2018 Mercyhealth Partner Benefits Book...• Vision Insurance • MetLife critical illness,...

2018 Mercyhealth Partner Benefits Book

Table of Contents

Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Health insurance benefits overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

CHIP notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

MercyCare EPO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

EPO Summary of coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

MercyCare EPO HDHP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

EPO HDHP Summary of coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

MercyCare PPO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

PPO Summary of coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

MercyCare PPO HDHP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

PPO HDHP Summary of coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Prescription drug coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Dental insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Vision appliance insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Life insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Mercy Health Corporation employees’ retirement plan . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Flex spending plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Voluntary benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Short-term disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Long-term disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Domestic partner coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Important contact information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Qualifying event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Mercyhealth Benefits

Welcome to our 2018 partner benefit bookWhether you are reviewing this at Open Enrollment or if you’re a new hire, this book is filled with important information for you and your family .

Our partners are our most valuable resource . As such, Mercyhealth is committed to offering a comprehensive partner benefit program with multiple options to meet the varied needs of our partners . Health and dental premiums are paid with pre-tax dollars and we offer multiple ways for partners to set aside other pre-tax dollars with flexible spending accounts and health savings accounts . Some benefits are paid for completely by Mercyhealth, some the cost is shared, and for a few voluntary options, the partner pays the entire cost but enjoys the benefit of group pricing .

We encourage you to review the materials thoroughly and make your decisions carefully . Please contact your Human Resources representatives if you would like additional information or have any questions about these benefits, policies or services .

Programs and policies can be modified, changed or discontinued at any time at the discretion of Mercyhealth .

Coverage begins: For open enrollment, January 1, 2018 .

For a new partner, or newly benefit eligible partner, under the following schedule:

First of the month following 30 days of employment or eligibility • Health insurance • Dental insurance • Vision Insurance • MetLife critical illness, accident, hospitalization and

pet insurance • Flex spending accounts

First of the month following 90 days of employment or eligibility • Life insurance

• Universal life insurance

• Short-term disability

• Long-term disability

ImportantPlease refer to summary plan descriptions or plan documents for additional information . If there is a conflict between this material and the plan documents, the plan documents govern .

1

Be sure to readthis booklet carefully before making your benefit selections .

This booklet is a summary of benefits available .

Contact Human Resources for additional information .

Health insurance benefits overviewVendor: MercyCare

You and Mercyhealth share responsibility for the cost of the health care coverage for you, your spouse/ domestic partner, and qualified dependents . Under the Affordable Care Act, eligibility is determined by the number of hours you work over a pre-determined eligibility period . Partners who work an average of 30 hours per week or more are considered full-time for health insurance premium purposes .

Partners who work an average of 20-29 hours per week are considered part-time for health insurance premium purposes . Your premium contribution also depends on who is covered and the type of plan you choose .

Partners and their spouse/domestic partner enrolling in health insurance that are tobacco-free will be eligible for a reduction in their health insurance premium . To receive the appropriate premium, partners and their spouse/domestic partner must attest that they are tobacco-free when enrolling online .

Partners eligible for health insurance who choose not to elect coverage are required to waive coverage . Partners who do not enroll or waive coverage will automatically be enrolled in the MercyCare EPO HDHP plan.

2

Non-Tobacco User Tobacco User

MercyCare EPO

Full-Time

Part-Time

Partner + Child(ren)

Partner

Partner + Spouse

Partner + Family


Partner

Partner + Spouse

Partner + Family $1,114 .36

$639 .00

$733 .06

$344 .50

$1,006 .84

$579 .46

$663 .92

$314 .26

$837 .20

$485 .48

$555 .12

$267 .74

$763 .31

$443 .12

$507 .86

$246 .56

$1,064 .36

$589 .00

$683 .06

$294 .50

$956 .84

$529 .46

$613 .92

$264 .26

$787 .20

$435 .48

$505 .12

$217 .74

$713 .31

$393 .12

$457 .86

$196 .56

$699 .00

$391 .00

$466 .50

$220 .50

$633 .44

$356 .54

$424 .34

$203 .28

$530 .00

$302 .12

$358 .00

$139 .52

$470 .67

$268 .40

$320 .02

$159 .20

$649 .00

$341 .00

$416 .50

$170 .50

$583 .44

$306 .54

$374 .34

$153 .28

$480 .00

$252 .12

$308 .00

$89 .52

$420 .67

$218 .40

$270 .02

$109 .20

MercyCare EPO HDHP

MercyCare PPO

MercyCare PPO HDHP

MercyCare EPO

MercyCare EPO HDHP

MercyCare PPO

MercyCare PPO HDHP

Monthly Premium Contributions

Self-Employed Family Members: MercyCare insurance plans do not cover health care costs related to injuries on the job . Mercyhealth partners with self-employed family members are advised to obtain workers compensation coverage for those members who are on their MercyCare plan .

Domestic Partner Coverage: Health insurance coverage is an eligible domestic partner benefit . See page 25 for details .

3

CHIP notificationPremium 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 Mercyhealth, the state you live in 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 Wisconsin, you can contact the Wisconsin Medicaid office at (800) 362-3002, or view (https://www .dhs .wisconsin .gov/publications/p1/p100095 .pdf) to find out if premium assistance is available .

If you or your dependents are already enrolled in Medicaid or CHIP and you live in Illinois, you can contact the Illinois Comprehensive Health Insurance Plan at (800) 962-8384 or email infodesk .chip@illinois .gov .

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your state Medicaid or CHIP office or dial (877) KIDS NOW or visit insurekidsnow.gov to find out how to apply . If you qualify, you can 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 a MercyCare health insurance plan, Mercyhealth must allow you to enroll in a 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 a health insurance plan contact the Department of Labor at askebsa.dol.gov or (866) 444-EBSA (3272) .

If you live in a state other than Wisconsin and you would like to see if a premium assistance program is available or you would like more information on special enrollment rights, you can contact either:

U.S. Department of Labor Employee Benefits Security Administration

www .dol .gov/ebsa

(866) 444-EBSA (3272)

U.S. Department of Health and Human ServicesCenters for Medicare & Medicaid Services

www .cms .hhs .gov

(877) 267-2323, ext . 61565

Health insurance eligibility for adult child(ren)Your adult child(ren) can be added to your MercyCare health insurance plan at the time of hire, qualifying event or open enrollment if they are less than 26 years old (regardless of marital status) .

