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2017Benefit Information
MyBenefitsCaring for our Exceptional Employees
NOTE: Important benefit forms are located
in this booklet
Entity/Region Contact Name Phone Email Fax
All St. Louis Network, Hospital and Physician Organization Employees
St. Louis HR Service Center 314-989-2090hrservicecenter@ ssmhealth.com
314-622-6482
Mid-Missouri
SSM Health St. Mary’s Hospital – Audrain
Christy Smiley Dawn Weber
573-582-8610 573-582-8600
[email protected] [email protected]
314-989-6825
SSM Health St. Mary’s Hospital – Jefferson City
Lynette Otto 573-681-3149 [email protected] 573-681-3628
SSM Health St. Francis Hospital – Maryville
Ilissa Craig 660-562-7928 ext. 7401
[email protected] 660-562-7978
Southern Illinois
SSM Health Good Samaritan Hospital – Mt. Vernon and St. Mary’s Hospital – Centralia
Kim Chasteen-Smith 618-436-8713 [email protected] 618-436-8013
Oklahoma
St. Anthony Shawnee Hospital
Gayle Little 405-214-1597SAH.HRBenefits@ ssmhealth.com
314-989-6831
St. Anthony HospitalPam Fowler Colisha Evans
405-272-6111 405-272-6031
SAH.HRBenefits@ ssmhealth.com
314-989-6832
IHT, Health at Home and System/Corporate
IHT, Health at Home, System Office
Health Businesses Benefits 314-989-2181 [email protected] 314-989-2877
Benefit/HR Representatives Contact Information
Dear SSM Health employee:
At SSM Health, we value you and thank you for the exceptional commitment you make to our Mission and to serving others every day. You are SSM Health!
We are pleased to provide you with a personal benefits package to fit your needs and those of your family. Our market-competitive, comprehensive benefits package includes medical, dental and vision, along with life, long-term disability coverage, health and child/elder care reimbursement accounts, adoption reimbursement, an employee assistance program, retirement program and more. All eligible employees who participate in our 403(b) Employee Contribution Plan may receive a match from SSM Health on a portion of your contribution.
We have worked hard to maintain our competitive benefit levels over the past several years. In fact, we continue to pay a significant portion of the medical insurance premium for employees and their families.
Details of our 2017 personal benefits plan offerings are outlined within this informational booklet. If you have further questions about your benefits at SSM Health, please contact your local Human Resources team.
Thank you for your commitment and dedication to our Mission and for providing an exceptional experience for our patients and the customers we serve.
Sincerely,
Lynn D. BruchhofSenior Vice President - Human Resources
Through our exceptional health care services, we reveal the healing presence of God.
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TABLE OF CONTENTS
YOUR PERSONAL BENEFITS Introduction ............................................................................................2Employee self-service new hire benefits enrollment ..............4
YOUR BENEFIT INFORMATION Medical Plan............................................................................................ 16Pharmacy ................................................................................................. 18Dental Plan ..............................................................................................20Vision Plan ...............................................................................................22Eligible Dependents ............................................................................24Health Care Reimbursement Account ..........................................26Child/Elder Care Reimbursement Account ...............................28Group Life, Accidental Death & Dismemberment, Long-Term Disability Plan .........................30Voluntary Dependent Term Life ......................................................32Voluntary Short-Term Disability ......................................................34Voluntary Enriched Life .....................................................................36Notices & Reminders ..........................................................................37Frequently Asked Questions ............................................................38
REQUIRED DOCUMENTSCHIP Notice ............................................................................................39Non-Discrimination Notice ...............................................................40
FORMSAdult Surcharge Waiver - Employee .............................................41Adult Surcharge Waiver - Employer .............................................43
INTRODUCTION TO YOUR PERSONAL BENEFITSSSM Health is committed to helping employees lead a healthy lifestyle by offering a comprehensive benefits package to fit their needs.
You have the opportunity to design your own personal benefits package at SSM Health. You can choose the medical, dental, vision, life, accidental death and dismemberment and long-term disability coverages that best meet your needs. In addition, health and child/elder care reimbursement accounts, dependent term life, short-term disability and supplemental life coverages are available on a voluntary basis.
Another feature of our benefits package is the ability to pay for your share of the insurance costs with pre-tax dollars, before federal, social security and in most cases, state taxes. By paying with pre-tax dollars, it may mean more money in your paycheck.
This informational booklet provides key features of the personal benefits offered at SSM Health and is for reference purposes only. When there is a discrepancy between this information and information in the Summary Plan Description (SPD), the SPD will prevail.
IMPORTANT BENEFIT INFORMATION:Your dental and vision election will be “locked” for two years when you make an election. Therefore, if you elect coverage in 2017, you must keep that election for 2018, unless you have a qualifying change in status.
After your initial election is made,life insurance may only be increased by one level.
The forms you may need for benefit enrollment are located at the back of this booklet or on the MyHR portal located on SSM Health’s Intranet:
• Adult Surcharge Waiver
• LDA Supporting Documentation (Available on MyHR only)
You will receive a printed confirmation of your election which is your opportunity to review your personal benefits package.
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Understanding Your OptionsBefore you start the enrollment process, we encourage you to read about the plans we offer so you can make the most informed decision about your coverage. You have 31 days inclusive of date of hire to make your elections and we ask that you please reach out to a benefits representative with any questions you may have. To learn about your options, please locate the following documents applicable to your location:
• This Benefit Overview book
• Summary of Benefits and Coverage (SBC)
• Summary Plan Description, available on MyHR
• Glossary of Health Coverage and Medical Terms, available on MyHR
Ready to Enroll:Logging into MyHR1. Launch internet browser. NOTE: The recommended browser for Employee
Self-Service is Internet Explorer 9. IE10 and higher can only be used in compatibility mode. While you may be able to use Mozilla Firefox or Google Chrome, those browers are not supported. MyHR is not compatible with Apple IOS Safari (i.e., iPhone, iPad, etc.).• If you are accessing MyHR INTERNALLY: Click the MyHR Human Resources Portal icon located on your entity’s home page, then click Access Employee Self-Service. If you are
accessing MyHR EXTERNALLY: Go to myhr.ssmhc.com
2. Click on Employee Benefits, MyHR - Benefits information. Enter your username and password at the log in screen.
3. Click LOG ON. Your SSM Health Employee Services home screen will appear. NOTE: If you are a manager, you will need to click on the SSM Self-Service tab.
4. Click the Benefits link.
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5. Select the New Hire Enrollment link. Please refer to the yellow arrow which shows the dates of your enrollment period.
6. A Terms and Conditions pop-up will appear. Please click Accept to go to your enrollment. If you do not want to enroll at this time, then click Decline.
Before you get started, please ensure that the Quick Help is displayed to help guide you in the enrollment process. To enable, click in the right hand corner of the page. Choose Display Quick Help.
It’s important to note that this is a 7-step process, and you should not expect to rush through this. In this guide, there is a warning sign at the end of each section to remind you that your data entries ARE NOT saved until you navigate to the Review and Save section and click Save. If you need to pause your enrollment at any time, please remember to navigate to the Review and Save section and click Save to ensure your data saves. Then you can pickup where you left off when you return.
Enrollment Notice There are times when the MyHR portal will be unavailable during the beginning of the week due to payroll processing. You will not be able to make your elections during this time but instead will receive a message in the MyHR portal letting you know that your information will be view only and un-editable. We ask that you please revisit MyHR at a later time to make your elections.
Note: If your enrollment period is almost over while the portal is inaccessible, please contact your local benefits representative; you will need to manually fill out your benefits form.
Personal Profile
1. You will now see the Personal Profile section of benefits enrollment. 2. You can review and edit your personal information by choosing Edit
Personal Profile:
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Editing your Personal Profile 3. By clicking Edit Personal Profile it will bring you to a new window. 4. To edit your Personal Data, click the Pencil icon:5. You will be brought to a new page that looks like this:
6. Please note that you do not have to make any changes here. The only fields you are able to edit are those that are in white. The blue fields are un-editable. If you need to change any information in the blue fields, please contact your local HR representative.
