2019 - AMITA Health · 2 Benefits Guide 2019 Welcome to the AMITA Health Benefits Program AMITA...

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2019

ASSOCIATE BENEFITS GUIDE

2 Benefits Guide 2019

Welcome to the AMITA Health Benefits Program

AMITA Health is committed to maintaining a positive and productive work environment – one that is dedicated to

providing the utmost quality care to those we serve in our community.

To accomplish our mission, it takes the special talent of many competent and highly-skilled people.

To succeed in a competitive healthcare market, AMITA Health strives to employ only the most capable

and dedicated associates at all levels, which includes providing a generous associates benefits program.

Please review the enclosed associate benefits documents and retain them for your personal files.

Feel free to contact us if you have any further questions.

Sincerely,

AMITA Health Benefits Department

This Benefits material briefly describe the excellent benefits program that is available as part of employment with AMITA Health. This information is not a contract.

Any of the benefits, policies or procedures may be changed as the organization requires, and nothing contained in this material shall be construed as creating an

expressed or implied obligation or contract on the part of the AMITA Health.

Benefits Guide 2019 3

Table of Contents

Overview and How to Enroll .................................................................... 4

Dependent Documentation ..................................................................... 5

Qualifying Life Events ............................................................................. 6

Paid Time Off .......................................................................................... 7

Medical Plan ........................................................................................... 8

Prescription Drug Coverage .................................................................. 11

Dental Plan ........................................................................................... 12

Vision Plan ............................................................................................ 15

Benefit Plan Premiums - Health, Dental and Vision ............................... 17

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

Basic Life and Voluntary Life / AD&D .................................................... 20

Short Term Disability Plan ..................................................................... 23

Long Term Disability Plan ...................................................................... 24

Permanent Life Insurance with Long Term Care .................................... 25

Accident Insurance ............................................................................... 26

Critical Illness Insurance ....................................................................... 27

Employee Assistance Program ............................................................. 29

Legal Plan ............................................................................................. 30

Retirement ............................................................................................ 31

Diabetes Management .......................................................................... 34

Commuter Benefits ............................................................................... 35

Additional Benefits ................................................................................ 39

Vendor Contact Listing .......................................................................... 40

Mobile Applications ............................................................................... 41

Important Notices .................................................................................. 42


Overview

In today’s changing world, your benefits are an

increasingly valuable part of your total pay. AMITA

Health knows how important having the right

benefits are to you and your family.

We are pleased to offer you a wide range of bene-

fit plan features and choices. The benefit plan year

begins January 1 and ends December 31.

Whether you’re single or have a family, you’ll find

plans here to suit your unique needs. You will be

able to customize a package of benefits to meet

those needs–with an opportunity annually to

change your selections as your needs change.

This booklet will help you learn more about your

choices, so you can make educated decisions

when you enroll.

WHO’S ELIGIBLE

You are eligible to enroll in benefits if you are a full-

time or part-time associate regularly scheduled to

work a minimum of 20 hours per week.

Temporary associates or those working fewer than

20 hours per week are not eligible.

Your eligible dependents include:

• Your spouse

• Your children up to age 26 (including natural

children, stepchildren, or adopted children)

• Your disabled children of any age, provided they

became disabled before age 26 and while

covered by the plan

You may be asked to provide proof of eligibility. If

you cannot provide the requested documentation,

your dependent coverage will be terminated.

ENROLLING IN OUR BENEFIT PLANS All associates must enroll through Benefit Express on-line through their secure website: www.amitahealthbenefits.com within 31 days from date of hire or qualified life event.

You will need your 8-digit associate ID number found in iAMITA > rAMITA > My Information > Associate Id

number and the social security numbers for all dependents you plan to add.

Associates who fail to enroll within 31 days from date of hire, or qualified life event must wait until next

enrollment period.

Hint: The website can only be entered through Internet Explorer not through Google.

Various documents will help in certifying your

dependents. To see a complete list of acceptable

documents please refer to page 5 of this guide.

Provide copies of the documents – not originals as

these will not be returned to you.

If you are submitting a copy of your most recent

Federal Tax Return, please submit the first page

only which shows your dependents (you may hide

social security numbers and income by blacking

out).

We only accept government Issued documents

such as marriage license, birth certificate, or court

ordered documents.

These documents are due within 31 days from

your hire date or status change date.

Please submit documents with a cover sheet with

your name, associate ID number and contact tele-

phone number to:

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Dependent Documentation

DEPENDENT DOCUMENTATION GUIDE

DEPENDENT TYPE AGE DOCUMENTATION REQUIREMENTS

Legal Spouse

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• Government Issued Marriage Certificate and last year filed Federal Tax

Return OR

• Government Issued Marriage Certificate and Proof of Joint Ownership

Issued in last 6 months OR

• Government Issued Marriage Certificate ONLY (if married in current

calendar year).