Your adult child(ren) can choose to stay on your health plan until the end of the month in which they turn age 26, even if they are eligible for their own employer-sponsored insurance plan .

Military dependent–requires individual consultation .

4

MercyCare EPO summary of benefitsThe foundation of MercyCare Health Plans is to have each MercyCare member develop a caring, professional relationship with a Primary Care Physician (PCP) who will coordinate and manage their medical care . All MercyCare plans require members to use the provider network established except in the case of emergency care .

Provider network This is a group of providers contracted with the plan to provide services for members within a specific geographic location as specified in MercyCare’s Provider Directory . A participating provider is a specific provider who is listed in the MercyCare Provider Directory as a participating provider in the specific network .

Choosing a primary care physician (PCP) A PCP is a doctor who practices in one or more of these fields: Family Medicine, Internal Medicine and Pediatrics . Each family member must select a doctor in one of these fields . Women may select an OB/GYN for routine gynecologic and obstetrical care, yet must still select a PCP for all other services . Please refer to our Provider Directory for a complete list of network PCPs .

Specialist providers MercyCare Health Plans has a comprehensive list of specialists to meet the health care needs of its members . You do not need a referral from your PCP to see any network specialists, but you are encouraged to coordinate specialist care with your PCP .

Emergency care Members who have a medical emergency within the MercyCare service area should, if possible, seek immediate attention at the nearest network provider . Members who have a medical emergency outside the MercyCare network should seek care at the nearest emergency facility . MercyCare should be notified within 48 hours, or as soon as possible .

MercyCare EPOMonthly premium contribution

Non-Tobacco UserMercyCare EPO

Full-Time

Part-Time


Partner

Partner + Spouse

Partner + Family


Partner

Partner + Spouse

Partner + Family $763 .31

$443 .12

$507 .86

$246 .56

$713 .31

$393 .12

$457 .86

$196 .56

$470 .67

$268 .40

$320 .02

$159 .20

$420 .67

$218 .40

$270 .02

$109 .20

Tobacco UserMercyCare EPO

5

Deductible

Coinsurance

Office visit charge-Primary Care Provider

Office visit charge-Specialist

Medical maximum out of pocket

RX maximum out of pocket

Preventive services

Diagnostic services (lab and x-ray) includes office location

Hospital inpatient services**

Hospital outpatient services**

Emergency room charge (waived upon admission)

Ambulance

Urgent and immediate care charge

Mental health inpatient**

Mental health day treatment**

Mental health outpatient

Durable medical equipment & prosthetics

Physical, speech and occupational therapy

Stay Healthy Benefit

$0 single, $0 family

10% coinsurance

$30 copay

$40 copay

$3,000 single, $6,000 family


$0

10% coinsurance

$750 copay per hospital admission per stay per member . 10% coinsurance

10% coinsurance

$100 copay

$0

$50 copay


10% coinsurance

$30 copay

20% coinsurance

10% coinsurance

$200 maximum benefit per year per adult / $400 maximum per family

N/A

N/A

N/A

N/A

N/A

N/A

Not covered

Not covered

Not covered

Not covered

$100 copay

$0

$60 copay

Not covered

Not covered

Not covered

Not covered

Not covered

N/A

Non-Network ProvidersYou Pay

**Prior authorization required for these services

Tier 1

Tier 2

Tier 3

Tier 4

Prescription Drug Coverage

$15 copay

$30 copay or 20% coinsurance up to max $50


25% coinsurance

Network ProvidersYou Pay

These benefits are a partial outline of health services under the Policy . Refer to your Schedule of Benefits for applicable limits to these health services . If differences exist between this Summary and the Summary Plan Description (SPD), the SPD governs .

EPO Summary of coverage

6

MercyCare EPO HDHP summary of benefitsThe foundation of MercyCare Health Plans is to have each MercyCare member develop a caring, professional relationship with a Primary Care Physician (PCP) who will coordinate and manage their medical care . All MercyCare plans require members to use the provider network established except in the case of emergency care .

Provider network This is a group of providers contracted with the plan to provide services for members within a specific geographic location as specified in MercyCare’s Provider Directory . A participating provider is a specific provider who is listed in the MercyCare Provider Directory as a participating provider in the specific network .

Choosing a primary care physician (PCP) A PCP is a doctor who practices in one or more of these fields: Family Medicine, Internal Medicine and Pediatrics . Each family member must select a doctor in one of these fields . Women may select an OB/GYN for routine gynecologic and obstetrical care, yet must still select a PCP for all other services . Please refer to our Provider Directory for a complete list of network PCPs .

Specialist providers MercyCare Health Plans has a comprehensive list of specialists to meet the health care needs of its members . You do not need a referral from your PCP to see any network specialists, but you are encouraged to coordinate specialist care with your PCP .

Emergency care Members who have a medical emergency within the MercyCare service area should, if possible, seek immediate attention at the nearest network provider . Members who have a medical emergency outside the MercyCare network should seek care at the nearest emergency facility . MercyCare should be notified within 48 hours, or as soon as possible .

MercyCare EPO High deductible health plan (HDHP)Monthly premium contribution

Non-Tobacco UserMercyCare EPO HDHP

Full-Time

Part-Time


Partner

Partner + Spouse

Partner + Family


Partner

Partner + Spouse

Partner + Family $837 .20

$485 .48

$555 .12

$267 .74

$787 .20

$435 .48

$505 .12

$217 .74

$530 .00

$302 .12

$358 .00

$139 .52

$480 .00

$252 .12

$308 .00

$89 .52

Tobacco UserMercyCare EPO HDHP

7


Deductible

Coinsurance


Office visit charge-Specialist

Medical and RX maximum out of pocket

Preventive services

Diagnostic services (lab and x-ray)




Ambulance

Urgent and immediate care charge

Mental Health inpatient**

Mental Health day treatment**

Mental Health outpatient

Durable medical equipment and prosthetics




0% coinsurance after deductible




$0












$200 maximum benefit per adult / $400 maximum per family

N/A

N/A

N/A

N/A

Not covered

Not covered

Not covered

Not covered




Not covered

Not covered

Not covered

Not covered

Not covered

Non-Network ProvidersYou Pay


Tier 1-4



Network ProvidersYou Pay

Health Savings Account (HSA). Partners choosing this plan have the option to participate and make contributions to a Health Savings Account . The money that contribute to your HSA is portable, meaning that it is not subject to the “use it or lose it” rules that Flex Spending Accounts (FSA) have and can be carried over from year to year . Partners who choose to participate in this plan and also participate in the Mercyhealth Flex Spending Account will be required to participate in a limited purpose Flex Spending Account .

