2017 Benefits Decision Guide - ProHealth Care Benefits Decision Guide. 2 ... Upon hire (minimum age...

2017 Benefits Decision Guide

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Table of Contents

Benefit Eligibility & Enrollment ................................................................................................................................................................ 5

Your Medical Plans at a Glance ................................................................................................................................................................. 7

Medical Plan Rates ……...………………………...……………………………………………….…………………………………..…11

Medical Outline of Benefits ……………………………………………………………………………………………………………...12

Provider Network-WIDS ......................................................................................................................................................................... 16

H.S.A. ..................................................................................................................................................................................................... 17

Flexible Spending Accounts .................................................................................................................................................................... 18

Dental ...................................................................................................................................................................................................... 22

Vision ...................................................................................................................................................................................................... 25

Life and Accidental Death and Dismemberment (AD&D) Insurance ..................................................................................................... 27

Voluntary Life and Voluntary AD&D Insurance .................................................................................................................................... 28

Short Term Disability (STD) .................................................................................................................................................................. 30

Long Term Disability (LTD) ................................................................................................................................................................... 31

Educators Credit Union............................................................................................................................................................................ 31

Critical Illness and Accident Insurance, Prepaid Legal and Identity Theft .............................................................................................. 32

401(k) ...................................................................................................................................................................................................... 33

Insurance Directory/Benefit Resources .................................................................................................................................................... 35

Paid Time Off (PTO) .............................................................................................................................................................................. 36

ProShare................................................................................................................................................................................................... 38

MetLife Personal Property/Liability Insurance ........................................................................................................................................ 40

Appendix

Health Care Reform and Your ProHealth Care Benefits .......................................................................................................................... 42

Notice of Privacy Practice ....................................................................................................................................................................... 45

Wellness Program Disclosure .................................................................................................................................................................. 52

Newborns’ and Mothers’ Health Protection Act of 1996 ......................................................................................................................... 54

Women’s Health and Cancer Rights Act of 1988 .................................................................................................................................... 54

Summary of Benefits and Coverage (SBC) ............................................................................................................................................. 54

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) ................................................................ 55

Your Prescription Drug Coverage and Medicare .................................................................................................................................... 58

Employee Rights and Responsibilities Under the Family Medical Leave Act……...……………………………………………………60

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Benefit Eligibility

Benefit

Full-Time (36 hours or

more/week or 72 hours or

more per pay period)

Regular Part-Time

(20 -35 hours/week or

40-71 hours/pay

period)

Part-Time (Less than 20 hours/week) And Pool

Enrollment Effective

Date

Medical Plan - You may elect to enroll within 31 days of

your date of hire. X X A

Dental Plan - You may elect to enroll within 31 days of

your date hire. X X A

Vision Plan - You may elect to enroll within 31 days of

your date hire. X X A

Health Savings Account – You must be enrolled in

a high deductible health plan. You may enroll or change your elections at any time.

X X A

Flexible Spending Accounts - You may elect to

enroll within 31 days of your date of hire. X X A

Life and AD&D (Accidental Death and Dismemberment) Insurance - Company Provided – You will be automatically enrolled.

X X B

Life Insurance – Voluntary – You may elect to

enroll within 31 days of your date of hire. X X B

Short -Term Disability - You will be automatically

enrolled. X X B

Long -Term Disability – Company Provided - You will be automatically enrolled.

X X B

Long – Term Disability – Voluntary - You may

elect to enroll within 31 days of your date of hire. X X B

401(k) X X X C

401(k) - Employer Match X X C

Paid Time Off (PTO) X X C

Enrollment Effective Dates

A - First of the month following hire date B - First of the month following 90 days of employment C - Upon hire (minimum age 18 for 401(k) Plan)

ProHealth Care is pleased to offer a comprehensive suite of health and welfare benefits to our employees, described in this booklet. Please review this material carefully so that you can make an informed decision and select the benefits that best suit you and your family.

Eligible Dependents

You must enroll in benefits in order to enroll your eligible dependents. If you enroll your dependents, they may only be enrolled in the same coverage you have for yourself.

Determine your dependents eligibility and required documents before enrolling by reviewing the criteria below.

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Your eligible dependents include:

Provided they meet the requirements above, eligible dependent children (regardless of where they reside) include:

Your natural children,

Your adopted children or children placed with you for adoption,

Your stepchildren and/or

Children for whom you are the legal guardian.

Dependent children also may be covered under the Medical Plan if they are required to be covered under a Qualified Medical Child Support Order as an “Alternate Recipient”. You are responsible for determining the tax dependent status of dependents when you add them to your health insurance coverage. Consult IRS Publication 501 and IRS Notice 2010-38 for tax dependent guidelines and tests, or speak with a tax advisor.

Spousal Surcharge

You may choose to cover your spouse under the ProHealth Care Medical Plan; however, you will

pay a surcharge if your spouse is eligible for coverage through his or her employer, regardless of

whether or not that medical coverage was elected. If your spouse is not eligible for medical

coverage through his or her employer, not working, or works for ProHealth Care, then you are

eligible for a waiver of the spousal surcharge. The spousal waiver form is available electronically on

the Human Resources page, as well as on Employee Self-Service.

The biweekly spousal surcharge is $75 after tax. ProHealth will randomly audit employees who

have elected to waive the spousal surcharge.

Enrolling in Your Benefits

You may enroll in benefits in one of four coverage categories:

Single

Employee + Child(ren)

Employee + Spouse

Family

Note: You do not need to enroll in the same coverage level for each benefit. For example, you may enroll in medical with family coverage, but enroll in dental with single coverage.

Your eligible dependents include: Benefit Plan

Health Dental Vision

Legally married spouse

Unmarried children who are not on active military duty and younger than 19

Physically or mentally disabled and dependent on you

Full-time students (as defined by the college or university ) between the ages of 19 and 25 and not married

Adult children between the ages of 19 and 26 and are not fulltime students or on active military duty

http://www.irs.gov/pub/irs-pdf/p501.pdf

http://www.irs.gov/pub/irs-drop/n-10-38.pdf

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When You Can Change Your Coverage

Open enrollment —typically held in November is your opportunity to select or make changes to your benefit coverage. You may make changes other times during the year if you experience a qualifying event, such as marriage, birth, loss of other coverage, etc.

If you experience a qualifying event, contact Human Resources within 31 days of the change. You will need to provide the following information with supporting documentation on the appropriate form:

The type of status change, divorce, marriage, birth/adoption, spouse loss of coverage

The date the change occurred

The new or changed benefit coverage requested

If you do not contact Human Resources within 31 days of the qualifying status change, you will not be able to make any changes to your benefit elections until the next annual open enrollment period (unless you experience another qualifying status change).

Your Medical Plans at a Glance

ProHealth Care offers two medical plan options, both of which emphasize wellness, prevention and wise health care spending.

The two medical plan options are:

ProHealth PPO Plan This plan operates like a traditional PPO.

ProHealth High-Deductible Plan Under this option ProHealth Care will contribute the

incentive amounts to a Health Savings Account (HSA). You may make before-tax personal

contributions to the Health Savings Account, up to a maximum set annually by the Internal

Revenue Service. At the end of the year, any unused amounts in your Health Savings

Account are rolled over and added to your account for the following year.

The two options are alike in many ways

Both operate like traditional PPO plans, enabling you to seek care from any licensed health care provider, in-network or out-of-network.

Both pay 100% of the cost of preventive care services at in-network providers, and 90% of the cost of most other Tier 1 health care services after you meet your deductible.

For more details, see “Medical Outline of Benefits” beginning on page 12.

Paying for Medical Services The amount you pay for medical services will depend on whether you see an in-network or out-of-network provider. Claims will be submitted on your behalf to the plan administrator if you see an in-network provider. In most cases, out-of-network providers will submit your claims directly to the plan administrator. If your provider will not file for you, submit a claim form and documentation of services to Aetna at the address on the claim form (claim forms can be found at www.aetna.com).

http://www.aetna.com/

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Out of Area Coverage Dependents who live outside of the coverage area will receive Tier 1 coverage when obtaining care from one of Aetna’s providers under the Aetna Open Choice PPO. For more information, contact Human Resources at 262-928-4185. To locate an Aetna in-network national provider:

1. Go to the Aetna website www.aetna.com 2. Click on “Find a Doctor” link at the top of the screen. 3. Click under what type of plan are you considering.

A plan offered by my employer 4. Input the name of the provider or click on the type of provider needed. 5. Select a Plan: Open Choice® PPO 6. If you have any questions or need assistance please contact Aetna customer service at 1-

800-414-08766.

The following eight counties are NOT eligible for Out of Network consideration using Aetna’s providers: Dodge, Jefferson, Milwaukee, Ozaukee, Racine, Walworth, Washington, and Waukesha.

Emergency Care If you have an emergency condition, go to the nearest emergency room immediately. Emergency care is covered even out-of-network, although at a different coinsurance amount. In emergent situations, emergency care is covered at the in-network benefit level even though it may be out-of-network.

Additional Resources Aetna, the plan administrator of the Medical Plan, offers a variety of tools and resources to help you:

Make more informed decisions about your care,

Communicate better with your doctors and

Save time and money by showing you how to get the right care at the right time.

Aetna’s Informed Health Line makes it possible to talk directly to a registered nurse anytime, 24 hours a day, seven days a week. When you call the Informed Health Line at 1-800-556-1555, you also can listen to the Audio Health Library, which explains thousands of health conditions. Aetna’s secure Aetna Navigator member Web site at www.aetna.com gives you access to the Healthwise Knowledgebase, where you can find out more about a health condition you have or medications you take. It explains things in terms that are easy to understand.

Coordination of Benefits If you or your dependents are covered under the ProHealth Care medical and/or dental plan and another group plan, the two plans may coordinate benefits. Special rules determine which plan will pay benefits first. Generally speaking, you will not benefit from coverage under more than one plan, so think carefully about whether it is cost effective for you to participate in both plans.

Under coordination of benefits rules, the combined benefit from both of your plans will not exceed the benefit you would have received from each medical plan individually. The other plan will be the primary payer if any of the following conditions are present:



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If the other medical plan is primary, the ProHealth Care plan will pay benefits only up to the amount you would have received if it were the only plan. Other rules determine which plan pays first if your children are covered under both the ProHealth Care plan and a spouse’s medical plan.

Note: You should always check plan documents for coordination of benefit rules.

Prescription Drug Benefit Both medical plan options include prescription drug coverage. Your share of the prescription cost will depend on the type of medication you purchase and whether you purchase the drug through an in-network retail pharmacy or through the mail order program. Drugs are assigned to one of three tiers; each tier represents a group or category of drugs and has its own co-pays or coinsurance amount as shown in the benefit outline on page 15. The drug formulary, is a listing of the drugs in each tier, it is available at www.Aetna.com, select Individuals & Families, then Aetna Pharmacy > Preferred Drug List > Three Tier Open Aetna Value Plus. All prescriptions will be filled as generic unless your physician specifies “Dispense as Written” or “DAW” on each prescription. If your physician does not specify “Dispense as Written” and you elect the non-generic drug, you will pay your share of the cost plus the difference in price between the drug chosen and the generic drug.

Specialty Medications The ProHealth Care pharmacy benefit plan includes coverage for what are considered Specialty Medications. Specialty drugs treat complex, chronic diseases and because of the complex therapy needed, a pharmacist or nurse should check in with you often during your treatment. These drugs may include self-injectable, infused or select oral medications that may require refrigeration and may not be available at retail pharmacies. You may obtain one fill of the medication through a retail pharmacy if available. But ongoing refills will need to be obtained from a participating specialty pharmacy, like Aetna Specialty Pharmacy or from the onsite pharmacies at the ProHealth Care facilities. To learn which drugs are considered Specialty drugs, visit www.AetnaSpecialityCareRx.com

The Mail Order Advantage If you or a family member take preventive medications for a long-term or chronic condition (such as diabetes, coronary artery disease or arthritis), you can save time and money by obtaining those medications through the mail order service. You save time by not having to refill your prescription every month and by having your prescription mailed to your home. You also save money by obtaining a three-month supply of your medication by mail order for the cost of two co-pays.

Definitions

After-tax: Payroll deductions taken after federal, state, and Social Security taxes are taken out.

Premiums for voluntary life insurance, voluntary accidental death and dismemberment (AD&D) insurance, and voluntary long term disability insurance are paid with after-tax dollars.

Annual out-of-pocket maximum: A dollar limit on the amount you have to pay for services in

any calendar year. The two Medical Plan options pay 100% of charges for covered services after the annual out-of-pocket maximum is met.

http://www.aetnaspecialitycarerx.com/

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Before-tax: Payroll deductions taken before federal, state, and Social Security (FICA) taxes are

taken out. Before-tax deductions reduce your taxable income, therefore reducing your current tax liability. Employee costs for medical, dental and vision plan are paid with before-tax dollars, as are contributions to a medical or dependent care flexible spending account (FSA).

Coinsurance: A percentage of the cost of covered services that you must pay after the deductible

is met. The two medical plan options pay 90% of charges for most medical services received in Tier 1 after the deductible is met. You pay 10% of the charges (your coinsurance).

Copay: A flat dollar amount you pay at the time services are received. Under the medical plans, for example, a specialist office visit under the ProHealth PPO plan requires $35 copay.

Deductible: The amount of money you pay for certain covered services in a calendar year before

the plan pays.

Reasonable and customary: A fee is generally considered to be reasonable and customary

(R&C) if it is consistent with the average or commonly charged fee for a particular service within a specific geographic area. You are responsible for any out-of-network fees above R&C levels.

Spousal Surcharge: An additional fee charged for spouses enrolled on the ProHealth Care

medical plan who are eligible for another employer’s health plan.

Summary of Benefits and Coverage (SBC): The Affordable Care Act (ACA) requires health

plans and health issuers to provide applicants and enrollees with a concise document providing simple and consistent information about the health plan benefits and coverage. This document is called a summary of benefits and coverage (SBC).