7. If you make a change, click Save and Back. If you do not wish to make a change at this time, click Cancel.
8. Once you are back on the edit Personal Profile page, you may click the Pencil icon next to Addresses to change or add a new address.
9. Be sure to click Save and Back if you make any edits.10. To return to the New Hire Enrollment page, click Exit.
Dependent and/or Beneficiary Section1. Navigate to icon 2, labeled Dependents and/or Beneficiaries by either
clicking Next (located at the top of the page) or by clicking on the Dependents and/or Beneficiaries icon.
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WARNING: Before you proceed please make sure that you read the directions carefully. If you need to delete any information (i.e., you add a dependent by mistake, please contact HR to help you fix the issue). You can ONLY add and edit dependents/beneficiaries. You CANNOT delete them once they have been entered.
Adding Dependent and/or Beneficiary Information2. It is necessary to add your dependent and beneficiary information before
continuing the enrollment process. Please only add those individuals you plan to cover under one of our health or insurance plans. To add dependents or beneficiaries, choose the Edit Dependents and/or Beneficiaries button. NOTE: You must complete an Adult Surcharge Waiver if you are covering your spouse or LDA on your medical plan who does not have medical coverage provided by his/her current employer. This form is available for download on the Benefits page within MyHR or in the back of this booklet.You must complete and return this form to Human Resources to avoid the Adult Surcharge.
You will be able to enroll a Spouse, Child, LDA, or LDA Child. In addition, you can designate a beneficiary for Life Insurance and AD&D Insurance Only. If you wish to designate a beneficiary who is not your spouse or dependent (i.e., designate a Trust) you would select the Life Insurance and AD&D Beneficiary Only.
3. Click Edit Dependents and/or Beneficiaries:
A new window will open. To add a dependent or beneficiary, click
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4. This action will open a new window and all the text fields will be editable. Note: All fields with asterisk (*) are required fields. Information must be entered into these fields.
NOTE: The last name of the dependent is defaulted to display the last name of the employee. If the dependent’s name differs from that of the employee then please make corrections as needed. The gender button defaults to display the last gender entered. So if you added a “male” dependent, the next time you try to add a new dependent it will automatically display “male.” Please be cautious of this and enter the correct gender of your dependent.
Saving Dependent and/or Beneficiary Information 5. Once you have verified the information entered, click Save and Back to
return to the previous page. To cancel any of the changes or exit, click either Close or Cancel. You will then return to the previous page.
6. Continue adding dependent/beneficiary records or add an External Organization if applicable. Repeat steps 2-5. Review all dependent/beneficiary records added. Once you have finished making edits to your dependents and/or beneficiaries, exit the window by clicking Close.
7. You will now be back on the New Hire Enrollment Benefit and Dependents page.
IMPORTANT! If you enrolled an LDA or LDA child, you must complete additional paperwork and submit to your benefit representative in order to obtain coverage.
Selecting Health Plans
1. Navigate to icon 3, labeled Health Plans by either clicking the Next button (located at the top of the page) or by clicking on the Health Plans icon.
NOTE: Employees working in Wisconsin that wish to enroll in Dean or GHC will need to enter their selection in MyHR and complete the additional enrollment process/forms needed for the insurance companies in order to obtain coverage. Completed forms need to be returned to your local human resources department.
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Viewing Health Plans2. You will now be able to view your health plans:
Health Plans - The plans you see below are the default elections. Please note the start date of each benefit. You can select a plan in the table to change or skip to the next step in the guided activity. To make a change, choose the pencil icon. You will be able to review your options under each plan and make a new election. You will also have the opportunity to select the dependents you wish to add to the plan. You will be able to save your benefit elections in The Review and Save step of the guided activity.
NOTE: SSM Health has pre-populated the health benefits for which are eligible to participate. If you wish to have medical, dental, and/or vision coverage, you must make your selections. If you do not make any changes to the pre-populated fields, you will not be enrolled in SSM Health benefits.
Selecting Health Plans3. To change your health plans, click on Pencil icon next to each of the Benefit type you wish to edit. A new window will appear with your options to make a new election.
Tier Definitions: There is a special column for each plan type called Coverage. Coverage stands for the amount of coverage you want. Do you want to cover just yourself, do you want to cover 1 dependent, or do you want to cover a family?
1 – EE Only: YOU are the only one eligible for the plan. No dependents and/or beneficiaries are allowed.
2 – EE + 1: YOU and 1 DEPENDENT can be added to a plan. If you DO NOT have any dependents, then DO NOT select this coverage amount. 3 – EE + F: YOU and 2 or MORE DEPENDENTS can be added to a plan. If you DO NOT have 2 or more dependents that you want to add to a plan then DO NOT select this coverage amount.
4. Select the plan you would like by clicking a plan and the row of information will be highlighted.
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5. If you had previously added dependents, they will be available in this list to enroll in a specific plan. To add a dependent to a plan, check the box in front of each dependents name.
6. Click the Add button when you are ready to make this election. Click Cancel if you wish to cancel your election. You will return to the previous page.
7. Check to see the new plan populates correctly with the appropriate dependents.
8. Repeat steps 3-7 for each health plan you would like to update.
Warning: It’s important to remember this system DOES NOT SAVE your selections until you reach the Review and Save step and click Save at the end of the enrollment process.
Insurance Plans 1. Navigate to icon 4, labeled Insurance Plans by either clicking Next located at the top of the page or by clicking the Insurance Plans icon.
Adding Insurance Plans 2. You will now be able to view your Insurance plans:
Insurance Plans - The plans you see are the default elections. Please note the start date of each benefit. You can select a plan in the table to change or skip to the next step in the guided activity. To make a change, choose the pencil icon. You will be able to review your options under each plan and make a new election. You will also have the opportunity to select the beneficiaries you wish to add to the plan. For Supplemental Life Insurance, you will need to request additional paperwork from human resources if you are interested in enrolling. You will be able to save your benefit elections in The Review and Save step of the guided activity.
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Note: Auto-enrolled plans are the standard plans SSM Health selects for you. YOU ARE ALLOWED TO CHANGE THE AUTO-ENROLLED PLANS. If you do not want to change the plans you are auto-enrolled in, leave them as is and you will be enrolled in the defaulted value.
3. To change your insurance plan from the standard option, click the pencil icon next to the Benefit Type you wish to modify. A new window will appear with your options to make a new election.
4. Select the coverage you would like by clicking the option and the row of information will be highlighted.
5. If you have added beneficiaries, you have the option to allocate the percentage each should inherit. Please note, for Employee Life Insurance and AD&D, you have the choice to designate each has a Primary or Contingent. A beneficiary cannot be a Primary and a Contingent and each column will need to total 100%. The system will help you if you make an error in your totals.
6. Click Add to select your plan. Click Cancel to discard the change and return to the previous page.
7. Check to see the new plan populates correctly.
8. Repeat steps 3-6 for each insurance plan you would like to change.
Warning: It’s important to remember this system DOES NOT SAVE your selections until you reach the Review and Save step and click Save at the end of the enrollment process.
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Retirment Savings - 403 (b) Employee ContributionThis section is where you can elect or make changes to your 403(b) contribution.
1. Navigate to icon 5, labeled Savings Plans by either clicking Next located at the top of the page or by clicking on the Savings Plans icon.
2. Click the plus sign to create a new election
3. Enter the percentage or dollar amount you wish to contribute each pay period.
4. Click Add when finished
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Health Care and Child/Elder Care Reimbursement Accounts1. Navigate to icon 6, labeled Flexible Reimbursement Accounts by either
clicking Next located at the top of the page or by clicking on the Flexible Reimbursement Accounts icon.
Selecting Health Care or Child/Elder Care Reimbursement Accounts2. You will now be able to view your Reimbursement Accounts:
Reimbursement Accounts - You can select a plan in the table or skip to the next step in the guided activity. To make an election, choose the plus sign icon and enter the dollar amount for recurring pay period deductions. Please note: the maximum annual contributions in each plan are prorated by month of hire.
3. To add a reimbursement account, click next to the benefit type. To make a change to a plan, click the pencil icon. A new window will generate for each savings plan when you select the pencil or add icons.
4. You will be able to select the dollar amount you would like to be deducted from your paycheck on an annual basis. So if you would like to only deposit $2,000 for the year, SSM Health would be deducting $76.92 from your paycheck, per pay period.
