6.37 (166)
5.66 (147)
4.96 (129)
4.25 (110)
3.54 (92)
8.62
7.76
6.90
6.03
5.17
4.31
(224)
(202)
(179)
(157)
(134)
(112)
10.15 (264)
9.14 (238)
8.12 (211)
7.11 (185)
6.09 (158)
5.08 (132)
*Hours will vary based on actual hours worked
ADDITIONAL SERVICES & BENEFITS
*Employee Wellness
Program:
Variety of activities for employees and families.
*Deaconess RN OnCall:
For questions regarding an acute illness or injury, call 450-7681 or
1-800-967-6795, 24 hours a day, 365 days a year, to speak with an RN.
*Health Science Library:
Library on the Hospital premises.
*Resource Center:
Books, tapes, videos, journals providing the latest information on
conventional and holistic practices.
*Transfer of benefits if
relocating from Voluntary
Hospitals of America facility.
*Career Ladder for designated areas.
*Incentive for working straight evening and/or night shifts in designated positions and areas.
*Incentive for working straight weekends only in designated positions and areas.
6
October 2014
Medical Options
Benefit Enrollment
The Deaconess Employee benefits program offers you the flexibility to choose the options that best suit
your needs.

You have 31 days from your date of hire/benefit eligibility date to make your benefit elections
online.

Coverage is effective on the First of the Month following one full month of employment in a
benefit eligible position and will remain in force until the end of the plan year (September 30 th) or
until the last day you are employed in a benefit eligible position.

Mid-Year changes to elections are only allowed due to a change in family status. Detailed
information on what qualifies as a change in family status is provided on a following screen of
this benefits website. You can also call the Benefits Section of Human Resources at 450-2025 for
any questions regarding family status changes.

Open Enrollment is each year in August for an effective date of October 1 st. You are allowed to
make changes as needed to your benefit elections during Open Enrollment.
Which benefit programs am I eligible for?
Employees who are authorized to work 40 or more
hours per pay period are eligible for…
Medical coverage, dental coverage, employee and
dependent life/AD&D coverage, long-term
disability coverage, short-term disability coverage,
Flexible Spending Accounts
Employees who are authorized to work fewer than 40
hours per pay period (excluding DSS and temporary)
are eligible for…
Flexible Spending Accounts
Who are eligible dependents to cover on my benefits?
Your Spouse
Someone you are currently, legally married to in
accordance with state law recognized in Indiana
and can provide verification of your legal marriage
(e.g. legally recognized marriage certificate /
license, federal/state income tax return). It does
not include common law marriage, domestic
partner, roommate, etc.
Your Child
Children up to age 26 regardless of student,
marital, etc status for all health, dental and
dependent life insurance plans.
Your Step-child
Step-children if they reside with you
Or
If your spouse is responsible for their medical and
dental expenses through court order
Human Resources is open Monday through Friday from 7:00 a.m. to 4:30 p.m. You may e-mail questions to
the Benefits staff by going to deaconess.com, click on “For Employees,” and click on “Your Benefit Questions.”
7
Medical
Options
Introduction
SIHO Insurance Services is the Third Party Administrator (TPA) for Deaconess Health System
Employees. SIHO is a full service employee benefits administration company with offices in Bloomington,
Columbus, Evansville, Indianapolis and Seymour, Indiana. This benefits guide is designed to introduce
you to your benefit plan options.
One of the advantages of SIHO is their focus on and attention to customer service. SIHO’s helpful staff is
ready to assist you with whatever questions or concerns you might have.
Advantages of the Health Plan
 A range of health care options
 Preventive care coverage
 Affordable options for individuals, families and spouses
 Helpful SIHO staff to answer your questions
The staff includes:

Member Services—Representatives who will help you understand your health care
benefits and walk you through the claims process.

Employer Services - Utilizing a team concept, the employer services
representatives funnel service inquiries to the most efficient and expert resource to
resolve issues quickly and completely.

Account Management—These individuals work with your employer to help them
understand how the benefit program is working and to troubleshoot any concerns.

Medical Management—SIHO Medical Management consists of physicians and
Registered Nurses to help you with the Pre-certification process, as well as
assisting with long-term illnesses.
Defining the Terms in this benefits guide:
Co-pays— The flat fee charged by the plan for certain services such as physician office visits and
prescription drugs.
Annual deductible—The amount you pay first before the plan begins paying expenses for covered
services.
Out-of-pocket maximum—The maximum amount you can pay each year in deductibles and coinsurance
for covered services.
Coinsurance—The percentage you pay when you receive care once you have met the annual deductible.
In-Network and Out-of-Network Providers—In-network providers are doctors, hospitals and other health
care facilities that have agreed to accept a discounted payment, thereby reducing the cost of health care
for you and your employer. This means you can see any provider, but the health plan pays a greater share
of the costs when you use the service of an in-network provider.
Pre-certification—The process you should follow if you or a dependent is hospitalized.
Pre-certification will avoid any unnecessary reduction in benefits for non-covered or non- medically
necessary services.
8
Medical Options
Making Mid-Year Changes to Benefits
Outside of your initial benefit enrollment and the annual Open Enrollment period, you may add or drop
dependents to your FlexPlan benefit package within 31 days following a family status event, which includes:

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




Your marriage
Birth of your child
Legal adoption
Death of an eligible dependent
Divorce or Legal Separation1
Loss or Gain of another Group-Employer insurance plan
Relocation out of the network area
An eligible dependent for benefit purposes is considered to be:
 Your spouse
 Your child up to 26 years of age regardless of student status for all health plans, dental plan, and
dependent life insurance
 Step-children if they reside with you
 Step-children if your spouse is responsible for their medical and dental expenses through court order
Benefits you are eligible to change due to a family status event include:





Medical coverage (level of coverage AND/OR medical option)
Dental coverage
Your Optional Life Insurance
Your Dependent Life Insurance
Flexible Spending Accounts (Health Care and Dependent Care)
All changes must be consistent with the family status event. Any employee or spouse electing a medical option
due to a family status event MUST complete the required health screening during the annual Fall health screening
session. Please contact the Wellness Center at 812-450-2429 for further health screening information.
All changes must be made online and written proof (i.e. marriage certificate, birth certificate, death certificate, divorce
decree, court order, or letter from spouse’s employer) must be submitted to the Benefits Office within 31 days of the
effective date of change.
This documentation is required within 31 days of the family status change in order to fulfill the
Consolidated Omnibus Budget Reconciliation Act (COBRA) requirements.
YOUR PENDING BENEFIT ELECTIONS
WILL NOT BE ACCEPTED OR PROCESSED
UNTIL THE REQUIRED WRITTEN DOCUMENTATION
IS RECEIVED IN THE BENEFITS OFFICE.
If you do not experience one of the above events during the plan year, you may not make changes to your
benefit elections. The next opportunity to make changes to your benefit elections will be the following August for
an effective date of October 1st. If you have any questions as to what constitutes a family status change or what
written proof is required, please contact the Benefits Office at 450-7383.
Conexis will notify the dependent regarding the Consolidated Omnibus Budget Reconciliation Act. Under COBRA, coverage may be continued for dependent
children up to 36 months if they no longer qualify as the employee’s dependent under the insurance plan.
9
Medical Options
Employee Wellness Program & Incentives
Wellness Program
In an effort to promote a healthy lifestyle, all employees and spouses enrolling in a medical option for health insurance
coverage must complete a health screening each Fall. This health screening is an annual requirement and all covered
employees and spouses must screen each year between September and December to continue their health insurance
incentive for the following plan year.
You will automatically receive the Employee Wellness Incentive and the Spouse Wellness Incentive with your initial
enrollment in one of the medical options. However, you and your spouse must complete any assigned follow-up
programming from your annual Fall health screening in order to continue the Wellness Incentives for the following plan
year, beginning on October 1st.
The Wellness Incentives are not a discount. You will see the full employee rate deducted from each of your paychecks.
The Wellness Incentive(s) are added as an earning to each of your paychecks.
HEALTH SCREENING & WELLNES INCENTIVE REQUIREMENTS
FOR OCTOBER 1, 2015
All covered Employees & Spouses MUST complete the annual required health
screening between September 2014 and December 2014 to be eligible for the Wellness
Incentive.
NO WELLNESS SCREENING BY 12/2014=
NO WELLNESS INCENTIVE ON 10/01/15
All assigned Follow-up Programming MUST be completed & submitted to the Wellness
Center as instructed no later than 6/2015 to receive the Wellness Incentive.
NO FOLLOW-UP PROGRAMMING BY 06/2015 =
NO WELLNESS INCENTIVE ON 10/01/15
Health Screening Calendar will be made available by the Wellness Center at Deaconess.com/For Our
Employees for scheduling appointments.
10
MedicalOptions
Options
Medical
Standard Medical Option
The Standard option is a preferred provider plan in which a specified deductible must be met before coverage begins.
Members are allowed to move within the OneCare provider network of physicians without referral for insurance purposes.
For those who reside in the OneCare Service Area there is no coverage for out-of-network services. If an employee has a
need for care that cannot be provided within the OneCare network, a OneCare physician can submit a request for a
referral to be reviewed and approved or denied as determined by SIHO.
Advantage Medical Option
The Advantage option is a preferred provider plan in which a specified deductible must be met for certain services before
coverage begins. However, the deductible does not apply to Physician Office visits or outpatient diagnostic studies.
Members are allowed to move within the OneCare provider network of physicians without referral for insurance purposes.
For those who reside in the OneCare Service Area there is no coverage for out-of-network services. If an employee has a
need for care that cannot be provided within the OneCare network, a OneCare physician can submit a request for a
referral to be reviewed and approved or denied as determined by SIHO.
11
D
ADDITIONAL BENEFITS OF THE
ONECARE NETWORK
eaconess values the ability to provide
employees and their families with
competitive benefits, including access to
a network of high-quality providers. In a climate
where the cost to provide employee benefits
continues to rise for employers nationwide,
our partnership with the OneCare Network
has enabled Deaconess to continue to provide
competitive benefits at competitive rates for the
2014–2015 plan year—including no increase in
employee premiums, deductibles or maximum
out-of-pocket expenses.
The OneCare network provides Deaconess
employees and their families with:
zzLocal access: OneCare Network providers are
convenient to where you live and work.
zzAccessible experts: No referrals are required to
see specialists within the OneCare network.
zzEmergency coverage: If you have an emergency
when traveling outside the OneCare service
area, you always go to the nearest emergency
room, and the visit will be covered at an innetwork rate.
As we remain committed to the health and wellbeing of our employees and their families, we
remain committed to the OneCare Network for the
2014–2015 plan year.
zzOut-of-town convenience: If you are on
WHY THE ONECARE NETWORK?
vacation or are temporarily outside the service
area, you have coverage for emergency
and urgent care when medically necessary.
Dependents who live outside the service area
also have coverage.
In 2013, Deaconess Health made the transition to
the OneCare Network of providers, which includes
most Deaconess Health System physicians and
other community providers. This transition helped
us ensure that Deaconess employees and their
families have access to high-quality providers who
work together to improve coordination of care for
our employees.
zzNo-cost preventive care: Routine office visits
for you or your child, preventive screenings,
physicals, well-child visits, immunizations, and
preventive care tests done at your doctor's
office and which follow the latest evidencebased medical guidelines are fully covered.
Across a participating provider network, improved
coordination of care helps ensure that patients
receive the right care at the right time. What does
this mean for our employees? Better care, better
health outcomes and a reduced overall cost of
care. In combination with employee wellness, care
coordination helps us ensure that employees and
their families get the care they need to live healthy
lives at less expense.
zzCompetitive rates: Members have access to
high-quality providers at competitive rates
for our local area, including for services
like emergency care, urgent care, inpatient
hospitalization and outpatient surgeries.
DEPTH AND BREADTH OF
PARTICIPATING PROVIDERS AND
FACILITIES
We pay approximately 80 percent of our
employees’ premium costs, so if we can keep our
cost increases to a minimum, we can keep yours
to a minimum, too. Or, like this year, we can avoid
raising your premium costs altogether.
The online provider directory is now up to date
with information for all providers currently
participating in the network. Go to the OneCare
Provider Directory link on Empowered Benefits to
search the full list of participating providers and
facilities.
All of these are benefits of the OneCare Network.
We continue to evaluate our primary and specialty
care provider network in an effort to ensure that
our employees have access to a comprehensive
suite of services and providers.
12
THE SERVICE AREA
More than 650 primary and specialty care physicians
participate in the network at more than 30 unique
facilities, including emergency and urgent care. In
addition to primary care and pediatric practitioners,
members have affordable access to a variety of
excellent specialists, including but not limited to:
zz Allergists
zz Neurosurgeons
zz Audiologists
zz Orthopedic
zz Behavioral Health
Specialists
zz Cardiovascular
Specialists
zz Dermatologists
zz Ear, Nose and Throat
Specialists
zz Endocrinologists
zz General Surgeons
zz Hematologists
zz OB/GYNs
zz Neurologists
If you live inside the service area, you must see
a OneCare Network provider to receive benefits.
Generally, the service area includes individuals
residing in Vanderburgh, Warrick, Posey, Gibson
and Henderson counties (see below for a full list of
zip codes included in the service area).
With more than 650 participating providers in the
network, employees who live inside the service
typically live or work a short distance from a
selection of providers. The map below shows the
density of participating providers by county.
Specialists
zz Pain Management
Specialists
zz Physical and
Occupational
Therapists
zz Podiatrists
zz Pulmonary Medicine
Specialists
zz Reproductive
Specialists
zz Rheumatologists
zz Urologists
All Zip Codes Included in the Service Area
ZIPCity
ZIP City
47601Boonville
47724 Evansville
47610Chandler
47725 Evansville
47612 Cynthiana
47648 Ft. Branch
47613Elberfeld
47617 Hatfield
47701Evansville
47639Haubstadt
47708Evansville
47619 Lynnville
47710 Evansville
47620 Mt. Vernon
47711 Evansville
47631 New Harmony
47712Evansville
47629Newburgh
47713Evansville
47630Newburgh
47714 Evansville
47660 Oakland City
47715Evansville
47633Poseyville
47719Evansville
47634Richland
47720Evansville
47638 Wadesville
42420 Henderson, KY
Many facilities in the OneCare Network have
multiple locations. Check the online directory to
search for a participating facility near you.
zz Deaconess Clinic
zz Deaconess Breast Center
zz Deaconess Cancer Services
zz Deaconess Comprehensive Pain Center
zz Deaconess Diabetes Center
OUTSIDE THE ONECARE SERVICE AREA
zz Deaconess Diagnostic Center
zz Deaconess VNA Plus Home Health and Hospice
If you live outside the OneCare service area, you
will still receive the highest level benefits if you
choose to see a OneCare provider. However, you
will receive some benefits if you see providers in
the SIHO, Encore or PHCS networks, but you will
pay a higher share of the cost for these services.
zz Deaconess Home Medical Equipment
zz Deaconess Sleep Center
zz Deaconess Regional Laboratories
zz Deaconess Weight Loss Solutions
zz Deaconess Riley Children’s Specialty Center
zz Deaconess Wound Care Center
zz Evansville Surgery Center Associates
zz Progressive Health Rehabilitation
zz Center for Orthotic Prosthetic Care
zz Riverside Prosthetics
HOSPITALS
zz Deaconess Hospital
zz Deaconess Gateway Hospital
zz The Women’s Hospital
zz The Heart Hospital at Deaconess Gateway
zz Deaconess Cross Pointe
zz Healthsouth Deaconess Rehabilitation Hospital
URGENT CARE
zz Deaconess Urgent Care Centers
13
PHCS Healthy Directions and PHCS Networks
PHCS Healthy Directions. As indicated by the logo on the back of your ID card, Deaconess members on the exclusive
OneCare Network plan have access to the PHCS Healthy Directions Network for Emergency or Urgent Care when
traveling, studying or residing outside the area served by OneCare. As with your Primary Network, your plan's
copays and/or in-network coinsurance levels apply so your out-of-pocket costs are lowest when seeking care in the
extended PPO.
Front of Card
Back of Card
PHCS Network - For Members Residing Outside the OneCare Network Service Area — A PHCS logo on the front of
your member ID card indicates you have access to the PHCS network, which serves as your optional PPO network. Your
benefit plan's copays and/or in-network coinsurance levels apply to the Tier 2 benefits. The PHCS Network offers access
in all states to over 4,500 hospitals, 70,000 ancillary care facilities and 700,000 healthcare professionals.
Front of Card
Back of Card
To find a PHCS/PHCS Healthy Directions Provider
www.multiplan.com
Or call:
PHCS Healthy Directions: 800.678.7427
PHCS Network: 800.922.4362
Continued on Next Page
14
PHCS Healthy Directions and PHCS Networks
Member’s living in the OneCare area with Dependents outside the
area and emergency care:
Q – If I live inside the OneCare area but my dependent child lives outside the
OneCare area, such as a college student or with their custodial parent, what
network does my dependent child access?
A – The dependent will access the PHCS Healthy Directions Network. The phone
number and web address for PHCS Healthy Directions is located on the back of the
ID card.
Q – If I live inside the OneCare area but am traveling outside the area and
experience an emergency situation, will I have coverage?
A – Yes, you will be covered under the PHCS Healthy Directions Network. If the situation is a true medical emergency, then benefits will be paid at the OneCare benefit
level and subject to appropriate copay, coinsurance and deductible associated to that
tier coverage.
Members living outside the OneCare area with Dependents living
outside the OneCare area and emergency care:
Q – I live outside the OneCare area but my dependent child, such as college
student or with their custodial parent, lives in a different state, what network
does my dependent child access?
A – The dependent will access the PHCS Network located on the front of the ID card.
You may access PHCS at www.phcs.com or call 800-922-4362 to determine if the
provider is in network.
Q – If I live outside the OneCare area but am traveling outside the area and
experience an emergency situation, will I have coverage?
A – Yes, you will be covered under the PHCS Network. If the situation is a true medical emergency then benefits will be paid at the OneCare benefit level and subject to
appropriate copay, coinsurance and deductible associated to that tier of coverage.
15
Deaconess Health System
Employee Health Benefit Plan
Deaconess Health System Facilities
 Boston IVF at The Women’s Hospital
 Deaconess Hospital (incl. Gateway campus) inpatient/outpatient services including but not
limited to:
 Outpatient PT, OT & Speech Therapy
 Outpatient Laboratory Services/Diagnostic Centers
 Outpatient Radiology, CT, MRI, Endoscopy/GI Lab /Diagnostic Centers
 DME & Infusion
 Radiation Therapy Services (Chancellor Center for Oncology)
 Wound Care Center
 Deaconess Breast Center
 Deaconess Clinic Pediatric After Hours
 Deaconess COMP Center
 Deaconess Cross Pointe Center
 Deaconess Diabetes Center
 Deaconess Heart Hospital
 Deaconess Riley Children’s Specialty Clinic
 Deaconess Urgent Care Centers
 Deaconess Sleep Center
 Deaconess Weight Loss Solutions
 Deaconess Comprehensive Pain Center
 Deaconess VNA Plus, LLC
 Home care, Hospice
 Evansville Surgery Center
 HealthSouth Deaconess Rehabilitation Hospital inpatient and outpatient services including but
not limited to:
 Outpatient PT, OT & Speech Therapy
 Outpatient Imaging Services
 Short-Stay Transitional Rehab
 Midwest Radiologic Imaging
 Progressive Health
 The Women’s Hospital
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October 1, 2014 – September 30, 2015
Brief Comparison Chart of 2 Medical Options
Subscribers Living in OneCare Service Area and Their Dependents
STANDARD
ADVANTAGE
Services received from OneCare Network Providers
Routine Annual Preventive Care
Covered in full, including FDA-approved
contraceptives and sterilizations for women.
$900 per member
Annual Deductible
Once covered members of a family have met
$1,800 of deductibles in total, no further
deductibles apply
Annual Maximum-Out-of-Pocket
$3,000 per member
$500 per member
Once covered members of a family have met $1,000 of
deductibles in total, no further deductibles apply
$2,500 per member
INCLUDES DEDUCTIBLE AND MEDICAL CO-PAYS - EXCLUDES PRESCRIPTION DRUG MEMBER
PAYMENTS
Once covered members of a family have incurred two times the per member amount, no further deductible or
medical co-insurance applies
Primary Care Physician Office Visit
20% AFTER deductible
$10 co-pay + 20% Dx, procedures and facility
charges
Specialist Physician Office Visit
$25 co-pay + 20% Dx, procedures and facility
charges
Covered in full, limited to one exam per
benefit year.
Covered in full, limited to one exam per benefit
year.
Urgent Care Facility Visit
$25 co-pay + 20% Dx & procedures
Emergency Room Visit Emergency
Emergency Room - Non
Emergency
$100 co-pay + 20% AFTER deductible
In-Patient Hospitalization
Outpatient Surgery/ Advanced
Imaging
Facility Charges:: 20%
Professional Charges: 20% AFTER deductible
Routine Eye Exam
Network Providers are limited to OneCare Network Providers. Other than routine eye exams, services received from a facility or
professional provider who does not participate in the OneCare Network are NOT covered under either option unless:
 You are traveling outside the OneCare service area and require emergency or urgent care.
 You require services that are not available from a OneCare Network Provider. In that situation, your OneCare Network
Provider can refer you to IU Health, Encore or SIHO Network Provider(s) with prior approval from SIHO. Approved services
received from those providers will be covered.
 Your dependent resides outside the OneCare Service Area and receives services from a PHCS Healthy Directions Network
Provider.
Prescription drug benefits are the same in both options.
October 1, 2014 – September 30, 2015
Brief Comparison Chart of 2 Medical Options
Subscribers Living Outside OneCare Service Area and Their Dependents
STANDARD
Provider Category
Routine Annual
Preventive Care
Any Network Provider
Annual Deductible
Any Network Provider
ADVANTAGE
Services received from Network Providers
$900 per member
$500 per member
Once covered members of a family have met $1,800
of deductibles in total, no further deductibles apply
Annual MaximumOut-of-Pocket
Once covered members of a family have met $1,000 of
deductibles in total, no further deductibles apply
OneCare Network Providers
$3,000 per member
$2,500 per member
Encore, SIHO, IU or PHCS Network
Providers
$6,000 per member
$5,000 per member
INCLUDES DEDUCTIBLE AND MEDICAL CO-PAYS - EXCLUDES PRESCRIPTION DRUG MEMBER
PAYMENTS
Once covered members of a family have incurred two times the per member amount, no further deductible or medical
co-insurance applies
Primary Care
Physician Office
Visit
$10 co-pay + 20% Dx, procedures & facility
charges
Providers
charges
Specialist Physician
Office Visit
charges
Providers
charges
Any Provider
Covered in full, limited to one exam per
benefit year.
Covered in full, limited to one exam per benefit
year.
Routine Eye Exam
Urgent Care Facility
Visit
Emergency Room
Visit - Emergency
Emergency Room Non Emergency
In-Patient
Hospitalization
Outpatient Surgery/
Advanced Imaging
OneCare Facility
$25 co-pay + 20% Dx & procedures
Facility
30% AFTER deductible Dx & procedures
Any Provider
OneCare Facility
Facility
Providers
OneCare Facility
Facility
Providers
OneCare Facility
20%
Facility
Providers
Network Providers are limited to OneCare, Encore, SIHO, IU or PHCS Network Providers. Other than routine eye exams, services
received from a facility or professional provider who does not participate in one of these Networks are NOT covered under either
option unless you require emergency or urgent care while traveling.
18
October 1, 2014 – September 30, 2015 Advantage Option
All figures reflect the amount you pay for Covered Health Services.
OneCare
Professional
Provider
OneCare Facilities
Apply per Benefit Year to all services with Co-insurance or Co-payment marked with an asterisk.
Annual Deductibles
Maximum Out-of-pocket
Includes Deductible and Medical Co-payments; Excludes Rx Co-payments
Per Covered Person
$2,500
Family Limit
$5,000
Preventive Care
Well baby care, routine annual exams for individuals
over age 2, plus FDA-approved contraceptives and
sterilization procedures for women.
Routine Vision Services
One routine exam per Benefit Year
Not Covered
Covered in full
Not Covered
Covered in full
Covered in full
$10 co-pay +
20%
for Dx and procedures
$25 co-pay +
20%
Primary Care Physician (PCP)
Physician Office Services
Specialist
Inpatient Services
Injections
Serum & Testing
Inpatient Hospital
Skilled Nursing Facility (60 day limt per Benefit Year)
Organ/Tissue Transplants
Covered transplants other than cornea and kidney
Cornea and kidney covered the same as other condition
Outpatient Services
Ambulatory Hospital and Outpatient Surgery:
Performed in a hospital or Ambulatory Care Center.
Advanced Imaging: CTs, PETs, MRIs, MRAs and sleep
studies
Other Imaging and Lab: Laboratory and radiology
services that are not Advanced Imaging
Not Covered
Not Covered
20%
20%*
20%*
20%*
20%*
20%*
Not Covered
Not Covered
Not Covered
Not Covered
20%*
20%*
Not Covered
20%*
20%
Not Covered
20%*
20%
Not Covered
20%*
20%
Not Covered
20%*
Outpatient Therapy
Emergency Services
Hospital Emergency Room: Emergency Medical
Conditions. (If admitted, see Inpatient Services.)
20%*
20%*
Covered at OneCare
benefit level
Hospital Emergency Room: Other conditions
20%*
$100 co-pay per visit
then 20%*
Not Covered
$25 co-pay + 20%
for Dx & procedures
Not Covered 1
Ambulance (per use)
Mental Health Services
Chemical Dependency/
Substance Abuse
1
Not Covered
Max of 30 visits per condition. If different
types of Therapy performed on the same day,
each considered a separate Therapy visit
Speech, occupational and physical therapy
Urgent Care Center (not Hospital emergency room)
Home Health Care/DME
Hospice Services
Infertility
Diabetes Training
Maternity Services
Not Covered
$500
$1,000
Per Covered Person
Family Limit
Allergy Services
Providers not in
OneCare
Subject to $10,000 Medical Lifetime Maximum
Copay waived if part of Deaconess Wellness Care Plan
Office Visit
Outpatient
Inpatient
20%*
20%*
20%*
20%*
20%*
50%*
50%*
$10 co-pay
$10 co-pay
Covered the same as any other condition
$10 co-pay
20%
20%
20%*
20%*
Same as if OneCare
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Urgent Care Center services are covered at the OneCare benefit level for those who require Urgent Care outside the OneCare area while traveling
19
October 1, 2014 – September 30, 2015 Standard Option
OneCare
Professional
Provider
OneCare Facilities
Annual Deductibles
Per Covered Person
$3,000
Family Limit
$6,000
Preventive Care
Allergy Services
Inpatient Services
Specialist
Injections
Serum & Testing
Inpatient Hospital
Outpatient Services
studies
Not Covered
Covered in full
Not Covered
Covered in full
Covered in full
20% *
20%*
Not Covered
Not Covered
20%*
20%*
20%*
20%*
20%*
20%*
Not Covered
Not Covered
Not Covered
Not Covered
20%*
20%*
Not Covered
20%*
20%*
Not Covered
20%*
20%*
Not Covered
20%*
20%*
Not Covered
20%*
Outpatient Therapy
Emergency Services
20%*
20%*
Covered at OneCare
benefit level
20%*
then 20%*
Not Covered
Ambulance (per use)
1
Not Covered
Max of 30 visits per condition. If different
types of Therapy performed on the same day,
each considered a separate Therapy visit
Hospice Services
Infertility
Diabetes Training
Maternity Services
Substance Abuse
Not Covered
$900
$1,800
Per Covered Person
Family Limit
Providers not in
OneCare
Office Visit
20% *
20%*
20%*
20%*
20%*
20%*
50%*
50%*
$10 co-pay
$10 co-pay
20%*
20%*
Outpatient and Inpatient
20%*
Not Covered 1
Same as if OneCare
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Urgent Care Center services are covered at the OneCare benefit level for those who require Urgent Care outside the OneCare area while traveling
20
October 1, 2014 – September 30, 2015 Advantage Option
OneCare
Professional
Provider
OneCare Facilities
Other Encore, SIHO,
IU or PHCS Provider
Annual Deductibles
$500
$1,000
Per Covered Person
Family Limit
Per Covered Person
$2,500
Family Limit
$5,000
Preventive Care
Covered in full
Covered in full
20%*
20%*
Not Covered
Not Covered
Not Covered
Not Covered
20%*
20%*
30%
30%*
30%*
30%*
20%* if COE
otherwise Not Covered
20%*
20%
30%*
Not Covered
studies
20%*
20%
30%*
Not Covered
20%*
20%
30%*
Not Covered
30%*
Not Covered
Allergy Services
Injections
Serum & Testing
Inpatient Services
Inpatient Hospital
20%*
Emergency Services
20%*
20%*
20%*
20%*
then 20%*
$100 co-pay per visit then
Substance Abuse
Office Visit
Outpatient
Inpatient
Not Covered
Not Covered
Not Covered
Max of 30 visits per condition. If different types of Therapy performed on
the same day, each considered a separate Therapy visit
Ambulance (per use)
Hospice Services
Infertility
Diabetes Training
Maternity Services
Covered in full
20%
20%*
20%*
20%*
Specialist
Outpatient Therapy
Not Covered
$30 co-pay + 30% for
Dx and procedures
$45 co-pay +
30% for
Dx and procedures
Outpatient Services
Not Covered
$5,000
$10,000
$10 co-pay +
20%
$25 co-pay +
20%
Providers not in
OneCare, Encore,
SIHO, IU or PHCS
Not Covered
30%*
Not Covered
$25 co-pay + 20%
for Dx & procedures
30%*
Not Covered 1
20%*
20%*
20%*
20%*
30%*
20%*
20%*
30%*
50%*
50%*
50%*
$10 co-pay
$10 co-pay
Not Covered
$10 co-pay
$10 co-pay
20%
20%
20%
20%*
20%*
20%*
1
Covered at OneCare
benefit level
Same as
Encore/SIHO/IU/Other
PHCS Provider
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Urgent Care Center services are covered at the Other Encore, SIHO, IU or PHCS benefit level for those who require Urgent Care while traveling in an area where there is not a OneCare, Encore, SIHO, IU or PHCS Network
Provider.
21
October 1, 2014 – September 30, 2015 Standard
Option
OneCare
Professional
Provider
OneCare Facilities
Other Encore, SIHO,
IU or PHCS Provider
Annual Deductibles
$900
$1,800
Per Covered Person
Family Limit
Per Covered Person
$3,000
Family Limit
$6,000
Preventive Care
Allergy Services
Inpatient Services
Outpatient Services
Not Covered
$6,000
$12,000
Covered in full
Covered in full
Emergency Services
Hospice Services
Infertility
Diabetes Training
Maternity Services
Substance Abuse
Covered in full
30%*
30%*
Not Covered
Not Covered
20%*
20%*
20%*
20%*
20%*
20%*
Not Covered
Not Covered
Not Covered
Not Covered
20%*
20%*
30%*
30%*
30%*
30%*
20%* if COE
otherwise Not Covered
20%*
20%*
30%*
Not Covered
studies
20%*
20%*
30%*
Not Covered
20%*
20%*
30%*
Not Covered
30%*
Not Covered
Specialist
Injections
Serum & Testing
Inpatient Hospital
20%*
Outpatient Therapy
Not Covered
20% *
20%*
Providers not in
OneCare, Encore,
SIHO, IU or PHCS
Not Covered
Max of 30 visits per condition. If different types of Therapy performed on
the same day, each considered a separate Therapy visit
20%*
20%*
20%*
20%*
then 20%*
$100 co-pay per visit then
20% *
30%*
30%*
Ambulance (per use)
20%*
20%*
Office Visit
Not Covered
20%*
20%*
30%*
20%*
20%*
30%*
50%*
50%*
50%*
$10 co-pay
$10 co-pay
Not Covered
20%*
20%*
20%*
Outpatient and Inpatient
1
20%*
20%*
Covered at OneCare
benefit level
Not Covered
Not Covered 1
Same as
Encore/SIHO/IU/Other
PHCS Provider
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Urgent Care Center services are covered at the Other Encore, SIHO, IU or PHCS benefit level for those who require Urgent Care while traveling in an area where there is not a OneCare, Encore, SIHO, IU or PHCS Network
Provider.
22
Preventative
Health
Benefit –
Services Covered
Preventive
Health
Benefit
- Services
Covered
Child Preventive Care (birth to 18 years)
Preventive physical exams, including routine, periodic, and school enrollment physical exams
Age-appropriate screening tests
Newborn screenings, including well-baby care and well-child care, based on the American
Academy of Pediatric Guidelines
Vision screening (as part of complete physical examination)
Hearing screening (as part of complete physical examination)
Developmental and behavioral assessments
Oral health assessment
Screening for lead exposure
Routine blood count
Blood pressure
Height, weight and body mass index (BMI)
Comprehensive metabolic panel
Screening for depression
Screening and counseling for obesity
Behavioral counseling to promote a healthy diet
Screening and counseling for sexually transmitted infections
Pelvic exam and Pap test, including screening for cervical cancer
Fluoride supplement for children birth to 6 years old
Immunizations
Current Childhood and Adolescent Immunization Schedule as approved by the Advisory
Committee on Immunization Practice (ACIP), the American Academy of Pediatrics (AAP) and
the American Academy of Family Physicians (AAFP)
Hepatitis A vaccine
Hepatitis B vaccine
Diptheria, Tetanus, Pertussis vaccine
Varicella (chicken pox)
Influenza (flu) virus vaccine
Pneumococcal (pneumonia) vaccine
Human Papillomavirus (HPV) vaccine
Haemophilus influenza type b (Hib) vaccine
Poliovirus vaccine
Measles virus vaccine, Mumps virus vaccine, Rubella virus vaccine (MMR)
Meningococcal (meningitis)
Rotavirus
23
Preventive
Health
Benefit
Covered
Preventative
Health
Benefit -– Services
Services Covered
Adult Preventive Care (19 years and older)
Adult routine physical examinations, including preventive physical exams
Age-appropriate screening tests:
Eye chart vision screening
Routine hearing screening
Comprehensive metabolic panel
Blood pressure
Height, weight, and BMI
Screening for depression
Diabetes screening
Prostate cancer screening including digital rectal exam and routine prostate specific antigen
(PSA) testing
Breast cancer screening, including routine screening mammograms; additional
mammography views required for proper evaluation and any ultrasound services for
screening of breast cancer, if determined Medically Necessary by your Physician, are also
covered
Pelvic exam and Pap test, including screening for cervical cancer
Screening for sexually transmitted infections
HIV screening
HPV screeing
Bone density test to screen for osteoporosis, including routine bone density testing for
women
Colorectal cancer screening including fecal occult blood test, barium enema, flexible
sigmoidoscopy, screening colonoscopy and CT colonography (as appropriate). Examinations
and tests will be covered as recommended by the current American Cancer Society
guidelines or by the United States Preventive Services Task Force guidelines (for services
with an “A” or “B” rating). Covered as a preventive procedure every 10 years after age 50.
Cervical dysplasia screening
Breastfeeding support, supplies and counseling
Contraceptive counseling and FDA-approved contraceptive medical services
Screening during pregnancy (including but not limited to, gestational diabetes, hepatitis,
asymptomatic bacteriuria, Rh incompatibility, syphilis, iron deficiency anemia, gonorrhea,
chlamydia and HIV)
Intervention services (includes counseling and education);
- Screening and counseling for obesity
- Genetic counseling for women with a family history of breast or ovarian cancer
- Behavioral counseling to promote a healthy diet
- Primary care intervention to promote breastfeeding
- Counseling related to aspirin use for the prevention of cardiovascular disease
(does not include coverage for aspirin)
- Screening and behavioral counseling related to tobacco use
- Screening and behavioral counseling related to alcohol misuse
- Counseling related to chemoprevention for women with a high risk of breast
24
Preventative
Health
Benefit –
Services Covered
Preventive
Health
Benefit
- Services
Covered
-
cancer
Screening and counseling for interpersonal and domestic violence
Annual dilated eye examination for diabetic retinopathy
Routine urinalysis
Aortic aneurysm screening (men)
Rabies vaccine
Hemophilus influenza b (Hib) vaccine for adults
Ultrasound services for screening of breast cancer, if determined Medically Necessary by your
Physician
Diabetes self-management training for individuals with insulin dependent diabetes, noninsulin dependent diabetes or elevated blood glucose levels when Medically Necessary,
ordered by a Physician or a podiatrist and provided by a healthcare professional who is
licensed, registered or certified under state law.
Immunizations
Adult Immunization Schedule by age and medical condition as approved by the Advisory
Committee on Immunization Practice (ACIP) and accepted by the American College of
Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP).
Hepatitis A vaccine
Hepatitis B vaccine
Diptheria, Tetanus, Pertussis vaccine
Varicella (chicken pox)
Influenza (flu) virus vaccine
Pneumococcal (pneumonia)
Human Papillomavirus (HPV) vaccine
Measles virus vaccine, Mumps virus vaccine, Rubella virus vaccine (MMR)
Meningococcal (memingitis)
Zoster (shingles)
25
Network Service Area
Postal Code
City
State
47601
Boonville
IN
47610
47612
47613
47701
47708
47710
47711
47712
47713
47714
47715
47719
47720
47724
47725
47648
47617
47639
47619
47620
47631
47629
47630
47660
47633
47634
47638
42420
Chandler
Cynthiana
Elberfeld
Evansville
Evansville
Evansville
Evansville
Evansville
Evansville
Evansville
Evansville
Evansville
Evansville
Evansville
Evansville
Ft. Branch
Hatfield
Haubstadt
Lynnville
Mt. Vernon
New Harmony
Newburgh
Newburgh
Oakland City
Poseyville
Richland
Wadesville
Henderson
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
KY
26
Medical Options
EMPLOYEE CONTRIBUTION CHART
effective October 1, 2014 thru September 30, 2015
Rates for PART TIME employees
*Part time employee = authorized 40-59 hours each pay period
**MEDICAL OPTIONS
Employee Employee Employee + Employee
Only
+ Spouse Child(ren) + Family
Bi-Weekly Employee
Rates 2013-2014
Standard Option
$68.81
$132.49
$111.02
$174.63
Advantage Option
$98.35
$189.79
$163.07
$254.45
*All covered Employees & Spouses MUST screen between September &
December 2014.
*All follow-up programming MUST be completed & submitted to Wellness as
instructed in order to receive the Wellness Incentive on 10/01/2015.
Bi-Weekly Wellness Incentives 2014-2015
Employee Wellness Incentive
$33.93
Spouse Wellness Incentive
$11.30
**Pre-tax benefit
Rates for FULL TIME employees
*Full time employee = authorized 60-80 hours each pay period
**MEDICAL OPTIONS
Bi-Weekly Employee
Rates 2013-2014
Standard Option
Advantage Option
Employee Employee Employee + Employee
Only
+ Spouse Child(ren) + Family
$45.75
$76.74
$88.11
$148.38
$70.93
$125.67
$113.22
$197.24
*All covered Employees & Spouses MUST screen between September &
December 2014.
*All follow-up programming MUST be completed & submitted to Wellness as
instructed in order to receive the Wellness Incentive on 10/01/2015.
Bi-Weekly Wellness Incentives 2014-2015
Employee Wellness Incentive
$33.93
Spouse Wellness Incentive
$11.30
**Pre-tax benefit
27
Prescription Benefit
Prescription Drug Benefits
Advantage & Standard Medical Options
The Prescription Drug benefits which follow apply to both the Advantage and the Standard options.
Deaconess Family
Pharmacy
Envision Network
Pharmacy
10%: $5 Min to $30 Max
20%: $30 Min to $40 Max
20%: $50 Min to $65 Max
25%: $125 Max
20%: $10 Min to $40 Max
30%: $45 Min to $60 Max
30%: $75 Min to $100 Max
Not Covered 2
$0
$0
$0
50%-subject to annual max
$0
Not Covered
Non-Network
Pharmacy
30 Day Supply or Less
Rx Tier 1 - Generic
Rx Tier 2 - Preferred Brand 1
Rx Tier 3 - Non-Preferred Brand 1
Specialty Medication
Smoking Cessation Medications 3 (Zyban
only)
 Contraceptives 4
 Infertility Medication 5