Employee Health & Wellness Clinics When you have a health care need, remember that ProHealth Care offers immediate care services for employees and their dependents age six and older at the employee health & wellness clinics. Clinics are open from 8 a.m. to 4:30 p.m. and are located at ProHealth Care’s existing occupational health and employee health locations: Waukesha Memorial Hospital, Mukwonago, Oconomowoc Physician Center, Watertown, and New Berlin. The clinics can be used for the following services:

Upper respiratory and ear infections Cuts, scrapes, and lacerations Sore throat Persistent cough Viral symptoms Pink eye

Bladder infections Minor stomach ailments Sprains and strains Minor rashes Other conditions that typically would be

seen in urgent care Employees using this service will be seen by a nurse practitioner or physician assistant. Providers will diagnose, treat and manage medical conditions that require timely care, but are not serious enough to warrant an emergency department visit. Walk-in visits are accepted, though appointments are preferred (call Employee Health at 262-928-5900 for an appointment). A $10 copay per visit can be paid by cash, check, or credit card. Bring your Aetna medical insurance card to your visit (medical insurance is only billed for services outside of your office visit, such as lab and radiology).

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Health Risk Assessment Rate Guidelines

To be eligible for a discount on your medical premiums, you (and your spouse if enrolling in coverage) must be nicotine-free. Health Risk Assessment (HRA) at no cost to all employees who are enrolled or plan to enroll in the ProHealth Care-Aetna medical plans. By examining your health-related behavior and health history, an HRA can help you take control of your health, identify and prevent potential health risks, and begin living a life of enhanced wellness. The HRA includes a biometric screening (height, weight, blood pressure, fasting lipid profile and glucose and nicotine test) and a short health survey. In addition to the obvious health benefits, you (and your spouse, where applicable), may be eligible for an annual discount on your health insurance premiums if you participate in the HRA and meet the necessary criteria (nicotine-free). Employees and their spouses who enroll in the health plan may choose not to participate in the HRA; however, they will not be eligible for the insurance premium reduction. You must fast and not use nicotine to participate: options do not exist. If you participate in the HRA, your spouse must participate at the same level in order to receive the premium discount. The premiums you will see during the online enrollment process reflect the non-discounted rate. By being nicotine-free and completing the online assessment as well as fasting lipid profile and glucose test, you may be eligible for an annual discount which will be reflected in your health insurance premiums. See the i-Net or Employee Self Service (ESS) for more information.

2017 Biweekly Medical Premium Rates

FULL-TIME EMPLOYEE

PROHEALTH PPO PROHEALTH HIGH-DEDUCTIBLE PLAN

Non Discounted

Rate Discounted Rate Non Discounted

Rate Discounted Rate

Single $112.50 $80.75 $67.10 $35.35

Employee + Child(ren) $173.00 $141.35 $93.60 $61.85

Employee + Spouse* $229.45* $166.00* $136.10* $72.65*

Employee + Family* $286.20* $222.80* $160.85* $97.45*

Regular Part Time Employee

PROHEALTH PPO PROHEALTH HIGH-DEDUCTIBLE PLAN

Non Discounted Rate Discounted Rate

Non Discounted Rate Discounted Rate

Single $170.30 $138.55 $92.35 $60.65

Employee + Child(ren) $274.25 $242.60 $137.80 $106.15

Employee + Spouse* $348.30* $284.80* $188.05* $124.60*

Employee + Family* $445.75* $382.25* $230.65* $167.20* *PLEASE NOTE: If your spouse is eligible for another employer’s medical plan and you insure him or her under the ProHealth Care plan, you will pay an after-tax surcharge of $75 biweekly. Benefit deductions will be taken the first two pay dates of the month. Months with three pay periods will not have deductions on the third pay date. It is your responsibility to review the benefit deductions on your paycheck stub for accuracy and report any issues to Human Resources for resolution.

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Medical Outline of Benefits January 1, 2017

ProHealth Care PPO ProHealth Care High Deductible

Provision/Benefit Tier 1 Tier 2 Tier 3 Tier 1 Tier 2 Tier 3

Network

* PHC - ProHealth Care

CHW – Children’s Hospital of Wisconsin WIDS – Waukesha Integrated Delivery System

MCW – Medical College of Wisconsin (Note: This does not

include Froedtert Community Physicians)

ProHealth and CHW facilities

PHC affiliated and UW

physicians and

facilities*

Non-PHC WIDS Network

facilities and MCW*

Out of Network Froedtert and

Community Memorial hosptials

PHC and CHW facilities

PHC affiliated and UW

physicians and

facilities*

Non-PHC WIDS Network

facilities and MCW*

Out of Network Froedtert and

Community Memorial hospitals

Annual Deductible Amount

$600 single

$1,200 family

$1,200 single

$2,400 family

$1,600 single

$3,200 family

$1,500 single

$3,000 family

$2,000 single

$4,000 family

$2,500 single

$5,000 family

Deductibles do not cross accumulate between Tiers.

Deductibles do not cross accumulate between Tiers.

If an individual family member meets the single deductible, that family member will then move to co-

insurance. The family deductible (which includes the individual deductible) then needs to be reached before

other family members move to co-insurance.

The full family deductible must be met before anyone moves into co-insurance.

Annual Out-of-Pocket Limit

(Includes deductible and medical copays)

$2,400 single

$4,800 family

$4,800 single

$9,600 family

$6,000 single

$12,000 family

$4,500 single

$9,000 family

$5,000 single

$10,000 family

$5,500 single

$11,000 family

Annual out of pocket maximums do not cross

accumulate between Tiers. This means the amounts you pay toward your deductible and

out-of-pocket maximum for services in one network tier will no longer apply toward the

deductible and out-of-pocket maximums in the

other tiers.

Annual out of pocket maximum cross accumulate

between Tiers.

If any covered family member meets the individual out-of-pocket maximum based on the tier, that family

member will be covered at 100% for the remainder of

the year. The family out-of-pocket maximum (which includes the individual out-of-pocket maximum) then

needs to be reached before other family members are covered at 100%.

If any covered family member meets the mandated ACA individual out-of-pocket maximum $6,850, that

family member will be covered at 100% for the

remainder of the year. The family out-of-pocket maximum (which includes the individual out-of-pocket

maximum) then needs to be reached before other family members are covered at 100%.

Pre-existing Conditions Waived Waived

Professional Services

Physician (other than Specialist) office visits

(office visit charge only)

Does not include chiropractic services

$25 copay then

100% of charges

60% after

deductible

50% after

deductible

90% after

deductible

60% after

deductible

50% after

deductible

Specialist office visits

(office visit charge only)

$35 copay, then 100% of

charges

60% after deductible





Urgent Care

(exam charge only)

$25 copay, then

100% of charges

60% after

deductible

50% after

deductible

90% after

deductible

60% after

deductible

50% after

deductible

Inpatient Hospital Physician Visit 100% of charges






Pathologist/Radiologist, other than an Independent Radiologist or Pathologist

(does not include mammograms and pap smears)







Radiology, pathology and anesthesiology services provided and billed by an independent radiologist,

pathologist or anesthesiologist







Covered Oral Surgical Services 90% after

deductible

60% after

deductible

50% after

deductible

90% after

deductible

60% after

deductible

50% after

deductible

Inpatient, Outpatient and Office Surgery/Surgical

Assists/Anesthesia, other than Independent Anesthesiologist (Professional Service Fees)

90% after

deductible

60% after

deductible

50% after

deductible

90% after

deductible

60% after

deductible

50% after

deductible

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Professional Services

Routine Prenatal Visits

(Does not include delivery charges )

100% of charges



100% of charges



Hospital Services - Does not apply to alcoholism, drug use and nervous or mental disorders

Inpatient Hospital Services

Includes x-rays, labs and miscellaneous hospital expenses

90% after

deductible

Preadmission certification required or

confinement will be subject to a penalty of 10% not to exceed

$500

60% after

deductible



$1,000

50% after

deductible



$1,500

90% after

deductible

Preadmission certification required or confinement

will be subject to a penalty of

10% not to exceed $500

60% after

deductible



$1,000

50% after

deductible



10% not to exceed $1,500

Inpatient and Outpatient Radiation, Chemotherapy, Dialysis, Infusion Therapy







Outpatient miscellaneous hospital expenses 90% after deductible






Outpatient radiology and laboratory services 90% after deductible






Emergency room visit - emergency room charge only $150 copay plus Deductible, then 90% of charges (waived if admitted)


Emergency room services provided during an emergency room visit

90% after deductible 90% after deductible

Preventive Services

Routine medical exams, including well baby care

(Exam charge only)

100% of charges

deductible waived



100% of charges

deductible

waived



Preventive Services, including mammograms and

pap smears

100% of charges

deductible waived



100% of charges

deductible

waived



Colonoscopies

(limited to one every five years)

100% of

charges

deductible waived

(If surgery

services

performed,

Outpatient

surgical coverage

applies)

60% after

deductible

50% after

deductible

100% of

charges

deductible

waived

(If surgery

services

performed,

Outpatient

surgical

coverage

applies)

60% after

deductible

50% after

deductible

Immunizations

(excludes travel immunizations)

100% of charges

deductible waived



100% of charges

deductible

waived



Other Covered Health Care Services

Physical, speech, and occupational therapy billed through clinic - (Evaluation or evaluation and therapy)

$35 copay then 100% of

charges






Outpatient physical, speech, and occupational therapy billed through clinic - (Therapy only)

100% of

charges

60% after

deductible

50% after

deductible

90% after

deductible

60% after

deductible

50% after

deductible

Physical, speech, and occupational therapy billed through hospital - (Evaluation or evaluation and therapy)

90% after

deductible

60% after

deductible

50% after

deductible

90% after

deductible

60% after

deductible

50% after

deductible

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Outpatient physical, speech, and occupational therapy billed through hospital - (Therapy only)

100% of charges






Ambulance services 90% after deductible 90% after deductible

Prosthetic devices (other than dental prosthetics) 90% after deductible






Nutritional counseling for morbid obesity and any

other health condition

(Limited to $500 per calendar year)

90% after

deductible

60% after

deductible

50% after

deductible

90% after

deductible

60% after

deductible

50% after

deductible

Durable medical equipment 90% after

deductible

No Coverage No Coverage 90% after

deductible

No Coverage No Coverage

Dental services:

- dental repair of your sound natural teeth due to an injury,

- extraction of teeth to prepare the jaw for radiation treatment; and

- sealants on existing teeth to prepare the jaw for

chemotherapy treatment

90% after

deductible

60% after

deductible

50% after

deductible

90% after

deductible

60% after

deductible

50% after

deductible

Chiropractic Care Office visit charge only

(Limited to 15 visits per calendar year)

$35 copay, then

100% of charges

60% after

deductible

50% after

deductible

90% after

deductible

60% after

deductible

50% after

deductible

Allergy Services

(vials, injections and medical supplies if no office

visit is charged)


charges

Copayment

applies to each

service






Contraceptives (Generic) - Injections, Implants, IUD's and Diaphragms (and related services)

100% of charges






Infertility Services

limited to $2,500 lifetime maximum per participant for surgical

and non-surgical treatments; $2,500 lifetime for prescription

drugs







Home Care

(limited to 40 visits per calendar year)







Home Hospice Care

(unlimited visits)







Skilled nursing services in a licensed skilled nursing facility (limited 120 days per calendar year)







Dialysis treatment of kidney disease 90% after deductible






TMJ treatment - oral surgical services and non-

surgical treatment

90% after

deductible

60% after

deductible

50% after

deductible

90% after

deductible

60% after

deductible

50% after

deductible

Organ transplants

see benefit

book for covered

transplants;

transplant-related services

subject to Plan's benefits for the specific service

60% after

deductible

50% after

deductible see benefit

book for covered

transplants;

transplant-related

services subject to

Plan's benefits

for the specific service

60% after

deductible

50% after

deductible

Note: All diagnosed transplants (bone marrow/stem cell, heart, lung, heart and lung, liver, pancreas, kidney and pancreas) except cornea and kidney must

undergo a pre-transplant evaluation at Mayo clinic, unless travel is medically contraindicated or a $2,000 penalty will be applied. Patients under age 19 are not required to participate in this program.

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Treatment of Alcoholism, Drug use and Nervous or Mental Disorders

Nervous & Mental - Inpatient Hospital 90% after deductible



$500








$1,500




$500




$1,000





Nervous & Mental - Outpatient and Transitional $25 copay

then 100% of

the charges






*Alcoholism & Drug use - Inpatient Hospital 90% after

deductible



$500

60% after

deductible




50% after

deductible



$1,500

90% after

deductible



$500

60% after

deductible



$1,000

50% after

deductible




*Alcoholism & Drug use - Outpatient and Transitional


charges






Prescription Drugs

Prescription Drugs (including insulin, oral

contraceptives and diabetic supplies)

Mandatory Generic for both plans

Mandatory Specialty – One fill at retail, ongoing refills

need to be obtained from Aetna’s Specialty Pharmacy or from the onsite pharmacies at ProHealth Care.

Pharmacy drug guide – Three Tier Open Aetna Value Plus

Prescription copays count towards your out of

pocket maximum.

Retail: 30 day supply

Tier 1 - $15

Tier 2 - 40% up to $50

Tier 3 - 50% up to $75

Specialty Pharmacy: Injectable medications 30 day

supply

Tier 2 injectable drugs - $50 copay

Tier 3 injectable drugs - $100 copay

Mail Order: 90 day supply

Tier 1 - $30

Tier 2 - 40% up to $100

Tier 3 - 50% up to $150

Retail: 30 day supply

Deductible then 10%

$10 copay for certain preventive medications

Specialty Pharmacy: Injectable medications 30 day supply

Deductible then 10%

Mail Order: 90 day supply

Deductible then 10%

$20 copay for certain preventive medications

Every effort has been made to report accurately the coverage, benefits and limitation of the plan.

If there is any difference between this publication and the official plan document, the plan document will govern. ProHealth Care reserves the right to amend, modify or terminate all or part of the plan.

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Provider Network

Find a Participating Provider The ProHealth Care Employee PPO and High Deductible health plans use the Waukesha Integrated Delivery System (WIDS) provider network. Participants in the employee health plan should see participating WIDS providers to receive the preferred, Tier 1 benefit levels.