Biological Child Age 0 up

to 26 • Government Issued Birth Certificate ONLY.

Disabled Biological Child

Over 26

• Government Issued Birth Certificate AND

• Completed disabled child certification form (must be medically certified

by a physician as disabled).

Step-Child

Age 0 up

to 26

• Government issued Birth Certificate AND

• Associate’s Government issued Marriage Certificate.

Disabled Step-Child

Over 26

• Government issued Birth Certificate AND

• Associate’s Government issued Marriage Certificate AND



Adopted Child

Age 0 up

to 26

• Adoption Placement Agreement and Petition for Adoption ONLY OR

• Adoption Certificate ONLY.

Disabled Adopted Child

Over 26

• Adoption Certificate AND



Legal Ward

Age 0 up

to 26


• Court Ordered Document of Legal Custody.

Disabled Legal Ward

Over 26


• Court Ordered Document of Legal Custody AND



Qualified Medical Child

Support Order

Age 0 up

to 26

• Qualified Medical Child Support Order ONLY. Must be ordered for the

associate or spouse.

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Qualifying Life Events

The annual open enrollment period is the only time you can change benefit plans or add/drop dependents during

a plan year, unless you experience a qualifying family status change. A qualifying event to change benefits during

the plan year is defined as a change in your status due to:

• New employment

• Marriage

• Birth or adoption of a child(ren)

• Death of an immediate family member

• Divorce

• Loss or gain of insurance coverage by your spouse’s employer-sponsored coverage

• Unpaid leave of absence by you or your spouse

• Ineligibility of a dependent

• Termination of employment

To change your benefit elections, you must notify AMITA Health Benefits Department within 31 days of the quali-

fying event triggering the need for the change. For example, if you were married September 3, you would need to

notify the AMITA Health Benefits Department (within 31 days of the marriage).

YOUR BENEFIT CHOICES

AMITA Health provides a wide variety of benefits. Some are provided automatically at no cost to you. Other benefits are available if you elect them. Review the guide in detail to see which benefits you need to create a successful program designed to meet your needs and, if applicable, the needs of your family.

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Paid Time Off

Paid Time Off (PTO)

PTO is available to all Full-Time and Part-Time associates who are regularly scheduled to work 40 hours or

more per pay period. Associates are eligible to use PTO for any supervisor-approved reason, including

vacations, personal business or illness.

Paid Time Off (PTO) Accrual

Non-exempt (hourly) associates PTO is accrued based on hours worked in a pay period (not to exceed 80 hours

for this purpose). The amount associates may earn will depend on their job classification, length of service,

and hours worked in a pay period (with exception of premium hours, e.g., call pay, stand-by pay, etc.). Current

Associates may accumulate up to a maximum of 320 hours. PTO accruals will cease until the accumulated PTO

falls below the maximum.

PTO Accrual Schedule for Non-exempt (hourly) (cap at 320 hours)

Completed Years of Service

Years (Months per Year) Hours Per Year* Days Per Year* Accrual Per Hour Paid

0-1 (0-11.9) 128 16 0.061538

2-3 (12-35.9) 136 17 0.065385

4-5 (36-59.9) 152 19 0.073077

6-8 (60-95.9) 168 21 0.080769

9-11 (96-131.9) 192 24 0.092308

12-15 (132-179.9) 200 25 0.096154

16+ (180+) 216 27 0.103846

Example to Pro-rate: If you work 72 hours a pay period and your year of service is 1 year 0.0161538 (hourly accrual rate) x 72 pp hours = 4.43 x 26 (pay periods/year) = 115.20 (annual hours)

Paid Time Off (PTO) Front Loaded Plan

Annual Front-Loaded PTO will be awarded to exempt (salaried) associates and available for use at the

beginning of each year. During pay period one of each year, 27 days of non-accrued PTO will be advanced

into the associate’s bank (prorated based on FTE). Unused PTO hours are forfeited following the last pay

period of the year.

Legal/Observed Holidays

Legal Holidays are available to all Full-Time and Part-Time associates. New Year’s Day, Martin Luther King Day,

Good Friday, Memorial Day, July 4th, Labor Day, Thanksgiving Day and Christmas Day. These holidays are in

addition to PTO. All associates required to work on a recognized holiday will have those holiday hours added to

his/her PTO bank. Those holiday hours will then be available to use as any other PTO hours.