Not Covered--You pay
100%
Over 30 Day, Up to 90 Day Supply
 Rx Tier 1 - Generic
 Rx Tier 2 - Preferred Brand 1
 Rx Tier 3 - Non-Preferred Brand
1
 Specialty Medication
 Smoking Cessation Medications (generic
only) 3
 Contraceptives 4
 Infertility Medication 5
10%: $12 Min to $50 Max
20%: $70 Min to $100 Max
20%: $125 Min to $163 Max
Not Covered
Not Covered--You pay
100%
$0
$0
50%-subject to annual max
Diabetic testing supplies are covered under the prescription drug benefit.
1
If a Generic version is available and a Preferred Brand or Non-Preferred Brand is received, the Member pays the applicable cost share plus the
difference in cost between the Generic version and the drug received, regardless of whether requested by the prescribing Provider or the Member.
2
The first fill of designated Specialty Medications will be covered at an Envision Network Pharmacy at the same member cost sharing as applies to
Specialty Medications filled by the Deaconess Family Pharmacy. Second and subsequent fills of designated Specialty Medications will only be covered
by the Plan if filled by the Deaconess Family Pharmacy. However, for Members who are COBRA beneficiaries, Retirees or Eligible Dependents of a
Retiree and who reside in a state outside the Deaconess Family Pharmacy’s service area, subsequent fills of designated Specialty Medications will be
covered, with the Deaconess Family Pharmacy member cost-sharing applied, if filled through the Costco Mail Order pharmacy.
3
Members actively participating in a tobacco cessation educational session will be eligible for a three month prescription of Zyban at a $0 copay; If
Zyban fails, Members actively participating in a tobacco cessation educational session will be eligible for a three month prescription of Chantix at a
$40 copay. If beneficiary requires a precertification longer than the initial three months, additional months (up to a total of 6 months) may be
approved by the Deaconess Employee Wellness Department if the Member is still participating in tobacco cessation educational sessions.
4
If a Generic version is available and a Preferred Brand or Non-Preferred Brand is received, the Covered Person pays the difference in cost between
the Generic version and the drug received, regardless of whether requested by the prescribing Provider or the Covered Person.
5
Infertility medications are subject to a $5,000 annual maximum combined for 30 Day Supply or Less and Over 30 Day, Up to 90 Supply.
Important Notes