What is WIDS? The WIDS Network is a partnership among ProHealth Care hospitals and clinics and closely affiliated Waukesha County independent medical groups.

Where Can I Find the Directory? Access the provider directory by going to:

www.WIDSNetwork.com –or- On the iNet Human Resources Tab The Provider Directory lists all of the participants in both Tier 1 and Tier 2 of the network.

The use of Tier 2 and Tier 3 providers and facilities will result in additional out-of-pocket cost to you.

Important to Remember:

Network preferred providers change periodically. The WIDS on-line directory is updated on a weekly basis. Since this directory frequently changes, it is important to verify that the health care provider is in-network prior to receiving services. Otherwise, you will be required to pay a larger portion of the cost of the covered services by an out-of-network provider.

Physicians who have Medical Staff privileges with ProHealth facilities may or may not be participants in the WIDS provider network.

If you have a question about a provider listed on the WIDS website, please contact Cara Boyer at 262-928-4767 or by e-mail at [email protected].

http://www.widsnetwork.com/

mailto:[email protected]

http://www.widsnetwork.com/widsProviderDirectory/widsProviderDirectory/consumer?cmd=GoHome

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HSA

Feature

HSA (ProHealth High-Deductible Plan)

Establishing an Account Elect to enroll in the HSA and enter the amount you wish to contribute to the account.

Contributions Company incentive contributions, plus optional before-tax personal contributions up to an annual maximum set by the IRS. For 2017 you can contribute up to: • $3,400 (individual coverage) or • $6,750 (family coverage) You may contribute an additional $1,000 per year as a “catch-up” contribution if you will be age 55 or older by year-end and are not enrolled in Medicare. (If your spouse will be 55 or older, is not enrolled in Medicare and wishes to make a catch-up contribution, he or she will need to open an individual HSA.) Please note: Employer and employee contributions count towards the annual maximum.

Account Earnings Accumulated amounts in your HSA earn interest, compounded monthly. In addition, once you have $2,000 in your account, you may elect to transfer a portion of your HSA to an investment account.

Can I change my contributions at any time?

Yes. You may contribute by check or electronic funds transfer, and you may stop, change or add to your contributions at any time (subject to the annual maximum).

Tax Liability Company incentive contributions are considered a benefit and are not subject to federal or state tax. Your personal before-tax contributions reduce your current tax liability and are not taxed when withdrawn if used for a qualified medical expense. Interest earned on your account also is not taxed.

Eligibility Benefit eligible employees who are not enrolled in any other coverage other than another high deductible health plan and are not enrolled in Medicare. This includes being covered by a spouse’s FSA as well.

Using The Money You will receive an HSA Visa debit card to access your account. You can use the card to pay for your portion of medical expenses covered under the Plan (e.g., deductibles and coinsurance), as well as other qualified medical expenses, including dental and vision expenses.

Unqualified Expenses You can use the HSA for your portion of covered expenses under the Medical Plan as well as other qualified health care expenses (as with a Flexible Spending Account). You cannot use the HSA to pay for cosmetic procedures, expenses for which you can be reimbursed under any health care plan, your Medical Plan premium, or premiums for other health care plans (e.g., Dental or Vision).

Unspent Balances at Year-End

Any unspent balance in your account at year-end is rolled over and added to your account for the following year.

Unspent Balances at Termination

Your HSA belongs to you. If you leave the company or the Plan for any reason, the account remains in your name and you continue to have access to the money. You also may continue to contribute to the account, up to the annual IRS maximum.

Health Savings Account (HSA): Individual account that you set up to receive company-funded

incentive amounts, and into which you can make optional before-tax contributions up to an annual maximum determined by the IRS. You can use the HSA to offset a portion of your costs under the Medical Plan and to pay for qualified expenses not covered by the Plan such as certain over-the-counter medications. You also can let the account grow and earn interest, and use it for future medical expenses. If there is money in your account at the end of the year, it carries over into the next year. The money in your Health Savings Account belongs to you. If you leave the medical plan or leave employment with ProHealth Care, the dollars will remain in that account and are NOT forfeited.

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Flexible Spending Accounts

Flexible Spending Accounts (FSAs) offer an easy way to save money while paying for health care or dependent care (child care) expenses. You set aside before-tax dollars to pay for eligible out of pocket expenses during the year — in other words; you get a tax break for putting money aside for expenses you would have paid for anyway. Note: Before enrolling in the Medical or Dependent Care (child care/elder care) FSA, it’s important to understand the following IRS restrictions:

File by the deadline. For 2017, you will have until March 31, 2018, to file claims for any eligible expenses incurred between January 1, 2017 and December 31, 2017.

Plan your contributions carefully. At the end of the year, unused money in an FSA is forfeited. To avoid this, estimate your expenses as accurately as possible and be conservative when electing how much to contribute.

No transfers. You may not transfer money between the Dependent Care (child care) FSA and the Medical FSA.

Medical Flexible Spending Account (FSA)

The Medical FSA gives you the ability to pay for out of pocket medical, dental, vision and certain other eligible out-of-pocket expenses with before-tax dollars that you contribute to your flexible spending account. You can contribute to a Medical FSA whether or not you are enrolled in a ProHealth Care medical plan.

Contribution Limits for Medical Reimbursement

Minimum annual contribution: $ 100 Maximum annual contribution: $2,550

Eligible Expenses

You can find a list of eligible flexible spending account expenses at www.aetna.com/fsa. In the past, the Medical FSA could be used to pay for over-the-counter (OTC) drugs. Due to health care reform, the Medical FSA may no longer be used for OTC drugs without a directive from a medical provider.

Dependent Care (child care/elder care) Account

This account allows participants to pay for eligible dependent care expenses with before-tax dollars. It may appeal to you if you have predictable expenses associated with the care of a child or disabled adult that you claim as a dependent on your tax return. To use this account your eligible dependent must require day care or elder care to allow you to work. If you are married, you can participate in the Dependent Care FSA only if your spouse is employed or a full-time student for at least five months during the year while you are working, or disabled/elderly and unable to provide for his or her own care.

Contribution Limits for Dependent Reimbursement

Minimum annual contribution: $ 100 Maximum annual contribution: $5,000

http://www.aetna.com/fsa

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Eligible Dependents To be eligible, the individual receiving the care must be claimed as a dependent on your tax return and be a child under the age of 13 or an adult who normally spends at least eight hours in your home each day and cannot care for himself or herself because of a physical or mental disability.

Eligible Expenses You can find a list of eligible dependent care account expenses at www.aetna.com/fsa.

You must incur an expense in order to be reimbursed for it from your Dependent Care Account. Expenses are incurred when the service is rendered — not when they are billed, charged or paid for. When you pay eligible dependent care expenses, obtain a receipt. Complete the Dependent Care Reimbursement Claim form and attach the receipt (or have the caregiver sign the form). Send it in as instructed on the form, and Aetna will reimburse you for your eligible expenses. Claim forms are available at www.aetna.com or on ProHealth iNet – Human Resources Tab. You must report the name, address and Social Security or tax identification number of each dependent care provider when you submit a request for reimbursement.

Something to Consider The IRS allows two types of tax advantages for dependent care expenses. You may either file for a federal tax credit on your annual tax return or you can be reimbursed with before-tax dollars contributed to the Dependent Care FSA, but you may not do both with the same expense. For example, if you have two or more eligible dependents and spend at least $6,000 in dependent care expenses in 2017, you may contribute $5,000 to the dependent Care FSA and take $1,000 as a tax credit. Depending on your income, either the Dependent Care FSA or the tax credit may be more advantageous. You may wish to consult a tax advisor before deciding which option is best for you.

A Note about Social Security Although it is to your advantage to make before-tax contributions to an FSA to pay for out-of-pocket medical, dental, vision, prescription drug and dependent care expenses, you should be aware that before-tax contributions reduce the amount of earnings used to determine your Social Security benefits. Because your ultimate Social Security benefit is based on your earnings, this salary reduction could cause a slight reduction in the benefit. However, any reduction in your future Social Security benefits probably would be offset by the current tax savings you receive by participating in the FSAs


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FSA Streamline Feature The FSA Streamline Feature automatically pays any out of pocket eligible medical expenses if there are dollars available in your health care flexible spending account. To enroll in Streamline, log into the PayFlex website. 1. Log on to https://payflexdirect.com 2. Click on Financial Center, then click on the drop down arrow to select your account.

3. Click on Health Plan Activity Options located on the left hand side under Health Plan Activity.

4. Click on Health Plan Activity Options.

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5. Select the plan types you want to be automatically reimbursed from your FSA.

Definitions Flexible Spending Account (FSA): An account you can use to set aside money before-tax for specific expenses such as medical, dental, or dependent care. Contributions made within a calendar year must be used for expenses incurred in that year; unused money at the end of the year is forfeited. Limited Flexible Spending Account: A special FSA for individuals who enroll in the ProHealth High-Deductible Plan. This FSA can be used for dental and vision expenses at any time, but can only be used for medical expenses after the medical plan deductible is met.

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Dental

Delta Dental is the largest and oldest dental-benefits specialist in the country. It was built on the guiding principle that dental benefits should be simple and hassle-free. Delta Dental of Wisconsin was founded in 1962 with the same goal. Combined, member companies of the Delta Dental Plans Association serve more than 59 million people in nearly 97,000 groups nationwide. With some PPO plans, you don’t get much choice of providers. And if you go out of network, your provider may balance-bill you. But your Delta Dental PPO plan is different. The Delta Dental PPO network, with more than 165,000 dentist locations nationwide, is backed by Premier network, with more than 247,000 dentist locations nationwide – almost 80% of the nation’s dentists. Your lowest out-of-pocket costs come from seeing a Delta Dental PPO dentist, but you’ll also enjoy cost advantages if you see a Delta Dental Premier dentist. That means savings on out-of-pocket costs and better choice. Here’s an example:

PPO Savings, With A “Safety Net” Delta Dental PPO

Dentist Delta Dental

Premier Dentist Out-of-Network

Dentist

Dentist’s Normal Fee $720 $720 $720

Allowed Amount $590 $680 $680

Dentist Fee Adjustment Due to Delta Agreement

$130 $ 40 None

50% Benefit paid by Plan $295 $340 $340

Patient Responsibility $295 $340 $380

Advantages of Delta Dental Network Dentists

Delta Dental PPO

Network Dentist

Delta Dental Premier Network Dentists

Non contracted

Dentists

Agreed-to fee ceilings (no balance-billing): Dentist agrees to fee ceilings. If his/her normal charge is higher than the fee ceiling, he/she can't pass the balance on to you. √ √

Additional fee schedule savings: Dentist agrees to a reduced fee schedule. Saves out of pocket expenses for you. √

Convenient claims processing: Dentist is required to file claims on your behalf, saving you the hassle of doing so yourself. Claims payments go directly to the dentist. √ √

Treatment guarantees: Examples - Repair or replace dental restorations should they fail within 24 months. √ √

Confirming Your Coverage If you are not sure of the effective date of your coverage, please call Delta at 800-236-3712 before you have any dental work done. Also, before scheduling appointments for extensive dental care, you may ask your dentist to send the treatment plan to Delta Dental. The plan will be reviewed by Delta and a Predetermination of Benefits form will be returned to you and your dentist. You and your dentist may then discuss the treatment and your out-of-pocket costs. Delta encourages you to be informed about your dental care

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Summary of 2017 ProHealth Care Dental Plan Benefits

Benefit Description

Delta PPO*

In-Network Delta Dental Preferred Provider

Delta Premier

Out-of-Network or Other Provider

Calendar Year Deductible $ 50 Single $100 Family

$ 75 Single $150 Family

Calendar Year Maximum $1,500 per individual $1,000 per individual

Diagnostic & Preventative

Exams

Cleanings

Fluoride Treatments (up to age 19)

Space Maintainers

X-rays

Sealants (up to age 19)

100% Covered 100% Covered

Basic and Major Services

Emergency Pain Treatment

Fillings

Endodontics – Surgical and nonsurgical

Periodontics – Surgical and nonsurgical

Extractions – Surgical and nonsurgical

Other oral surgery

80% Covered

Deductible applies

80% Covered

Deductible applies

Major Restorative Services

Crowns, inlays, onlays

Dentures

Bridges

Repairs and adjustments to bridges and dentures

Implants

50% Covered

Deductible applies

50% Covered

Deductible applies

Orthodontia Orthodontia is covered for enrolled dependent children under age 19

50% Covered

Deductible applies

$1,500 lifetime maximum

50% Covered

Deductible applies

$1,000 lifetime maximum Special Plan Provisions – Evidence Based Integrated Care: Expanded benefits for persons with medical conditions that have oral health implications. Conditions include:

Diabetes

Pregnancy

Specific heart conditions that pose a risk of certain types of infection

Kidney failure or dialysis

Suppressed immune system

Cancer therapy

Periodontal disease

Requires self-enrollment by the patient or his/her dentist at Delta Dental’s website, or by calling 800-236-3712.

Dependent Eligibility – Dependents are eligible through the end of the month in which they attain age 26; except as noted for orthodontics and sealants.

*Your lowest out-of-pocket costs will come from seeing a Delta Dental PPO dentist.

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2017 Per Pay Period Dental Rates

Provider Network

www.deltadentalwi.com has a lot to offer. You can use it to obtain coverage information under your plan, check the status of a claim, find a network dentist, evaluate your oral health and learn ways to improve and protect it. Benefit Advisors are available every weekday from 7:30 a.m. to 5 p.m. (Central Time) to answer your questions at 800-236-3712.

Vision Plan

ProHealth Care’s vision plan is administered by Vision Service Plan (VSP). VSP has a network of more than 41,000 quality vision care providers nationwide.

The vision plan is 100% voluntary (i.e., employee-paid only) benefit.

No ID cards are necessary and none will be mailed to you. At your

appointment, you should tell your provider your vision coverage is through VSP. Your VSP provider and VSP will handle verifying your coverage. To locate a provider visit www.vsp.com.