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Medical Plan

Eligibility

All full-time or part-time benefit eligible associates may elect coverage. Eligible dependents include your legal spouse,

and children up to the date in which they turn age 26. Any unmarried child of any age with a mental or physical

handicap or disability who is incapable of self-support is eligible provided they became disabled before age 26 and

while covered by the plan.

Coverage Levels

You can choose from four levels of coverage: • Associate Only • Associate + Spouse

• Associate + Child(ren)

• Family

Coverage Begins

If you enroll in this plan, coverage is effective the 1st of the month following 30 days of employment.

Coverage Ends

Coverage ends on the last day of employment or when you cease to be an eligible associate. Dependents

terminate on the day of their 26th birthday. Please see the Medical Plan book for additional instances when

coverage ends.

AMITA Health Medical Plan

AMITA Health will offer associates a Preferred Provider Organization (PPO) plan administered by Automated Benefit

Services (ABS) and it consists of the BlueCross BlueShield’s national provider network. PPO plans allow associates to

seek services from the provider of their choice.

The AMITA Health Medical Plan is a ‘tiered’ network with three tiers: (1) * SmartHealth Network consisting of AMITA

Health (Adventist Midwest Health, Alexian Brothers and Presence Health), Ascension and Adventist Health System

facilities and contracted providers; (2) BlueCross BlueShield National Provider Network; and (3) Out of Network –

facilities and providers not contracted with BlueCross BlueShield National Provider Network. You and your family

members will experience a significantly higher level of benefits when receiving your care from an AMITA provider. If

you choose to seek care outside of AMITA Health, you will have access to BlueCross BlueShield’s national provider

network.

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Certain services may require satisfying a deductible. Once the deductible is satisfied by the member, the plan will begin

paying a portion of your remaining charges known as co-insurance. AMITA Health PPO plan provides associates financial

security by placing an out-of-pocket limit on an associate’s health care expenses.

Associates are free to seek services from the provider of their choice, however, associates’ out-of-pocket expenses will be

significantly lower when services are received from an AMITA Health provider.

Health Benefits Subsidy is offered to Full-Time associates at the time of the annual open enrollment or initial enrollment

for benefits (New hire or from PRN to Full-time benefits eligible status). The Health Benefits Subsidy is designed to assist

associates who may not have affordable access to healthcare. The subsidy provides a discount of:

• 25%, 50%, 75% or 100% on associate bi-weekly deductions for coverage on the SmartHealth PPO plan.

• 50% or 100% on deductibles, coinsurance and maximum out-of-pocket costs for covered expenses under the

SmarthHealth PPO medical plan for care that you and covered dependents receive in the PPO Plan Tier 1 Network.

(The discount does not apply to co -payments)

• The subsidy also includes reduced pharmacy copays for associates who qualify for all levels of the subsidy.

Associates have 31 days to apply from the initial enrollment period or by the deadline provided during the annual open

enrollment period.

For more information about the Health Benefits Subsidy and how to apply, please visit iAMITA > Departments > Human

Resources > Benefits > Health Plan Subsidy or www.amitahealthbenefits.com.

Please review both the schedule of benefits below as well as your bi-weekly premiums on www.amitahealthbenefits.com.

Deductible: The amount you owe before insurance or plan begins to pay.

Co-insurance: Once the deductible is met, this is the share of the costs of a covered service for which the member

is responsible. It is a percent (%) of the allowed amount of the service.

Co-payment: This is a fixed amount you pay for a covered service. This amount can vary depending on the service

received. The co-pay may or may not count toward the deductible.

Network Providers: These are facilities, providers, and suppliers who have a contract to deliver services under the

network, which is managed by the insurer.

Out-of-Pocket Maximum: This is the most the enrolled associate will pay during the year before the plan begins to

pay 100% of the allowed amount.

Precertification: A decision by the plan that a service, treatment, prescription drug or durable medical equipment

is medically necessary.

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http://www.amitahealthbenefits.com/



2019 Schedule of Benefit

Benefits Tier 1 AMITA Network Tier 2 National Network (BCBS)

Tier 3 Out-of-Network*

Claims questions, benefit questions, eligibility Contact ABS Customer Service at (844) 659-2519

Find a doctor View provider directory at www.mysmarthealth.org All eligible expenses apply towards all deductibles and out-of-pocket maximums.