EPO HDHP Summary of coverage

8

MercyCare PPO coverage levels and providersTier 1: MercyCare PPO provides the highest level of benefits whenever you obtain health care services from a Mercyhealth provider . Tier 1 providers are listed in the Provider Directory . The highest level of benefit is described in the Tier 1 Benefits column of the Schedule of Benefits . 1. On the web, go to mercycarehealthplans.com. 2. Click on find a doctor/facility . 3. Select MercyCare PPO and then follow the instructions .

Tier 2: Tier 2 providers are those who are not Tier 1 providers but are found in the First Health complementary network of providers . When you use this level of benefits, you pay a greater share of the cost of health care services you receive . This level of benefit is described in the Tier 2 Benefits column of the Schedule of Benefits . On the web go to firsthealthcomplementary.com to find the providers who are participating at this level . Please be aware that even though the following providers/hospital groups may be found on the First Health complementary website, they are not available to you as a Tier 2 provider: Aurora Health Care, Beloit Health System, SSM Health – formerly Dean Health System/St. Mary’s Hospital, OSF HealthCare System, Swedish American Health System.

Tier 3: A Tier 3 provider is any provider who is not listed in the MercyCare Provider Directory or on the First Health complementary website (excluding those providers listed above) . When you use this level of benefits, you pay the greatest share of the cost of health care services you receive . Tier 3 benefits are subject to usual and customary charge limitations . This tier of benefit is described in the Tier 3 benefits column of the Schedule of Benefits .

MercyCare PPOMonthly premium contribution

Non-Tobacco UserMercyCare PPO

Full-Time

Part-Time


Partner

Partner + Spouse

Partner + Family


Partner

Partner + Spouse


$579 .46

$663 .92

$314 .26

$956 .84

$529 .46

$613 .92

$264 .26

$633 .44

$356 .54

$424 .34

$203 .28

$583 .44

$306 .54

$374 .34

$153 .28

Tobacco UserMercyCare PPO

9


Deductible

Coinsurance


Office visit charge-specialist

Medical maximum out of pocket (Level 1 and Level 2 combined)

RX maximum out of pocket

Preventive Services

Diagnostic Services (lab and x-ray), includes office location




Ambulance

Urgent care charge








15 % coinsurance

$30 copay

$40 copay



$0

15% coinsurance


15% coinsurance

$100 copay

$0

$50 copay


15% coinsurance

$30 copay

20% coinsurance

15% coinsurance

$200 maximum benefit per adult / $400 maximum per family


25 % coinsurance

$50 copay

$60 copay

$0

25% coinsurance

$1,600 copay per hospital admission per stay per member . 25% coinsurance

25% coinsurance

$100 copay

$0

$75 copay


25% coinsurance

$50 copay

25% coinsurance

25% coinsurance

N/A

$0 single, $0 samily

50 % coinsurance

$60 copay

$70 copay

$8,000 Single, $16,000 Family

50% coinsurance

50% coinsurance


50% coinsurance

$100 copay

$0

$75 copay


50% coinsurance

$60 copay

50% coinsurance

50% coinsurance

N/A

Tier 1 Tier 2 Tier 3


Tier 1

Tier 2

Tier 3

Tier 4


$15 copay



25% coinsurance

PPO Summary of coverage

10

MercyCare PPO HDHP coverage levels and providersTier 1: MercyCare PPO provides the highest level of benefits whenever you obtain health care services from a Mercyhealth provider . Tier 1 providers are listed in the Provider Directory . The highest level of benefit is described in the Tier 1 Benefits column of the Schedule of Benefits . 1. On the web, go to mercycarehealthplans.com. 2. Click on find a doctor/facility . 3. Select MercyCare PPO and then follow the instructions .

Tier 2: Tier 2 providers are those who are not Tier 1 providers but are found in the First Health complementary network of providers . When you use this level of benefits, you pay a greater share of the cost of health care services you receive . This level of benefit is described in the Tier 2 Benefits column of the Schedule of Benefits . On the web go to firsthealthcomplementary.com to find the providers who are participating at this level . Please be aware that even though the following providers/hospital groups may be found on the First Health complementary website, they are not available to you as a Tier 2 provider: Aurora Health Care, Beloit Health System, SSM Health – formerly Dean Health System/St. Mary’s Hospital, OSF HealthCare System, Swedish American Health System.

Tier 3: A Tier 3 provider is any provider who is not listed in the MercyCare Provider Directory or on the First Health complementary website (excluding those providers listed above) . When you use this level of benefits, you pay the greatest share of the cost of health care services you receive . Tier 3 benefits are subject to usual and customary charge limitations . This tier of benefit is described in the Tier 3 benefits column of the Schedule of Benefits .

MercyCare PPO HDHPMonthly premium contribution

Non-Tobacco UserMercyCare PPO HDHP

Full-Time

Part-Time


Partner

Partner + Spouse

Partner + Family


Partner

Partner + Spouse


$639 .00

$733 .06

$344 .50

$1,064 .26

$589 .00

$683 .06

$294 .50

$699 .00

$391 .00

$466 .50

$220 .50

$649 .00

$341 .00

$416 .50

$170 .50

Tobacco UserMercyCare PPO HDHP

11


Deductible

Coinsurance


Office visit charge-specialist

Medical and RX maximum out of pocket (Integrated)


Preventive Services

Diagnostic services (lab and x-ray), includes office location




Ambulance

Urgent and immedicate care charge







0% coinsurance

0 after deductible

0 after deductible


100% coverage













0% coinsurance

0 after deductible

0 after deductible


100% coverage













0% coinsurance

0 after deductible

0 after deductible


100% coverage













** Prior authorization required for these services

Tier 1-4



$200 maximum benefit per year per adult / $400 maximum benefit per family

Health Savings Account (HSA). Partners choosing this plan have the option to participate and make contributions to a health savings account . The money you contribute to your HSA is portable, meaning that it is not subject to the “use it or lose it” rules that Flex Spending Accounts (FSA) have and can be carried over from year to year . Partners who choose to participate in this plan and also participate in the Mercyhealth Flex Spending Account, will be required to participate in a limited purpose Flex Spending Account .

