St. Vincent Health 2021 Benefits Guide 1

St. Vincent Health 2021 Benefits Guide 1


We are pleased to offer to you and your family a very competitive benefit package.

St. Vincent Health is proud of our team members and we are equally proud of our

commitment to provide you quality benefit options. Insurance plans and options

can be confusing and complicated. We devote considerable time to carefully review

the coverages and plans available, and selected the plans we feel provide the best

coverage for our team members.

Our benefit package includes a quality medical, dental, vision and group life

insurance plan, along with retirement plan options that is an asset to you and your

family.

We pledge to continually review and update our benefits package so that it

provides the services you need to enhance the quality of your life.

Thank you for all you do!

Brett Antczak, MHA CMPE

O: 719-486-7161 C: 970-216-7153

[email protected]


WHO IS ELIGIBLE?

If you are a full-time or part-time employee at St. Vincent Health you are eligible

to enroll in the benefits described in this guide.

If you are enrolling as a new employee, benefit coverage will be effective on the

first day of the month following, or coinciding with 30 days of employment. You

may choose to enroll your eligible dependents in many of our benefits. Eligible

dependents include your spouse and dependent children. See coverage for

dependent age.

HOW TO ENROLL

The first step is to make your benefit elections. Once you have made your

elections, you will not be able to change them until the next open enrollment

period unless you have a qualified change in status. The benefits you elect will be

effective through December 31st of the year you are hired.

OPEN ENROLLMENT

Our plan year runs January 1st through December 31st. With each new plan year you

have an opportunity to make certain changes in your benefits. This is referred to as

Open Enrollment. The effective date of changes made during Open Enrollment is

January 1st. The elections you make during Open Enrollment and as a New

Employee will remain for the entire plan year unless you have a qualified status

change event.

MAKING CHANGES

Unless you have a qualified change in status, you cannot make changes to the

benefits you elect until the next open enrollment period. Qualified changes in

status include: marriage, divorce, legal separation, birth or adoption of a child,

change in child’s dependent status, death of spouse, child or other qualified

dependent, change in residence due to an employment transfer for you, your

spouse, commencement or termination of adoption proceedings, or change in

spouse’s benefits or employment status.


Medical Insurance

Cigna Health Insurance

Benefits In-Network Out-of-Network

Deductible: Plan Year (January 1 through December 31)

Individual - $1,500

Family Max - $3,000

Individual - $1,500

Family Max - $3,000

Co-Insurance (Cigna/You) 80% / 20% 50% / 50%

Co-Insurance Maximum Individual - $4,000

Family Max - $8,000

Individual - $8,500

Family Max - $17,000

Medical Out-of-Pocket

Maximum Per Plan Year

Individual - $5,500


Individual - $10,000


Physician Services: In-Network Out-of-NetworkPrimary Care Physician (PCP) $25 Co-Pay/visit 50% Co-Insurance

Specialist Office Visit $50 Co-Pay/visit 50% Co-Insurance

Preventive Care / Screening/

Immunization

No charge/visit

No charge/immunizationDeductible does not apply

50% Co-Insurance/visit


Diagnostic Test

(x-ray, blood work)

No charge/visitDeductible does not apply

50% Co-Insurance

Imaging

(CT/PET, MRI)20% Co-Insurance 50% Co-Insurance

Chiropractic Service 20 Visit Maximum Not covered

Emergency Room 20% Co-Insurance 20% Co-Insurance

Urgent Care $25 Co-Pay/visitDeductible does not apply

50% Co-Insurance

Facility Services:Inpatient/Outpatient Services 20% Co-Insurance 50% Co-Insurance

Pregnancy/Childbirth Services 20% Co-Insurance 50% Co-Insurance

Prescription Drugs:Generic (Tier 1) $15 Co-pay/prescription Not covered

Preferred (Tier 2) $35 Co-Pay/prescription Not covered

Non-preferred (Tier 3) $70 Co-Pay/prescription Not covered

CIGNA HEALTH INSURANCE

LOW DEDUCTIBLE PLAN

Covered Services: All costs are

after your deductible has been met.Amounts You Pay Amounts You Pay


Medical Insurance

Cigna Health Insurance

Benefits In-Network Out-of-Network

Deductible: Plan Year (January 1 through December 31)

Individual - $3,500

Family Max - $7,000

Individual - $5,000


Co-Insurance (Cigna/You) 80% / 20% 50% / 50%

Co-Insurance Maximum Individual - $1,500

Family Max - $3,000

Individual - $5,000


Medical Out-of-Pocket

Maximum Per Plan Year

Individual - $5,000


Individual - $10,000


Physician Services: In-Network Out-of-NetworkPrimary Care Physician (PCP) 20% Co-Insurance/visit 50% Co-Insurance/visit