Third and subsequent fills of maintenance medications will only be covered by the Plan if filled by the Deaconess
Family Pharmacy.

Pre-authorization is required for certain medications. Quantity limits apply to certain medications. Before some
medications are covered, certain criteria must be met or another drug in the same therapeutic class must have
been tried.
28
Prescription Benefit
Deaconess Family Pharmacy
Deaconess Family Pharmacy offers you the ability to have your prescriptions filled by our trusted Deaconess
pharmacists and the opportunity to save money on your copayments. The pharmacy is located at the Main Campus.
 Phone: 812-450-DRUG (3784)
 Hours:
 Main Campus = Monday-Friday 7:00 am - 7:00 pm, Saturday 9:00 am - 2:00 pm
 Gateway Pharmacy pickup = Monday-Friday 7:00 am - 7:00 pm, Saturday 9:00 am - 2:00 pm
 The Women’s Hospital Pharmacy pickup = Monday-Friday 7:00 am - 2:00 pm
Mail Order
Mail service is available from the Deaconess Family Pharmacy. Prescriptions for a 90-day supply can be mailed at no
additional cost to addresses in Indiana, Kentucky and Illinois. Prescriptions for less than a 90-day supply will incur a $5
mailing charge per shipment. Contact the Pharmacy staff for more information.
Maintenance Medications
Maintenance medications are defined as medications you must take on a monthly basis, with the exception of narcotics.
You may receive two 30-day fills of a maintenance medication at the Deaconess Family Pharmacy or any other
EnvisionRxOptions network pharmacy of your choice. It is important to note that you will be required to obtain your third
and subsequent fills of maintenance medications from the Deaconess Family Pharmacy.
Step Therapies/Quantity Limits
Prior authorization is required for certain medications. Quantity limits apply to certain medications. For some medications,
you may need to try another therapeutically equivalent drug before the prescribed medication will be covered.
Specialty Pharmacy
There are certain complex medications that have special storage and handling requirements. These include costly
injectable and oral medications and select chemotherapeutic medications. They are considered specialty medications.
If you are taking a specialty medication, you will be able to obtain your first fill from any EnvisionRxOptions network
pharmacy. After that, all fills must go through Deaconess Family Pharmacy.
The specialty medication copayment structure is 25% coinsurance with a maximum of $125.00 per prescription limited to
a 30-day supply.
Contraceptives
Pursuant to the Affordable Care Act, the Deaconess Employee benefit will cover prescription contraceptives at no
copayment. If a member chooses to receive a brand name medication when an equivalent generic is available, the
member will pay the difference between the price of the brand received and the generic equivalent.
EnvisionRxOptions Website
You may find additional information about your prescription benefit at http://www.envisionrx.com. You must first create
an account, as follows:
1. Click on the “Not Registered? Click here to register today!” link located on the left side of the page.
2. To create your account, enter all the required information and press the “Register” button.
Once your account has been created you will have access to the following information:






Overview of your plan and benefits
Drug coverage and pricing, including co-pays
Mail order information
Direct member reimbursement form
Prescription history
Participating pharmacies
If you have any questions regarding your prescription benefit or to find an Envision Network pharmacy, do not hesitate to
call the EnvisionRxOptions Customer Service Help Desk at 1-800-361-4542.
29
Dental
Option
Dental Option
Dental Health Options through HRI offers a broad network of tri-state dentists and specialists to choose
from, which results in no balance billing for covered members. There are no claim form hassles with
HRI—covered employees will receive a dental card.
Other highlights of the plan include:

Annual coverage maximum of $1,500 per person

Dependents covered up to age 26, regardless of student status

Preventive care at 100% coverage

No deductibles for any services

No waiting periods

Crowns are covered at 80/20

No pre-existing condition clauses

Orthodontic benefit with $1,500 lifetime maximum per person
Employee contribution rates for the HRI dental option are listed on the next page. A summary chart of
the dental plan can be found on the page after the contribution rates.
Employee Contribution Chart
effective October 1, 2014 thru September 30, 2015
DENTAL OPTION
(Pre-tax Benefit)
Employee
Only
Employee
+ Spouse
Employee
+
Child(ren)
Employee +
Family
$7.09
$15.38
$15.38
$22.49
Bi-Weekly Employee Rates
2014 - 2015
HRI Dental Option
If you are enrolled in HRI Dental and do not have a dental insurance
card, please call HRI Customer Service at 1-800-727-1444.
30
Dental Option
For
DENTAL HEALTH OPTION 4
CONGRATULATIONS! You and your family have the opportunity to enroll in Dental Health Options through Health
Resources Inc (HRI).
Members using participating providers enjoy
· No deductibles.
· No claim forms.
·
·
No waiting periods.
No pre-existing condition clauses.
·
No balance billing.
·
A large dentist network, including
specialists.
·
Exams, x-rays, routine cleanings, and
fluoride covered at 100% with few
limitations.
·
High maximum annual benefits.
Most tri-state dentists are providers in the HRI network. To ensure your dentist is participating, please visit our website
at www.hri-dho.com.
Complete an online Subscriber Enrollment Application to begin coverage. NO ONE MAYADD, DROP OR CHANGE
COVERAGE DURING EACH CONTRACT PERIOD unless a change of family status or employment termination
occurs.
As a subscriber, you will receive ID cards. You may also access a detailed PlanBook of covered procedures, verify
coverage, or check on claims for you and your covered dependents on our website www. hri- dho.com at any time of day.
Every time you use Dental Health Options, you will receive an Explanation of Benefits that confirms claim status too.
31
Dental Option
LIMITATIONS
Dental Health Options (DHOs) offer coverage for many services, but some restrictions apply. Coverage for some procedures is limited by age, frequency, or
specific teeth. Change of coverage or reinstatement of coverage does not eliminate frequency limitations.
The following are some of the limitations associated with this plan. For a complete list, refer to the Planbook.
· Charges for more than two examinations, of any procedure code combinations, are not allowable within any consecutive 12 month period.
The 12 month period is NOT based on contract year or calendar year.
· Routine teeth cleaning and applying fluoride are covered every 6 months.
· X-rays of your whole mouth will be paid by HRI once every 4 years. Cavity-checking x-rays (bitewings) are covered once per 12 months. Obviously, x-rays
should be taken as often as your particular need indicates.
· Fillings will not be covered if they are replacements within 3 years of the original or placed within 3 years of a crown.
For work in progress, HRI recognizes the American Dental Association’s definition for the date of service/payment.
Provider dentists are independent contractors and are not HRI employees.
Although reasonable effort has been made to represent the intent of contract language, the Master Group Contract controls the relationship of the parties at
all times.
GENERAL EXCLUSIONS
All DHOs are issued subject to the following general exclusions.
1. Within the HRI service area, claims will not be paid for services rendered by dentists who are not contractual providers for HRI, except for emergency
services performed at least 50 miles from the nearest office of any provider dentists.
2. To be considered for payment, a claim must be submitted within 1 year from the date of service.
3. HRI will not pay claims for the following:

Procedures which are not listed in the employer’s Master Group Contract.

Dental services rendered before the effective date of coverage or after the last day in which coverage terminated.

Dental services covered under non-dental insurance.

Charges made by hospitals.

Services performed primarily to rebuild occlusion or for full mouth reconstruction.

Claims for enrollees until HRI receives the appropriate premium payment.