PPO HDHP Summary of coverage

12

Prescription drug coverageFour-tier drug plan for MercyCare EPO and PPO plans

What is a four-tiered drug plan? It incorporates four levels of benefits .• Tier 1 is for preferred generic drugs . It has the lowest copay .• Tier 2 covers our preferred brand name drugs and some select generics . It has the second lowest copay .• Tier 3 represents all non-preferred brand and generic drugs .• Tier 4 represents specialty drugs and will have coinsurance .This drug plan uses a defined formulary, that lists covered drugs and tier placement . All drugs listed are available to our members unless otherwise determined to be excluded . Our designated Pharmacy Benefit Manager and/or MercyCare determine the placement of drugs within each tier of this formulary .

Other changes may occur to this formulary as determined by MercyCare or our designated Pharmacy Benefit Manager . A current formulary is available online at mercycarehealthplans.com .

Paying for your prescription Participating Pharmacy Benefits: Tier 1: Preferred Generic Drugs: • $15 copay per prescription drug order (30-day supply)Tier 2: Preferred Brand Name and Select Generic Drugs: • $30 minimum copay or 20% of total cost up to a maximum of $50 copay per prescription drug order

(30-day supply) Tier 3: Non-preferred Brand and Non-preferred Generic Drugs: • $100 minimum copay or 50% of total cost up to a maximum $150 copay per prescription drug order

(30-day supply) If the price of your prescription drug is less than your copay, you will pay the lower amount. Tier 4: Specialty Drugs: • 25% of total cost . They do not typically qualify for mail orderThe maximum out-of-pocket expense for this plan is $3,600 (single)/$7,200 (family) . After reaching the maximum out-of-pocket, prescriptions drugs are covered at 100% . If the price of your prescription drug is less than your copay, you will pay the lower amount .

Prior approval Certain formulary drugs require prior approval from MercyCare before coverage is provided . If you are on a medication and would like to know if it requires a prior approval, please call Customer Service at (800) 895-2421 .

Non-covered drugs• Fertility drugs .• Any drug or medicine that is taken by or administered to you while you are a patient in a licensed hospital,

rest home or sanitarium, extended care facility, convalescent hospital, skilled nursing facility or similar institution .

• Anti-obesity and anorexients .• Prescription drugs, that the eligible person is entitled to receive without charge from any Worker’s

Compensation laws or any municipal state or federal program .

13

• Any drug when used for a cosmetic treatment or for the treatment of the aging process .• Any drug when used for treatment of hair loss or excessive hair growth .• Any medication used to obtain, treat or enhance sexual performance and/or function . This includes

dysfunction caused by organic diseases .• Special formulations of covered drugs such as sustained release intended primarily for convenience of the

patient, as deemed by MercyCare, are not covered .• Special packaging of covered drugs intended primarily for convenience of the patient, as deemed by

MercyCare, are not covered .• Retin-A, for members age 40 and older .

Definitions Generic: A generic equivalent means a prescription drug available from more than one drug manufacturer that has the same active therapeutic ingredient as the brand or trade name prescription drug prescribed to you .

Preferred drug: Branded and generic drugs on our preferred drug list as determined by our designated Pharmacy Benefit Manager and MercyCare .

Non-preferred drug: All branded and generic drugs not on our preferred drug list .

Specialty drug: Drugs that typically require special storage, handling, or administration . Medications included in this designation are required to be dispensed by a specialty pharmacy as noted in the formulary .

This is a Summary of Benefits only, and does not outline all the benefits and exclusions.

Mercyhealth pharmacy extended supply programAll Mercyhealth pharmacies offer the three-month supply for the price of two months . Partners have the option to pick up their 90-day prescription at any Mercyhealth retail pharmacy . If they choose to have their 90-day supply mailed, the Mercyhealth Mall Pharmacy will continue to be the mail order pharmacy .

Not all medications are good candidates for extended supply . Examples are antibiotics, medications that are taken on an “as needed” basis and medications that require special handling like refrigeration . This includes the specialty drugs listed on Tier 4, which are only covered as a 30-day supply .

Extended supply copay reductions cannot be combined and are not additive with other copay reduction programs, such as pill splitting . Partners can benefit from the incentive that reduces their copays the greatest, but unfortunately cannot combine programs . For more information or to sign up call (608) 755-8700 or (877) 597-6627 .

Information is also available on the MercyCare website at mercycarehealthplans.com.

14

Dental insuranceVendor: Delta Dental IL

Your dental benefit plan provides a comprehensive program to ensure your dental health . Coverage is included for important preventive care and also for treatment needed as a result of dental disease or accidental injury . Partners hired to work 20 to 29 hours per week ( .5 - .74 FTE) are considered part-time for premium purposes . Partners hired to work 30 hours per week or more ( .75 – 1 .0 FTE) are considered full-time for premium purposes .The following summary does not cover all plan details . Further information can be found in the Summary Plan description . That document provides a thorough explanation of your dental plan, including any limitations or exclusions that might apply . If there are any discrepancies between information found here and the group contract, the group contract shall govern .

Dental insurance eligibility for adult child(ren)Your adult child(ren) can be added to your Mercyhealth dental insurance plan at the time of hire, qualifying event or open enrollment if they are less than 26 years old (regardless of marital status) .

Your adult child(ren) can choose to stay on their parents dental plan until the end of the month in which they turn age 26, even if they are eligible for their own employer-sponsored insurance plan .

Domestic partner coverageDental insurance coverage is eligible as a domestic partner benefit . See page 25 for details .

With Delta Dental PPO and Premier Networks:• You can go to any licensed general or specialty dentist .• You will maximize your benefits by receiving care from a Delta Dental PPO or Delta Dental Premier network

dentist .• Delta Dental’s network dentists have agreed to reduced fees as payment in full, which means you will likely

save money by going to a Delta Dental PPO or Delta Dental Premier network dentist . Non-network dentists have not agreed to accept our reduced fees as payment in full, which means they may bill you for any charges over our allowed fees .

• You are charged only the patient’s share at the time of treatment . Delta Dental pays its portion directly to network dentists .

• Enhanced Benefit Program offers additional coverage for individuals who have specific health conditions (including pregnancy, diabetes, high-risk cardiac conditions, and suppressed immune systems) that can be positively affected by additional oral health care .

Member ConnectionYou may register on Delta Dental of Illinois’ website, deltadentalil.com . Once registered, you can get real time benefit information, check claim status, sign up for electronic Explanation of Benefits and print a temporary ID card .