Deductible • Individual

• Family

$300

$600

$1,000

$2,000

$2,000

$4,000

Coinsurance

• Plan Pays 90% after

AMITA Network Deductible

70% after National

Network Deductible

50% after OON Deductible

• You Pay 10% coinsurance after


30% after National Network

Deductible


Total Out-Of-Pocket Maximum (Deductible plus coinsurance and copays) Medical Out of Pocket

• Individual

• Family

$4,000

$8,000

$5,850

$11,700

$0

$0

Rx Out of Pocket

• Individual

• Family

$1,500

$3,000

$1,500

$3,000

N/A

N/A

Lifetime Maximum Unlimited

Services AMITA Network National Network Out-of-Network*

Preventive Service Annual Routine Physical, Well Baby/Child Care, Routine Immunizations, Annual

Gynecological Exam/Annual Mammogram, Screening Colonoscopy

$0

$0

50% coinsurance after

OON Deductible

Outpatient/Diagnostic Services • Diagnostic Infertility Testing, Physical/Occupational/Speech Therapy (Annual

Maximum - 60 Visits), Lab, Pathology, Radiation and Chemotherapy,

Radiology, Outpatient Surgery




National Network

Deductible


OON Deductible

High Tech Radiology MRI, PET Scan, MRA Pre-Certification Required



Pre-Certification Required 30%

coinsurance after National

Network Deductible

Pre-Certification Required

50% coinsurance after OON

Deductible

• Dialysis 10% coinsurance after



National Network Deductible


Deductible

Office Visits Primary Care (Family Practice/General Internal

Medicine/Pediatrics)

$15 Copay

$30 Copay

50% aft 50% coinsurance after

OON Deductible er Deductible

• Specialist (Including OB/GYN) $35 Copay $50 Copay


Deductible

• Pre/Postnatal Care $15 Copay $30 Copay


Deductible

• Chiropractic Office Visit (Annual maximum - 60 visits)

Ancillary services are subject to deductible/coinsurance $15 Copay $30 Copay


Deductible

Mental Health • Individual Therapy/Group Therapy

$15 Copay $30 Copay 50% coinsurance after OON

Deductible

• Inpatient Admission/Partial Day Treatment, Intensive

Outpatient Therapy



30% coinsurance after AMITA

Network Deductible


Deductible

Substance Abuse • Individual Therapy/Group Therapy

$15 Copay $30 Copay 50% coinsurance after OON

Deductible

• Intensive Outpatient Therapy, Acute Inpatient Care 10% coinsurance after



Network Deductible


Deductible

Emergency Care • ER Visit

$150 Copay $150 Copay $150 Copay

• Urgent Care $35 Copay $50 Copay


Deductible

• Ambulance 10% coinsurance after



Network Deductible


Network Deductible

• Medical Transfer/Transport (non-emergent) Pre-Certification

Required

Pre-Certification

Required

Pre-Certified

Required

Inpatient Services • Per Admission

• Room and Board

• Ancillary Services

• Surgery

• Anesthesia

• Physician Charges






Network Deductible



Deductible

• Emergency Room Admission 10% coinsurance after



National Network Deductible 50% after OON Deductible

• Extended Care Facility (Annual maximum - 120 days) 10% coinsurance after



National Network Deductible 50% after OON Deductible

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http://www.mysmarthealth.org/


Other Services • Durable Medical Equipment (DME)






Network Deductible


50% after Deductible

• Prosthetics & Orthotics (P&O) 10% coinsurance after


30% coinsurance after Nation-

al Network Deductible


Deductible

• Foot Orthotics - 2 pairs every 3 years 50% coinsurance after

AMITA Network Deductible 50% after Network Deductible


Deductible

• Hearing Aid (3-year maximum - $2,000) 10% coinsurance after





Deductible

• Home Health Care (Annual maximum - 100 visits) 10% coinsurance after





Deductible

• Hospice 10% coinsurance after





Deductible

• Allergy Testing & Treatment 10% coinsurance after





Deductible

• Bariatric Surgery Pre-Certification Required





Network Deductible



• Organ/Bone Marrow/Other Transplants Pre-Certification Required





Network Deductible



• Wellness/Disease Management

• Diabetic Education

$0

$0


Deductible • Smoking Cessation Intervention (Counseling)

This is a brief summary of benefits, which are subject to change. In the case of a conflict between this summary and the official Summary Plan Description, the language in the Summary Plan Description will prevail. For further details about plan benefits, please contact Cus-

tomer Service at the number shown on the back of your ID card. Network Description: Tier 1 represents the AMITA network, which is comprised of participating AMITA providers and facilities, as well as the broader Ascension AMITA network. Your out-of-pocket costs will always

be lower when utilizing a AMITA provider. Tier 2 represents BCBS participating providers. Members should make every effort to utilize a BCBS provider whenever a AMITA provider is not available in their area. Contraceptive Coverage: The U.S. Department of Health and Human