Claims for services which are not completed.

Claims for duplicates, lost, or stolen prostheses or appliances.

HRI will pay claims for eligible dependents until age 26 regardless of student status.

Dependents who suffer a permanent physical or mental disability that precludes their gainful employment may qualify for coverage beyond the
applicable age limit. However, HRI accepts each individual employer’s definition of “dependent”. Such definition has precedent over HRI’s criteria.
In 1986, a group of dedicated dentists recognized the need for a quality dental plan for employer groups. As practicing dentists,
this group understood the concerns of their patients. You, the patient, desire high quality care when you need it and at affordable rates,
you like the freedom to choose your own dentist and don’t want a dental plan that makes you change. You want dental plans that are
easily understood and for claims to be paid promptly. You want administrators of a dental plan to treat you fairly and with
understanding.
Health Resources, Inc. was founded with these principles in mind. Over the years we have expanded and made additional
improvements to our dental coverage. You have the freedom to choose your own participating dentists. There are no deductibles.
Exams, x-rays, and preventive services are covered at 100%. We provide coverage for pre-existing conditions. Our dental plans offer a
broad range of coverage with the best possible value.
Our mission statement is, .To improve the dental health of the public through the use of prepaid dental plans.. And for twenty
years that is exactly what we have delivered to our subscribers. We look forward to continuing that promise to our customers. I hope
that you feel as excited as I do about Health Resources, Inc.’s Dental Health Options and enroll today!
Sincerely,
Allan L. Reid, DMD, MBA
President/Chief Executive Officer
CUSTOMER SERVICE
(800) 727-1444
www.hri-dho.com
CLAIMS
CLAIMS@hri-dho.com
ELIGIBILITY
ENROLLMENT@hri-dho.com
32
Dental Option
PREVENTIVE SERVICES
Routine teeth cleaning
Fluoride applications (no age
restrictions) (does not include Fluoride
Varnish applications)
Sealants (under 15 years of age,
permanent molar teeth only)
Space maintainers (under 13 years of
age,
not orthodontic retainers)
Fixed, unilateral, and bilateral
Removable, bilateral
Recementation
FILLINGS & CROWNS
Silver fillings
Primary teeth
Permanent teeth
White Fillings
Anterior teeth
Posterior teeth
Inlay/Onlay (gold & porcelain)
Crowns (single tooth only)
Porcelain/ceramic jackets(“caps”)
Full cast
¾ cast
Prefabricated stainless steel crowns
Recementation
Other restorative services
Temporary filling
Crown buildup including pins
Pin Retention
Post & Core
Labial veneers (“bonding”)
DENTAL SERVICES COVERED AT 100%
DIAGNOSTIC SERVICES
DIAGNOSTIC SERVICES (Cont.)
Surgical films of jaws
Examinations
Periodic, limited, comprehensive,
TMJ films
periodontal
Cephalometric film
Other Procedures
Radiographs (x-rays)
Complete series (full mouth x-rays)
Pulp vitality tests
Panoramic films
Diagnostic casts
Single x-ray(s)
Diagnostic photographs
Cavity checking
ENDODONTICS
Vital Pulpotomy (primary teeth only)
Pulp Therapy (primary teeth only)
Root canal Therapy
Anteriors
Premolars
Molars
Retreatment
Apexification
Periapical procedures
Apiceoctomy
Retrograde filling
Root amputation
Hemisection
Preparation for post
PERIODONTICS
Gingivectomy, per quadrant
Crown lengthening
PERIODONTICS (Cont.)
Osseous surgery
Soft tissue grafts
Distal or proximal wedge
Scaling and root planing
ORAL SURGERY
Extractions (Routine removals or
exposed roots)
Surgical removals
Impactions
Tooth reimplantation
Surgical exposure or unerupted tooth
Biopsy, soft tissue
Incision and drainage of abscess
(intraoral)
Frenectomy
Excise hyperplastic tissue (removal of
excess gum tissue)
FIXED BRIDGEWORK
ADJUNCTIVE SERVICES
Bridge pontics & retainers
Palliative emergency treatment
Resin bonded (Maryland) bridge
Anesthesia
Recementations
General anesthesia
Post and core
Intravenous sedation
Analgesia (nitrous oxide)
REMOVABLE PROSTHODONTICS Cast Coping
Complete/Immediate dentures
Other Procedures
Partial dentures
Occlusal Splints for bruxism
ORAL SURGERY
All acrylic
Alveoloplasty (smoothing of bone)
Athletic mouth guards
Metal framework, acrylic saddles
Removal of benign lesions and cysts
Bleaching (anterior teeth, supervised
Repairs
Removal of exostosis
in office)
Reline
TMJ manipulation under anesthesia
Tissue Conditioning
Sialolithotomy
Overdentures
*Coverage for some procedures is limited by age, frequency, or specific teeth.
PERIODONTICS
Guided tissue regeneration
Full mouth debridement
Periodontal maintenance
33
FlexibleSpending
Spending Accounts
(FSA)
Flexible
Account
FSA’s are pre-tax reimbursement accounts in which employees can direct a certain amount of their
earnings to use for healthcare expenses not covered by insurance or daycare expenses while you work.

ADP administers both of the Flexible Spending Account options.

Employees may direct as little as $5 each pay period up to a maximum of $96 into the medical
care account.

For the dependent care account, you may direct as little as $5 each pay period up to a maximum
of $190.

Because the money is pre-tax, taxable income is reduced and take-home pay is greater than it
would otherwise be, if the same expenses were paid with after-tax dollars.
Medical Care Accounts

Used for healthcare expenses not covered by insurance.

Annual Health Care FSA elections are available in full on the first day of coverage.

Employees enrolled in Healthcare FSA’s will have the option to use a debit card for medical
expenses. A debit card will be mailed to employees home address from ADP.
Dependent Care Accounts

Used for Child Care and Adult Care Expenses.

Licensed and private sitters may be used as long as a receipt, with the sitter’s Tax ID Number or
Social Security Number clearly listed, is turned in with the claim form.

For dependent care expenses, there is also a dependent care tax credit, which, for some people,
may provide greater savings than the flexible spending account. Please consult an independent
financial or tax advisor for which dependent care option best fits your needs.
You can view your FSA account information through Empowered Benefits.
When budgeting money for either FSA, be conservative.
Under IRS rules, any money you don’t use for expenses during the plan year is forfeited.
Also, please keep in mind that you may not transfer money from one account to another.
34
Flexible Spending Account
35
Flexible Spending Account
36
Basic Employee Life and
Accidental Death & Dismemberment
Employees authorized 40 or more hours a pay period are automatically enrolled in basic employee life insurance and
accidental death and dismemberment coverage in an amount equal to 1 times your base annual salary (rounded up to the
next $1000) up to certain limits with a $20,000 minimum, at no cost to you.
You will need to list your beneficiary for this basic life insurance policy on Empowered Benefits. Primary and Secondary
beneficiaries may be indicated.
Eligible Beneficiaries include
 any individual over the age of 18*
 charities
 Trust funds as set up in a legal document
*If you list a beneficiary under the age of 18 and your life insurance needs to be paid out, all monies may go to your
estate until settled. An alternative beneficiary to list for your dependents under the age of 18 may be your spouse, a
Trustfund as set up in your will, or any person who would be financially responsible for your dependents.
37
Optional Employee Life and
Accidental Death & Dismemberment
and Dependent Life Insurance
Deaconess welcomes The Hartford as our new provider for life and disability insurance. With Hartford, employees will
have increased Basic life coverage, new dependent life options, and lower costs for the optional life plans. We no longer
have packages with spouse life and child life combined. Due to changes, Dependent Life Insurance will not roll
into the next plan year! If you wish to continue dependent life insurance you will need to re-enroll. If you do not make
elections for dependent life, current elections will end on 9/30/14.
Basic Life and AD&D Insurance
Basic Life and AD&D will now be 1X annual base salary up to certain limits. All
employees with an annual salary less than $20,000 will continue to receive a
basic life insurance policy of $20,000. Deaconess pays for this coverage.
Optional Life and AD&D packages are available at 100%, 200% or 300% of your
base annual salary to a maximum of $500,000.
Optional Life and AD&D
Insurance
Employee
Age Oct 1st
< 30
Rates per
$1000
$0.022
30-34
$0.026
35-39
$0.035
40-44
$0.048
45-49
$0.073
50-54
$0.106
55-59
$0.150
60-64
$0.258
65-69
$0.402
70-74
$0.666
75+
$1.174
Spouses can have up to 50% of what the employee elects (including Base and
Optional coverage) up to $50,000. You must elect in $5,000 increments.
Dependent Spouse
Life Insurance
Dependent Child
Life Insurance
Employee
Age Oct 1st
< 30
Rates per
$1000
$0.038
30-34
$0.048
35-39
$0.064
40-44
$0.091
45-49
$0.139
50-54
$0.219
55-59
$0.333
60-64
$0.438
65-69
$0.697
70-74
$1.217
75+
$2.206
You can purchase $10,000 per child for $0.29 each pay period regardless of the
number of children covered. Children are covered to age 26.
38
Short-term Disability
Coverage
Short-term
and Long-term
and
Disability
Coverage
Long-term Disability Coverage
Employees authorized 40 or more hours a pay period are automatically enrolled in Short-term disability and Long-term
disability coverage at no charge.*

Short-term disability benefit provides 60% of your base rate of pay starting on the 8th day after your injury or
sickness.
o