Partner + Spouse

Full-Time

Part-Time

Work Status

$22 .00

$16 .00


$55 .00

$41 .00

Partner

$78 .00

$59 .00

Partner + Family

$44 .00

$34 .00

Monthly Premium Contribution

15

Finding a dentistVisit our website, deltadentalil.com and click on Provider Search .Example of Your Copayment with Delta Dental Network Dentists and Non-Network Dentists• Delta Dental PPO: Lowest out-of-pocket costs and network protection .• Delta Dental Premier: Higher out-of-pocket costs than PPO, but may be lower than non-network and

network protection .• Non-network: You may have the highest out-of- pocket costs .

Customer ServiceCall (800) 323-1743 to access our automated phone system or speak to a Customer Service Representative from 7 am to 7 pm, Monday through Thursday and 7 am to 6 pm, Friday, Central Time . Our automated phone system is available 24 hours a day, seven days a week, and offers dentist listings and claim information .

You can also connect with us through our mobile app, Facebook, Twitter, our blog and more .

Learn moreYou can learn more about your Delta Dental of Illinois dental plan by reading the information included in your enrollment kit .

The information on the following page is a brief summary of your dental plan and the services it covers . There are some limitations on the expenses for which your dental plan pays . If you have specific questions regarding benefit coverage, limitations, exclusions, or non-covered services, please refer to your Certificate of Coverage/Dental Benefit Booklet or contact Delta Dental of Illinois .

The patient’s share is the coinsurance/copayment, any remaining deductible any amount over the annual maximum and any services your plan does not cover .

Note: Delta Dental imposes no restrictions on the method of diagnosis or treatment by a treating dentist. A benefit determination relates only to the level of payment that your group dental plan is required to make.

The American Dental Association recommends that a child’s first dental visit be by age one or the first tooth – whichever is sooner . It is suggested to add the newborn at time of birth or next open enrollment . If you would like more information on this recommendation, visit ada.org .

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Delta Dental insuranceSummary of benefits and covered services

Prescription drug coverageAnnual Maximum

Annual Deductible(applies to Basic/Major only)

Dependents eligible to age 26

Preventive/diagnostic

• Oral evaluations (two per calendar year)

• X-rays (bitewings – once per calendar year; full mouth series - once every three years)

• Prophylaxis (cleaning; two per calendar year)

• Fluoride treatment (twice per calendar year for children under age 19)

• Space maintainers

• Sealants

Basic

• Fillings

• Posterior composites

• Panoramic x-ray

• Oral surgery

• Periodontics

• Endodontics

• Crowns, jackets, cast restorations

• General anesthesia (in conjunction with oral surgery)

• Non-surgical TMJ

Major

• Fixed/removable bridges

• Partial/full dentures

• Implants

Orthodontia

• Lifetime Ortho . Maximum (for dependents under age 19 only)

Billing

$1,500/person

$50/person$100/family

Delta Dental PPO Network

100% of reduced fee*

80% of reduced fee*

$1,000/per dependent

50% of reduced fee* subject to lifetime maximum

*You will not be “balance billed” for charges exceeding Delta Dental’s allowed PPO fees

$1,500/person


Delta Dental Premier Network

100% of MPA**

80% of MPA**


50% of dentist’s usual fee subject to lifetime maximum

**You will not be “balance billed” for charges exceeding Delta Dental’s maximum plan allowances (MPAs)

$1,500/person


Out-of-Network

100% of MPA***

80% of MPA***


50% of dentist’s usual fee subject to lifetime maximum

***You are responsible for charges exceeding Delta Dental’s maximum plan allowances (MPAs)


50% of MPA***50% of MPA**50% of reduced

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Vision appliance insuranceVendor: Delta Dental IL

Mercyhealth partners who work a minimum of 20 hours per week (0 .5 FTE) are eligible to enroll in a voluntary vision appliance plan . This plan is for appliances only (for example, glasses, contacts) . Vision exams are covered under your MercyCare health plan .

DeltaVision® is provided by ProTec Insurance Company, a wholly owned subsidiary of Delta Dental of Illinois, in association with EyeMed Vision Care networks . DeltaVision offers members vision appliance benefits that combine choice, value and wellness . Your DeltaVision program provides vision appliance insurance to you (and your family, if applicable) according to the following information .

Prescription drug coverage

Frames:Any available frame at provider location

Standard plastic lenses: Single visionBifocal TrifocalStandard progressive (in addition to lens) Premium Progressive (in addition to lens)

Lens options: UV coatingTint (solid and gradient)Standard plastic scratch coatingStandard polycarbonateStandard anti-reflective coatingOther add-ons and services

Contact lenses:(Contact lens allowance covers materials only)Conventional

Disposable

Visually required

Frequency: ExaminationLenses or contact lenses Frames

$130 allowance, 20% off balance

over allowanc

$25 copay$25 copay$25 copay$65 copay$65, 20% off retail price, then apply $120 allowance

$15$15$15$40$4520% discount off retail price

$0 copay, $100 allowance, 15% off balance over $100

$0 copay, $100 allowance, 15% off balance over $100

$0 copay, paid-in-full

$65

$25$40$55$40$40

N/AN/AN/AN/AN/AN/A

$80

$80

$210

Out-of-Network AllowanceSelect Network Member CostVision Care Services

N/AOnce every 12 monthsOnce every 24 months

Partner + Spouse

$4 .34


$9 .51

Partner

$13 .72

Partner + Family

$8 .48

Monthly premium contribution

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Additional discountsMember receive a 20% discount at in-network providers on items not covered by the program . This discount may not be combined with any other discounts or promotional offers and the discount does not apply to contact lenses or an in-network provider’s professional services . Retail prices may vary by location .

Members also receive a 40% discount on complete pair eyeglass purchases and a 15% discount on conventional contact lenses at in-network providers once the funded benefit has been used .

After initial purchase, replacement contact lenses may be obtained via the Internet at substantial savings and mailed directly to the member . Details are available at deltadentalil.com/deltavision . The contact lens benefit allowance is not applicable to this service .

Network informationYou may choose to go to any licensed optometrist, ophthalmologist and/or dispensing optician whenever you need vision care . However, there may be significant cost advantages when you receive treatment from an in-network provider .

We offer two easy ways to locate an in-network provider 7 days a week, 24 hours a day . You can either:• Search our online provider directory at deltadentalil.com/deltavision; or• Use the automated phone system by calling (866) 723-0513

Using your vision appliance program1. An in- network provider participates in the EyeMed Vision Care Provider network . You will only receive in-

network benefits from Select network providers . Please note: the network provider will need the primary enrollee’s name and date of birth to verify eligibility .