Services, the Department of Labor and the Internal Revenue Service have jointly released final regulations regarding women’s preventive services under the Affordable Care Act (“ACA”). The ACA requires group health plans to provide coverage for “contraceptive services” as part

of an array of women’s preventive services that must be included in health plans without cost sharing to covered participants. AMALX-MED-300 AMADV-MED-300

Prescription Drug Coverage

Associates enrolled in the Medical Plan automatically receive the Prescription Drug Coverage benefit which is managed

through Cigna. Members will receive their own Pharmacy ID card in addition to their Medical ID cards. For a complete

listing of medications covered you may go to www.myCigna.com.

Use of AMITA in-house pharmacies may reduce your medication expense and you can only receive a 90 Day Supply

through our in-house pharmacies. Certain medications require approval from Cigna before they’re covered by the

plan. If you are not sure a medication requires approval, please check on-line or call the toll-free number on the back

of your Cigna ID card. In these cases, if your doctor feels that an alternative medication isn’t right for you, he or she

can ask Cigna to consider approving coverage of your medication.

Prescription Drug Coverage

In-House Pharmacies Retail Pharmacies Out-of-Network*

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Individual MOOP (Rx) $1,500 $1,500 N/A

Family MOOP (Rx) $3,000 $3,000 N/A

Generic $5 $10 N/A

Preferred Brand 85%

($25 Min / $50 Max)

75%

($40 Min / $80 Max)

N/A

Non-Preferred Brand 80%

($50 Min / $100 Max)

75%

($80 Min / $160 Max)

N/A

Generic - 90 Day Supply $10 N/A N/A

Preferred Brand - 90 Day Supply 85%

($50 Min / $100 Max)

N/A N/A

Non-Preferred - 90 Day Supply 80% ($100 Min / $200

Max)

N/A N/A

Specialty Rx - 30 Day Supply 85% ($50 Min / $100

Max)

75%

($80 Min / $160 Max)

N/A

*Please note: 90-day supplies must be filled by the AMITA Health In-House Pharmacies. Prescription drugs classified as Specialty medications may only be filled up to a 30-day supply through an AMITA Health In-House pharmacy or Cigna

Home Delivery. One 30-day supply grace fill is allowed at retail.

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http://www.mycigna.com/


Dental PPO

Eligibility

All full-time or part-time benefit eligible associates may elect coverage. Eligible dependents include your legal

spouse, and children up to the date in which they turn age 26. Any unmarried child of any age with a mental or

physical handicap or disability who is incapable of self-support is eligible provided they became disabled before

age 26 and while covered by the plan.

Coverage Levels

You can choose from four levels of coverage:

• Associate Only

• Associate + Spouse


• Family

When Coverage Begins


When Coverage Ends


terminate on the day of their 26th birthday. Please see the Dental Plan book for additional instances when

coverage ends.

AMITA Health Dental Plan

AMITA Health provides you with a choice of 2 dental PPO plans through Delta Dental the “High” and “Low” Plan.

With the Delta Dental Preferred Provider Organization (PPO) plans, you have the freedom to visit any licensed net-

work or non-network Dentist for covered services. You do not have to designate a primary care dentist. Plus, you

can visit any dental specialist for covered benefits up to an annual limit without waiting for prior approval from the

plan. You will generally save on the cost of covered dental care when you use a dentist who participates in the PPO

network.

Search Delta Dental’s online dentist directory at www.deltadentalil.com

AMITA Health is part of the Delta Dental PPO Plus Premier Network– meaning you can go to any dentist

in the PPO or Premier Network

The PPO toll free number is 800-323-1743

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http://www.deltadentalil.com/


DENTAL PLAN HIGHLIGHTS HIGH PLAN

AMITA Health - Adventist Midwest Health #11510

AMITA Health - Alexian Brothers Health System #11506

AMITA Health – Presence Health #11506

Annual Deductible (applies to Basic and Major Services Only) $50/person; $150/family

Annual Maximum $1,500/person

Enhanced Benefits Program Your plan provides additional cleanings and/or

applications of topical fluoride to people with

specific health conditions that put them at risk

for oral health disease.