Dental Rates

Full Time

Per Pay Period Employee Contribution

Regular Part-Time

Per Pay Period Employee Contribution

Single $ 6.20 $10.70

Employee + Child(ren) $13.15 $22.55

Employee + Spouse $13.80 $23.70

Family $20.05 $34.45

http://www.vsp.com/

http://www.deltadental.com/DentistSearch/DentistSearchController.ccl?DView=DentistDentistSearch

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2017 VSP Basic Vision Benefits Summary

Benefit Description Copay Frequency

Your Coverage with a VSP Provider WellVision Exam Focuses on your eyes and overall wellness $10 Every calendar year

Prescription Glasses $20 See frame and lenses

Frame $175 allowance for a wide selection of frames

$195 allowance for featured frame brands

20% savings on the amount over your allowance

Included in Prescription

Glasses Every other calendar year

Lenses Single vision, lined bifocal, and lined trifocal lenses

Polycarbonate lenses for dependent children


Glasses Every calendar year

Lens Enhancements

Standard progressive lenses

Premium progressive lenses

Custom progressive lenses

Average savings of 20-25% on other lens enhancements

$55 $95 - $105 $150 - $175

Every calendar year

Contacts (instead of glasses)

$175 allowance for contacts; copay does not apply

Contact lens exam (fitting and evaluation) Up to $60 Every calendar year

Diabetic Eyecare Plus Program

Services related to diabetic eye disease, glaucoma and age-related macular degeneration (AMD). Retinal screening for eligible members with diabetes. Limitations and coordination with medical coverage may apply. Ask your VSP doctor for details.

$20 As needed

Suncare $175 allowance for ready-made non-prescription sunglasses instead of prescription glasses or contacts

$20 Every other calendar year

Extra Savings

Glasses and Sunglasses

Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details

20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam.

Retinal Screening

No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam Laser Vision Correction

Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities

Your Monthly Contribution

$4.06 Employee Only $8.10 Employee + spouse $8.66 Employee + child(ren) $13.86 Employee + Family

Your Coverage with Out-of-Network Providers

Visit vsp.com for details, if you plan to see a provider other than a VSP network provider. Exam - up to $45 Single Vision Lenses - up to $30 Lined Trifocal Lenses - up to $65 Contacts - up to $105 Frame - up to $70 Lined Bifocal Lenses - up to $50 Progressive Lenses - up to $50

Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change in the event of a conflict between this information and your organizations contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location

Contact 800-877-7195 | vsp.com

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2017 VSP Vision Plus Benefits Summary

Benefit Description Copay Frequency

Your Coverage with a VSP Provider WellVision Exam Focuses on your eyes and overall wellness $10 Every calendar year

Prescription Glasses $20 See frame and lenses

Frame $175 allowance for a wide selection of frames

$195 allowance for featured frame brands

20% savings on the amount over your allowance



Lenses Single vision, lined bifocal, and lined trifocal lenses

Polycarbonate lenses for dependent children



Lens Enhancements

UV Protection

Polycarbonate Lenses

Anti-Reflective Coatings

Progressive Lenses

Average savings of 20-25% on other lens enhancements

$0 $15 $30 $50

Every calendar year

Contacts (instead of glasses)

$175 allowance for contacts; copay does not apply

Contact lens exam (fitting and evaluation) Up to $60 Every calendar year

Diabetic Eyecare Plus Program

Services related to diabetic eye disease, glaucoma and age-related macular degeneration (AMD). Retinal screening for eligible members with diabetes. Limitations and coordination with medical coverage may apply. Ask your VSP doctor for details.

$20 As needed

Suncare $175 allowance for ready-made non-prescription sunglasses instead of prescription glasses or contacts

$20 Every other calendar year

Extra Savings

Glasses and Sunglasses

Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details

20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam.

Retinal Screening

No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam Laser Vision Correction

Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities

Your Monthly Contribution

$9.70 Employee Only $19.44 Employee + spouse $20.80 Employee + child(ren) $33.22 Employee + Family

Your Coverage with Out-of-Network Providers

Visit vsp.com for details, if you plan to see a provider other than a VSP network provider. Exam - up to $45 Single Vision Lenses - up to $30 Lined Trifocal Lenses - up to $65 Contacts - up to $105 Frame - up to $70 Lined Bifocal Lenses - up to $50 Progressive Lenses - up to $50

Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details Coverage information is subject to change in the event of a conflict between this information and your organizations contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location

Contact 800-877-7195 | vsp.com

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Life and Accidental Death & Dismemberment Insurance

ProHealth Care provides life and accidental death and dismemberment (AD&D) insurance to full-time and regular part-time employees. You can add to your coverage by purchasing voluntary life insurance for you, your spouse and your dependent children. If you pass away while you are covered by the company’s life insurance benefits, your beneficiary will receive a payment equal to the amount of basic life insurance you have plus voluntary life insurance you buy. If you pass away as a result of a covered accident, your beneficiary will receive an AD&D benefit in addition to your life insurance benefit. You will need to designate your beneficiary on-line using Metlife’s MyBenefits website.

1. Log on to www.metlife.com/mybenefits and enter ProHeatlh Care in the Company Name field. Click the “Next” button.

2. You will then see the “Welcome to MyBenefits” page where you can register as a MyBenefits user or if you have already registered, enter your name and password.

3. Once you log into MyBenefits, select the “group Life Insurance” link. 4. Across the top page, you will see “Life Summary”, “Learn”, “Calculate”, Beneficiaries”,

Common Questions”, Contact Specialist”. Click on “Beneficiaries” and follow instructions to complete.

If you have any questions regarding making a beneficiary designation, please contact MetLife at 1-866-492-6983.

Basic Life and AD&D Insurance ProHealth Care pays the full cost of basic life and AD&D insurance for full-time and regular part-time employees.

Eligibility Coverage Effective Date

Basic Life Insurance Basic AD&D Coverage

Staff

(Less than 3 years of service)

First of the month following 90 days of employment

1 times your basic annual earnings rounded to next higher $1,000 ($500,000 maximum)


Staff

(More than three years of service)

First of the month following 90 days of employment

1.5 times your basic annual earnings rounded to next higher $1,000 ($500,000 maximum)


Managers, Directors and Physicians

First of the month following date of hire

1.5 times your basic annual earnings rounded to next higher $1,000 ($1,000,000 maximum)


Vice Presidents, Presidents and Chiefs

First of the month following date of hire

2 times your basic annual earnings rounded to next higher $1,000 ($1,000,000 maximum)


This information is meant to answer the most frequently asked questions, and is a summary of the available benefits. For additional information, a certificate of insurance is available on ProHealth Care iNet – Human Resources tab.

http://www.metlife.com/mybenefits

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Company - provided Life and AD&D Insurance for all employees will be reduced by 50% of the original amount at age 70. If your coverage begins for company-provided Life and AD&D Insurance at age 70 or older, the above age reductions will apply to:

Any Guarantee Issue Amount available without evidence of insurability; and

The maximum amount of insurance for which you are eligible.

Imputed Income: The IRS places a value on life insurance coverage in excess of $50,000 that is provided through before-tax group insurance programs. That value is determined by your age and the amount of your coverage, and is known as “imputed income.” It is calculated using “uniform premium levels” established by the IRS. The value of your group life insurance coverage in excess of $50,000 is added to your gross income for federal tax purposes. The company is required to withhold federal income tax and FICA from your regular pay based on the amount of imputed income.

Voluntary Life and Accidental Death and Dismemberment Insurance

As a full-time or regular part-time employee, you can purchase additional term life insurance coverage in $10,000 increments up to $500,000 maximum for staff and up to $1,000,000 for leaders and physicians. You can also enroll in up to $300,000 of coverage for yourself with no medical questions if you apply when you first become eligible. You may add accidental death and dismemberment (AD&D) coverage to your optional life insurance amount for an additional premium. Benefits are paid in case of an accidental death or dismemberment, as outlined in the policy.

Eligibility Employee Voluntary Life Insurance

Employee Voluntary AD&D

Staff $10,000 increments, $500,000 maximum

$10,000 increments, $500,000 maximum

Managers, Directors, Physicians, Vice Presidents, Presidents and Chiefs

$10,000 increments, $1,000,000 maximum

$10,000 increments $500,000 maximum

You pay the full cost of voluntary life insurance. The premium depends on your age and your level of coverage. See the rate table on page 30. Coverage is reduced by 50% at age 70. All applicants age 60 and over are required to fill out the Evidence of Insurability form.

Voluntary Spouse and Dependent Life Insurance You may buy life insurance for your spouse and/or your dependent children, whether or not you purchase voluntary life insurance for yourself. You are automatically the beneficiary for any dependent life insurance coverage you purchase for your spouse and/or dependent children.

Coverage for Your Spouse You may buy insurance for your spouse of up to $50,000 with no medical questions (exception: age 60 and older requires evidence of insurability) if you apply when you first become eligible. Additional coverage is available in $10,000 increments ($250,000 maximum). Coverage amounts for spouses over $50,000 are subject to evidence of insurability. Spouse amounts will reduce by 50% when the spouse reaches age 70. Applicants age 60 and over are required to fill out the Evidence of Insurability form.

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Coverage for Your Dependent Children You also may purchase life insurance to cover your unmarried children. There is no limit to the number of eligible dependent children who can be covered (and the cost is the same regardless of the number of children covered). The plan pays the full benefit amount in the event of any covered dependent child’s death. The coverage is $10,000 for children age 15 days to 26 regardless of fulltime student or marriage status.

Accelerated Benefit Option (ABO) A “living benefit” is automatically included on both you and your spouse’s optional life insurance coverage. The living benefit is designed to help offset expenses due to a terminal illness and is paid to you (or your spouse) while you are still living. The living benefit provides up to 80% of your Basic Life amount not to exceed $500,000. The covered person must be diagnosed with a terminal illness that is expected to result in death within 12 months of the diagnosis.

Portability The voluntary life insurance coverage for yourself, your spouse and your dependent children is portable, which means that you can keep your coverage at your current rates even if you leave your job. Another option is conversion, which means that you and your spouse may apply for an individual permanent policy with the same coverage without answering any medical questions. A written application must be made within 31 days of termination of employment or loss of eligibility. An additional fee may be applied depending on the payment method. To enroll, go MetLife’s website www.metlife.com/mybenefits.

http://www.metlife.com/mybenefits

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2017 Voluntary Employee and Spouse Life Rates

Age Non-Smoker Rate

Per Pay Period Rate Per $1,000 Smoker Rate

Per Pay Period Rate Per $1,000

0-24 $0.0235/$1,000 $0.0270/$1.000

25-29 $0.0235/$1,000 $0.0300/$1,000

30-34 $0.0320/$1,000 $0.0430/$1,000

35-39 $0.0365/$1,000 $0.0480/$1,000

40-44 $0.0365/$1,000 $0.0505/$1,000

45-49 $0.0600/$1,000 $0.0805/$1,000

50-54 $0.0965/$1,000 $0.1230/$1,000

55-59 $0.1810/$1,000 $0.2150/$1,000

60-64 $0.2525/$1,000 $0.3115/$1,000

65-69 $0.5295/$1,000 $0.6350/$1,000

70+ $0.9685/$1,000 $1.102/$1,000 Example: $150,000 (coverage amount)/1,000 X .060 (age 45-49 nonsmoker) = $9.00 per pay period.

Voluntary Employee and Spouse AD&D Rates

Per Pay Period Rate Per $1,000

$0.0075

Example: 150,000/1,000 x $0.0075 = $1.13 per pay period.

Voluntary Dependent Child Life Rates

Per Pay Period Rate

$0.8025

Short Term Disability (STD) / Salary Continuation

Short Term Disability/Salary Continuation provides you with income if you become disabled and unable to work due to a non-work related medical condition. It covers illness or disability after you missed 7 consecutive calendar days due to a disability. You may use PTO for the first seven calendar day waiting period. You may also supplement your short term disability with PTO to bring your compensation up to 100%.

Eligibility Regular part-time and full-time employees are eligible for this benefit on the first of the month following 90 days of employment.

Coverage Level and Duration All Staff, Managers and Directors: 60% of base earnings

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You are eligible for up to 6 weeks of STD/Salary Continuance during your first year of employment and up to 26 weeks after first year of employment. You may use your PTO to supplement up to 100% of bi-weekly salary.

If you are disabled and need to apply for Short Term Disability/Salary Continuance or have any questions about this benefit, contact the MetLife Claims Center at 1-877-638-8269.

Long Term Disability

Long term disability is available to you if you remain disabled and unable to work after a 180 day waiting period.

Eligibility Regular part-time and full-time employees are eligible for this benefit on the first of the month following 90 days of employment. Leaders and physicians are eligible for this benefit, the first of the month following date of hire.

Coverage Level and Duration Hourly Staff: 33 1/3 % of salary Exempt Staff: 66 2/3 % of salary

Voluntary Long-Term Disability Buy-Up Hourly staff have the option to buy-up to the 66 2/3% benefit as a new hire or at open enrollment. This additional buy-up is paid for by you.

For additional information on the Long Term Disability insurance and to view and/or print the insurance certificate, please go to ProHealth Care’s iNet – Human Resources tab.

Voluntary Long Term Disability Rate: ($.00303 X Annual Salary) / 24 pay periods

Educators Credit Union ProHealth Care is an Educators Credit Union Preferred Partner company. As a ProHealth Care employee or retiree, you are eligible to become a member of Educators Credit Union. Educators Credit Union is a full-service financial cooperative offering loan and savings options along with money management tools, financial wellness, and educational resources. ProHealth Care employees have access to special Preferred Partner benefits in addition to regular Educators member benefits. Preferred Partner Perks

Welcome loan – Within the first 90 days of employment, employees can receive a credit card for up to $5,000 at 0% APR for six months.

Direct deposit incentive – Sign up for net pay direct deposit to a new Educators checking account and receive 14,500 points for Perks points, Educators’ credit and debit card reward program. The 14,500 points can be redeemed for $100 cash, a .50% consumer loan discount, a .50% share certificate rate increase or several other options. They can also be

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saved and combined with other points you earn and redeemed for other retail gift cards or travel.

Get paid early – Educators posts payroll direct deposit up to one day early.

Loan rate – Receive an extra .25% off fixed-term loan rates for vehicle, home equity, personal or other loans (lines of credit and first mortgage loans excluded).