2. Pay your copayment and any other charges not covered at the time of service . No paperwork is required .You continue to save on additional eyewear purchases any time you present your card to an in-network provider .

If you select a provider who is not in the network, you do not receive preferred pricing and you may be asked to provide full payment to your out-of-network provider at the time of service . To receive benefit reimbursement, submit a completed claim form (available at deltadentalil.com/deltavision, along with itemized receipts from your provider and your prescription to:

DeltaVision Claims Processing c/o EyeMed Vision CareP .O . Box 8504 Mason, OH 45040-7111

ExclusionsIn no event will coverage exceed the lesser of:

1. The actual cost of covered services or materials or

2. The limits of the policy, shown in the schedule .

Lost or broken lenses, frames, glasses or contact lenses will not be replaced except in the next benefit period .

Benefits may not be combined with any discount, promotional offering or other group benefit programs . Benefit allowances provide no remaining balance for future use within the same benefit period .

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Life insuranceVendor: The Standard

Group Term Life Mercyhealth provides Term Life Insurance benefits to partners hired to work 20 hours or more a week ( .5 FTE) . Eligibility begins the first of the month following 90 days of employment . Term life is equal to one times annual salary up to $150,000* with Accidental Death and Dismemberment (ADD) . Further information can be found in the summary Plan Description .

*Physician maximum $350,000

Supplemental Life You may purchase your own supplemental life insurance coverage up to four times your annual earnings up to a maximum of $1,000,000 . Eligibility begins the first of the month following 90 days of employment for partners that are hired to work 20 hours or more a week ( .5 FTE) . You may increase the coverage during each open enrollment by one times your annual earnings without proof of insurability . Evidence of insurability is required if you want to request more than $600,000 worth of coverage, enroll or increase your coverage during the plan year . However, you may discontinue your coverage any time .Your premium is based on your age bracket and the amount of coverage chosen . The table below shows the monthly rates per $1,000 of coverage based on age:

• You can choose to purchase additional term life insurance in increments of one, two, three or four times your benefit pay .

• Premium contributions are made with after-tax dollars; premiums adjust the month following a salary increase and/or a birthday if your age ends in 5 or 0, beginning at age 35 (for example; 35, 40, 45, etc .)

• You can choose supplemental life insurance if you want a greater level of coverage . Remember–you may not increase your life insurance by more than one level of Benefit Pay from year to year, unless you submit evidence of insurability .

Monthly rate

35 - 39

Under 30

30 - 34

$0 .11

$0 .10

$0 .08

Age Monthly rate

50 - 54

40 - 44

45 - 49

$0 .40

$0 .24

$0 .15

Age Monthly rate

65 - 69

55 - 59

60 - 64

$1 .38

$0 .69

$0 .46

Age Monthly rate

70 - 74

75+ $6 .37

$3 .18

Age

Dependent Term Life You may purchase life insurance at two levels of coverage for eligible dependents . Eligibility begins the first of the month following 90 days of employment for partners hired to work 20 hours or more a week ( .5 FTE) . Dependent child means:

1. Your unmarried child from live birth through the end of the calendar month in which your child reaches age 26 or

2. Your unmarried child who meets either of the following requirements a. The child is insured under the group policy and, on and after the date on which insurance would

otherwise end because of the child’s age, is continuously disabled . b. The child was insured under the prior plan on the day before the effective date of your employer’s

coverage under the group policy and was disabled on that day, and is continuously disabled thereafter .3. The date dependent life insurance ends is the date the dependent ceases to be a dependent .4. The monthly premium covers all eligible children and spouce .

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Mercy Health Corporation employees’ retirement planVendor: VOYA

403(b)Mercyhealth partners are offered a 403(b) plan that allows the option to contribute on a pre-tax basis a portion of your earnings to an account, up to the annual federal maximum . There are over 30 investment options to choose from . You can enroll anytime by contacting Rohlik Financial Services at (800) 236-2608 . You may also change your investment options, beneficiaries, and deferral electives at any time by contacting Rohlik Financial Group or going online at voyaretirementplans.com .

Auto-enrollment Mercyhealth believes that all partners should take an active approach in contributing towards their retirement; therefore, Mercyhealth will automatically enroll partners into a VOYA retirement plan at 3% . If you do not want to contribute to your plan, you have the option to opt out but your account will remain open for any qualifying discretionary contributions .

Auto-escalationFor partners who want to contribute to a 403(b) account but do not want to be actively involved will be eligible for an automatic contribution increase of 1% each calendar year up to a maximum contribution of 6% .

Matching contribution If you work a minimum of 1,000 hours by your first anniversary you will be eligible for a matching contribution . Otherwise, matching eligibility will begin after the calendar year in which you complete 1,000 hours of service . Mercyhealth will contribute up to 100% of the first 4% of your earnings that you contribute up to the federal compensation limit . The matching contribution will be deposited into your VOYA account at the same time your contribution is deposited . When you have two years of service with Mercyhealth, as defined by the Plan, you are vested (gain ownership) in this benefit .

Discretionary contribution For each year in which you work a minimum of 1,000 hours, Mercyhealth will contribute a discretionary contribution of up to 2% based on your W-2 earnings from the previous calendar year to your VOYA account . When you have one year of service with Mercyhealth, as defined by the Plan, you are vested (gain ownership) in this benefit . The discretionary contribution is deposited into your VOYA account in October each year and is based on the successful completion of system-wide performance and financial goals . Partners do not have to contribute their own earnings to be eligible for the discretionary contribution .

For both supplemental and dependent term life you may increase the coverage by one level during each open enrollment without proof of insurability . During the plan year, you may enroll if there is a change in your family status, or increase the level of coverage with approved evidence of insurability . However, you may discontinue the coverage anytime during the plan year .Note: A partner may not be insured as both a partner and a dependent. A child may not be insured by more than one partner.

Premium Per Month

Option 1: $10,000 coverage for spouse, $5,000 per child

Option 2: $25,000 coverage for spouse, $10,000 per child

Level of Coverage

$3 .00

$6 .50

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Roth contributionMercyhealth partners may also make Roth contributions to their VOYA 403(b) account . Roth contributions are eligible for the matching contribution .