Lifetime Orthodontic Maximum $1,500/person

Delta Dental PPO Network Dentist

Delta Dental Premier® Network Dentist

Non- Network Dentist

PREVENTIVE/DIAGNOSTIC SERVICES Not subject to annual maximum • Routine exams (twice per benefit year)

• Dental prophylaxis (twice per benefit year)

• X-rays (bitewings-twice per benefit year; full mouth-every three years)

• Fluoride treatments (once per benefit year to age 19)

• Space maintainers (once per lifetime to age 14)

• Sealants (to age 16)

• Periodontal maintenance

• Emergency exams and palliative treatment

100%*

100%**

100%***

BASIC SERVICES • Amalgam and composite resin (anterior) fillings

• Posterior composites (tooth colored fillings on back teeth)

• Non-surgical Periodontics

• Surgical Periodontics

• Endodontics

• Oral surgery – simple extractions

• Oral surgery – surgical extractions including general anesthesia

• IV sedation

• Denture repairs

80%*

80%**

80%***

MAJOR RESTORATIVE SERVICES • Implants

• Cast restorations – crowns, onlays, post and core

• Prosthodontics – bridges, partial dentures and complete

50%*

50%**

50%***

ORTHODONTICS-dependents to age 26 and Adults Treatment necessary for proper alignment of teeth

50%* 50%** 50%***

No TMJ Coverage 0% 0% 0%

*Delta Dental PPO dentists accept payment based on the lesser of the submitted fee (their usual fee) or Delta Dental’s allowed PPO fee. PPO network

dentists cannot charge you for costs exceeding the PPO fee. **Delta Dental Premier dentists accept payment based on the lesser of the submitted fee (their usual

fee) or Delta Dental’s maximum plan allowance. Premier dentists may not charge you for costs exceeding the maximum plan allowance. ***Non-network dentists

(non-Delta Dental PPO/non-Delta Dental Premier) do not agree to accept Delta Dental’s allowed fees as payment in full; payment is based on the lesser of the

submitted fee (their usual fee) or Delta Dental’s maximum plan allowance. These dentists can charge you for costs exceeding the maximum plan allowance.

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DENTAL PLAN HIGHLIGHTS LOW PLAN

AMITA Health - Adventist Midwest Health #11510

AMITA Health - Alexian Brothers Health System #11506

AMITA Health – Presence Health #11506

Annual Deductible (applies to Basic and Major Services Only) $75/person; $225/family

Annual Maximum $1,000/person

Enhanced Benefits Program Your plan provides additional cleanings and/or

applications of topical fluoride to people with spe-

cific health conditions that put them at risk for oral

health disease.

Lifetime Orthodontic Maximum $1,000/person

Delta Dental PPO Network Dentist

Delta Dental Premier® Network Dentist

Non-Network Dentist

PREVENTIVE/DIAGNOSTIC SERVICES Not subject to annual maximum • Routine exams (twice per benefit year)

• Dental prophylaxis (twice per benefit year)

• X-rays (bitewings-twice per benefit year; full mouth-every three years)

• Fluoride treatments (once per benefit year to age 19)

• Space maintainers (once per lifetime to age 14)

• Sealants (to age 16)

• Periodontal maintenance

• Emergency exams and palliative treatment

100%*

100%**

100%***

BASIC SERVICES • Amalgam and composite resin (anterior) fillings

• Posterior composites (tooth colored fillings on back teeth)

• Non-surgical Periodontics

• Surgical Periodontics

• Endodontics

• Oral surgery – simple extractions

• Oral surgery – surgical extractions including general anesthesia

• IV sedation

• Denture repairs

60%*

60%**

60%***

MAJOR RESTORATIVE SERVICES • Implants

• Cast restorations – crowns, onlays, post and core

• Prosthodontics – bridges, partial dentures and complete

50%*

50%**

50%***

ORTHODONTICS-dependents to age 26 and Adults Treatment necessary for proper alignment of teeth

50%* 50%** 50%***

No TMJ Coverage 0% 0% 0%

*Delta Dental PPO dentists accept payment based on the lesser of the submitted fee (their usual fee) or Delta Dental’s allowed PPO fee. PPO network

dentists cannot charge you for costs exceeding the PPO fee. **Delta Dental Premier dentists accept payment based on the lesser of the submitted fee (their usual

fee) or Delta Dental’s maximum plan allowance. Premier dentists may not charge you for costs exceeding the maximum plan allowance. ***Non-network dentists

(non-Delta Dental PPO/non-Delta Dental Premier) do not agree to accept Delta Dental’s allowed fees as payment in full; payment is based on the lesser of the

submitted fee (their usual fee) or Delta Dental’s maximum plan allowance. These dentists can charge you for costs exceeding the maximum plan allowance.

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Vision Plan

Eligibility

All full-time or part-time benefit eligible associates may elect coverage. Eligible dependents include your legal spouse,

and children up to the date in which they turn age 26. Any unmarried child of any age with a mental or physical

handicap or disability who is incapable of self-support is eligible provided they became disabled before age 26 and

while covered by the plan.