Specialist Office Visit 20% Co-Insurance/visit 50% Co-Insurance/visit

Preventive Care / Screening/

Immunization

No charge/visit

No charge/immunizationDeductible does not apply



Diagnostic Test

(x-ray, blood work)20% Co-Insurance 50% Co-Insurance

Imaging

(CT/PET, MRI)20% Co-Insurance

50% Co-Insurance + $750

penalty

Chiropractic Service 12 Visit Maximum Not covered

Emergency Room 20% Co-Insurance 50% Co-Insurance

Urgent Care 20% Co-Insurance 50% Co-Insurance

Facility Services:Inpatient/Outpatient Services 20% Co-Insurance 50% Co-Insurance

Pregnancy/Childbirth Services 20% Co-Insurance 50% Co-Insurance

Prescription Drugs:Generic (Tier 1) $10 Co-pay/prescription Not covered

Preferred (Tier 2) $30 Co-pay/prescription Not covered

Non-preferred (Tier 3) $60 Co-pay/prescription Not covered

Covered Services: All costs are

after your deductible has been met.Amounts You Pay Amounts You Pay

CIGNA HEALTH INSURANCE

HIGH DEDUCTIBLE PLAN


MYCIGNA ONLINE

Create your myCigna Online Account at: https://my.cigna.com/

Creating your myCigna online account gives you access to these features:

Find Care and Costs - Search for in-network providers, procedures, cost

estimates, and more.

View Claims - See a list of your most recent claims, their status, and

reimbursements.

Manage Spending Accounts - Review your spending account balances,

contributions, and withdrawals, all in one place.

Update Your Profile - Make sure your contact information is up-to-date so

you don’t miss out on important notifications about your plan.

MYCIGNA MOBILE APP

Download the myCigna® App. The myCigna® app makes it easier than ever to stay

in-network—and save. Download the app today!

.*


HEALTH SAVINGS ACCOUNT

WHAT IS A HEALTH SAVINGS ACCOUNT?

A Health Savings Account (HSA) is a member-owned account that let you save pre-

tax dollars for future qualified medical expenses. You can invest HSAs—and funds

never expire. An HSA is like a retirement account for medical related expenses.

Investing in your HAS can be an important part of your total retirement portfolio.

AM I ELIGIBLE FOR A HEALTH SAVINGS ACCOUNT?

HSAs are available only to those with a High-Deductible Health Plan.

HSA CONTRIBUTION LIMITS

Tax year Individual coverage limit Family coverage limit

2020 $3,550 $7,100

2021 $3,600 $7,200

At age 55, members can contribute an additional $1,000 beyond IRS limits.

HealthEquity provides access to three (3) types of investment options to suit your

individual risk tolerance and financial goals:

Cash Account: HealthEquity’s standard, low interest, cash account. This is

the default option when opening an HSA.

Yield Plus: Allows members to increase their earning potential with minimal

risk. Interest rates vary based on your HAS balance, but are higher than our

federally-insured interest rates. Funds invested in Yield Plus are not

federally-insured, but remain liquid in your HAS for spending or investing as

desired.

Mutual Funds: HealthEquity provides access to a selected line of investments

to allow members to choose a strategy best fitting their needs.

For more information, and to learn more about HealthEquity, visit

www.HealthEquity.com, or call 866-346-5800 to speak with an advisor.

http://www.healthequity.com/


Dental Insurance

Benefits

Deductible: Plan Year (January 1 through December Max Benefit Per Year

Orthodontic Maximum

Provider Network:

Delta Dental

PPO™

Provider

Delta Dental

Premier®

Provider

*Non-

Participating

Provider

Diagnostic & Preventative

Oral Exams and Cleanings

X-Rays

SealantsFluoride Treatments

Basic Services

Basic Restorative (Fillings)

Oral Surgery

Endodontics

(Root Canal Therapy)Periodontics

(Gum Disease Treatment)

Major Services

Prosthodontics

(Dentures, Bridges)

Special Restorative Crowns,

Implants, and Onlays

Covered Services:

All costs are after your deductible

has been met.

Amounts You Pay Amounts You Pay Amounts You Pay

DELTA DENTAL

PPO PLUS PREMIER PLAN

Individual - $50 / Family Max - $150

$2,000 per person

Not Covered

50% 50% 50%

20% 20% 20%

0% 0% 0%


DELTA DENTAL MEMBER ACCOUNT

Create your Delta Dental Member Account at https://www.deltadental.com/

The benefits of creating an account are:

View plan information

Download forms

View claims

Track dental activity

Find a Dentist

DELTA DENTAL MOBILE APP

Access your insurance and the tools to help you use it anytime, anywhere with

the Delta Dental mobile app. App features may vary by geographic area and

individual dentist participation.