Notes: For your Health Care Reimbursement Account you must select a dollar amount between $52 - $2,550. (Minimum dollar amount of $52, and a maximum of $2,550.)* Remember: this amount is based on an annual amount.
For your Child/Elder Care Reimbursement Account you must select a dollar amount between $52 – $5,000. (Minimum dollar amount of $52, and a family maximum of $5,000.)* Remember: the $5000 family maximum is inclusive of both your election and if applicable, your spouse’s election.
The maximum amount that a new hire can contribute to both the Health Care or Child/Elder Care reimbursement account is prorated based on your hire date.
5. Click Add to select your plan. To discard your changes, click Cancel. You will return to the previous page.
6. Check to see the new plan populates correctly.
7. Repeat steps 3-5 for each plan you would like to change.
Warning: It’s important to remember this system DOES NOT SAVE your selections until you reach the Review and Save step and click Save at the end of the enrollment process.
Review and Save Section 1. Navigate to icon 7, labeled Review and Save by either clicking Next located at the top of the page or by clicking the Review and Save icon. You
can review your changes, and save them to finalize the enrollment process by choosing Save. You can edit the benefits plans at any time during the enrollment period.
Viewing Review and Save Section2. You will be able to view all of the plans you have selected.
Note: you may see three different sections - Plans to be changed - Unchanged plans - Plans not enrolled in
3. All the plans that you have changed will appear in the Plans to be Changed section.
4. All the plans with no changes will appear in the Unchanged Plans section.
5. All the plans that you have chosen no election will appear in the Plans Not Enrolled in section.
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Saving your Plans6. To SAVE all of your benefits you would like to be enrolled in click Save: 7. To cancel/change any of the plans, click either Close or navigate back to
the individual plan pages using the number icons in the workflow.
Benefit Election SummaryOnce you have clicked Save, you will be brought to the Benefit Election Summary.
1. Please ignore the following message:
2. You can navigate back to enrollment and make further changes if you choose the Go to Enrollment link.
3. In order to view your plans further, please click the Benefit Participation Overview link.
Important: Benefit Election Summary – Subject to change based on benefit review. Final confirmation will be mailed to your home address.
Benefits Participation Overview1. EXIT out of new hire enrollment.
2. Click on the Benefits link.
3. Click on Benefits Participation Link.
4. You will be able to view all the benefits you elected.
Please remember you have 31 days inclusive of date of hire to enroll or make changes to your elections using this online process. Once your enrollment period ends, you will be locked into your elections for an entire year. If you have a qualifying change in status, your elections can be changed accordingly. Please contact a benefit representative if this is the case. Changes must be made within 31 days of the qualifying event.
Questions about your Benefits?Please call your benefits representative to help answer any questions that you are unable to find in our online resources.
YOUR MEDICAL PLANYou may “Opt Out” of Medical Coverage
Please see the Summary of Benefits and Coverage document in your new hire packet or on the MyHR portal located on SSM Health’s Intranet for details of the medical plan options available to you in your region.
Adult Surcharge for Medical Coverage - $75 There will be an additional $75 surcharge added to the first two paychecks each month for covering your adult dependent. This applies to either your spouse or Legally Domiciled Adult (LDA) covered under an SSM Health medical plan if that adult dependent is eligible for medical coverage through his/her employer.
To WAIVE the adult surcharge, complete the form located in the back of this booklet. If you are covering an adult who is employed and not eligible for medical coverage, your spouse’s employer must complete the form in the back of this booklet or you must obtain a letter from your spouse’s employer and return it to the Human Resources Department.
Medical Plan Contribution Discount Employees are eligible for a discount on employee contributions (payroll deductions) for coverage under an SSM Health medical plan as long as the following criteria is met:
• Must be a full- or part-time employee eligible for medical coverage with at least one year of continuous employment.
• Certain guidelines based on your total household income and the number of your dependents - see form for details.
If guidelines are met, a full-time employee will be eligible for a 50% discount on medical plan contributions. Part-time employees will receive the same absolute dollar amount a full-time employee receives for the same election. The discount applies to medical coverage for an employee only, employee plus one or family. It does not apply to any other benefit.
In order to apply after one-year of employment, complete the Medical Contribution Plan form (avaialble on MyHR) and submit along with supporting documentation to Human Resources within 31 days of your eligibiliy date.
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Dependent InformationSee Eligible Dependent page of this booklet for more information.
Coordinating Medical and Dental Plan BenefitsIf you are enrolled in medical and /or dental coverage under another plan outside of SSM Health, please review the “Coordination of Benefits” section in the Summary Plan Description - restrictions may apply.
Health Care Reimbursement Account (HCRA) Can HelpIf you participate in the HCRA, your out-of-pocket expenses can be reimbursed on a pre-tax basis.
Notice of Privacy PracticesThis Notice explains how your medical information is used and the rights you have under the Health Insurance Portability and Accountability Act (HIPAA). It can be found in the most recent Summary Plan Description (SPD) for the medical, dental or vision option you elected.
Required Notice: Reconstructive SurgeryAll SSM Health medical insurance plans will cover charges for reconstructive surgery following a mastectomy, provided the mastectomy was a covered expense. In accordance with plan provisions we will cover:
1. Reconstruction of the breast on which the mastectomy was performed;
2. Surgery and reconstruction of the other breast to produce symmetrical appearance; and
3. Prostheses (including implants and special bras) and physical complications of all stages of mastectomy, including lymphedemas
4. Nipple and areola reconstruction and repigmentation.
YOUR PHARMACY BENEFIT WITHIN YOUR MEDICAL PLANYou cannot “Opt Out” of the Pharmacy Benefit; this benefit is included in your medical plan.Manual claim forms will only be allowed in very unique situations
NOTE: CVS is not a covered pharmancy under this plan.
Important Information: Using Navitus Health Solutions www.navitus.com 866-333-2757
Prescription Co-Pays:
Description 30 Days Supply at Retail
90 Days Supply at Retail or Mail Order
Tier 1 - Formulary generics and low cost brands $8 $20
Tier 2 - Formulary brands and high cost generics $30 $75
Tier 3 - Non-Formulary brands and generics $60 $150
Out-of-Pocket Maximum: All plans include an out-of-pocket maximum of $1,600 per person or $3,200 per family for prescriptions drugs.
Tier 1 Formulary - Generic drugs and some low cost brands reduce your co-pays. If you do not choose a Tier 1 drug when it is available, you will pay the difference between Tier 1 and Tier 2, plus your applicable co-pay.
Mail Order Service - Mail order can be a convenience for members who take maintenance medications. You can receive up to a 90-day supply through your mail order provider, WellDyneRx. Call 866-333-2757 and a Navitus representative can answer your questions about mail order. You may also start the process online at welldynerx.com.
Medicare: Part D Coverage Notice Requirement - The SSM Health pharmacy benefit meets the definition of “creditable” coverage. SSM Health will provide the Notice for your records when you are age 64 and older by October of the current calendar year and an active participant in an SSM Health medical plan. If you are an SSM Health member enrolled in Medicare, but not due to age (i.e., end stage renal disease, disability), please contact your local Human Resources Department to request a Notice.
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What to do and what to expect from your Pharmacy Benefit
• Prior Authorization - You may be required to receive a prior authorization from your doctor to ensure you are covered for a certain prescription drug. Please remember that prior authorization letters must be renewed annually.
• Always identify yourself as a Navitus member - Remember to tell your pharmacist when you pick up your prescription that you are a Navitus member, even if you do not have your I.D. card, to receive the lowest out-of-pocket cost. Only under very rare circumstances can a claim be filed for reimbursement after the service has been provided.
• Updated preferred and non-preferred drug lists - In order to respond to the many advancements in the pharmaceutical industry, our list (called a formulary) of preferred/non-preferred drugs is subject to change. When possible, changes will occur on January 1. You will be informed in advance to ensure there is time to contact your doctor(s). However, changes can also occur at any time during the year.