There is a 90 day waiting period for newly benefit eligible employees.
Long-term disability benefit provides 60% of your base rate of pay when disabled more than 180 days.
o
There is a 90 day waiting period for newly benefit eligible employees.
*Salaried supervisor and physician disability benefits are outlined in the Income Continuation Guidelines or physician
contract. Contact the Benefits Office with any questions regarding salaried supervisor or physician disability benefits.
39
401k Enrollment
401(k) Plan Enrollment
401(K) ENROLLMENT IS NOT DONE THROUGH EMPOWERED BENEFITS,
BUT DIRECTLY THROUGH FIDELITY.
PLEASE READ BELOW FOR FURTHER INSTRUCTIONS.
Under a 401(k) plan, you choose to contribute a percentage of your pay to one or
more funds on a menu of investment options. The money you contribute and your
investment earnings are not subject to federal or state income tax until it is paid out
to you. Fidelity will mail a 401(k) enrollment packet to your home address 2-4 weeks
after your hire date. 401(k) enrollment is done thru the Fidelity website or toll-free
number.
If you do not enroll yourself within 30 days of hire, you will
automatically be enrolled in a life cycle fund at 3% of your
earnings. If you do NOT want to participate in the 401(k)
plan at this time, you need to contact Fidelity and waive
your contributions within the first 30 days of hire.
Employees may direct 1 to 50% of their paycheck into the 401(k). Deaconess will
match a percent of the first 6% of contributions when meeting all criteria. Deaconess
match is guaranteed at 25% of the first 6%. Additional match may occur if Deaconess
meets or exceeds its financial targets. Deaconess also contributes a base contribution
of 2% to 5% of your eligible pay base on years of service to your 401(k) plan.
With the Deaconess 401(k) Plan, you have a choice of multiple funds representing a
wide variety of investment options and risk/return profiles. You can start, change, or
stop your 401(k) plan at any time by calling Fidelity at 1-800-343-0860 or going
online to www.fidelity.com/atwork.
40
Employee Wellness
Did you know?
Deaconess Health System is committed to providing physical activity and wellness opportunities for our
employees. We have been recognized as a 2013 Platinum Level Recipient of the American Heart
Association’s Start! Fit-Friendly Companies Recognition program for providing a culture of wellness in
our workplace and with an American Heart Workplace Innovation Award. The Wellness Council of
Indiana has named Deaconess Hospital a winner of its 5 star award for creating a corporate culture that
supports employee wellness.
Health Screening
The health screening is a free service and will focus on five key health indicators: blood pressure, body
mass index, lipid profile (cholesterol), blood glucose and tobacco use. At the session, a Deaconess
Wellness coach will review the test results and help develop a plan to address your unique health issues.
The screening and coaching will take about 30 minutes. One way to shorten this experience is to bring
your own lab results if you have all tests needed and the date is July 1, 2014 or after.
Follow-up Programming and Activities
By the end of the screening, each individual will have a personal wellness plan, or follow-up
programming, to complete. The follow-up programming can include an exercise log, blood pressure log,
additional sessions with a Wellness Coach to discuss progress and develop personal goals, office visits
with a physician, or educational classes. Please note that while the follow-up programming is required in
order to be eligible for the Employee and/or Spouse Wellness Incentive, it is optional if an employee does
not wish to participate. Both the employee and spouse have a CHOICE to complete the follow-up
programming and receive the Wellness Incentive or not complete the follow-up programming and
therefore not receive the Wellness Incentive.
Education and Resources
Deaconess offers many health promotion and management programs to employees and their spouses
through the Deaconess Wellness Department. These offerings range from healthy meal options at our
cafeteria, to tobacco cessation programs, to lifestyle modification programs. We will be advertising and
promoting these programs during the next year.
41
Employee Wellness
Personal Health Screenings—What to Expect
The health screenings are performed at the Main Campus in the Wellness Center located in the old
Radiation Therapy department in the basement, unless specified elsewhere. Screenings on the Gateway
campus are held in the conference rooms. This area is arranged for maximum privacy during testing and
one-on-one Wellness coach discussions.
Here’s what you can expect:
 Before your screening
For the most accurate (and useful) test results, you should not eat anything and only drink water
during twelve hours prior to your appointment. Please take any routine medications, as long as
food is not required. You don’t need to do anything else to prepare for the screening, nor do you
need to bring anything with you unless you are providing your own lab results from your
physician. Please bring reading glasses if needed, you will be required to fill out paperwork.
 When you arrive
You will be greeted by screening staff who will provide you with information and materials and
will get you started through the screening process.
 What tests will be performed
The screening staff will:
- Measure your height and weight
- Calculate your body mass index and body fat percentage
- Take your blood pressure
- Finger Stick to test your lipid profile and blood glucose levels and
A1C if you are diabetic
 Reviewing results and planning
After the tests are performed, you will meet with a Deaconess Wellness Coach to review your
results. Your coach will discuss your test results, explain what they mean and suggest options to
address any health risks that are identified. You will leave your session with a personal wellness
plan.
42
Employee Wellness
Answers to Questions We’ve Received
Q. What tests are conducted during the health screening?
A. The screening staff will perform a finger stick to determine total cholesterol, HDL-cholesterol, LDLcholesterol, triglycerides and blood glucose levels. They will also take your blood pressure and measure
your height, weight, BMI and body fat %. They will not test for hepatitis, HIV or illegal drugs.
Q. When are the screenings and how do I make an appointment?
A. Screenings will begin October 2014. Employees will need to schedule an appointment online at
www.deaconess.com, on the “For Employees” page. Sign ups will begin September 1, 2014.
Q. Do I need to get a health screening through the Deaconess Employee Wellness program if
I’ve had a physical exam recently?
A. You do need to participate in a health screening. If your exam included lab work performed on or
after July 1, 2014, please bring a copy to your health screening. Lab work needs to include the following
tests: total cholesterol, HDL, LDL, triglycerides, blood glucose and an A1C if diabetic. If you do the
required lab work you will NOT need to fast for your appointment. Please schedule your health screening
with the Wellness coach online at www.deaconess.com, on the “For Employees” page on or after
September 1, 2013.
Q. Do I need to get a health screening and receive coaching through the Deaconess
Employee Wellness Program if I have regular check-ins with my physician?
A. Yes a health screening will still be required to be eligible for medical insurance.
Q. I’m pregnant. Should I get my health screening now or wait until I have my baby?
A. To be eligible for medical insurance next year, you must participate in a health screening. Your
height, weight, BMI, blood glucose, lipid testing and blood pressure will be waived. You will still meet
with a Deaconess Wellness coach and review tobacco status and any follow- up programming that may
be required. You DO NOT need to fast as blood work will not be completed.
Q. Can you give me directions to the Wellness Center where most of the health screenings
are taking place?
A. Go to the main hospital lobby. From the Information Desk, locate the main elevators that are nearby.
Take these elevators down to the basement. In the basement, follow the pink signs marked “Wellness
Center.”
Q. Do I need to fast before my health screening?
A. Yes. For the best results, you should only drink water and do not eat at all during the twelve hours
prior to your screening appointment. Fasting means no food, gum, mints, or liquids other than water.
Please drink plenty of water and take any medications as long as no food is required.
Q. Will I have privacy during my health screening?
A. Yes. The Wellness Center is located in the Old Radiation Therapy Department in the hospital basement
which has lots of space for maximum privacy. Each screening will take place in a separate station.
43
Employee Wellness
Q. Are my health screening results confidential?
A. Only the healthcare professionals who assist you with your careplan will have access to your personal
results in order to provide the advice necessary for you to understand your health status and the steps
you can take to improve it.
Q. Can Deaconess require me and my spouse to have a screening to be eligible for medical
benefits?
A. Yes, and other local and national companies are implementing similar programs. As healthcare costs
continue their astronomical rise, many employers are looking for ways to manage these costs while
keeping medical coverage affordable—for employees and the company. There are many factors that
contribute to rising costs that we cannot do anything about. One thing we can do, however, is manage
our personal health and make smart use of our healthcare services. That’s what Deaconess Employee
Wellness is all about.
Q. What do I need to do to be eligible for the Wellness Incentive?
You need to complete a health screening by December 20, 2014 (Remember, if you’ve had a physical
exam since July 1, 2014 and can provide the required test results -lipid profile and glucose-, you don’t
need to fast for your health screening at Deaconess). You need to work with a Deaconess Wellness coach
to carry out the follow-up programming you received as part of your health screening. Your personal
wellness plan will need to be completed by June 30, 2015.
Typically, the plan will outline actions for you to take and will involve meeting periodically throughout the
year with a Wellness coach who will give support, check on your progress, answer your questions and
provide information. The goal is active involvement in working towards a healthy lifestyle—not specific
outcomes. For example, no one will be asked to lose 10 pounds to be eligible for the Wellness Incentive.
Depending on your personal health situation, you may be asked to participate in a seminar or other
program, for example a tobacco cessation or diabetes management program. Some of these options
may cost the employee and/or spouse money out of his/her own pocket to participate. Please note that
while the follow-up programming is required in order to be eligible for the Employee and/or Spouse
Wellness Incentive, it is optional if an employee does not wish to participate. Both the employee and
spouse have a CHOICE to complete the follow-up programming and receive the Wellness Incentive or not
complete the follow-up programming and therefore not receive the Wellness Incentive.
Q. Must my spouse have a health screening to be covered under my medical plan beginning
October 1, 2015? What about my children?
A. Yes, a health screening for your spouse is required for coverage. If your spouse follows through on
his/her personal wellness plan, he/she will qualify for the Spouse Wellness Incentive. Dependent children
are not included in the health screening program.
Q. Can my spouse schedule a health screening during the times posted for employees?
A. Yes, the posted schedule applies to employees and their spouses.
44
Employee Wellness
Q. If I cover my spouse under my Deaconess medical plan, will I get a bigger incentive if my
spouse also gets a health screening?
A. You will both receive a Wellness Incentive if you both complete a health screening, follow through and
submit both of your completed personal wellness plans by the posted due date(s).
Q. My spouse works full-time, M-F, 7:30 AM – 5:00 PM, at a location several miles from
Deaconess Hospital. Will he/she be able to get a health screening without taking time off
work?
A. The Wellness Center will open at 6 AM and close at 6 PM on specified days as well as being open on
some scheduled Saturdays, to accommodate such situations. The Deaconess Employee Wellness staff will
work with anyone who is having difficulty getting to the Wellness Center during its business hours.
Please contact us for further details.
Q. If I don’t have medical coverage through Deaconess Hospital, am I required to get a
health screening? Can I get a screening if I want one?
A. If you do not participate in a Deaconess medical plan, you are not required to get a health screening,
but you are encouraged to take advantage of this valuable, free service. The cost of these tests typically
exceeds $50.
Q. If I’m a tobacco user, will I be eligible for medical coverage next year? What about the
Wellness Incentive?
A. If you complete a health screening within the required time period, you will be eligible for medical
coverage beginning
October 1, 2015, provided you meet all other eligibility criteria. You may also be eligible for the Wellness
Incentive if you follow through and submit your completed personal wellness plan by the posted due
date.
Q. How do I benefit from participating in the Deaconess Employee Wellness program?
A. There are four important ways you may benefit from the program: a free health screening and
personal wellness plan, improved health, cost savings (through reduced medical premiums and fewer
healthcare expenses) and enhanced ability to serve your patients and customers.
Q. What does the hospital gain from offering the Deaconess Employee Wellness program?
A. Hospital leadership believes that improved health and health management will ultimately help us serve
our patients and customers better and more efficiently. It will also help the hospital manage its rising
healthcare costs and continue to offer medical coverage at a price that is affordable for you and the
hospital.
45
Deaconess Employee Services
Services that Deaconess offers to you and your family
DEACONESS CONCERN
MEDICATION THERAPY
MANAGEMENT CLINIC
Concern offers free confidential counseling.
Counselors are available when you need them
at a location near you. Evening and daytime
appointments are available for your convenience.
Call 812-471-4611 for more information.
The Medication Therapy
Management Clinic offers a
personalized one-on-one visit
with a pharmacist to help ensure
that you’re getting the most from
your medications. Please call
812-450-4MTM.
DEACONESS RN ON CALL
Offered to all Deaconess
employees and immediate family.
Registered nurses are available
24 hours a day to answer your
questions about any acute illness
or injury. Call 812-450-7681 or
800-967-6795.
THE RIGHT STUFF STORE
This store offers discounted diapers, Ensure,
latex gloves, alcohol swabs, syringes and
underpads. Please call 812-450-3411 for more
information.
DIABETES CARE PROGRAM
DEACONESS FAMILY PHARMACY
The diabetes care program offers
free diabetes education to all
diabetic employees and their eligible
dependents who carry Deaconess
insurance. Call Employee Wellness at
812-450-2429 for more information.
Deaconess Family Pharmacy is a full-service
pharmacy offering prescription medications and
over-the-counter items at a discounted price.
Please call 812-450-DRUG for more information
or stop by the pharmacy in Deaconess Hospital.
MEDICATION ASSISTANCE PROGRAM
DEACONESS EMPLOYEE
WELLNESS
The Medication Assistance Program works
with drug companies and foundations that
can help you get your medications at no or
reduced cost when you need help. Call 812450-2319 for more information.
The employee wellness department offers free
nutrition counseling and blood pressure checks
and hosts a weight loss support group. Please
call 812-450-2429 with any questions.
GYM DISCOUNTS
DEACONESS LACTATION ROOM
Many gyms offer discounted
rates for Deaconess employees.
Please check with your local
gym for more information.
The lactation room at Deaconess Hospital is
located in room 3108 on the third floor (type
in 3108# to enter the room). This room offers
privacy for nursing mothers.
DEACONESS FITNESS CENTER
FREE BREAST PUMPS
The Deaconess Fitness Center is free for all
employees. They offer a convenient location,
long operating hours to fit your schedule, and
qualified fitness professionals to help you meet
your fitness goals. Call 812-450-7251 to set up
your Fitness Center orientation.
Each breastfeeding mother qualifies for one
Medela breast pump per plan year covered at
100%! Contact Employee Wellness at 812-4502429 or Deaconess Home Medical Equipment at
Gateway, 812-842-3789, for more information.
Employees not on Deaconess medical insurance,
please check with your insurance provider.
46
FREE GLUCOMETER
DEACONESS CHILDREN’S
ENRICHMENT CENTER
If you obtain health insurance through
Deaconess, you or your eligible dependents
who are diabetic can receive an Abbott
(FreeStyle) or Bayer glucometer (Contour/
Breeze 2) at no cost. Simply call 1-866-2248892 for a Freestyle glucometer or 1-877229-3777 for a Bayer glucometer and identify
EnvisionRxOptions as your pharmacy benefits
administrator. Abbott or Bayer will take care of
the rest.
Deaconess offers an Enrichment Center for
children ages six weeks to five years. Children
receive hands-on experience from the
knowledgeable teachers of the Enrichment
Center. The center is dedicated to giving your
child exceptional early childhood education. For more information on how to enroll, please
contact the Deaconess Children’s Enrichment
Center at 812-450-7282.
CASE MANAGEMENT SERVICES
DEACONESS CHILDREN’S
ENRICHMENT CENTER’S
SUMMER CAMP
This free service is offered to Deaconess
employees and their spouses who have
diabetes or other chronic illnesses. Benefits of
the program include individualized assessment
to identify resources, help with disease
management education, and support services.
For more information, please call our RN care
coordinator at 812-426-9433.
Deaconess offers a summer camp to all schoolaged children. The camp opens at 5:30 a.m.
and closes at 6:30 p.m. Monday–Friday. Camp
highlights include art, music, games and
an assortment of field trips: Hartke Pool,
Wesselman Woods Nature Preserve, Mesker
Park Zoo and much more! For more information,
please call 812-450-7282.
CELL PHONE DISCOUNT
Many cell phone providers offer a discount for
Deaconess employees. Please call your cell
phone provider for more information.
www.deaconess.com
47
812-450-7681 or 1-800-967-6795
Deaconess RN OnCall
D
id you know that as a Deaconess employee,
you and your immediate family have access to
Deaconess RN OnCall?
RN OnCall is available 24 hours a day, 7 days a week,
including holidays. Our registered nurses field a variety
of health care questions, from the minor to the very
urgent. If you aren’t sure if you should call your doctor
or seek medical help for a particular problem, you can
call our RN OnCall, and she will use a medically preapproved set of guidelines and tell you what level of
care you need, if any.
This can save you time and money by avoiding an
emergency room visit for a problem that could be
addressed by your doctor. Or it could prevent you from
waiting to see a doctor when it is a more urgent matter
that should be taken care of in the emergency room.
This can be particularly helpful if you are traveling—
just call our toll-free number at 1-800-967-6795.
Here are a few examples of situations in which RN
OnCall could help:
 You’ve been out working in the yard and notice that you
have what you think is a bug or spider bite. The area is
very red, painful, and it’s starting to swell. You are also
starting to itch all over. What should you do?
 You’ve been battling a cough and cold all week. It’s
Friday evening, and the doctor’s office is closed.
You’re running a temperature now, and the cough has
worsened to the point that your chest hurts when you
breathe deeply. Should you tough it out until Monday
and see if you feel better?
 You are on vacation in Florida and step on a jelly fish.
It hurts. Call us, and we can give you care advice and
perhaps keep you from spending your vacation time and
money at an urgent care or ED.
 Your son/daughter is away at college and is ill or has a
health care question. Again, our services extend to them.
We look forward to serving your health care needs
through the Deaconess RN OnCall program. Call us any
time at 812-450-7681 or 1-800-967-6795.
48
Where to Go...
MD office
Urgent Care
Animal Bites