457(b)In addition to contributing to the Mercyhealth Corporation Employees’ Retirement Plan, all highly compensated partners have the option to increase their tax-deferred contributions by contributing to a 457(b) account through VOYA . The 457(b) account is not eligible for any matching contributions . Federal contribution maximums apply . Partners can enroll at any time through Rohlik Financial Services and have the same investment options as the 403(b) .

All accounts are accessible online at voyaretirementplans.com or contact a representative at Rohlik Financial Group at (800) 236-2608 .

Flex spending plansHealth savings account/Medical/Dependent careVendor: Health Equity

Mercyhealth partners hired to work 20 or more hours per week ( .5 FTE) are eligible to participate in the flexible spending plan . The flexible spending plan allows you to set aside pre-tax dollars from your paycheck to pay for qualified medical and dependent care expenses . Consequently, you pay less income tax and increase your take home pay . Eligible medical expenses include out-of-pocket health, dental and vision related expenses . The appropriate amount will be deducted bi-weekly from your paycheck on a pre-tax basis .

Please evaluate your situation carefully and conservatively before determining how much, if any, you want to set aside for the various expenses in a flexible spending plan as restrictions apply . You may change the benefits elected during the plan year only if there is a major family status change (qualifying event) . Call Human Resources or Health Equity at (866) 346-5800 with any questions .

Health Savings Accounts (HSA)Participants in the MercyCare EPO HDHP or PPO HDHP may elect to contribute to a Health Savings Account (HSA) . The dollars are set aside on a pre-tax basis to pay for medical expenses . Partners can contribute up to $3,450 with a single plan or $6,900 with a family plan to the Health Savings Account . Partners 55 or older are eligible to contribute an additional $1,000 .

If you participate in a Health Savings Account, you can also enroll in a limited purpose medical account for planned dental and vision expenses . You may also use it for medical expenses after you have satisfied your annual deductible .

Flexible Spending MedicalYou can choose to set aside money from each paycheck to pay for those expenses not covered by insurance such as your deductible, your coinsurance, and your copays . This is a pre- tax deduction, which means that you don’t pay any federal, state, or Social Security taxes on the dollars you set aside .

The maximum amount you can set aside is $2,650 . The money can be used to reimburse you for any expenses incurred between January 1, 2018 or when you become eligible (whichever is later) and December 31, 2018, or when you are no longer eligible (whichever is first) . Your reimbursement claim must be submitted by March 31, 2019 . Under federal law, the medical plan allows for a carryover of $500 for the next plan year; however, any remaining amount over $500 will be forfeited .

22

Dependent care:You can choose to set aside up to $5,000 annually from your paycheck to pay for eligible dependent care expenses that allow you (and your spouse if you’re married) to work, look for work, or attend school full-time . Expenses must be related to:

• Dependent children under age 13

• A person of any age you claim as a dependent on your federal income tax return, and who is mentally or physically incapable of self-care . This would include an elder or other adult dependent .

Under federal law, any unused dollars remaining at the end of the plan year in a dependent care plan will be forfeited .

Note: You cannot change the amount of a flexible spending account deduction, except at open enrollment, unless you have a change in family status.

Voluntary benefitsLong-term care insurance (Legacy Services)All partners and family members are eligible to purchase long-term care insurance at any time through Legacy Services . Long-term care insurance is a benefit that goes beyond medical care and nursing care to include assistance you could need if you ever have a chronic illness or disability that leaves you unable to care for yourself for an extended period of time . You can receive long-term care in a nursing home or in your own home, in the form of help with such activities as dressing or bathing, etc . Long-term care can be of help to a young or middle-aged person who has been in an accident or suffered a debilitating illness, but older people use most long-term care services . Your premium is based on your age and the type of coverage you select . For further information, contact Legacy Services at (800) 230-3398 .

Universal Life Insurance (VOYA)If you are hired to work 20 or more hours per week ( .5 FTE), you are eligible to purchase universal life insurance coverage underwritten by VOYA . This program allows you to apply for an individual life insurance policy . You can also apply for individual life insurance policies for your spouse, dependent children and, in most cases, grandchildren, even if you choose not to apply for your own policy . The premium you pay is based on the death benefit you select . For more information or to enroll contact Rohlik Financial Group at (800) 236-2608.

529 college savings programsAll Mercyhealth partners are eligible at any time to participate in 529 college savings programs through payroll deduction . These programs allow partners to set aside dollars specific to college education costs and interest earned is tax-free . For more information or to enroll, contact Rohlik Financial Group at (800) 236-2608.

Auto and home insurance (Travelers)If you are hired to work 20 or more hours per week ( .5 FTE), you are eligible to receive special program rates through Travelers Insurance on your auto, home, and other personal insurance . Periodically, eligible partners receive information packets sent directly to their home from Travelers . This benefit is available to partners throughout the year . For more information, please call Travelers at (800) 842-5075 .

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Voluntary benefits continued

MetLife PlansIf you are hired to work 20 or more hours per week (0 .5 FTE), you are eligible to purchase the following benefits . Contact Williams-Manny Insurance Group at (815) 227-8923 .

• Accident insurance Accident insurance will cover your family for a wide variety of accidental injuries including broken bones,

cuts, concussions, dislocations and second or third degree burns . It provides a lump sum payment when a person has medical services and treatments related to accidental injuries, such as certain doctor visits, ambulance transportation, medical testing and physical therapy . It can be a valuable complement to your medical insurance .

This type of insurance can help protect your savings from unexpected expenses and provides payment directly to you, that you can use any way you see fit .

• Critical illness A serious illness such as cancer, heart attack or stroke will bring unexpected expenses that are not

covered by your health insurance . At the same time, a critical illness may affect your ability to earn an income, which may cause you to dip into your savings . This plan can help you pay for expenses such as essential living expenses if you’re not able to work, pay for medical co-pays and deductibles, or for additional care while you recover .

• Hospitalization insurance Will allow you to receive a lump-sum payment when you first go into the hospital, then receive daily

amounts paid for each day in the hospital . Payments will be paid directly to you to use as you see fit .

Nationwide/Williams-MannyIf you are hired to work 20 or more hours per week (0 .5 FTE), you are eligible to purchase the following benefits . Contact Williams-Manny Insurance Group at (815) 227-8923 .

• Pet insurance Pets play an important role in a family’s life however when an accident or illness occurs it can set you

back $1,000’s . This plan will allow you to be reimbursed for eligible veterinary expenses for medical problems and conditions such as accidental injuries, poisonings and illness-even cancer . Office procedures include diagnostic tests, x-rays, lab fees surgeries and hospitalization . Your pet’s prescriptions are even covered . There are plans for dogs and cats starting at 6 weeks of age and plans also available for birds, ferrets, reptiles and other exotic pets .