Home loan – Employees receive $100 off closing costs on a first mortgage purchase or refinancing of a home loan. Low down payment alternatives are also available.

Critical Illness Insurance Critical Illness Insurance provides you with a lump-sum benefit payment to be used at your discretion in the event you experience one of many covered conditions, like:

Hearth Attack

Cancer

Stroke

Kidney Failure

Major Organ Transplant For more information, go to ProHealth Care’s i-Net – Human Resources.

Accident Insurance Accident insurance pays you a benefit in the event you or your covered family members are injured in an accident. It is not a replacement for medical coverage. Accident insurance provides you with comprehensive insurance coverage for initial care, injuries, treatment, and follow up care. For more information go to ProHealth Care’s i-Net – Human Resources.

Pre-Paid Legal with Legalguard Signing contract, preparing legal documents, buying or selling real estate, and dealing with identity theft are all critical and potentially stressful times when we could benefit from having professional legal assistance. ProHealth Care offers LegalGUARD that can help you take control of your legal and financial matters with fewer worries. For more information go to ProHealth Care’s i-Net – Human Resources.

Identity Theft Protection You have access to special identity theft safeguards through LifeStages identity Theft management Services. LifeStages provides personalized proactive and resolution services to help you manage your identity, resolve fraud and minimize damage at every stage of life, including:

Lost Wallet/Document Replacement

Child Identity Theft Support

Tax/Financial/Medical/Travel Identity Theft Support

And more You will receive monthly newsletters, alerts and reminders when you enroll in the LifeStages program. For more information go to ProHealth Care’s i-Net – Human Resources.

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ProHealth Retirement Savings Plan ProHealth Care, Inc. is pleased to provide its employees with a 401(k) Retirement Savings Plan which provides a hassle free, easy way to invest for retirement.

ProHealth Retirement Savings 401(k) Plan Overview

Who can participate? All employees over age 18 (except employees classified as contractor, leased, temporary, student or intern) are eligible to

participate in the plan.

When may I join? If you’re not already enrolled, you can start participating at any time. You may change your deferral rate and investment elections at any time.

How much can I contribute to the plan?

You may contribute from two to 75 percent of your compensation (on a pre-tax or post-tax basis) up to $18,000* (in 2016). If you are 50 years of age or older you may contribute an additional $6,000* (in 2016).

*These dollar amounts typically change every year.

Does ProHealth Care provide a match?

ProHealth Care will match 50 percent on the first 10 percent of your earnings you contribute to the plan. Contributing 10 percent of your won pay will get you the full company match of 5 percent, for a combined total of 15 percent. Employees with a 0.5 or greater FTE are eligible for matching contributions.

The employer match becomes 100 percent vested after three years of service.

The employer match is made each paycheck you make a contribution to the plan.

Can I contribute on a pre-tax and post-tax (i.e. Roth) basis to the plan?

Yes, you can elect to contribute to the plan on a pre-tax, post-tax (Roth) basis or combination of both. You also have the option to convert pre-tax dollars in the plan to Roth contributions. For additional information, contact Transamerica at 800-755-5801 or online at phc.trsretire.com.

Can I stop or change my contributions?

You may increase, decrease or stop your contributions at any time online at phc.trsretire.com or by phone at 800-755-5801. Contribution changes are allowed each payroll and will be processed as soon as administratively possible.

Automatic increase service

You choose how to invest your plan account (your contributions, employer match and any rollover contributions) by selecting from investment options provided under the plan. You may order mutual fund prospectuses online at phc.trsretire.com. You have several options:

Create your own investment strategy using any combination of plan funds.

Select the Target Date Fund based on your retirement date to establish your investment mix based on a retirement year. Your account will automatically be rebalanced so that it becomes more conservative over time.

Choose a single asset-allocation fund that suits your investment profile.

Enroll in the Managed Advise service. For an additional fee, Transamerica’s team of licensed investment advisors will manage the investments within your account. This total retirement solution manages your entire account and offers automatic investment diversification and rebalancing, exclusive access to one-on-one advice from retirement counselors, and more.

Open a Schwab Personal Choice Retirement Account* (PCRA). PCRA is a self-directed investment account that allows you to direct purchases and sales within your account. PCRA is designed for individuals who seek more flexibility, increased diversification and a greater role in managing their retirement savings. By establishing a PCRA, you assume responsibility for controlling your investments.

When can money be withdrawn from my plan account?

Funds may be withdrawn from your plan account due to your:

Retirement

Disability

Death

Separation from service

Hardship withdrawal request

Loan request

In-service withdrawal beginning at age 59 1/2

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Can I withdraw my vested balance from my 401(k) account before I retire?

You may withdraw funds at age 59 ½ or for a financial hardship, as defined in the plan.

If I leave ProHealth Care, what happens to my plan account?

You are always entitled to your contributions and rollover contributions. If you leave employment before three years of service, you will forfeit any employer contributions. You have three options for your vested money:

Leave it in the ProHealth Retirement Savings Plan.

Roll it into another qualified retirement savings plan with a new employer or a personal IRA.

Take the money as income, subject to applicable taxes and possible penalties, in a single lump sum or in partial payments.

How do I obtain information about my plan account?

You will receive a personalized account statement quarterly. The statement shows your account balance as well as any contributions and earnings credited to your account during the reporting period. You can get up-to-date information about your account balance, contributions, investment choices and other plan data by contacting Transamerica at 800-755-5801 or online at phc.trsretire.com.

How often can I change my investment elections?

Investment elections may be changed at any time by contacting Transamerica at 800-755-5801 or online at phc.trsretire.com. Transfers among investment options may be made at any time and may be subject to certain restrictions.

How do I enroll in the plan?

Please contact Transamerica at 800-755-5801 or online at phc.trsretire.com.

How do I elect and change my beneficiary information?

It is very important that you designate at least one beneficiary for your retirement account so your assets can be distributed according to your wishes upon your death. Sign in to phc.trsretire.com. Under the Home menu, click Beneficiaries and follow the prompts. You will need to beneficiary’s Social Security number, date of birth and address to complete the process. Please note that if you are married and wish to designate someone other than your spouse as a primary beneficiary, notarized consent from your spouse is required.

Where can I get more details on the ProHealth Retirement Savings 401(k) Plan?

The summary Plan Description is available on i-Net at Human Resources, Retirement Benefits. If you prefer a paper copy, contact Human Resources at [email protected].

Who can I contact if I have questions?

For information about the ProHealth Retirement Savings 401(k) Plan, your account balance, investment options, retirement planning tools and more, visit Transamerica at phc.trsretire.com, or call 800-755-5801.

How do I make an appointment to meet one-on-one with a Transamerica representative?

Schedule your individual session today by calling Transamerica at 800-755-5801 or online at: https//booknow.appointment-plus.com/7qrt9ntk/. You are invited to bring a guest.

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Insurance Directory/Benefit Resources

PROVIDER TELEPHONE WEB SITE or EMAIL

Medical/Prescription Drug

Aetna 800-414-0766

Member Registration www.aetna.com

Drug Cost Calculation – Log on: RXOnly1 Password: RXonly1

https://member.aetna.com/MbrLanding/login.fcc?

Health Plans Comparison https://www.aetna.com/planselection/mbrDis.jsp?id=474

Medical Provider Network

WIDS 262-928-4767 https://widsnetwork.phci.org

Flexible Spending Accounts

Aetna 888-678-8242

www.Payflex.com

Dental Plan

Delta Dental 800-275-6230 www.deltadentalwi.com

Vision Plan

Vision Service Plan (VSP) 800-877-7195 www.vsp.com

Company-provided and Voluntary Life

MetLife 262-928-4185 www.metlife.com

Company-Provided and Voluntary AD&D (Accidental Death & Dismemberment)

MetLife 262-928-4185 www.metlife.com

Short Term Disability

MetLife Claims Center 877-638-8269 https://mybenefits.metlife.com

LTD (Long Term Disability)

MetLife 877-638-8269 https://mybenefits.metlife.com

Family Medical Leave of Absence (FMLA) MetLife

877-638-8269 https://mybenefits.metlife.com

401(k) Plan – Retirement Planning Consultant (on-site)

414-208-6100 [email protected]

https://booknow.appointment-plus.com/7qrt02lg/

401(k) Plan (Record Keeper)

Transamerica

Enroll – 888-676-5512 Changes/withdrawals –

800-755-5801 phc.trsretire.com

Benefit Questions 262-928-4185 [email protected].

Meyer Group, Inc. - Critical Illness, Accident, Pre-Paid legal and Identity Theft

800-755-7077 myrgrp.com

[email protected]

SuccessFactors

- Update your demographic information https://sf.phci.org

Employee Self Service (ESS)

Log onto ESS to: - Enroll in benefits - View your paychecks - Change Direct Deposit & Tax info - View your available PTO time

https://ess.phci.org


https://member.aetna.com/MbrLanding/login.fcc

https://www.aetna.com/planselection/mbrDis.jsp?id=474

http://www.payflex.com/

http://www.deltadentalwi.com/

http://www.vsp.com/





https://sf.phci.org/

https://ess.phci.org/

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Paid Time Off (PTO)

PTO Policy Highlights The Paid Time Off (PTO) program is a system that provides an accrued bank of hours from which an employee must draw from to receive pay when they don’t meet their normally scheduled work hours. This bank combines traditional vacation, holiday and short-duration sick time into a single paid account, which must be used for planned days off and short illnesses. PTO is not used for jury duty and bereavement pay. Use of PTO must be properly scheduled and approved in advance by department management. Employees on Family Medical Leave (FMLA) should consult with Employee Health Services regarding their use of PTO prior to the leave.

PTO may be used in increments of 15 minutes or more for hourly employees. Exempt employees may take PTO in increments of 1 hour with a 4 hour minimum.

The first seven consecutive days of a Short Term Disability leave (Qualifying or Non- Qualifying Family Medical Leave) may be paid from this account for all employees.

Employees with PTO time available are required to use PTO when vacation time, holiday

time, or individual sick days are used.

When an employee is given Approved Time Off (ATO) they are not required to use PTO.

PTO Eligibility Employees who have a full time equivalent equal and/or greater than a .5 are eligible to accrue paid time off. RN’s who participate in the weekend only programs are also eligible to accrue paid time off. Paid Time Off may be accumulated from year to year, not to exceed the established maximum number of hours based upon years of service. Once the maximum hours are reached, your accrual will stop until your balance is below the limit.

Procedure Time off must be properly scheduled and approved by department management, in advance if possible, prior to using any PTO. In the case of illness, the employee should notify his/her department manager as soon as possible and get authorization to use PTO to cover the absence. Excessive unplanned absences may result in disciplinary action up to and including termination of employment. Employees receive payment of their accrued PTO hours upon termination. Approved time off (ATO) is the recognized terminology for cancel time. Employees utilizing ATO will continue to earn PTO while taking ATO. PTO time does not accrue on short-term disability payments. If an employee changes from full-time or regular part-time to part-time status, Pool status or 7/70, PTO is paid out at the time of the status change. In addition, if a non-management employee moves into a management role, PTO is paid out at the time of the employment change. Employees transferring between the ProHealth Care entities will carry their balance with them.

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Holidays Legal holidays are included in PTO accruals and include New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day. During the pay periods in which these days fall, an employee is required to use appropriate PTO time to ensure they meet their required scheduled hours. If an employee does not work the legal holiday but accepts an additional shift, no PTO time is required for use. PTO is calculated on hours worked times accrual rate based on your years of service. See chart below. Example: I am a 10 year employee and work 48 hours in a pay period. (48 hours x .1231 = 5.9088 hours of PTO accrued during the pay period) Your PTO balance can be found on Employee Self Service (ESS) Website https://ess.phci.org.

Years of Service

0-4 5-9 10-14 15-19 20+

PTO Accrual Rate (per hour worked)

.0885 .1077 .1231 .1347 .1385

PTO Days

23 28 32 35 36

PTO Hours

184 224 256 280 288

Maximum Hours Allowable in PTO bank

184 224 256 280 288

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ProShare Bonus Program

The purpose of the ProShare Plan is to provide incentive compensation for eligible employees of ProHealth Care and its subsidiary companies (collectively, the “System”) which directly relates their financial reward to the System’s achievement of certain financial and on-financial objectives. The primary purpose of this plan is to support the System’s mission to achieve continued growth and demonstrate value through:

A seamless continuum of patient-centered care;

Nationally recognized outcomes;

Responsible and efficient use of health care resources; and A focus on the health of our community.

We will achieve this vision in partnership with talented and caring employees, physicians and volunteers who share a passion for our mission. The ProShare Plan shares the System’s success and rewards participants for their active contributions to that success. ProShare provides motivation for performance which might not otherwise be achieved. To be most effective, the ProShare Plan must meet the following specific objectives:

Improve performance by providing a mechanism to set and achieve corporate goals that reflect outstanding performance.

Maximize the viability of the System, given current and future reimbursement issues, by emphasizing and reinforcing the importance of quality and cost effectiveness.

Reinforce the System’s planning process, resulting in acting with direction, not reaction.

Increase awareness of the corporate culture by emphasizing teamwork.

Encourage team “systemness” among ProHealth employees through aligned goals and collaborative efforts.

Help recruit and retain high quality staff.

Participants in this plan must be employed (full time, regular part time, part time or pool) by one of the following participating entities:

ProHealth Care

Waukesha Memorial Hospital

Oconomowoc Memorial Hospital

ProHealth Care Medical Group

ProHealth Home Care

WMH or OMH Foundation (excluding Development Officers)

Waukesha Health System

The following employees shall not be eligible for the ProShare Plan:

All employees with a title of Manager, Director, Vice President, or Chief

Empathia employees

WMH or OMH Foundation Development officers

Employees of joint ventures and affiliated serviced (i.e. West Wood, National Regency, ProHealth Aligned, or the Rehabilitation Hospital of Wisconsin)

Employed physicians

Temporary employees

Employees who are on a performance development plan at time of payment

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Newly hired participants must have been hired into their position prior to the first full pay period in the fiscal year third quarter to be eligible for the plan. Newly hired participants who started during the first pay period in the fiscal year third quarter or after will not be eligible to participate in the plan until the next plan year. The ProShare Plan is made up of two components:

50% - achievement of System operating margin goals

50% - achievement of patient satisfaction goals

General Payment Guidelines

1. The ProShare goad attainment fund shall be calculated at the end of the fiscal year. 2. Results of the System Operating Margin and System Patient satisfaction shall be calculated

on a consolidated basis for all plan participants. 3. Participant payments shall be determined by dividing the total ProShare Pool attained for the

year by the applicable total Participating Payroll. The result shall be multiplied by the individual’s yearly Participating Payroll to determine each participant’s gross ProShare payment.