What is Step Therapy? A step therapy program encourages the safe and cost-effective use of prescription drugs. It requires a “step” approach to get coverage for certain high-cost drugs. This means that to get coverage, you may need to first try a proven, safe and cost-effective medication before moving to a more costly treatment, if necessary. If your doctor prescribes that you “skip” steps, your doctor will submit a prior authorization request and receive approval for the drug to be covered. Contact Navitus toll-free at 866-333-2757 for more information.
NOTE: The SSM Health Pharmacy Plan does NOT coordinate with other pharmacy plans.
Specialty PharmacyNavitus SpecialtyRx helps members who are taking medications for certain chronic illnesses or complex diseases by providing services that offer convenience and support. This program is part of your pharmacy benefit and is mandatory. Mandatory means your specialty medication must be obtained via a Navitus SpecialtyRx pharmacy.
Health Care Reimbursement Account (HCRA) Can HelpIf you participate in the HCRA, your out-of-pocket expenses can be reimbursed on a pre-tax basis.
YOUR DENTAL PLANYou may “opt out” of Dental coverageThe following table summarizes the high/low deductible dental plans that are available. There is not a network of providers; you choose your dental care provider.
Plan Low HighAnnual DeductibleYou will pay per person $100 $50
Annual MaximumPlan will pay per person $1,000 $1,500
Preventive Services Deductible does not applyPlan will pay per personRoutine exam, cleaning, x-rays
100% 100%
Basic ServicesPlan will pay per personCavity fillings, tooth extractions, treatment of gum disease
50% 80%
Major Services Plan will pay per personNew crowns, dentures, implants, bridge pontics, tooth extractions
50% 50%
Orthodontic ServicesPlan will pay per personPre-existing condition applies
Not Available 50%
Lifetime Ortho MaximumPlan will pay per person (maximum) N/A $2,000
(no age limit)
Coordinating Dental Plan BenefitsIf you are enrolled in dental coverage under another plan outside of SSM Health, please review the “Coordination of Benefits” section in the Summary Plan Description - restrictions may apply.
Dental LockYour dental election will be “locked” for two years if you make a change. Therefore, if you make a dental election in 2017, you must keep that election for 2018 unless you have a qualified change in status.Y
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YOUR DENTAL PLANCovered Dental Expenses
Examples Covered ExpensesType I Procedures:Diagnostic and Preventive
• Routine examinations, limited to two (2) per calendar year
• Cleaning, including prophylaxis treatment• X-ray examinations• Space maintainers
Type II Procedures:Basic Services
• Regular cavity fillings• Oral surgery and tooth extractions, including
pre- and post-operative care• Root canal therapy, including necessary
x-rays, cultures and periodontics• Repair and adjustments to dentures • Treatment of periodontal and other diseases
of the gums and tissues of the mouth• Anesthesia and its administration in
connection with oral surgery, extractions or other covered dental services
• Repair and re-cementing of inlays, onlays, crowns and bridges
Type III Procedures:Major Services
• Gold inlay fillings (three surfaces), new crowns and single crown restorations
• Full and partial dentures• Bridge pontics• Implants
Type IV Procedures:Orthodontic Treatments
We will pay the reasonable and customary charges of an appropriate provider for orthodontic services and supplies given in connection with a course of orthodontic treatment, including space maintainers in preparation of orthodontic treatment. Pre-existing condition applies.
Health Care Reimbursement Account (HCRA) Can HelpIf you participate in the HCRA, your out-of-pocket expenses can be reimbursed on a pre-tax basis.
Dependent InformationSee Eligible Dependent page of this booklet for more information.
NOTE: The SSM Health Vision Plan does NOT coordinate with other vision plans.
YOUR VISION PLANYou may “opt out” of Vision coverageExam OnlyComprehensive vision examination only.
Exam and MaterialComprehensive vision examination plus lenses, contacts and frames.
The following chart provides a description of the benefits and co-payments for the vision care benefit:
Basic Plan Features
Co-Payment Schedule if you use
a Vision Service Plan (VSP) Provider
Allowance Available if you
use an Out-of-Network
Provider
How Often you Can Use these Services - With or Without a Vision Service Plan
(VSP) Provider
Comprehensive Vision Examination
Fully covered after $10 co-payment
$40 Once every 12 months
Lenses Glass or Plastic
• Single• Bi-focal• Tri-focal• Lenticular
Fully covered after $25 co-payment
$40$60$80$125
Once every 12 months
Contact Lenses• Evaluation Fee
& Fitting Costs (E&F)
• Necessary *• Elective **
15% discount up to $60
100%$130 allowance (E&F not included)
$210$105
Once every 12 months
Standard Frames *** $25 co-payment, if lenses are NOT purchased
$150 allowance
$45 Once every 24 months
* When needed following cataract surgery or to correct extreme visual acuity problems that cannot be corrected with spectacle lenses and/or certain conditions of Anisometropia and Keratoconus.
** When contacts are chosen in lieu of lenses for eye wear.*** Certain frames are covered in full by VSP, after the co-payment is met. Those that are not covered in full,
are available at a reduced cost.
Vision LockYour vision election will be “locked” for two years if you make a change. Therefore, if you make a vision election in 2017, you must keep that election for 2018 unless you have a qualified change in status.
Discount for Laser Eye Surgery - Vision Service Plan (VSP) members may be eligible for laser eye surgery discount. Contact VSP or your VSP provider for details.
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How the Vision Plan works:1. If you need assistance in locating a VSP participating provider, call Vision
Service Plan (VSP) at 800-VSP-7195 (800-877-7195), or visit vsp.com.
2. Call a VSP participating provider to make an appointment. Identify yourself and eligible dependents as VSP members. NOTE: You will NOT receive an identification card for the vision care benefit; however, you can print one at vsp.com.
3. The VSP participating provider will contact the Vision Service Plan to verify your eligibility plan coverage and will obtain authorization so you can receive services and materials.
4. VSP will reimburse you for services received from any licensed optometrist, optician or ophthalmologist.
The materials covered are lenses and standard frames. Additional features such as tinting, scratch coating, designer frames or progressive lenses for bi- or tri-focals will be the member’s responsibility even if a VSP provider performs the services.
The following are examples:
Service Retail Cost Employee’s Co-Payment
In-Network
Exam $80 $10
Contacts Fitting Fee $50 $42.50
Contact Lenses $130 $0
TOTAL $260 $52.50
Service Retail Cost VSP Allowance
Employee’sResponsibility
Out-of-Network
Exam $80 $40 $40
Frames $120 $45 $75
Bi-Focal Lenses $80 $60 $20
TOTAL $280 $145 $135
NOTES: • Employee responsibility is the retail cost minus the VSP out-of-
network allowance.
• If additional services are purchased (i.e., tinting or progressive line for bi-focals) those costs will be the complete responsibility of the member.
Health Care Reimbursement Account (HCRA) Can HelpIf you participate in the HCRA, your out-of-pocket expenses can be reimbursed on a pre-tax basis.
Dependent InformationSee Eligible Dependent page of this booklet for more information.
NOTE: The SSM Health Vision Plan does NOT coordinate with other vision plans.
ELIGIBLE DEPENDENT INFORMATIONDependent Definition for Medical, Dental and Vision
1. An eligible child up to age 26 (your dependent, foster child(ren), adopted child(ren), step-child(ren), step-child(ren), children for whom you have legal custody)
2. A disabled child (regardless of his/her age) who is not able to support himself/herself because he/she has a physical or mental condition that limits movement, senses or activities provided that the disability began before he/she reached his/her nineteenth (19th) birthday
3. The spouse of an eligible employee including same-sex spouse
4. A Legally Domiciled Adult (LDA) NOTE: Only ONE adult (spouse or LDA) may be covered on all health plans.
5. The dependent child(ren) of an LDA
Legally Domiciled Adult (LDA) Employees have an opportunity to cover one additional adult that may not be his/her spouse, known as a Legally Domiciled Adult (LDA). NOTE: One adult plus the employee allowed - total of two. The employee and dependent must reside in the same household full-time.
A legally domiciled adult could be an adult child who no longer meets the definition of eligible child, a parent, relative or another adult. The LDA’s dependent child(ren), even if the child(ren) reside in another household, can also be covered.