Coverage Levels

You can choose from four levels of coverage:

• Associate Only

• Associate + Spouse


• Family



When Coverage Ends


terminate on the day of their 26th birthday. Please see the Vision Plan book for additional instances when

coverage ends.

AMITA Health Vision Plan

AMITA Health vision benefits are administered by Vision Service Plan (VSP). You can go to any eye care professional

you choose but if you use a VSP network provider you’ll pay less.

To use your VSP benefit:

• Create an account at www.vsp.com to review your benefits.

• To find a doctor who is right for you, visit www.vsp.com or call 1-800-877-7195

• At your appointment, tell your provider you have VSP. There is no ID card necessary. If you’d like a card

as a reference, you can print one on www.vsp.com.

• That is it! There are no claim forms to complete when you see a VSP provider.

Convenient online shopping! Eyeconic is an online eyewear store for VSP members.

You can visit Eyeconic to purchase eyewear or contact lenses with your VSP insurance – in-network.

Visit www.eyeconic.com and connect your VSP account to the Eyeconic store.

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http://www.vsp.com/

http://www.eyeconic.com/


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 organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may

vary by location. In the state of Washington, VSP Vision Care, Inc., is the legal name of the corporation through which VSP does business.

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Benefit Description Copay Frequency

Your Coverage with a VSP Provider

Well Vision Exam • Focuses on your eyes and overall wellness $10 Every 12 months

Prescription Glasses $15 See frame and

lenses

Frame • $160 allowance for a wide selection of frames

• $180 allowance for featured frame brands

• 20% savings on the amount over your allowance

• $90 Costco® frame allowance

Included in

Prescription Glasses

Every 12 months

Lenses • Single vision, lined bifocal, and lined trifocal

lenses

• Polycarbonate lenses for dependent children

Included in

Prescription Glasses

Every 12 months

Lens Enhancements • Scratch Resistant Coating

• Standard progressive lenses

• Premium progressive lenses

• Custom progressive lenses

• Average savings of 20-25% on other lens

enhancements

$0

$55

$95-105

$150-$175

Every 12 months

Contacts

(instead of glasses)

•$160 allowance for contacts; copay does not apply

• Contact lens exam (fitting and evaluation)

Up to $50 Every 12 months

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

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 Coverage with Out-of-Network Providers

Get the most out of your benefits and greater savings with a VSP network doctor. Your coverage with out-of-network providers will

be less or you’ll receive a lower level of benefits. Visit vsp.com for plan details.

Exam ................................... up to $45 Lined Bifocal Lenses ........................ up to $50 Progressive Lenses ........................... up to $50

Frame ..................................up to $70 Lined Trifocal Lenses ........................ up to $65 Contacts ................................................ up to $105

Single Vision Lenses ......... up to $30


AMITA 2019 Bi-Weekly Benefit Rates

MEDICAL RATES - Bi Weekly – Non-Wellness

Salary Banding Associate Associate + Spouse

Associate + Children

Family

Full-TIme Non-wellness Rates

$0-$14.42 $64.31 $130.28 $122.03 $188.00

$14.43-$28.85 $71.58 $149.19 $139.49 $217.10

$28.86-$48.08 $76.43 $161.81 $151.13 $236.51

$48.09+ $81.28 $174.42 $162.78 $255.91

Part-TIme Non-wellness Rates

Associate $123.75 $228.45 $206.30 $336.17

DENTAL RATES - Bi Weekly

Associate Associate + Spouse


Family

Full-Time Rates - Low Plan $4.46 $8.92 $10.85 $16.83

Part-Time Rates - Low Plan $12.76 $25.52 $31.06 $48.17

Full -Time Rates - High Plan $5.47 $10.95 $13.29 $20.61

Part- Time Rates - High Plan $15.66 $31.32 $38.02 $58.98

VISION RATES - Bi Weekly

Associate Associate + Spouse


Family

$4.08 $6.54 $6.68 $10.77

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Flexible Spending Accounts

Eligibility

All full-time or part-time benefit eligible associates may

elect coverage. Eligible dependents include your legal

spouse, and children up to the date in which they turn

age 26. Any unmarried child of any age with a mental

or physical handicap or disability who is incapable of

self-support is eligible provided they became disabled

before age 26 and while covered by the plan.

Coverage Begins

You must enroll in a Flexible Spending Account (FSA)

during your enrollment window to have an FSA, which

is effective the 1st of the month following 30 days of

employment, or during each open enrollment for the

first day of the new benefit year.