4. If a payment is calculated to be under $10, there will be no payment. If the payment is between $10 and $25, it is rounded up to $25.

5. Taxes and other required deductions including 401k contributions will be withheld when making ProShare payments.

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Personal Property and Liability Insurance Program

for ProHealth Care Employees

The group auto and home insurance program from MetLife Auto & Home® is available to employees. This program

allows you to apply to purchase quality group auto and home insurance at special group rates. A variety of policies are

available to you through the program, including:

Auto

Home

Landlord’s Rental Dwelling

Condo

Mobile Home

Renter’s

Recreational Vehicle

Boat

Personal Excess Liability (“Umbrella")

By participating in the program, employees may benefit from special group insurance rates that are designed to save them

money. There are also a variety of discounts for which you may be eligible.

For the payment of premiums, MetLife Auto & Home offers several hassle-free options.

Bank account deduction spreads your premiums over the policy term, which makes budgeting for your insurance easier.

(A down payment may be required.) There are no checks to write or dates to remember. Best of all, you won’t receive

any bills in the mail because everything is taken care of automatically. Home billing is also available.

To help you discover if participating in the program makes sense for you, you have access to free insurance reviews and

no-obligation premium quotes with one call to the toll-free MetLife® Benefits Line at 1 800 GET-MET 8 (1-800-438-

6388) to speak with an insurance consultant. To make the most accurate comparisons, have your current policies with you

when you call.

MetLife Auto & Home is a brand of Metropolitan Property and Casualty Insurance Company and its affiliates: Metropolitan General Insurance Company, Metropolitan

Casualty Insurance Company, Metropolitan Direct Property and Casualty Insurance Company, Metropolitan Group Property and Casualty Insurance Company, Economy

Premier Assurance Company, Economy Preferred Insurance Company, Economy Fire and Casualty Company, and Metropolitan Lloyds Insurance Company of Texas, all

with administrative home offices in Warwick, RI. In some instances, policies are provided by Liberty County Mutual Insurance Company. Coverage, rates, and discounts are

available in most states to those who qualify. L05078J4A(exp0709)MPC-LD

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Appendix

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Health Care Reform and Your ProHealth Care Benefits (PPACA) took effect January 1, 2014, with the goal of making health care available to all Americans, no matter their medical history or ability to pay. With these changes on the horizon, you may wonder how it will affect the health care benefits available to you as a ProHealth Care employee. The short answer is: ProHealth Care will continue to offer medical coverage in 2017. You will have additional choices from other sources, however, and it’s important that you understand your options.

A Snapshot of the Changes

Health Care Reform Change (as of January 1, 2014)

What it Means to You

Most Americans will be required to purchase minimum health insurance or pay a tax penalty. This referred to as the individual mandate.

Your ProHealth Care medical plan satisfies the requirement to have health insurance. If you enroll in a ProHealth Care medical plan, you will not be subject to a tax penalty.

Patient protections will be fully implemented. Insurers won’t be able to deny you coverage because of pre-existing conditions. They can’t charge you more because of your gender or health status, and you’ll be able to buy health insurance even if you are seriously ill.

Your ProHealth Care medical plan already includes these patient protections.

Insurers cannot place lifetime dollar limits on how much they will pay for essential health benefits.

Neither of the ProHealth Care medical plans includes a lifetime dollar limit.

Insurers can’t make you wait for more than 90 days for coverage to become effective.

Employees who enroll in a ProHealth Care medical plan can be covered as early as the first of the month following their date of hire.

You will be able to shop for health insurance in online health insurance marketplaces (also called exchanges).

You do not have to purchase health insurance through one of the new marketplaces. You still can purchase medical coverage through ProHealth Care during Open Enrollment, typically held in October. ProHealth Care will continue to pay the majority of your medical plan premium. If you purchase coverage through the marketplace, you will lose all ProHealth Care all Pro-Health Care contributions toward the cost of your medical coverage.

All health plans in the marketplaces must offer essential health benefits (EHB) – a minimum level of coverage.

Your ProHealth Care medical plans already offer these essential health benefits – and more.

The creation of health insurance marketplaces (also called exchanges) is a key component of health care reform. Exchanges are new organizations that create an organized and competitive market for buying health insurance, and enable you to make an apples-to-apples comparison of options available in your state. You still have access to ProHealth Care medical plans, and you don’t have to enroll in a marketplace option. But, if you want to know more, here are some basic facts:

Insurers will offer comprehensive plans with coverage for doctor, hospital, and other health care provider services and prescriptions drugs. You’ll be able to compare insurance options based on price, benefits, quality, and other features.

All marketplace options will cover essential health benefits, and there will be four basic levels of coverage – bronze, silver, gold, and platinum. The levels will vary in premiums and in the percentage of medical expenses the plans will cover. For example, bronze plans will have the lowest monthly premiums but members may pay more out of pocket when they receive medical care. Platinum plans, at the other end of the spectrum will cover more medical expenses and have higher monthly premiums and members may pay less out of pocket when they receive medical care. If you buy through the marketplace, you can choose the plan that best meets your health needs budget.

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Insurers won’t be able to refuse to cover you or charge you more just because you have a chronic or pre-existing condition. They also won’t be able to charge more for women than for men. They will, however, be able to charge individuals over age 50 up to three times more than younger individuals.

Health Care Reform Questions and Answers

Q: What is the individual mandate? A: The individual mandate requires most American to purchase a minimum level of health care insurance or pay a penalty. You can satisfy the coverage requirement by having coverage through an employer (such as a ProHealth Care medical plan), coverage you purchase on your own, or Medicaid. If you cannot afford a health plan, you may qualify for financial aid and you may not have to pay a penalty.

Q: Who is exempt from the individual mandate penalty? A: You’ll be considered exempt from the penalty if:

You have insurance through an employer or purchase individual insurance on your own.

You have insurance through Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), the Veteran’s Administration and/or Tricare (for active duty and retired military), Indian Health Services, or a health care sharing ministry.

You would have to spend more than 8% of your household income on the least expensive qualifying health insurance plan, even after tax credits and subsidies.

Your income falls below the threshold for filing a federal income tax return.

You live outside of the United States.

You are an undocumented immigrant, incarcerated, or a member of a Native American tribe, you qualify for a religious exemption, or you qualify for certain other exemptions.

Q: Am I eligible to receive government help in paying for health insurance? A: PPACA includes provisions to lower premiums and share certain expenses for people with low and modest incomes through tax credits and subsidies. These provisions are based on the federal poverty level, defined as earnings of about $11,490 per year for a single person or $23,550 for a family of four. However, if you have coverage through ProHealth Care, you already receive a “credit” to lower your premiums, since ProHealth Care pays the majority of the cost of your coverage.

Since ProHealth Care offers coverage that is considered affordable (the cost of the coverage is less than 9.5% of employee income) and meets the standard coverage requirements, if you choose to purchase coverage from an exchange, you will not be eligible for any ProHealth Care contributions, federal subsidies, or tax credits to help you pay the cost of health insurance.

Q: Can I still insure my children up to age 26 in the medical plan? A: Yes, the law lets children up to age 26 stay on their parent’s medical plan.

Q: Will I be taxed for the portion of the health insurance premium that is paid by ProHealth Care? A: No. Your contribution for a ProHealth Care medical plan is made pre-tax, so you are not taxed on that amount. And, although your W-2 form will show you how much ProHealth Care contributes on your behalf, the reporting is for informational purposes only. Under current law, you won’t be taxed on that amount.

If you purchase insurance through an insurance marketplace, any unreimbursed medical expenses (including premium payments) will be tax deductible on to the extent they exceed 10% of your gross income.

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Q: Can I still have a Health Savings Account (HSA)? A: Yes. The minimum level of coverage (bronze level) required to meet the individual mandate was specifically designed to allow for the purchase of a high-deductible health plan that would complement an HSA. Also, ProHealth Care’s High-Deductible Health Plan will continue to include an HSA.

Q: If I leave my ProHealth Care medical plan, can I re-enroll at a later date? A: Yes, You can re-enroll during next year’s Open Enrollment period for 2017 coverage or during the year if you experience a qualifying life event (e.g., loss of a job, death of a spouse, birth of a child).

Considering a Marketplace Option?

Here is information you may need if you decide to apply for coverage through the state health insurance marketplace.

Employer Name: ProHealth Care Inc. Employer Identification Number (EIN): 39-1486873

Employer Address: 725 American Ave., POB Suite 305 City: Waukesha State: WI Zip code: 53188 Who Can We Contact About Employee Health Coverage At This Job: Human Resources Phone Number: 262-928-4185 E-Mail Address: [email protected]

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ProHealth Care Health, Dental and Vision Plan

Notice of Privacy Practices

THIS NOTICE TELLS HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED

AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

ProHealth Care Health Plan is dedicated to keeping your health information private and secure.

When we release your health information, we make reasonable efforts to limit the use and release to

only the minimum necessary information and to those persons needed for the specific purpose.

To summarize, we are required by law to maintain the privacy of your health information and to

provide you with this Notice of our legal duties and privacy practices with respect to your health

information. This Notice provides you with the following important information:

How we use and disclose your protected health information

Your privacy rights with regard to your protected health information, and

Our obligation to you concerning the use and disclosure of your protected health information.

How ProHealth Care Health Plan May Use or Disclose Your Health Information

The following categories describe the ways that the ProHealth Care Health Plan may use and disclose

your health information. For each category of uses and disclosures, we will explain what we mean

and give some examples. Not every use or disclosure in a category will be listed. However, all the

ways we are permitted to use and disclose information will fall in one of the categories.

Without your permission we can use and release your health information for:

1. Payment. We may use and disclose your health information to make or collect payment for

treatment or services you receive. For example, we may use or disclose your health

information to:

Determine your eligibility for plan benefits

Obtain premiums

Make payment for treatment and services you receive from health care providers

Determine your health plan’s responsibility for benefits

Coordinate benefits

2. Healthcare Operations. We may use and disclose your health information to operate our

business.

Underwriting, premium rating, or related functions to create, renew, or to replace health

insurance or benefits

Quality assessment and improvement activities

Activities designed to improve health or reduce health care cost

Clinical guideline and protocol development or case management and care coordination

Accreditation, certification, licensing or credentialing activities

Reviews and auditing, including fraud and abuse detection programs, medical reviews,

legal services, audit services, and compliance related programs

Business planning and development, including cost management and planning, and

related analyses and formulary development

Submitting claims for stop-loss coverage

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Business management and general administrative activities, including customer service

efforts and resolution of internal grievances

3. Treatment Alternatives. We may contact you or your health care providers with

information about treatment alternatives and other related programs that may be of interest to

you.

4. Distributing Health Related Benefits and Services. We may use or disclose your health

information to provide information on health-related products and services that may be of

interest to you. If we receive compensation from a third party for providing you with

information about other products or services (other than drug refill reminders or generic drug

availability), we will obtain your authorization to share information with the third party.

5. As Required By Law. We may use or disclose your health information as required by

federal, state, or local law. The use or disclosure will be made in compliance with the law

and will be limited to the requirements of the law. For example, we may disclose medical

information when required by a court order in a legal proceeding, such as a malpractice

action. We are also required to report abuse or neglect of a child.

6. For Public Health Activities. We may need to report your health information to help

prevent or control disease, injury, or disability. This may include information for:

Reactions to drugs or problems with products and devices

Reporting exposure to disease or infection

7. For Health Oversight Activities. We may disclose your health information to health

agencies that monitor or regulate providers to be certain that you are given the correct and

proper care.

8. Judicial and Administrative Proceedings. We may disclose your health information in the

course of any administrative or judicial proceeding.

9. To Avoid a Serious Threat to Health or Safety. We may release some of your health

information to people in authority if we think that it will prevent or lessen a serious or

immediate danger to you or the safety or health of other people.

10. For Military or National Security Purposes. We may release your health information to

military and federal officials as required for lawful national security purposes, investigations,

or intelligence activities.

11. For Worker’s Compensation. We may share your health information as allowed by

workers’ compensation laws or other similar programs. These programs may provide

benefits for work-related injuries or illness.

12. Law Enforcement and Correctional Facilities. We may disclose your health information to

law enforcement officials in response to a court order signed by a judge, warrant or summons.

We may disclose your protected health information if necessary to report suspicious deaths,

crimes on our premises, crimes in an emergency, and for purposes of identifying or locating a

suspect or other person. We may disclose your health information to correctional institutions

or law enforcement personnel for certain purposes if you are an inmate or are in lawful

custody.

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13. To Those Involved with Your Care. If family members or close friends are helping care for

you, we may give health information about you to the extent necessary for them to help with

your care.

14. Disclosure to Sponsors. We may disclose your health information to the sponsor of your

group health plan for purposes of administering benefits under the plan.

15. With your written permission we may disclose your health information to anyone for any

purpose. If the reason we share health information is not listed above, we must first get your

written permission. You may withdraw your permission at any time, as long as you notify us

in writing. If you wish to withdraw your permission, please send your written request to

ProHealth Care Human Resources Department, at 725 American Ave., POB Suite 305,

Waukesha, WI 53188. If you revoke your permission, we will no longer be able to use or

disclose health information about you for the reasons covered by your written permission,

though we will be unable to take back any disclosures we have already made with your

permission.

Your written permission is necessary for most uses and disclosures of psychotherapy notes.

Your written permission is necessary for any disclosure of health information in which the ProHealth

Care Health Plan receives compensation.