For the LDA to qualify for coverage the LDA must:1. Reside in the same household with the employee, with the exception of
child(ren) of an LDA who reside in the other parent’s home or a child who is older than the age stated in the Eligible Child definition; and
2. Be a member of the employee’s household - not an employee (i.e., nanny); and
3. Be 19 years of age or older.
A different adult dependent cannot be covered under the various plans. For example, if an LDA is covered under a medical plan, a spouse cannot be covered under the employee’s dental plan. However, the employee could elect plus one coverage under the dental plan and cover a child.
Tax Form Documentation Requirement - The tax form required for review for the entire calendar year is the IRS 1040 form (or equivalent), two (2) calendar years prior to the effective date, (i.e., during 2017, the 2015 form will be required).E
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Legally Domiciled Adult Tax Implications If your LDA is NOT a dependent as defined by the IRS, there are tax implications for your election. The deductions for your portion of the elections will continue to be made on a pre-tax basis. In addition, your paycheck will also contain a tax adjustment for the value of the benefit you are receiving. The value of the benefit is based on total monthly premium amounts.
See a calculation example below. The actual number will vary depending on the plan you elect and your tax bracket. If you have any questions about your coverage, please contact your local Human Resources Department.
Assumptions:1. Elected employee plus family medical coverage
2. Total monthly premium (employer & employee portion) Employee Only $600 Family $1,000
3. 20% tax bracket TOTAL family premium minus total employee ONLY premium = Value
of the Benefit or $1,000 - $600 = $400
ESTIMATED taxes = taxable benefit times tax bracket or $400 x .20 = $80 per month/$40 per pay period
If you elected dental and/or vision coverage for an LDA, the total premium amounts for those benefits will also be included in the calculation.
A qualified LDA may or may not qualify as a dependent on the employee’s federal tax return. The reason this is important is two-fold:
First, a dependent that meets the IRS Section 152 definition (defines a qualified dependent) will allow the employee’s deduction to be taken on a pre-tax basis. If the LDA DOES NOT meet Section 152, then the premium associated with ALL dependents, even those that do qualify, will be taxed on an after-tax basis. A copy of page 1 from the employee’s tax filing from the previous year must be placed in the employee’s benefits file in Human Resources.
Second, the tax status also has an impact on whether a mid-year election change is permitted:
• If the dependent qualifies under IRS Section 152, the LDA is treated like all other dependents, except only ONE LDA can be covered during a calendar year. The IRS 152 and HIPAA change in status guidelines will apply (as detailed in the Summary Plan Descriptions).
• If the LDA is not an IRS 152 dependent, the LDA and/or the LDA’s dependents can be dropped at anytime during the year. HOWEVER, adding a non-IRS 152 dependent is restricted to ONCE PER YEAR. It should be noted, two (2) different LDAs cannot be covered during one calendar year. Therefore, if an employee begins a year covering an LDA and coverage for the LDA ends, an LDA cannot be added until the next January 1. NOTE: the dental and vision lock will still apply. The employee must notify their local Human Resources Department within 31 days of the event to add an LDA mid-year.
IMPORTANT NOTE: COBRA coverage WILL NOT be offered to an LDA and/or the LDA’s dependent(s). However, in the event of an employee’s death, three (3) months of “transitional” coverage will be allowed based on COBRA premium rates.
HEALTH CARE REIMBURSEMENT ACCOUNT (HCRA) Participation in the program is voluntaryNOTE: Debit cards are not available for the Health Care Reimbursement Account at SSM Health.
General GuidelinesThe Health Care Reimbursement Account (HCRA) allows benefit eligible employees to put money aside pre-taxed for qualified out-of-pocket health care expenses. Because contributions are deducted from your pay before Federal, State or Social Security taxes are calculated, which reduces your taxable income, the account is subject to IRS regulations.
An annual election is required each Plan Year you choose to participate. You may elect to contribute a minimum of $52 up to the maximum advised by Human Resources based on your hire date. Your annual election will be deducted in equal installments from your paychecks in the participating Plan Year (unless it is the third paycheck in a month).
Your contributions are to be used for eligible medical, dental and vision care expenses for you, your spouse and eligible dependents (after-tax LDAs do not qualify as eligible dependents under the HCRA). Contributions made in 2017 are only for expenses incurred during the 2017 Plan Year while you are an active participant. You will have until March 31 of the following year to submit claims incurred under the previous Plan Years’ contribution. All claims must be submitted with a post-mark date no later than March 31 if mailed, or by 11:59 pm if faxed or emailed, to be considered for reimbursement.
Reimbursement accounts are use-it or lose-it funds. Account balances do not carry over to the next Plan Year and unused funds will be forfeited.
Eligible/Non-Eligible Health Care ExpensesBelow are examples of eligible and non-eligible items and services for the Health Care Reimbursement Account. Eligible expenses must be incurred during your participation in the Plan.
Examples of Eligible Expenses (list is not inclusive)• Co-payments • Deductibles and Co-Insurance• Prescription Drugs (within USA) • Diabetic Supplies• Prescription Eyeglasses/Contacts • Contact Solution (reasonable amt.)• Lasik Vision Services • Hearing Aids• Non-Cosmetic Dental Services • Orthodontia Services• Chiropractic Adjustments • Acupuncture• Physical Therapy • Infertility Services
Examples of Non-Eligible Expenses (list is not inclusive)• Cosmetic Surgery • Electrolysis/Laser Hair Removal• Teeth Whitening • Over-the-Counter Medicines/Items• Drugs from Other Countries • Toiletries• Nutritional/Dietary Supplements • Health Club Dues• Late Payment/Missed Appt. Fees • Warranties/Service Agreements• Services Paid or Payable by Insurance • Insurance Premiums
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Estimating Your Health ExpensesThe guide below can help you estimate your health care expenses not covered under your insurance plan(s).
Medical Expenses Estimated Plan Year Expenses Vision Expenses Estimated Plan
Year Expenses
Deductibles $_____________ Co-Payments $_____________
Co-Payments $_____________ Contact Lenses $_____________
Prescription Drugs $_____________ Eyeglasses $_____________
SUBTOTAL $_____________ SUBTOTAL $_____________
Dental Expenses Estimated Plan Year Expenses Other Expenses Estimated Plan
Year Expenses
Deductibles $_____________ Chiropractor $_____________
Co-Payments $_____________ Hearing Aids $_____________
Restorative WorkCrowns, caps, bridges $_____________
Immunizations$_____________
SUBTOTAL $_____________ SUBTOTAL $_____________
TOTAL ESTIMATED EXPENSES $_____________
Orthodontia Claim ProcessingOnly orthodontia services provided with proper proof that they are incurred in the current Plan Year are eligible for reimbursement. Paying the full amount you will owe at the beginning of the treatment does not allow you to receive reimbursement for that amount; it will be prorated based on the number of months the services are expected to last. Any payment in advance of services cannot be reimbursed until the dates of services have occurred. For a more detailed explanation on how orthodontia reimbursement works with the HCRA, please see the HCRA Reference Guide on MyHR under the Benefits section.
Electronic Claim ProcessingElectronic claim processing is automatic and cannot be stopped. Please read the following information carefully to understand how this process works.
If you elect to participate in an SSM Health medical plan and/or the high or low dental plan, and the claims are administered by CoreSource, Navitus, Dean or GHC, submitting a Health Care Reimbursement Account Claim Form is NOT required. The electronic claim processing works as follows:
• Once eligible health care and dental expenses are incurred, the provider will file the claim with the third party administrator (TPA) - CoreSource and Navitus - or the insurance carrier - Dean or GHC.
• The TPA or insurance carrier will then adjudicate (process) the claim(s) then notify SSM Health of your out-of-pocket costs associated to those claims.
• Your eligible out-of-pocket costs will load electronically into the HCRA system and will be automatically reimbursed on your next available paycheck. The timeliness of the reimbursement appearing on your paycheck will depend on how soon the provider files the claim after the service is incurred and the time needed to process the claim.
NOTE: All out-of-pocket vision expenses must be submitted by completing a Health Care Reimbursement Account Claim Form and include supporting documentation. Employees at SSM Health Wisconsin facilities who elect Delta Dental will need to submit their eligible out-of-pocket dental expenses manually as well.