24

Short-term disabilityVendor: The Standard

Mercyhealth provides short-term disability insurance (STD) benefits to partners at two levels . Eligibility begins the first of the month following 90 days of employment and is paid 100% by Mercyhealth . The monthly benefit for those who are disabled is defined by the plan . Plan highlights are listed below . For further information, review the Summary Plan Discription (SPD) or contact Human Resources department .

Partners must apply for this benefit through the Standard by calling (866) 756-8116 or online at standard.com . Benefit is paid through your regular paycheck .

Short-term Disability Plan – Level 1

Eligibility: • FT status for .75 FTE (30 hrs/wk or greater)

• PT status .5 FTE (20 hrs/wk to 29/hrs/week)

Plan design • Coverage begins on the 8th calendar day missed for own disability through 90 days .

• 91 days of employment up to 4 .99 years = 60% of base salary

• 5 years and up = 70% of base pay

• Coverage limited to $15,000 per month maximum benefit

Short-term Disability Plan – Level 2Eligibility: • FT status for .75 FTE (30 hrs/wk or greater)

Plan design • Coverage beginning on the 91st day missed for own disability through 180th day .

• 60% of base pay

• Coverage limited to $15,000 per month maximum benefit

Long-term disabilityVendor: The Standard

Mercyhealth provides long-term disability insurance (LTD) benefits to partners that are hired to work 30 hours or more a week ( .75 FTE) . Eligibility begins the first of the month following 90 days of employment and is paid 100% by Mercyhealth . The monthly benefit for those who are disabled, as defined by the plan, equals 60% of base pay to a max of $15,000 . This benefit is paid directly to the partner by The Standard . See below for plan highlights . For further information review the Summary Plan Description (SPD) or contact Human Resources .

Plan design • Coverage for LTD begins after 180 day elimination period

• 60% of base pay to a max of $15,000 .

• Coverage for own disability only

• Own occupation first 24 months and any occupation thereafter .

25

Domestic partner coverageA domestic partner:

Is a person of the same or opposite gender as the Mercyhealth partner . The partners must be emotionally committed to each other and intend to remain each other’s interdependent domestic partner indefinitely . Tangible demonstration of interdependence may be achieved by the following:

• Common ownership of property

• Common ownership of a motor vehicle

• Proof of joint bank accounts or credit accounts

• Proof of a partner being designated as primary beneficiary for life benefits

• Assignment to each other of a durable property or health care Power of Attorney

The Mercyhealth employee and partner must both be at least 18 years of age or older and be mentally competent to enter into a contractual agreement;

• Must have the same place of residence as the Mercyhealth employee and have cohabitated there for a minimum of 12 months, with the intent of doing so permanently;

• Is not legally married or involved in another domestic partnership within the last 12 months;

• Is jointly responsible for the other’s welfare and financial obligations; and

• Is not related to the Mercyhealth partner by blood closer than would bar marriage in the state where he or she resides .

Children of domestic partners are also eligible for health and dental insurance coverage . Benefit eligibility requirements are the same .

The employer portion of the insurance premium that covers domestic partners and their children will be considered taxable income to the employee .

Domestic partners and children of domestic partners are not eligible for COBRA benefits should they lose coverage for any reason .

Domestic Partner Certification: All Mercyhealth employees wishing to add a domestic partner and any domestic partner children to their health or dental plan will need to complete Certification of Domestic Partnership . This form is available in Human Resources .

Cancel Date of Domestic Partner Coverage: In the event that the domestic partnership is terminated, you must notify Human Resources within 30 days . Insurance coverage will end at the end of the month in which the termination occurred .

Domestic partners of Mercyhealth employees are only eligible for Mercyhealth health and dental insurance coverage . Domestic partners are not eligible for any other Mercyhealth benefits including, flex benefit plans, life insurance, and voluntary benefit plans .

26

Important contact information If you have a change of name/address/phone number, please contact Human Resources to update your information . If you participate in the following benefit plans, please notify the venor directly .

Benefit

Accident insurance

Auto and home insurance

College savings 529 programs

Dental insurance

Flexible spending/benefit plans

FMLA

Health/Rx insurance

Life insurance:

• Group term, supplemental, dependent term

• Universal life

Long-term disability

Long-term care insurance

Pet insurance

Retirement plans: 403(b), 457(b)

Short-term disability

Vision appliance insurance

Vendor

MetLife/Williams-Manny Insurance Group

TravelersRohlik Financial GroupDelta Dental ILDeltaDentalIL .com

Health Equity

The Standard

MercyCare Health PlansMercyCareHealthPlans .com

First Health (for Tier 2 PPO plans only)

FirstHealthComplementary .com

The Standard

VOYA/Rohlik Financial Group

The Standard

Legacy Services

Nationwide/Williams-Manny Insurance Group

VOYA VoyaRetirementPlans .com

Rohlik Financial GroupThe Standard DeltaVisionDeltaDentalIL .com/DeltaVision

Contact Number

(815) 227-8923

(800) 842-5075

(800) 236-2608

(800) 323-1743

(866) 346-5800

(866) 756-8116

(800) 895-2421

(888) 937-4783

(800) 236-2608

(800) 368-1135

(800) 230-3398

(815) 227-8923

(800) 584-6001

(800) 236-2608

(866) 756-8116

(866) 723-0513

Human Resources

If you work inRock, Walworth or McHenry County

Winnebago County

(608) 756-6721

(815) 971-6110

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We hope you have found this Partner Benefit Book to be helpful . Additional information is available in Summary Plan Descriptions . If there are any difference between this document and any Summary Plan Description, the Summary Plan Description governs . For additional questions, please contact Human Resources .

Qualifying event A qualifying event is an event that results in the opportunity to make changes to one’s enrollment in employer-sponsored benefits such as health and dental insurance for which a qualified beneficiary (employee and the dependents) are eligible for COBRA benefits .

Examples of qualifying events are:

• Birth/adoption • Death • Divorce • End of domestic partnership

If you experience a qualifying event, you may have the option to enroll in or change your current benefits . To enroll or make changes, you must contact Human Resources within 30 days of the qualifying event .

• Loss of coverage• Marriage• A reduction in working hours

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Notes

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2018 Mercyhealth Partner Benefits Book...• Vision Insurance • MetLife critical illness,...

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