ProHealth Care Health Plan is prohibited from using or disclosing genetic information for

underwriting purposes, including determination of benefit eligibility. If we obtain any health

information for underwriting purposes and the policy or contract of health insurance or health

benefits is not written with us or not issued by us, we will not use or disclose that health information

for any other purpose, except as required by law.

Some of the uses and disclosures described in this notice may be limited in certain cases by

applicable State laws that are more stringent than Federal laws, including disclosures related to

mental health and substance abuse, developmental disability, alcohol and other drug abuse (AODA),

and HIV testing.

Your Health Information Rights

You have the right to:

1. Inspect and Copy Your Health Information. You have the right to inspect and receive

an electronic or paper copy of health information about you that may be used to make

decisions about your plan benefits. To inspect and copy such information, you must

contact:

Medical Plan Dental Plan Vision Plan

Aetna

PO Box 981106,

El Paso, TX 79998-1106

Delta Dental of Wisconsin

P.O. Box 828

Stevens Point, WI 54481-0828

VSP

P.O. Box 99705

Sacramento, CA 95899-7105

If you request a copy of the information, they may charge you a reasonable fee to cover

expenses associated with your request.

48 | P a g e

2. Request to Challenge or Correct Your Health Information. If you believe your health

information is not correct or is incomplete, you may ask us to change/correct the

information. To ask for an amendment, you must make your request including a reason

for your request in writing to the ProHealth Care Human Resources Department, at 725

American Ave., POB Suite 305, Waukesha, WI 53188. We may deny your request if we

did not create the information you want changed, the information is already accurate and

complete or for certain other reasons. If we deny your request, we will provide you with a

written explanation and information on how you can appeal the denial.

3. Request Restrictions on Certain Uses and Disclosures. You may ask that we limit how

your health information is used. We are not required to agree to your restriction request.

All requests for restrictions must be in writing to ProHealth Care Human Resources

Rewards Department, at 725 American Ave., POB Suite 305, Waukesha, WI 53188. We

will let you know if we can comply with the request.

4. As Applicable, Receive Confidential Communication of Health Information. You

have the right to ask that we share your health information with you in different ways or

places. For example, you may ask that we only communicate with you at a certain phone

number or by mail. We will attempt to meet reasonable requests for confidential

communications, but retain the right to deny such requests. All requests for confidential

communications must be in writing to ProHealth Care Human Resources Department, at

725 American Ave., POB Suite 305, Waukesha, WI 53188.

5. Receive a Listing of Disclosures. In some cases, you may ask for a list of those who

received your health information. This list must include the date your health information

was given, to whom it was given, a short description of what was given and why. We

must give you this list within 60 days unless we give you notice that we need an extra 30

days. We may not charge you for the first list, but may charge you if you ask for a list

more than once a year. The list will not include disclosures before April 14, 2003, or

disclosure (a) for payment or health care operations, (b) as authorized by you, and (c) for

certain other activities, including disclosures to you. Your request must be in writing and

should specify a time period of up to six years. The request should be sent to the

ProHealth Care Human Resources Department, at 725 American Ave., POB Suite 305,

Waukesha, WI 53188.

6. Obtain a Copy of This Notice. A paper copy of this Notice will be provided to you even

if you have received this Notice by electronic mail (e-mail). Even if you received a copy

of this notice before, you may still be asked to sign that you have received the Notice.

You may ask us to give you a paper or electronic copy of this Notice at any time. To

obtain a paper copy of this Notice, send your written request to the ProHealth Care

Human Resources Department, at 725 American Ave., POB Suite 305, Waukesha, WI

53188. You may also obtain a copy of this Notice from the iNet or Employee Self-Service

(ESS).

7. Right to be Notified of a Breach. You will be notified in the event of a breach of your

unsecured health information.

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Changes to this Notice and Distribution

We reserve the right to change our Notice of Privacy Practices at any time. Any changes to this

Notice will apply to all the health information we keep, including health information we created or

received before we made the changes, as well as any records we receive or create in the future.

As your health plan, we will provide a copy of our notice upon your enrollment to the plan and will

remind you at least every three years where to find our notice and how to obtain a copy of the notice

if you would like to receive one. If we have more than one Notice of Privacy Practices, we will

provide you with the Notice that pertains to you. The notice is provided to the named insured of the

plan and will pertain to the insured and dependents named under this insured.

As a health plan that maintains a website describing our customer service and benefits, we also post

to our website the most recent Notice of Privacy Practices which will describe how your health

information may be used and disclosed as well as the rights you have to your health information. If

our Notice has a material change, we will post information regarding this change to the website for

you to review. In addition, following the date of the material change, we will include a description of

the change that occurred and information on how to obtain a copy of the revised Notice in our annual

mailing to all individuals then covered by the plan.

Complaint Filing

If you believe your privacy rights have been violated, you may file a complaint with the ProHealth

Care Privacy Officer or with the Secretary of the Department of Health and Human Services, Office

of Civil Rights. We will not retaliate against you for filing such a complaint.

You may submit your request in writing to:

File a complaint or to comment on our privacy practices.

Amend your health information.

Access your health information.

Restrict certain used and disclosures.

Receive confidential communications.

Receive a listing of disclosures.

All requests in writing should be sent to ProHealth Care Human Resources Department at 725

American Ave., POB Suite 305, Waukesha, WI 53188.

You may contact the ProHealth Care Privacy Officer directly at (262) 928-4977, or leave a message

on the ProHealth Care Compliance Hotline at (262) 928-2415.

Communicating with Patients with Limited English Proficiency

Available Language Assistance Services

ATTENTION: If you do not speak English, language assistance services, free of charge, are

available to you. Call María Teresa Fernandez, Interpreter Services, is 1-262-928-4929 (TTY Relay

System is 1-800-874-9426).

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ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.

Llame María Teresa Fernandez, Servicios de Interpretación al 1-262-928-4929 (TTY Relay System

es: 1-800-874-9426).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen

zur Verfügung. Rufnummer: María Teresa Fernandez, 1-262-928-4929 (TTY 1-800-874-9426).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 María Teresa Fernandez,

1-262-928-4929 (TTY 1-800-874-9426)

ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés

gratuitement. Appelez le María Teresa Fernandez, 1-262-928-4929 (ATS 1-800-874-9426).

ध्यान दें: यदद आप ह िंदी बोलते हैं तो आपके ललए मुफ्त में भाषा सहायता सेवाए ंउपलब्ध हैं। María Teresa

Fernandez, 1-262-928-4929 (TTY 1-800-874-9426) पर कॉल करें।

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza

linguistica gratuiti. Chiamare il numero María Teresa Fernandez, 1-262-928-4929 (TTY 1-800-874-

9426).

خبردار: اگر آپ اردو بولتے ہیں، تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں کریں

María Teresa Fernandez, 1-262-928-4929 (TTY 1-800-874-9426).۔ کال

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. María Teresa

Fernandez, 1-262-928-4929 (TTY 1-800-874-9426).번으로 전화해 주십시오.

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số

María Teresa Fernandez, 1-262-928-4929 (TTY 1-800-874-9426).

OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno.

Nazovite Maria Teresa Fernandez 1-262-928-4929 Telefon za osobe sa oštećenim govorom ili

sluhom: 1-800-874-9426.

María Teresa Fernandez, 1-262-928-

4929 (TTY 1-800-874-9426).


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ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι

οποίες παρέχονται δωρεάν. Καλέστε María Teresa Fernandez, 1-262-928-4929 (TTY 1-800-874-

9426).

LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau


UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń

pod numer María Teresa Fernandez, 1-262-928-4929 (TTY 1-800-874-9426).

This communication regarding Available Language Assistance Services is effective by law October

16, 2016; however, the Language Assistance Services are available immediately and during open

enrollment.

Please contact the ProHealth Care Privacy Officer if you have any questions about this Notice or if

you want more information about the Privacy Practices at ProHealth Care Plan.

This Notice of Privacy Practices is effective September 21, 2016.

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Wellness Program Disclosure

The Employee Health and Wellness Program is a voluntary wellness program available to all ProHealth Care employees. This ProHealth Care Notice for Employer-Sponsored Wellness Program (Employer Notice), and including the ProHealth Care Health, Dental and Vision Plan Notice of Privacy Practices (Notice of Privacy Practices), tells how medical information about you obtained through the Employee Health and Wellness Program may be used, disclosed and protected by ProHealth Care, and how you can get access to this information. Please review these Notices carefully.

ProHealth Care and the ProHealth Care Health, Dental and Vision Plan are dedicated to keeping your Employee Health and Wellness Program health information private and secure. We are providing the following information to assure you that your information is treated as confidential, and used only for health plan administration, wellness program and other limited authorized purposes. When we release your health information, we make reasonable efforts to limit the use and release only the minimum necessary information, and to those persons needed for the specific purpose. The Employee Health and Wellness Program is designed and administered according to federal rules and laws permitting employer-sponsored wellness programs. Together they seek to improve employee health, identify potential health risks, prevent disease and protect your privacy. This authority includes the Americans with Disabilities Act of 1990 (ADA), the Genetic Information Nondiscrimination Act of 2008 (GINA), the Health Insurance Portability and Accountability Act (HIPAA), and the Affordable Care Act of 2010 (ACA), among other laws.

To summarize, as an employer offering a wellness program and a group health plan we are required by law to maintain the privacy of your health information and to provide you with these Notices of our legal duties and privacy practices with respect to your health information. These Notices provide you with the following important information:

What type of medical information will be obtained in the Employee Health and Wellness

Program and the specific purposes for which it will be used by ProHealth Care (Employer

Notice), and the ProHealth Care Health, Dental and Vision Plan (Notice of Privacy Practices),

Protections from disclosure of an employee’s medical information publically, and by ProHealth

Care as your employer and as an ADA covered entity (Employer Notice);

How the ProHealth Care Health Dental and Vision Plan as a HIPAA covered entity specifically uses

and discloses your protected health information , HIPAA restrictions on disclosure and sharing

of information, the methods used to prevent improper disclosure including compliance with

HIPAA regulations (Notice of Privacy Practices),your HIPAA privacy rights with regard to your

protected health information (Notice of Privacy Practices), and

Our Health, Dental and Vision Plan obligation to you concerning the use and disclosure of your protected health information (Notice of Privacy Practices).

EEOC Notice Regarding What Medical Information Is Obtained Through The ProHealth Care Employee Health and Wellness Program Employee Health and Wellness is a voluntary ProHealth Care wellness program intended to continually improve health for ProHealth Care employees. Additional economic incentives are available to employees and covered spouses who choose to participate in certain wellness activities, including WellAware 2016-2017, a voluntary health risk assessment (HRA) health survey, biometric screening, and who obtain a negative nicotine test score.

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The HRA is a web-based (OneCommunity) health survey that asks you a series of questions

about health-related activities, to identify individual injury risk factors, modifiable risks,

health needs, behaviors, medical conditions and chronic diseases (e.g., cancer, diabetes,

hypertension or heart disease).

The biometric screening measures height, weight, blood pressure, fasting lipid profile

(cholesterol, LDL, HDL, triglycerides), blood glucose. Employee Health and Wellness also includes incentives through a comprehensive, six-month medically supervised Weight Management Program, a three-month program of wellness and dietician coaching Jump Start Program, and an individualized, holistic care Diabetic Improvement Program. Participation in these programs may also require obtaining medical information through biometric screening measures and other patient information to assess medical, behavioral, physical and nutritional needs and to motivate positive change. If it is unreasonably difficult due to a medical condition for you to achieve the standards for incentives or reward under this program, or if it is medically inadvisable for you to attempt to achieve the standards, call us at (262) 560-4915 and we will work with you to develop another way to qualify. This information and other incentives are intended to promote health, manage disease, and provide follow-up results, interventions and options to improve health outcomes to benefit you and our community. It may also be used to offer you services through the wellness program. You are encouraged to share your results or concerns with your own doctor. The Wellness Program experience, combined with education, community support, other resources and personal motivators, creates momentum and a path for achievable, sustainable, positive change. Protections from Disclosure of Medical Information Publically and by ProHealth Care Individual information is collected and maintained on separate forms, in encrypted electronic files. This is separate from your personnel records, and treated as a confidential medical record. Medical information collected through the Employee Health and Wellness Program will not be disclosed publically and may never be used to make decisions regarding your employment. It only may be provided to your employer, ProHealth Care, in aggregate terms that do not disclose, or are not reasonably likely to disclose your identity, or the identity of other specific individuals, except for these specific, limited purposes:

Individual information may be provided to ProHealth Care as sponsor, as needed to administer

the ProHealth Care Health, Dental and Vision Plan (as further discussed in the Notice of Privacy

Practices section, “How ProHealth Care Health, Dental and Vision Plan May Use or Disclose Your

Health Information”);

Individual information may be provided to ProHealth Care as needed to carry out specific

activities related to the ProHealth Care Employee Health and Wellness Program, and to offer

you services or information related to your health and potential risks through the wellness

Program; or

Individual medical information may be provided to your ProHealth Care supervisors or

managers in limited situations to assist persons with disabilities in accordance with

confidentiality and non-discrimination laws. (e.g., ADA compliance, if you request a reasonable

accommodation; first aid to disabled person in the case of emergency). This Notice for Employer-Sponsored Wellness Program is effective for the ProHealth Care Health, Dental and Vision Plan year effective January 1, 2017.

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Newborns’ and Mothers’ Health Protection Act of 1996

In accordance with the Newborns’ and Mothers’ Health Protection Act of 1996, the Medical Plan does not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a Cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable), after consulting with the mother. In any case, the Medical Plan does not require that the provider obtain authorization for prescribing a length of stay shorter than 48 hours (or 96 hours).

Women’s Health and Cancer Rights Act of 1988

In compliance with the Women’s Health and Cancer Rights Act of 1998, the Medical Plan provides coverage for the following medical conditions in conjunction with a mastectomy:

Reconstruction of the breast on which the mastectomy was performed.

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

Prosthesis and treatment of physical complications in all stages of mastectomy, including lymphedemas.

These services will be provided in a manner determined in consultation with the attending physician and the patient. Coverage is subject to applicable deductibles and coinsurance amount that apply to other benefits under the Plan.