Additional InformationReimbursement from your Health Care Reimbursement Account will appear as a non-taxed portion on your paycheck.
CHILD/ELDER CARE REIMBURSEMENT ACCOUNT (CECRA)Participation in the program is voluntaryThe Child/Elder Care Reimbursement Account (CECRA) program allows you to reduce your taxable income with pre-tax payroll deductions and then use that money to reimburse yourself for eligible child/elder care expenses, i.e., daycare. A new election is required each year. An annual election can be anywhere from the minimum amount of $52, to the maximum advised by Human Resources based on your hire date. NOTE: The IRS sets this annual limit as a family limit; this means that you and your spouse cannot exceed a combined election of $5,000.
Since the CECRA program provides tax advantages, it is subject to IRS regulations. One of the provisions you should take into consideration when deciding on your election amount, is that once you elect to participate in the program, you cannot terminate participation or change your election amount, unless you have a qualified status change. Also, money left in your account is forfeited.
Eligible vs Non-Eligible Child/Elder Care Expenses:Contributions made in 2017 are only for eligible expenses incurred in the 2017 Plan Year while you are an active participant. Reimbursement is based on the dates the services are incurred, not when billed or when payment is made. Please see the following lists providing examples of eligible and non-eligible expenses:
Examples of Eligible Child/Elder Care Expenses (list is not inclusive):• Services provided by Child/Elder Care centers subject to state and local
licensing that meet all licensing requirements
• Child/Elder Care services provided by an individual inside or outside of your home, even if they live in your home, except amounts paid to:
• Your child under the age of 13;
• An individual you claim as your dependent for tax purposes;
• An individual who was your spouse any time during the taxable year; or
• The parent of the qualifying individual.
• Employment tax, room and board and wage expenses you pay for household services in your home that include the care of a qualifying individual
• Nursery school and other pre-kindergarten programs that includes educational elements
• Application fees, agency fees and deposits if they are required to be paid in order to obtain the Child/Elder Care services
• The cost of transportation by a Child/Elder Care provider of a qualifying individual to or from a place where care of that qualifying individual is provided
• Day camps and before and after school care
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Examples of Non-Eligible Child/Elder Care Expenses (list is not inclusive):• Any health, dental, vision or nursing home expenses
• Any tuition or education expenses for a child in kindergarten or a higher grade, including tutoring programs or summer school
• Food, clothing or supplies (i.e., lunch, t-shirts or diapers)
• Any portion of an overnight camp
• Entertainment, field trips or special instruction such as dance, swimming, or music lessons unless these costs are incident to and cannot be separated from the cost of caring for the qualifying individual
• The cost of transportation for you to take your dependent to and from a child/elder care provider
• Services that are 1) not provided in same Plan Year as your CECRA election, 2) prior to your Plan participation date, or 3) after your Plan participation date.
NOTE: Plan participation terminates on your last day of employment, the last day you are eligible to participate in the CECRA program or the day of your change in status that would allow you to drop participation in the Plan, including LOA.
• Expenses for which a child/elder care tax credit is given
ClaimsContributions made in 2017 are only for expenses incurred during the 2017 Plan Year while you are an active participant. You will have until March 31 of the following year to submit claims incurred under the previous Plan Years’ contribution. All claims must be submitted with a post-mark date no later than March 31 if mailed, or by 11:59 pm if faxed or emailed, to be considered for reimbursement.
Please note: The CECRA is intended to help you pay for eligible dependent care expenses to allow you to work. If you are on a leave of absence longer than two weeks, your contributions will be stopped because during this time, you do not meet the qualifications to participate. Expenses incurred for services while you are out on leave are not eligible for reimbursement.
GROUP TERM LIFEYou may not “opt out” of life insurance; however, there is an option offered that has no cost to youIf you select a life insurance option that provides you with more than $50,000 in life insurance, IRS regulations require you to pay a small amount of added income tax, based on an estimated value for that coverage.
NOTE: There is a one-level increase limitation that will be applied during open enrollment and qualified changes in status. The following options are available to choose from (maximum $1,000,000; EOI* limit is $750,000).
Coverage Options• $5,000 • Three (3) times annual base pay• One (1) times annual base pay • Four (4) times annual base pay• Two (2) times annual base pay • $50,000
*Evidence of Insurability (EOI) means a statement or proof of a person’s medical history upon which acceptance for insurance will be determined by Unum.
Travel Assistance Included with all Life InsurancesWhether you travel to a foreign country or more than 100 miles away from home, you may be eligible for assistance in the event of a medical emergency.
Emergency travel assistance is a service provided under your life insurance plan and is available 24-hours-a-day, 365-days-a-year for you and your eligible family members. This program includes:
• Hospital admission assistance• Emergency medical transportation• Prescription replacement assistance• Multilingual crisis management professionals• Referrals to Western-trained, English-speaking medical providers• Care and transport of unattended children
For more information about this service, visit unum.com/travelassistance or review the frequently asked questions.
To get help with a travel emergency call:• 800-872-1414; U.S. access code + 609-986-1234 — if you’re outside the
United States• Or email [email protected] with your reference number:
01-AA-UN-762490
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ACCIDENTAL DEATH & DISMEMBERMENT (AD&D)
You may not “opt out” of AD&D; however, there is an option offered that has no cost to you
The AD&D benefit will pay your beneficiary the elected AD&D amount if your death is a result of an accident. If you are injured, your AD&D insurance may pay you a portion of the benefit amount.
Eligible employees can choose from the following AD&D options (maximum $1,000,000):
Coverage Options• $5,000 • Three (3) times annual base pay• One (1) times annual base pay • Four (4) times annual base pay• Two (2) times annual base pay • $50,000
LONG-TERM DISABILITY (LTD)You may not “opt out” of LTDIf you are eligible for this benefit, the SSM Health pay-all LTD benefit provides you with important income protection if you become disabled. Options are listed below (excluding physicians and executives).
• Option 1: 50% of monthly earnings, to a maximum of $10,000 per month• Option 2: 60% of monthly earnings, to a maximum of $10,000 per month
There is a 90-day elimination period which means the long-term disability benefit will begin on the 91st day of total disability. Your monthly payment may be reduced by other sources of income.
VOLUNTARY DEPENDENT TERM LIFE (VDTL)You may “opt out” of Voluntary Dependent Term Life (VDTL); participation is voluntaryThere are four (4) options offered to eligible employees through Unum, a leading provider in the United States of group life insurance. These options will be available as “units,” taken through payroll deductions on an employee-pay-all, after-tax basis.
Option Coverage Pay Period Rates
0 Opt Out .00
1 $5,000 spouse/ $1,000 per child .89
2 $15,000 spouse/ $2,000 per child 2.63
3 $25,000 spouse/ $3,000 per child 4.37
NOTE: Since these are “units,” it does not matter how many children an employee has as long as they are “eligible” for coverage. In addition, if the employee elects the coverage and has a spouse or child(ren) only, the rate will not be adjusted.
Guidelines for Making Changes to your Dependent Term Life ElectionElection changes, as a result of a qualified change in status or during benefits open enrollment, will be limited to the “one-up” provision if you had a dependent that was previously eligible for this coverage but chose not to participate. The coverage level for the spouse or child cannot exceed the employee’s level of life coverage.
Domestic Partner DeclarationA Unum form titled “Domestic Partner Statement” must be completed before coverage will be in effect. The definition of Domestic Partner for Dependent Term Life Insurance is DIFFERENT than an LDA. See next page for specific information.
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Below please find seven (7) major features of the Voluntary Dependent Term Life Plan:
1. Only those eligible for the employer-sponsored group life plan will be eligible to elect dependent life coverage.
2. The coverage level for the spouse or child cannot exceed the employee’s level of life coverage. For example, if the employee has elected $5,000 of life coverage only dependent life option 1 can be selected. If the employee has elected one times his/her salary for life coverage and makes $22,000, only option 1 or 2 will be allowed.
3. Coverage for a totally disabled dependent cannot begin until the dependent is no longer deemed totally disabled.
4. Employees will have the opportunity to continue this benefit at the time of termination (personal conversion).
5. The beneficiary is automatically the employee.
6. Under this plan, the definition of dependent child is:• Unmarried natural offspring, lawfully adopted children and step-children.