Network

Plan Year

Covered DESCRIPTION CO-PAY FREQUENCY ALLOWED

Vision Exam Well vision exam. $10 Every Calendar Year

Prescription Glasses $10 See Frames and Lenses

Frames · $130 allowance

· $150 allowed for featured brands

· 20% savings over your allowance

· $70 allowance for Walmart®

/Sam's Club®/Costco® frames

IncludedEvery Other

Calendar Year

Lenses · Single vision, lined bifocal, and

lined trifocal lenses

· Impact-resistant lenses for

dependent children

Included Every Calendar Year

Standard progressive lenses $0

Premium progressive lenses $95-$105

Custom progressive lenses $150-$175

Avg. savings of 30% on other lens

enhancements

(

Contact Lenses

(Instead of Glasses)

· $130 allowance for contacts;

copay does not apply

· Contact lens exam

(fitting and evaluation)

Up to $60 Every Calendar Year

Primary Eyecare™ · Retinal screening for members with

diabetes

· Additional exams and services for

members with diabetes, $20 per exam

glaucoma, or age-related macular

degeneration.

· Treatment and diagnoses of eye

conditions, including pink eye, vision

loss, and cataracts available for all

members.

· Limitations and coordination with your

medical coverage may apply. Ask your

VSP doctor for details.

Up to $20

per examAs needed

Laser Vision

Correction

· Average 15% off the regular price

or 5% off the promotional price;

discounts only available from

contracted facilities.

As needed

VSP CHOICE

Lens Enhancements

Every Calendar Year

VSP Vision Insurance

January 1 through December 31


VSP CHOICE MEMBER ACCOUNT

Create your VSP Choice Member Account at https://www.vsp.com/

The benefits of creating an account are:

View plan information

Download forms

View claims

Track activity

Find a Vision Provider


HARTFORD LIFE INSURANCE

St. Vincent Health provides Life Insurance coverage at no cost to

the Employee, in an amount equal to 1x annualized pay.

AFLAC SUPPLEMENTAL INSURANCE

St. Vincent Health provides Employees the opportunity to

voluntarily purchase supplemental Accident, Short-Term

Disability, Hospitalization, Cancer, and/or Critical Illness

Insurance through AFLAC.

403(b) DEFINED CONTRIBUTION RETIREMENT PLAN

St. Vincent Health provides a 403(b) Defined Contribution

Retirement Plan.

The Plan is administered by OneAmerica, a national leader in

insurance and financial services.

Beginning July 1, 2021, St. Vincent Health will match 50% of Employees’

contributions up to 7% of eligible pay.

TUITION REIMBURSEMENT PROGRAM

St. Vincent Health values professional development, and

hopes to ease the burden of higher education.

Beginning July 1, 2021, SVH is offering a job related tuition

reimbursement program. SVH will reimburse employees up

to $2,500 annually for tuition and costs for satisfactorily completed coursework

approved through this program.


MONTHLY RATES/DEDUCTIONS

SVH HSA CONTRIBUTION

EE Only $72.35 EE Only $64.88 $84.63

EE + Spouse $185.02 EE + Spouse $165.93 $152.75

EE + Child(ren) $168.72 EE + Child(ren) $151.30 $139.84

EE + Family $253.22 EE + Family $227.90 $209.05

EE Only $1.87 EE Only $0.38

EE + Spouse $5.12 EE + Spouse $1.05

EE + Child(ren) $5.79 EE + Child(ren) $1.10

EE + Family $12.04 EE + Family $2.51

SVH HSA CONTRIBUTION

EE Only $96.47 EE Only $86.51 $79.66

EE + Spouse $323.79 EE + Spouse $290.37 $124.11

EE + Child(ren) $295.26 EE + Child(ren) $264.78 $113.22

EE + Family $443.14 EE + Family $397.41 $169.85

EE Only $3.12 EE Only $0.59

EE + Spouse $14.05 EE + Spouse $1.99

EE + Child(ren) $15.73 EE + Child(ren) $2.07

EE + Family $31.35 EE + Family $4.41

HARTFORD BASIC LIFE INSURANCE

Paid by St. Vincent Health - No Cost to the Employee

403(b) RETIREMENT PLAN WITH UP TO 7% MATCH

Defined Contribution 403(b) Retirement Plan with SVH Matching 50% of Employees'

Contributions up to 7% of eligible pay.