Summary of Benefits and Coverage (SBC) The Affordable Care Act (ACA) requires health plans and health issuers to provide applicants and enrollees with a concise document providing simple and consistent information about the health plan benefits and coverage. This document is called a Summary of Benefits and Coverage (SBC). The SBC is available on Employee Self Service (ESS) under Benefit Information and on the I-Net under the Medical Plan. For a paper copy, e-mail Human Resources at [email protected] or call Human Resources at 262-928-4185.


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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 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).

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 –

ALABAMA – Medicaid FLORIDA – Medicaid

Website: http://myalhipp.com/

Phone: 1-855-692-5447

Website: http://flmedicaidtplrecovery.com/hipp/

Phone: 1-877-357-3268

ALASKA – Medicaid GEORGIA – Medicaid

The AK Health Insurance Premium Payment Program

Website: http://myakhipp.com/

Phone: 1-866-251-4861

Email: [email protected]

Medicaid Eligibility:

http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: http://dch.georgia.gov/medicaid

- Click on Health Insurance Premium Payment (HIPP)

Phone: 404-656-4507

ARKANSAS – Medicaid INDIANA – Medicaid

Website: http://myarhipp.com/

Phone: 1-855-MyARHIPP (855-692-7447)

Healthy Indiana Plan for low-income adults 19-64

Website: http://www.hip.in.gov

Phone: 1-877-438-4479

All other Medicaid

Website: http://www.indianamedicaid.com

Phone 1-800-403-0864

http://www.healthcare.gov/

http://www.insurekidsnow.gov/

http://www.askebsa.dol.gov/

http://myalhipp.com/

http://flmedicaidtplrecovery.com/hipp/

http://myakhipp.com/


http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

http://dch.georgia.gov/medicaid

http://myarhipp.com/

http://www.hip.in.gov/

http://www.indianamedicaid.com/

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COLORADO – Medicaid IOWA – Medicaid

Medicaid Website: http://www.colorado.gov/hcpf

Medicaid Customer Contact Center: 1-800-221-3943

Website: http://www.dhs.state.ia.us/hipp/

Phone: 1-888-346-9562

KANSAS – Medicaid NEW HAMPSHIRE – Medicaid

Website: http://www.kdheks.gov/hcf/

Phone: 1-785-296-3512

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf

Phone: 603-271-5218

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP

Website: http://chfs.ky.gov/dms/default.htm

Phone: 1-800-635-2570

Medicaid Website:

http://www.state.nj.us/humanservices/

dmahs/clients/medicaid/

Medicaid Phone: 609-631-2392

CHIP Website: http://www.njfamilycare.org/index.html

CHIP Phone: 1-800-701-0710

LOUISIANA – Medicaid NEW YORK – Medicaid

Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331

Phone: 1-888-695-2447

Website: http://www.nyhealth.gov/health_care/medicaid/

Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – Medicaid

Website: http://www.maine.gov/dhhs/ofi/public-

assistance/index.html

Phone: 1-800-442-6003

TTY: Maine relay 711

Website: http://www.ncdhhs.gov/dma

Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid

Website: http://www.mass.gov/MassHealth

Phone: 1-800-462-1120

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/

Phone: 1-844-854-4825

MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP

Website: http://mn.gov/dhs/ma/

Phone: 1-800-657-3739

Website: http://www.insureoklahoma.org

Phone: 1-888-365-3742

MISSOURI – Medicaid OREGON – Medicaid

Website:

http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

Phone: 573-751-2005

Website: http://healthcare.oregon.gov/Pages/index.aspx

http://www.oregonhealthcare.gov/index-es.html

Phone: 1-800-699-9075

MONTANA – Medicaid PENNSYLVANIA – Medicaid

Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP

Phone: 1-800-694-3084

Website: http://www.dhs.pa.gov/hipp

Phone: 1-800-692-7462

NEBRASKA – Medicaid RHODE ISLAND – Medicaid

Website:

http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pag

es/accessnebraska_index.aspx

Phone: 1-855-632-7633

Website: http://www.eohhs.ri.gov/

Phone: 401-462-5300

NEVADA – Medicaid SOUTH CAROLINA – Medicaid

Medicaid Website: http://dwss.nv.gov/

Medicaid Phone: 1-800-992-0900

Website: http://www.scdhhs.gov

Phone: 1-888-549-0820

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid

Website: http://dss.sd.gov

Phone: 1-888-828-0059

Website: http://www.hca.wa.gov/free-or-low-cost-health-

care/program-administration/premium-payment-program

Phone: 1-800-562-3022 ext. 15473

http://www.colorado.gov/hcpf

http://www.dhs.state.ia.us/hipp/

http://www.kdheks.gov/hcf/

http://www.dhhs.nh.gov/oii/documents/hippapp.pdf

http://chfs.ky.gov/dms/default.htm

http://www.state.nj.us/humanservices/dmahs/clients/medicaid/

http://www.state.nj.us/humanservices/dmahs/clients/medicaid/

http://www.njfamilycare.org/index.html

http://dhh.louisiana.gov/index.cfm/subhome/1/n/331

http://www.nyhealth.gov/health_care/medicaid/

http://www.maine.gov/dhhs/ofi/public-assistance/index.html

http://www.maine.gov/dhhs/ofi/public-assistance/index.html

http://www.ncdhhs.gov/dma

http://www.mass.gov/MassHealth

http://www.nd.gov/dhs/services/medicalserv/medicaid/

http://mn.gov/dhs/ma/

http://www.insureoklahoma.org/

http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

http://healthcare.oregon.gov/Pages/index.aspx

http://www.oregonhealthcare.gov/index-es.html

http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP

http://www.dhs.pa.gov/hipp

http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/accessnebraska_index.aspx

http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/accessnebraska_index.aspx

http://www.eohhs.ri.gov/

http://dwss.nv.gov/

http://www.scdhhs.gov/

http://dss.sd.gov/

http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program

http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program

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TEXAS – Medicaid WEST VIRGINIA – Medicaid

Website: http://gethipptexas.com/

Phone: 1-800-440-0493

Website:

http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/def

ault.aspx

Phone: 1-877-598-5820, HMS Third Party Liability

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP

Website:

Medicaid: http://health.utah.gov/medicaid

CHIP: http://health.utah.gov/chip

Phone: 1-877-543-7669

Website:

https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf

Phone: 1-800-362-3002

VERMONT– Medicaid WYOMING – Medicaid

Website: http://www.greenmountaincare.org/

Phone: 1-800-250-8427

Website: https://wyequalitycare.acs-inc.com/

Phone: 307-777-7531

VIRGINIA – Medicaid and CHIP

Medicaid Website:

http://www.coverva.org/programs_premium_assistance.cfm

Medicaid Phone: 1-800-432-5924

CHIP Website:


CHIP Phone: 1-855-242-8282

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. Department of Health and Human Services

Employee Benefits Security Administration Centers for Medicare & Medicaid Services

www.dol.gov/ebsa www.cms.hhs.gov

1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to

respond to a collection of information unless such collection displays a valid Office of Management and

Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a

collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB

control number, and the public is not required to respond to a collection of information unless it displays a

currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law,

no person shall be subject to penalty for failing to comply with a collection of information if the collection of

information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately seven

minutes per respondent. Interested parties are encouraged to send comments regarding the burden

estimate or any other aspect of this collection of information, including suggestions for reducing this burden,

to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research,

Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or

email [email protected] and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 10/31/2016)

http://gethipptexas.com/

http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspx

http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspx

http://health.utah.gov/medicaid

http://health.utah.gov/chip

https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf

http://www.greenmountaincare.org/

https://wyequalitycare.acs-inc.com/



http://www.dol.gov/ebsa

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


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Important Notice from ProHealth Care, Inc. 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 ProHealth Care, Inc. 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. ProHealth Care, Inc. has determined that the prescription drug coverage offered by ProHealth Care, Inc. is, on average for all plan participants, expected to pay out 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 ProHealth Care, Inc. coverage will not be affected. You can keep this coverage if you elect Part D and this plan will coordinate with Part D coverage. If you do decide to join a Medicare drug plan and drop your current ProHealth Care, Inc. 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 ProHealth Care, Inc. 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.

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For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the office listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through ProHealth Care, Inc. changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:

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, therefore, whether or not you are required to pay a higher premium (a penalty). Date: October 1, 2016 Name of Entity/Sender: ProHealth Care, Inc. Contact: Office: Human Resources Address: 725 American Ave., POB Suite 305

Waukesha, WI 53188-1131 Phone Number: 262-928-4185

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EMPLOYEE RIGHTS AND RESPONSIBILITIES

UNDER THE FAMILY AND MEDICAL LEAVE ACT

Basic Leave Entitlement FMLA requires covered employers to provide up to 12 weeks of unpaid, job-

protected leave to eligible employees for the following reasons:

• for incapacity due to pregnancy, prenatal medical care or child birth;

• to care for the employee’s child after birth, or placement for adoption or

foster care;

• to care for the employee’s spouse, son, daughter or parent, who has a serious

health condition; or

• for a serious health condition that makes the employee unable to

perform the employee’s job.

a regimen of continuing treatment, or incapacity due to pregnancy, or incapacity due to a

chronic condition. Other conditions may meet the definition of continuing treatment.

Use of Leave

An employee does not need to use this leave entitlement in one block. Leave can be

taken intermittently or on a reduced leave schedule when medically necessary.

Employees must make reasonable efforts to schedule leave for planned medical treatment

so as not to unduly disrupt the employer’s operations. Leave due to qualifying exigencies

may also be taken on an intermittent basis.

Military Family Leave Entitlements

Eligible employees whose spouse, son, daughter or parent is on covered active

duty or call to covered active duty status may use their 12-week leave entitlement

to address certain qualifying exigencies. Qualifying exigencies may include

attending certain military events, arranging for alternative childcare, addressing

certain financial and legal arrangements, attending certain counseling sessions,

and attending post-deployment reintegration briefings.

FMLA also includes a special leave entitlement that permits eligible

employees to take up to 26 weeks of leave to care for a covered service-

member during a single 12-month period. A covered service member is:

(1) a current member of the Armed Forces, including a member of the

National Guard or Reserves, who is undergoing medical treatment,

recuperation or therapy, is otherwise in outpatient status, or is otherwise on

the temporary disability retired list, for a serious injury or illness*; or (2) a

veteran who was discharged or released under conditions other than

dishonorable at any time during the five-year period prior to the first date the

eligible employee takes FMLA leave to care for the covered veteran, and who

is undergoing medical treatment, recuperation, or therapy for a serious injury

or illness.*

*The FMLA definitions of “serious injury or illness” for current

service members and veterans are distinct from the FMLA

definition of “serious health condition”.

Benefits and Protections

During FMLA leave, the employer must maintain the employee’s health

coverage under any “group health plan” on the same terms as if the employee

had continued to work. Upon return from FMLA leave, most employees must

be restored to their original or equivalent positions with equivalent pay,

benefits, and other employment terms.

Use of FMLA leave cannot result in the loss of any employment benefit that

accrued prior to the start of an employee’s leave.

Eligibility Requirements

Employees are eligible if they have worked for a covered employer for at least

12 months, have 1,250 hours of service in the previous 12 months*, and if at

least 50 employees are employed by the employer within 75 miles.

*Special hours of service eligibility requirements apply to airline

flight crew employees.

Definition of Serious Health Condition

A serious health condition is an illness, injury, impairment, or physical or

mental condition that involves either an overnight stay in a medical care

facility, or continuing treatment by a health care provider for a condition that

either prevents the employee from performing the functions of the employee’s

job, or prevents the qualified family member from participating in school or

other daily activities.

Subject to certain conditions, the continuing treatment requirement may be

met by a period of incapacity of more than 3 consecutive calendar days

combined with at least two visits to a health care provider or one visit and

Substitution of Paid Leave for Unpaid Leave

Employees may choose or employers may require use of accrued paid leave while taking

FMLA leave. In order to use paid leave for FMLA leave, employees must comply with

the employer’s normal paid leave policies.

Employee Responsibilities

Employees must provide 30 days advance notice of the need to take FMLA leave when

the need is foreseeable. When 30 days notice is not possible, the employee must provide

notice as soon as practicable and generally must comply with an employer’s normal call-

in procedures.

Employees must provide sufficient information for the employer to determine if the leave

may qualify for FMLA protection and the anticipated timing and duration of the leave.

Sufficient information may include that the employee is unable to perform job functions,

the family member is unable to perform daily activities, the need for hospitalization or

continuing treatment by a health care provider, or circumstances supporting the need for

military family leave. Employees also must inform the employer if the requested leave is

for a reason for which FMLA leave was previously taken or certified. Employees also

may be required to provide a certification and periodic recertification supporting the need

for leave.

Employer Responsibilities

Covered employers must inform employees requesting leave whether they are eligible

under FMLA. If they are, the notice must specify any additional information required as

well as the employees’ rights and responsibilities. If they are not eligible, the employer

must provide a reason for the ineligibility.

Covered employers must inform employees if leave will be designated as FMLA-

protected and the amount of leave counted against the employee’s leave entitlement. If

the employer determines that the leave is not FMLA-protected, the employer must notify

the employee.

Unlawful Acts by Employers

FMLA makes it unlawful for any employer to:

interfere with, restrain, or deny the exercise of any right provided under FMLA; and

discharge or discriminate against any person for opposing any practice made

unlawful by FMLA or for involvement in any proceeding under or relating to FMLA.

Enforcement

An employee may file a complaint with the U.S. Department of Labor or may bring a

private lawsuit against an employer.

FMLA does not affect any Federal or State law prohibiting discrimination, or supersede

any State or local law or collective bargaining agreement which provides greater family

or medical leave rights.

FMLA section 109 (29 U.S.C. § 2619) requires FMLA covered employers

to post the text of this notice. Regulation 29 C.F.R. § 825.300(a) may

require additional disclosures.

For additional information:

1-866-4US-WAGE (1-866-487-9243) TTY: 1-877-889-5627

WWW.WAGEHOUR.DOL.GOV

of Labor U.S. Department of Labor /Wage and Hour Division

2017 Benefits Decision Guide - ProHealth Care Benefits Decision Guide. 2 ... Upon hire (minimum age...

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