Stitches

X-ray

Back pain































Mild Asthma
Headache/Migraine
Sprain, Strain
Nausea, Vomiting
Bumps, Cuts, Scrapes
Burning with Urination
Cough, Sore Throat
Ear or Sinus Infection
Eye Swelling, Redness
Minor Allergic Reaction
Minor Fever, Colds
Rash, Minor Bumps
Vaccination

Emergency Room
• Sudden loss of
consciousness
• Signs of heart attack
(sudden/severe chest pain
or pressure)
• Signs of stroke (numbness
of face, arm or leg on one
side of body, difficulty
talking)
• Severe shortness of breath
• High fever with stiff neck,
mental confusion, and/or
difficulty breathing
• Coughing up or vomiting
blood
• Cut or wound that won’t
stop bleeding
• Possible broken bone
• Poisoning
• Stab wound
• Sudden, severe
abdominal pain
• Trauma to the head
• Suicidal feelings
• Partial or total amputation
of limb
Check with provider; these services may be available.
Deaconess Urgent Care Locations
North ParkGateway
4506 First Avenue, Evansville
10455 Orthopaedic Drive, Newburgh
812-428-6161812-858-2100
Monday – Friday • 8:00 am – 8:00 pm
Monday – Friday • 8:00 am – 8:00 pm
Saturday – Sunday • 8:00 am – 8:00 pm
Saturday – Sunday • 8:00 am – 6:00 pm
Please note: Non-emergency visits to the emergency room (ER) are subject to additional fees.
49
We’re making
health care
MORE
CONVENIENT.
viewmychart.com
How You Benefit from
MyChart at Deaconess
MyChart is a secure, online health management tool
that connects Deaconess patients to their personalized
health information—from anywhere, any time of day for
both outpatient and inpatient visits.
As a MyChart user, you can:
 Request medication refills
 Send non-urgent messages to your doctor’s office
 View test results from a Deaconess facility
 View and request appointments
 Access hospital discharge information
 Receive important health reminders
 View and print information about your health,
medications, allergies and immunizations
How Do I Get a
MyChart Account?
During your doctor visit or hospital stay, we can help
you create a MyChart account. If an account is not
activated during that time, you’ll receive an activation
code on your visit summary or discharge instruction
sheet so you can create your own account. To create or
access your account, go to viewmychart.com.
Mobile apps available for:
50
M2385 (06-2014) mh
Your Deaconess Electronic Health Record
When You Choose a Deaconess
Facility for Lab and Radiology...
Deaconess Health System and
Deaconess Clinic doctors are using
an electronic health record to safely
manage and store your medical
information. This new system
provides many benefits to you.
Your results go directly to your electronic
chart, and the doctor who ordered the tests
will receive a message alerting him/her that
your results are available for review. Your
doctor can also look at your actual x-ray
images at any time from his/her computer.
One Chart
DEACONESS REGIONAL LAB LOCATIONS & HOURS
Everything related to you as a Deaconess patient
is in one system. Whether you are at your
Deaconess Clinic physician’s office, a Deaconess
Emergency Department, or any other Deaconess
facility, your medical information is available
immediately.
NEWBURGH/EAST SIDE
Deaconess Regional Lab East
(Gateway Campus)
4133 Gateway Blvd., Suite 110 • Newburgh, IN 47630
Telephone 812-858-6255 • Open M–F, 8:00 am – 5:00 pm
Deaconess Hospital Gateway Campus
(Inside the hospital, check in at Patient Registration)
4011 Gateway Blvd. • Newburgh, IN 47630
Telephone 812-842-3447
Open M–F, 7:00 am – 6:00 pm; Saturday, 7:00 am – 1:00 pm
Security
Your medical information is safe and secure;
it cannot be accessed without proper
authorization.
NORTH SIDE
Deaconess Regional Lab North
4494 First Avenue • Evansville, IN 47710
Telephone: 812-436-7293
Open M–F, 8:00 am – 5:00 pm; closed Noon – 1:00 pm
Safety
The system uses electronic prescriptions,
which eliminate the risk for many errors and
alerts your provider to possible medication
interactions. Additionally, your prescription is
sent directly to your pharmacy, giving them
extra time to have your medications ready
for pick-up.
MT VERNON
Deaconess Regional Lab Mt. Vernon
1900 West 4th St., Suite 6 • Mt. Vernon, IN 47620
Telephone: 812-838-2053 • Open M–F, 8:00 am – 5:00 pm
DOWNTOWN
Deaconess Regional Lab Main Campus
(Inside Deaconess Hospital; check in at Registration)
600 Mary Street • Evansville, IN 47747
Telephone: 812-450-3440
Open M–F, 6:00 am – 6:00 pm; Saturday, 7:00 am – 3:00 pm
Real-Time Access
• Deaconess doctors who are managing your
medical needs have real-time access to your
medical information so proper care can be
provided to you.
DEACONESS RADIOLOGY LOCATIONS & HOURS
Deaconess Hospital
600 Mary Street • Evansville, IN 47747
Open 24 hours, limited hours for some types of exams
• All of your medical information, including
laboratory tests, x-rays and other tests, are
sent directly to your electronic chart as long
as they are performed at a Deaconess facility.
This makes your results available to your
doctor much more quickly.
Deaconess Clinic Downtown
421 Chestnut Street • Evansville, IN 47713
Open: M–F, 8:00 am – 5:00 pm
Deaconess Gateway Hospital
Open 24 hours, limited hours for some types of exams
Midwest Radiologic Imaging
Hours: M–F, 8:00 am – 5:00 pm
• Doctor-to-doctor communication
regarding your care is readily available. Any
Deaconess doctor caring for you sees the
same information in your electronic record.
Gateway Health Center
4233 Gateway Blvd. • Newburgh, Indiana 47630
Hours: M–F, 7:00 am – 5:00 pm
51
Employee Enrollment Form
Fax to : (812) 450-3781
You may select a pickup location to be permanently added to each patient's file. If you do so, prescriptions will always be sent to this location.
If you elect to have your prescriptions mailed to you, you must provide a method of payment. Contact the Family Pharmacy staff at 450-3784.
Employee Name
Rx insurance ID and group #
Address
City, State, ZIP
Phone Number
DOB
Allergies
Childproof caps? Y / N
Pickup location (circle one): Main GW TWH Mail (see above)
Prescriptions to be transferred
Drug Name
Rx #
Pharmacy Name
Pharmacy Phone
Dependent Name
Relationship
Address
City, State, ZIP
Phone Number
DOB
Allergies
Drug Name
Rx #
Pharmacy Name
Pharmacy Phone
Dependent Name
Relationship
Address
City, State, ZIP
Phone Number
DOB
Allergies
Drug Name
Rx #
Pharmacy Name
Pharmacy Phone
Please use additional forms as necessary for more dependents or attach additional sheets as required for prescription transfers.
I understand that willfully providing false or misleading information concerning the identity of my spouse and/or dependents for
purposes of using the Family Pharmacy is a violation of hospital policy and will lead to disciplinary action.
Signature
52
Date
Regulatory Information
Newborns’ & Mothers’ Health Protection Act
Under the Newborns’ Act, the plan may not restrict benefits for a hospital stay in connection with childbirth to less
than 48 hours (96 hours in the case of a cesarean section), unless the attending provider (in consultation with the
mother) decides to discharge earlier.
Plans may not require providers to obtain authorization from the plan for prescribing the stay. In addition, plans may
not deny a stay within the 48-hour (or 96-hour) period because the plan’s utilization reviewer does not think such a stay is
medically necessary.
The plan must eliminate this preauthorization requirement with respect to hospital stays in connection with
childbirth for the first 48 hours (or 96 hours in the case of a cesarean section). The plan may impose such an
authorization requirement for hospital stays beyond this period. In addition, the plan may impose a requirement on the
mother to give notice of a pregnancy in order to obtain a certain level of cost-sharing or to use certain medical facilities.
However, the type of preauthorization required by this plan (within the 48/96 hour period and based on medical
necessity) must be eliminated.
Women’s Health & Cancer Rights Act of 1998
In accordance with the Women’s Health and Cancer Rights Act of 1998, SIHO Insurance Services’ covered members who undergo a mastectomy, and who elect breast reconstruction in connection with the mastectomy, are entitled to
coverage for:

Reconstruction of the breast on which the mastectomy was performed.

Surgery and reconstruction of the other breast to produce a symmetric appearance.
Prosthesis and treatment of physical complications at all stages of the mastectomy, including lymphedemas,
in a manner determined in consultation with the attending physician and the patient.
The coverage may be subject to coinsurance and deductibles consistent with those established for other benefits.

Premium Assistance Under Medicaid and the
Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your employer, your
State may have a premium assistance program that can help pay for coverage. These States use funds from their Medicaid
or CHIP programs to help people who are eligible for these programs, but also have access to health insurance through their
employer. If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance
programs.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact
your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents
might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or
www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you
pay the premiums for an employer-sponsored plan.
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well
as eligible under your employer plan, your employer must permit you to enroll in your employer plan if you are not already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, you can contact the
Department of Labor electronically at www.askebsa.dol.gov or by calling toll-free 1-866-444-EBSA (3272).
53
Effective: July 23, 2014
Deaconess Employee Health Plan
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.
OUR RESPONSIBILITIES: Deaconess Health System provides for a variety of employee health
benefits including medical options, prescription drug benefits, dental coverage, employee
assistance program coverage, and a health care expense account. These benefits are referred to
in this document as “the Plan.” Deaconess Health System is the “Sponsor” of the Plan. It has
entered into contractual arrangements with various benefit management entities to provide for the
daily operations of the Plan. These entities will be identified in this document as the
”Administrators”. The Health Insurance Portability and Accountability Act requires the Plan to
maintain your privacy and to provide you with this Notice of Privacy Practices describing our legal
duties and privacy practices. The Plan is required to abide by the terms of the Notice that is
currently in effect. This Notice does not apply to the HRI Dental Plan. Enrollees in this
plan will receive a separate Notice applicable to that plan.
HOW THE PLAN MAY USE AND DISCLOSE YOUR HEALTH INFORMATION: Certain
employees within the Deaconess Health System (most notably the Human Resources Director and
Benefit Section, Finance Department, Acute Care Case Manager and Health System Administration
perform various functions either on behalf of the Plan or on behalf of the Plan Sponsor.
The following categories describe different ways that the Plan uses and discloses health
information. For each category we explain what we mean and give some examples. Not every
use or disclosure in a category will be listed. However, all of the ways we are permitted to use and
disclose information will fall within one of the categories.