They also include an unmarried foster child(ren) and other child(ren) who are dependent on the employee for main support and living with the employee in a regular parent-child relationship. A child will be considered adopted on the date of placement in the employee’s home.
• Unmarried child(ren) from live birth but less than age 19. Stillborn children are not eligible for coverage.
• Unmarried full-time student at an accredited school, age 19 or over until his/her 26th birthday. Accredited schools means an accredited post-secondary institution of higher learning for full-time students beyond the 12th grade level.
NOTE: More than one employee may not cover a dependent child, and a dependent may not be covered as an employee and a dependent.
7. Unum includes “Domestic Partner” in the definition of a spouse. Your domestic partner is the person named in the Domestic Partnership Statement. The employee must comply, sign and provide the Human Resources Department this Statement which requires proof that the domestic partner has had the same permanent residence as the employee for six consecutive months prior to the date insurance would be effective for that domestic partner. The employee must not have signed a Domestic Partnership Statement with anyone else within the last six months of signing the latest statement. Also, the domestic partner must be at least 18 years of age, competent to contract, not related by blood that would bar marriage, the sole named domestic partner, not married to anyone else and the declaration of domestic partnership must be approved and recorded by the plan administrator.
VOLUNTARY SHORT-TERM DISABILITY (VSTD)
You may “opt out” of Voluntary Short-Term Disability (VSTD); participation is voluntary
There are two options to choose from: Option 1 - 50% of your weekly base pay, to a maximum of $500/week Option 2 - 60% of your weekly base pay, to a maximum of $2,500/week
Important Notes:• You will not be eligible to receive the VSTD benefit if you have a
pre-existing condition, up to three months prior to the effective date of coverage.
• It is extremely important for employees to evaluate their personal situation and determine if this Plan could be beneficial. Consider the number of hours in your PTO/EMTO bank, the impact to your family of an unpaid leave due to your personal illness or injury and understand that your election is “locked” for two years.
This VSTD income will begin after 14 calendar days or when you have exhausted all PTO/EMTO hours; whichever is later. The Plan requires that all PTO and EMTO hours be paid prior to receiving VSTD payments. Your payments will stop once Long Term Disability benefits begin. You may be eligible to receive VSTD income for up to a maximum of 11 weeks per disability. The benefit premiums are paid on an after-tax basis from 24 paychecks (first two paychecks of each month). Any VSTD benefits you may receive will be income-tax free. The VSTD payment will be sent weekly from Unum.
VSTD benefits may be reduced by the amount of other income replacement benefits you receive for the same disability, such as benefits from state-mandated disability.
You will be eligible to receive a weekly VSTD benefit based on the option you elect when you are deemed disabled by Unum due to your sickness (including pregnancy) or injury and you are:
1. Unable to perform the material and substantial duties of your regular occupation; and
2. On an unpaid leave with SSM Health; and3. Not working in any occupation; and4. Are under the regular care of a physician.
Reminders:• A work-related injury or any other type of NON-MEDICAL leave of
absence will not meet the definition of disabled under this program.• Standard medical guideline for a normal childbirth or for a C-Section
is 6 weeks (industry standard). If there are complications, an extension may be granted with medical documentation.
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Check your PTO/EMTO BankIMPORTANT NOTE: There will be limited opportunities to enroll and/or drop this coverage. The standard qualified change in status does NOT apply to this benefit.
You will only be able to enroll in the VSTD Plan:• During the annual open enrollment; or• Mid-year if your scheduled hours increase up to the minimum
hour requirement.
During the initial offering or the first time you become eligible for VSTD (increase number of scheduled hours to become eligible for medical coverage), you can elect either option.
Voluntary Short-Term Disability (VSTD)Your Voluntary Short-Term Disability will be “locked” for two years if you make a change. Therefore, if you make a change to your VSTD election in 2017, you must keep that election for 2018 unless you have a qualified change in status.You may drop VSTD coverage when you:
1. Have met the two-year lock requirement and elect to drop the coverage during the annual enrollment process; effective the next January 1;
2. Assume a position and the number of scheduled hours does not meet the minimum hours requirement; or
3. Are no longer employed by SSM Health.
This Plan does have a pre-existing condition limitation which applies if:• You received medical treatment, consultation, care or services including
diagnostic measures or took prescribed drugs or medicines in the three months just prior to your effective date of coverage; or
• You had symptoms for which an ordinarily prudent person would have consulted a health care provider in the three months just prior to your effective date of coverage; AND
• The disability begins in the 12 months after your effective date of coverage.
NOTE: You may still qualify for coverage for any other personal illness or injury that may occur. There are other instances when benefits will not be paid, please see the Summary Plan Description for details.
You will be required to contact Unum at 866-240-5800 to begin the VSTD process. If you qualify for VSTD benefits and are also a participant in the LTD plan, the information that is submitted will also begin the LTD process.
VSTD Deduction Calculation Example:Annual Salary $35,000
Divide Annual Salary by 52 - to get the weekly salary $673.08
Choose Your Election Option 50% 60%
Weekly Salary x Election Option (50% or 60%) $336.54 $403.85
Divide by 10 for Dollar Amount Round to the nearest cent $33.65 $40.39
Multiply by .44 - Monthly cost $14.80 $17.77
Divide by 2 - Pay period amount $7.40 $8.85
VOLUNTARY ENRICHED LIFE (VEL) Supplemental LifeParticipation in the program is voluntaryHighlights of this enhanced life insurance program include:
• Employee and/or spouse ($5,000 child rider available)
• Ease and convenience of automatic payroll deduction
• Interest-bearing account
• Portability
• Potential tax-deferred growth
• Tax-free withdrawals up to the total premiums paid (withdrawals will reduce your cash value and death benefit)
When making your life insurance election, consider the SSM Health Voluntary Enriched Life Insurance Plan (VEL) offered through MetLife.
After new hire eligibility has expired, employees may apply during open enrollment only. MetLife can accept or deny coverage. New hires have guaranteed issue.
Voluntary Enriched Life provides permanent coverage that goes beyond life insurance protection to include a tax-deferred way to build your assets. The flexible options within VEL can make it a valuable part of your family’s financial plan.
Through automatic payroll deduction, you can elect life insurance coverage for you and/or your spouse at the group rate.
Domestic Partner DeclarationDomestic Partner is included in the definition of spouse, if all the following criteria is met:
• Same residence as employee for at least 6 months;
• 18 years of age or older;
• Unmarried (both employee and domestic partner); and
• Not related by blood.
Enrollment packets are available through your local Human Resources Department. You are not able to enroll in this benefit using the telephone enrollment system.
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EFFECTIVE DATE OF BENEFITSQualified Change in StatusIf you have a qualified change in status during the Plan Year, you may be allowed to change your level of coverage before December 31. IRS guidelines limit the type of election change that can be made following each type of change in status. Report ANY qualified changes in status to your local Human Resources Department within 31 days of the event if you want to change your benefit election(s) to reflect the change. Eligible changes in status include, but are not limited to:
• Family changes such as marriage, divorce, legal separation, annulment, death of your spouse or dependent, birth, adoption or placement for adoption of your child, your dependent child ceases to satisfy the Plan’s eligibility requirements.
• Changes in employment status by you or your family member such as termination or commencement of employment, strike or lockout, commencement of or return from an unpaid leave of absence, change in worksite, or a switch from full-time to part-time or from salaried to hourly employment (or vise versa) that causes you or your family member to lose or gain eligibility for coverage.
Open Enrollment The other opportunity to make changes to your benefits is during the benefits open enrollment period. This gives you a chance to re-evaluate your benefit needs and make changes, except in circumstances when the “lock” applies. You will receive open enrollment materials in October for elections to be effective on January 1.
NOTICE OF PRIVACY PRACTICESThis Notice explains how your medical information is used and the rights you have under the Health Insurance Portability and Accountability Act (HIPAA). It can be found in the most recent Summary Plan Description (SPD) for the medical option you elected.
SUMMARY PLAN DESCRIPTIONS (SPDs)SPDs are available in your local Human Resources Department and also on the MyHR portal located on SSM Health’s Intranet; they explain the benefits in detail. This benefits information booklet was designed to summarize your personal benefits. If there is a discrepancy, the Summary Plan Descriptions will serve as the source of truth.