AFLAC SUPPLEMENTAL INSURANCE

Employee Paid, Voluntary Supplemental Insurance

PART-TIME EMPLOYEES PART-TIME EMPLOYEES

DELTA DENTAL INSURANCE VSP VISION INSURANCE

FULL-TIME EMPLOYEES

VSP VISION INSURANCE

PART-TIME EMPLOYEES PART-TIME EMPLOYEES

MEDICAL CIGNA LOW DEDUCTIBLE MEDICAL CIGNA HIGH DEDUCTIBLE

FULL-TIME EMPLOYEES

DELTA DENTAL INSURANCE

MEDICAL CIGNA LOW DEDUCTIBLE MEDICAL CIGNA HIGH DEDUCTIBLE

FULL-TIME EMPLOYEES FULL-TIME EMPLOYEES


LEGAL NOTICES SPECIAL ENROLLMENT NOTICE This notice is being provided to make certain that you understand your right to apply for group health coverage. You should read this notice even if you plan to waive health coverage at this time.

Loss of Other Coverage If you are declining coverage for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this Plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contribut ing toward the other coverage). Example: You waived coverage under this Plan because you were covered under a plan offered by your spouse's employer. Your spouse terminates employment. If you notify your employer within 30 days of the date coverage ends, you and your eligible dependents may apply for coverage under this Plan.

Marriage, Birth or Adoption If you have a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, or placement for adoption. Example: When you were hired, you were single and chose not to elect health insurance benefits. One year later, you marry. You and your eligible dependents are entitled to enroll in this Plan. However, you must apply within 30 days from the date of your marriage.

Medicaid or CHIP If you or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or become eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must request enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistance subsidy. Example: When you were hired, your children received health coverage under CHIP and you did not enroll them in this Plan. Because of changes in your income, your children are no longer eligible for CHIP coverage. You may enroll them in this Plan if you apply within 60 days of the date of their loss of CHIP coverage.

For More Information or Assistance To request special enrollment or obtain more information, please contact your Plan Administrator.

HIPAA PRIVACY NOTICE: Protecting your health information privacy rights The Plan’s policies protecting your privacy rights and your rights under the law are described in the plan’s Notice of Privacy Practices. Please contact Human Resources to request a copy of the Notice.

Women’s Health and Cancer Rights Act of 1998 (WHCRA) If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

All stages of reconstruction of the breast on which the mastectomy was performed;

Surgery and reconstruction of the other breast to produce a symmetrical appearance;

Prostheses; and

Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more information on WHCRA benefits, call your Plan Administrator.

Important Notice from St. Vincent Health About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with St. Vincent Health and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join

a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.


2. St. Vincent Health has determined that the prescription drug coverage offered is, on average for all plan participants, expected to payout as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current coverage may be affected. Please refer to the Prescription coverage summary within this booklet or the policy for additional details. If you do decide to join a Medicare drug plan and drop your current medical coverage, be aware that you and your dependents may not be able to get this coverage back.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with St. Vincent Health and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and whether or not you are required to pay a higher premium (a penalty).

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’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 www.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 1-877-KIDS NOW or www.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 www.askebsa.dol.gov or call 1-866-444-EBSA (3272). You may be eligible for assistance with paying your employer health plan premiums. Contact your State for more information on eligibility: Health First Colorado, https://www.healthfirstcolorado.com/get-help/, Email: [email protected], Call: 1-800-250-7741 Monday-Friday, 7:30 a.m. to 5:15 p.m.

To see if there is Premium Assistance in any other states or for more information on special enrollment rights, you can contact either: U.S. Department of Labor U.S. Employee Benefits Security Administration www.dol.gov/ebsa 1-866-444-EBSA (3272)

Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Ext. 61565

http://www.medicare.gov/

https://www.healthfirstcolorado.com/get-help/

mailto:[email protected]

http://www.cms.hhs.gov/


IMPORTANT CONTACT INFORMATION

This Guide is only intended to offer an outline of benefits. All details and contract obligations of plans are stated in the group contract insurance documents, including any disclosures (whether regarding “grandfathering” of plans or others) required by the new health reform law, the Patient Protection and Affordable Care Act (PPACA). In the event of conflict between this guide and the group contract insurance documents, the group contract insurance documents will prevail. Please contact your Human Resources Department for further information.

Cigna Health 1 (800) 997-1654

www.my.cigna.com

HSA Plan Administrator

Health Equity

1 (866) 346-5800

www.healthequity.com

Delta Dental of Colorado 1 (800) 610-0201

www.deltadentalco.com

VSP Vision 1 (800) 877-7195

www.vsp.com

403(b) Plan Administrator

One America

1 (800) 249-6269

www.oneamerica.com

Hartford Insurance See Human Resources

AFLAC Insurance See Human Resources

Human Resources Pete Reid

719-486-7162

[email protected]

Documents

St. Vincent Health 2021 Benefits Guide 1