To The Plan Sponsor. The Plan/Administrators may disclose your information to the Plan
Sponsor (your employer) in certain situations. The plan documents that regulate the Plan
restrict how the Plan Sponsor uses and discloses your information.
In addition, the Plan and its Administrators may disclose your "summary health information" to
the Plan Sponsor to obtain premium bids from health plans for the Plan's coverage or to
amend the Plan. "Summary health information" means your information that summarizes your
claims history, expenses or types, but the information will not identify you any more
specifically than your zip code.
Also, the Plan, may disclose to the Plan Sponsor information as to whether or not you are
participating in the Plan or are enrolled or disenrolled in the Plan.
The Plan may disclose your information to the Plan Sponsor in order for the Sponsor to carry
out plan administration functions.
The Plan may not disclose your information to the Plan Sponsor for the purpose of
employment-related actions or decisions or in connection with any other employee benefit plan
of the Plan Sponsor.
The Plan may not use or disclose your genetic information for underwriting purposes.
Underwriting purposes include, but are not limited to, activities such as determination of
eligibility or benefits or
computation of contribution amounts or premiums. Genetic
54
information includes the results of genetic testing as well as portions of your or your family
medical history that indicate the presence of a genetic condition.

For Payment. The Plan/Administrators may use and disclose your health information for the
purpose of:
o
o
o
o
o
o
o
o
o
o
o
o
o
obtaining premiums or to determine or fulfill the responsibility for coverage and
provision of benefits under the Plan;
coordination of benefits or the determination of cost sharing amounts;
adjudication or subrogation of health benefit claims;
processing claims;
billing;
claims management;
collection activities;
obtaining payment under a contract for reinsurance (including stop-loss insurance and
excess of loss insurance);
review of health care services with respect to medical necessity;
coverage under a health plan;
appropriateness of care, or justification of charges for the treatment and services
provided to you;
utilization review activities, including precertification and preauthorization of services,
and concurrent and retrospective review of services; and,
disclosure to consumer reporting agencies of any of the following protected health
information:






o

name and address;
date of birth;
social security number;
payment history;
account number; and
name and address of any relevant health care provider and/or health plan.
disclosure to another Covered Entity for its payment activities. (A Covered Entity is a
person, agency or organization subject to HIPAA.)
For Health Care Operations. The Plan and its Administrators may use and disclose your
health information for health care operations including:
o
o
o
o
o
o
o
o
o
case management and care coordination
conducting quality assessment and improvement activities, including outcomes
evaluation and development of clinical guidelines;
population-based activities relating to improving health or reducing health care costs;
reviewing the competence or qualifications of health care professionals;
evaluating practitioner and provider performance, and Plan performance;
accreditation, certification, licensing, or credentialing activities;
underwriting, premium rating, and other activities relating to the creation, renewal or
replacement of a contract of health insurance or health benefits, and ceding, securing,
or placing a contract for reinsurance of risk relating to claims for health care (including
stop-loss insurance and excess of loss insurance);
conducting or arranging for medical review, legal services, and auditing functions,
including fraud and abuse detection and compliance programs;
business planning and development, such as conducting cost-management and
planning-related analyses related to managing and operating the entity, including
formulary development and administration, development or improvement of methods
of payment or coverage policies; and
55
o
business management and general administrative activities of the Plan, including, but
not limited to:





management activities relating to implementation of and compliance with the
requirements of the HIPAA regulations;
customer service;
resolution of internal grievances; and
consistent with the applicable requirements of the HIPAA regulations, creating
de-identified health information, or a limited data set.
to another Covered Entity for certain operational purposes of the other
Covered Entity

To Your Legal Personal Representative. The Plan/Administrators may disclose information
about you to your legal personal representative.

To Your Family or Others Designated by You. Provided you have been given an
opportunity to agree or object, the Plan/Administrators may disclose limited information about
you to a member of your family or others that you designate who are involved in the payment
for your care.

As Required By Law. The Plan/Administrators will disclose your health information when
required to do so by federal, state or local law.

Marketing. The Plan/Administrators may use or disclose your information to market its
products or services or benefits, as well as to describe its network or details of the Plan. If
health-related products or services add value to the Plan's benefits, but are not part of it, and
are available only to an enrollee of the Plan, the Plan may use or disclose your information to
describe such products or services. In addition, the Plan may use or disclose your information
for marketing if communications are made face-to-face or if they are in the form of a
promotional gift of little value.

Health Oversight Activities. The Plan/Administrators may disclose your health information
to a health oversight agency for activities authorized by law. These oversight activities might
include audits, investigations, inspections, and licensure. These activities are necessary for the
government to monitor the health care system, government programs, and compliance with
civil rights laws.

Judicial Purposes. The Plan/Administrators may disclose your health information in
response to a court or administrative order. The Plan/Administrators may also disclose your
health information in response to a subpoena, discovery request, or other lawful process by
someone else involved in the dispute, but only if efforts have been made to tell you about the
request or to obtain an order protecting the information requested.

National Security and Intelligence Activities. The Plan/Administrators may release your
health information to authorized federal officials for intelligence, counterintelligence, and other
national security activities authorized by law.

Treatment Alternatives and Health-Related Benefits. The Plan/Administrators may use
and disclose your health information to tell you about or recommend possible health-related
benefits or services that may be of interest to you.
56

Individuals Involved in Payment for Your Care. The Plan/Administrators may release
health information about you to your responsible party, friend or family member who is
involved with payment for your care.

Third Parties. The Plan will disclose your information to a third party that performs services
on behalf of the Plan, but only if the third party signs a contract agreeing to protect your
information. The Plan utilizes third party administrators and independent utilization reviewers
– the Administrators - to handle the day-to-day plan activities. These Administrators hold the
detailed records related to the management and payment of your claims.

Whistleblowers. Your health information may be released by members of the workforce in
support of their belief that the Plan/Administrators have engaged in unlawful conduct.

Incidental Uses and Disclosures. The Plan/Administrators takes reasonable safeguards to
prevent improper uses or disclosures of your health information. Despite this, it can happen
that in the course of a permitted use or disclosure, your information is inadvertently seen or
heard by an unintended recipient. For example, despite reasonable precautions, a conversation
between members of the Plan regarding the processing of your claim could be overheard by
another party uninvolved in this action.
OTHER USES OF HEALTH INFORMATION: Other uses and disclosures of health information
not covered by this Notice or the laws that apply to us will be made only with your written
authorization. If you provide us authorization to use or disclose your health information, you may
revoke that authorization, in writing, at any time. If you revoke your authorization, we will no
longer use or disclose health information about you for the reasons covered by your written
authorization. You understand that we are unable to take back any disclosures we have already
made under the authorization.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION: You have the following rights
regarding health information we maintain about you:

Right to Request Restrictions. You have the right to request a restriction or limitation on
the health information that the Plan/Administrators use or disclose about you for payment or
health care operations. You also have the right to request a limit on the health information the
Plan discloses about you to someone who is involved in your care or the payment for your
care. The Plan is not required to agree to your request. If the Plan does agree, it will
comply with your request unless the information is needed to provide you emergency
treatment
You may request that providers release no information about you to the Plan/Administrators
regarding services rendered to you provided that you have made such request in accordance
with the provider’s policy and have paid in full out-of-pocket for the services rendered.
To request restrictions, you must make your request in writing. In your request, you must
describe (1) what information you want to limit; (2) whether you want to limit the use,
disclosure or both; and (3) to whom you want the limits to apply.

Right to Request Confidential Communications. If you think that disclosure of your
health information by the usual means could endanger you in some way, the
Plan/Administrators will accommodate reasonable requests to receive communications of
health information from the Plan/Administrators by alternative means or at alternative
locations.
57
If you want to exercise this right, your request to the Plan/Administrators must be in writing
and you must include a statement that disclosure of all or part of the information could
endanger you.

Right to Inspect and Copy. You have the right to inspect and copy information regarding
enrollment, payment, claims adjudication, and case or medical management record systems
maintained by the Plan and its Administrators. You can request that this information be
provided electronically so long as the information is stored electronically. Please note that
enrollment information is available from the Plan Sponsor while the remainder of this
information is maintained by the various Administrators hired by the Plan Sponsor to manage
the daily activities of the Plan.
To inspect and copy this information, you can submit your request in writing. If you request a
copy of the information, the record holder may charge a fee for the costs of copying, mailing
or other supplies associated with your request.

Right to Amend. You have the right to ask the Plan to amend your health and/or billing
information for as long as the information is kept by the Plan.
To request an amendment, your request must be made in writing and must include a reason
that supports your request.
The Plan may deny your request for an amendment if it is not in writing or does not include a
reason to support the request. In addition, it may deny your request if you ask to amend
information that:
o
o
o
o

Was not created by the Plan, unless the person or entity that created the information
is no longer available to make the amendment;
Is not part of the health information kept by or for the Plan;
Is not part of the information which you would be permitted to inspect and copy; or
Is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request a list of certain
disclosures that the Plan or its Administrators have made of your health information. The Plan
is not required to provide an accounting of disclosures made for the following purposes:
o
o
o
o
o
o
o
For Treatment, Payment, or Health Care Operations;
To you about your own health information;
Incidental to other permitted or required disclosures;
Where authorization was provided;
To family members or friends involved in your care (where disclosure is permitted
without authorization);
For national security or intelligence purposes or to correctional institutions or law
enforcement officials in certain circumstances; or
As part of a “limited data set” (health information that excludes certain identifying
information).
To request a list of disclosures, you must submit your request in writing. Your request must
state a time period that may not be longer than six years and may not include dates before
April 14, 2003. Your request should indicate in what form you want the list (for example, on
paper, electronically). The first list you request within a twelve-month period will be free. For
additional lists, we may charge you for the costs of providing the list. We will notify you of the
cost involved and you may choose to withdraw or modify your request at that time before any
costs are incurred.
58
How to Submit Your Written Request: In all instances described above, your written
request should be directed to the Agent or Administrators who administer the Plan on behalf of
the Plan Sponsor. The Human Resources Benefit Manager can provide you with forms to
submit your request and with address information. Alternatively, you may wish to contact the
Administrators directly as described below.
SIHO
Envision
RxOptions
EAP
Deaconess
Health System
HRI Dental
ADP
SIHO is the Third Party Administrator for the medical service claims for
the medical options of the Deaconess Employee Health Benefit Plan.
For claims issues and privacy issues, please contact the Privacy Officer
at 812-378-7052.
Envision RxOptions is the Third Party Administrator for prescription drug
claims for the medical options of the Deaconess Employee Health
Benefit Plan. For privacy issues, please contact Envision at 854-7672624.
The Employee Assistance Program is Deaconess Concern.
Contact Concern at: 812 471-4611
Enrollment information can be obtained directly from the Plan Sponsor
which is Deaconess Health System. Contact Human Resources Benefits
Office at (812) 450-2025.
HRI provides dental insurance. For claims issues and privacy issues,
please contact Customer Service at 800-727-1444
ADP is the Third Party Administrator for the Health Care Expense
Account. For privacy issues, please contact the Participant Benefit
Center at: 888-557-3156.
You may also direct privacy related questions to the Deaconess Health System Privacy Officer,
Candace Foster, who is also Privacy Officer for the Plan. See the CONTACT section below.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice.
You may ask us to 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 a paper copy of this Notice.
You may obtain a copy of this Notice at our web site at www.deaconess.com.
To obtain a paper copy of this Notice, contact the Benefits Section of the Human Resources
Office of Deaconess Hospital, Inc.
CHANGES TO THIS NOTICE: We reserve the right to change this Notice. We reserve the right
to make the revised Notice effective for health information we already have about you as well as
any information we receive in the future. The Notice will contain on the first page, in the top righthand corner, the effective date. In addition, if we revise the Notice, and you are still a participant
of the Plan, then we will offer you a copy of the current Notice in effect.
COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint
with the Plan or with the Secretary of the Department of Health and Human Services. To file a
complaint with the Plan, contact the Director of Human Resources or the Deaconess Health System
Privacy Officer at 600 Mary Street, Evansville, IN 47747. All complaints must be submitted in
writing. You will not be penalized for filing a complaint.
CONTACT: For more information on the Plan’s privacy policies or your rights under HIPAA, contact
the Human Resources Benefits Office at (812) 450-2025 or the Deaconess Health System Privacy
Officer at (812) 450-7223.
59
We know the health care decisions you make are very important. You deserve all the
information you need to make the right choices for you and your family.
Actual plan provisions are contained in the plan documents. In the event of any conflict
between this brochure or any other written or verbal summary of the plans and the actual
terms of the plans, the specific terms of the plans will govern.
www.siho.org
60

DEACONESS HEALTH SYSTEM

Transcription

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