FREQUENTLY ASKED QUESTIONSCan I make changes to my benefits any time during the year (qualified change in status)?The benefits you elect are intended to remain in effect from January 1 through December 31. There must be a qualifying event to make any changes to your benefits during the year.
Please review the complete list of all Election Change Events found in the Definitions section of the Summary Plan Description.
IMPORTANT: IRS guidelines limit the type of election changes that may be made following each type of change in status. Please report any qualified change in status to your local Human Resources Department within 31 days of the event if you wish to change your benefit election(s) to reflect the change in status. There are significant consequences if you do not notify Human Resources in a timely fashion.
If I have a qualifying event how are my deductions or credits handled?Deductions or credits are never prorated within a pay period. The date you become eligible for benefits or the date of a qualified change in status will determine when deductions/credits begin. If your effective date happens to be on the first day of a pay period, your new deductions/credits will begin immediately. If your effective date is any other day within a pay period, the new deductions/credits will begin the next FULL pay period.
The same guidelines are followed when coverage ends. If the change date occurs within a pay period, the deductions or credits will continue until the pay period following the qualifying event.
If my coverage ends due to an election change event or termination, how long will my coverage remain in effect?For medical (including pharmacy), dental and vision, your coverage will end on the last day of the month in which your change or termination occurred. Covered members, except LDAs, will be offered COBRA coverage.
For Life, AD&D, Long-Term Disability (LTD), Dependent Term Life (VDTL), Short-Term Disability (VSTD) and Voluntary Life (VEL), your coverage will end on the date of the change or termination. You will be offered a personal conversion option for Life, Voluntary Life (VEL) and VDTL, and in some instances, LTD.
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Premium Assistance Under Medicaid and the Children’s Health
Insurance Program (CHIP)If you or your children are eligible for Medicaid or Children’s Health Insurance Program (CHIP) and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, 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, contact your State Medicaid or CHIP office or dial 877-KIDS NOW or insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t 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, contact the Department of Labor at askebsa.dol.gov or call 866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2016. Contact your State for more information on eligibility:
IOWA - Medicaid TEXAS - Medicaid
Website: www.dhs.state.ia.us/hipp/Phone: 888-346-9562
Website: https://gethipptexas.com/Phone: 800-440-0493
MISSOURI - Medicaid WISCONSIN - Medicaid
Website: http://dss.mo.gov/mhd/participants/pages/hipp.htmPhone: 573-751-2005
Website: http://www.dhs.wisconsin.gov/publications/p1/p10095.pdfPhone: 800-362-3002
OKLAHOMA - Medicaid & CHIP FOR A FULL LISTING: ALL STATES
Website: http://www.insureoklahoma.orgPhone: 888-365-3742
Website: http://www.dol.gov/ebsa/pdf/chipmode1notice.pdf
To see if any other states have added a premium assistance program since July 31, 2016, or for more information on special enrollment rights, contact either:
U.S. Department of Labor U.S. Dept. of Health and Human Services Employee Benefits Security Admin Centers for Medicare & Medicaid Servicesdol.gov/ebsa cms.hhs.gov 866-444-EBSA (3272) 877-267-2323, Menu Option 4, Ext. 61565
OMB Control Number 1210-0137 (expires 11/30/2016)
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تفضلها التي باللغة معنا التواصل على لمساعدتك المجانية اللغوية المساعدة خدمات الصحية للرعاية CoreSource نظام يوفر :بالرقم اتصل أو بك الخاص الصحية الرعاية أخصائي اسأل .الصحية الرعاية على حصولك أثناء
(800) 990-9058 РУССКИЙ предоставляет бесплатные услуги языкового сопровождения чтобы помочь Вам общатьсяна предпочитаемом языке для получения медицинских услуг Обратитесь к медработнику или позвоните по номеру
ગજુરાતી હલે્થ આરોગ્ય સભંાળ માટે તમારી પસદંગીની ભાષામાં અમારી સાથે વાતચિત કરવામાં મદદ કરવા માટે નન શલુ્કભાષા સહાય સેવાઓ પરૂી પાડે છે તમારા આરોગ્ય સભંાળ વ્યવસાયીને પછૂો અથવા કૉલ કરો
Employee Name ____________________________ Employee # _______________ (Please print) Adult’s (Spouse/LDA) Name _____________________________________________________ If your adult dependent (Spouse or Legally Domiciled Adult) is eligible for medical coverage under his/her employer, there will be an additional $75 surcharge added to the first two paychecks each month to cover that adult under the SSM Health medical plan. Please circle the answer that best describes your adult dependent’s medical coverage to determine if the surcharge will apply to you and return to your local human resources department. Please circle the answer that best describes your adult dependent’s medical coverage to determine if the surcharge will apply to you and return to your local human resources department.
1. covered/eligible for Medicare/Medicaid?
If yes, sign the bottom and return this form by the due date. You will not pay the $75 surcharge.
Yes No
2. unemployed or self-employed with no employer medical coverage available? If yes, sign the bottom and return this form by the due date. You will not pay the $75 surcharge.
Yes No
3. employed by SSM Health? (both employed by SSM Health) If yes, sign the bottom and return this form by the due date. You will not pay the $75 surcharge.
Yes No
4. employed and NOT eligible for coverage under his/her employer’s medical plan? If yes, documentation MUST BE PROVIDED from your spouse/LDA’s employer confirming the dependent is not ELIGIBLE for medical coverage. Your $75 surcharge will continue until the documentation is received.
Yes No
KNOWINGLY SUBMITTING FALSE INFORMATION COULD RESULT IN DISCIPLINARY ACTION UP TO AND INCLUDING TERMINATION OF EMPLOYMENT. DEPENDENT ELIGIBILITY WILL BE FREQUENTLY AUDITED. I certify that all information on this Affidavit is true, correct and current as of the date signed. Failure to return this Affidavit means I understand the $75 surcharge will be deducted from my first two paychecks of the month and if the Affidavit is returned at a later time indicating my spouse or LDA does not have eligible coverage through his/her employer, I will NOT be refunded any previous surcharge amounts.
Employee’s Signature ____________________________ Date _______________ IMPORTANT NOTE: The Adult Surcharge Waiver must be renewed each year during Open Enrollment and does not automatically roll over.
SSM Health Adult Surcharge Waiver Affidavit Employee Form – 2017 Plan Year
41
SSM Health Employee’s Name __________________________ Employee # _______________ (Please print) Spouse/LDA’s Name _____________________________________________________ (Please print) Spouse/LDA Employer’s Name _____________________________________________________ (Please print) At SSM Health, if an adult dependent is eligible for medical coverage through his/her employer in 2017, there will be an additional surcharge to cover that adult under the SSM Health medical plan. The employee named above would like to waive the surcharge because of the reason below; however, we request verification.
My Spouse/LDA is employed and NOT eligible for medical coverage under his/her employer’s medical plan.
I certify that our employee listed above as the spouse/LDA does meet the criteria of employed but not eligible for coverage under this employer. All information on this Affidavit is true, correct and current as of the date signed.
________________________________________ ________________________________ Employer’s Signature Printed Name ________________________________________ Date KNOWINGLY SUBMITTING FALSE INFORMATION COULD RESULT IN DISCIPLINARY ACTION UP TO AND INCLUDING TERMINATION OF EMPLOYMENT. DEPENDENT ELIGIBILITY WILL BE FREQUENTLY AUDITED. I certify that all information on this Affidavit is true, correct and current as of the date signed. Failure to return this Affidavit means I understand the $75 surcharge will be deducted from my first two paychecks of the month and if the Affidavit is returned at a later time indicating my spouse or LDA does not have eligible coverage through his/her employer, I will NOT be refunded any previous surcharge amounts.
Employee’s Signature ____________________________ Date _______________
IMPORTANT NOTE: The Adult Surcharge Waiver must be renewed each year during Open Enrollment and does not automatically roll over.
SSM Health Adult Surcharge Waiver Affidavit Employer Form - 2017 Plan Year Optional form in lieu of employer letter
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