As part of the wide range of choices the AMITA benefits

program offers, you may also elect to set up a Flexible

Spending Account to help save income taxes on

predict- able eligible health and/or dependent care

expenses.

You may choose to set up either or both:

• A Health Care Flexible Spending Account

• A Dependent Daycare Flexible Spending Account

HOW A FLEXIBLE SPENDING ACCOUNT WORKS

Health Care Flexible Spending Account:

Estimate how much you expect to spend on eligible

health care expenses for the plan year (January 1, 2019

through December 31, 2019). Consider medical, dental,

vision, and hearing expenses not covered by the benefit

plans, such as copays and deductibles, as well as other

eligible expenses. The maximum contribution you may

elect is $2,650 per plan year. The minimum is $120 per

plan year.

• Pay for eligible health care expenses out of your own

pocket and submit a claim for reimbursement, with

a copy of any necessary documents (receipts,

explanation of benefits, etc.) to the ConnectYourCare

at the address listed on the claim form.

• Pay using a VISA payment card. Automatically records

purchase online and no need to pay upfront and wait

for reimbursement.

Dependent Daycare Flexible Spending Account:

Estimate your eligible expenses for dependent day care

while you work, or other dependent care expenses. The

maximum you may elect is based on your tax filing status:

$5,000 (if you are single or married and filing a joint

return) or $2,500 (if you are married and filing a separate

return).

• Pay for eligible dependent care expenses out of your

own pocket and submit a claim for reimbursement,

with a copy of any necessary documents (receipts,

etc.) to ConnectYourCare at the address listed on the

claim form.

• ConnectYourCare will direct deposit your

reimbursement into your designated account within

24-48 hours after processing your claim (Monday -

Friday) provided you have a balance. Otherwise,

your claim will be processed once a contribution

is received.

Make your elections:

• During Open Enrollment or any enrollment period

after you become eligible; or

• In the event of a qualifying life status change.

HEALTH CARE FLEXIBLE SPENDING ACCOUNT QUALIFYING EXPENSES

Any health care expenses qualifying under the Internal

Revenue Code for income tax purposes also qualify for

reimbursement through the Health Care Flexible Spend-

ing Account. If you use the account for these expenses,

you cannot take an income tax deduction as well.

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Flexible Spending Accounts

Eligible expenses include, but are not limited to:

• Deductibles, coinsurance, and copays – for medical,

dental, pharmacy, and vision care;

• Amounts you pay in excess of plan limitations for

allowed charges;

• Amounts in excess of annual or lifetime benefit

maximums;

• Expenses not covered or not fully covered by your

plan; and

• Certain over-the-counter medications if prescribed

by a physician.

DEPENDENT DAYCARE FLEXIBLE SPENDING ACCOUNT QUALIFYING EXPENSES

Any expenses qualifying for a Federal Child and Dependent

Daycare Tax Credit for income tax purposes also qualify for

reimbursement through the Dependent Daycare Flexible

Spending Account.

If you use the account to reimburse yourself for eligible

expenses, you cannot take the Federal Tax Credit for the

same expenses. Eligible expenses include those services

provided inside or outside your home while you work by

anyone other than your spouse or your dependents to care

for eligible dependent children (under age 13) or depen-

dents who are physically or mentally unable to care for

General Plan Rules

The Internal Revenue Service imposes the following rules

and regulations on pre-tax Flexible Spending Accounts:

• You lose any money left in your account at the end of the

plan year, so decide carefully how much to contribute

when you enroll each year. However, there is a 90-day

grace period after the end of the plan year to submit

eligible health care and dependent daycare expenses

incurred during the plan year.

• You may be eligible for a Federal Child and Dependent

Daycare Tax Credit and/or to deduct certain health care

expenses on your tax return. Be sure to talk to a tax

advisor to see whether the tax credits and deductions

or the Flexible Spending Accounts are the best choice

for you.

• For the Health Care Flexible Spending Account, you can

be reimbursed up to the full amount you elect to

contribute for the plan year even if funds are not yet

deposited into your account. However, you can only be

reimbursed up to the amount deposited into your

Dependent Daycare Flexible Spending Account at the

time of your claim.

• You cannot use money in your Health Care Flexible

Spending Account to be reimbursed for dependent day

care expenses, and you cannot use money in your

Dependent Daycare Flexible Spending Account to be

reimbursed for health care expenses. You also cannot

transfer money from one account to the other.

themselves for whom you contribute more than half of their • Flexible spending accounts (medical) allow $500 per

support. • Flexible Spending Accounts (medical) allow $500 per

year to be rolled over.

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Basic and Voluntary Life / AD&D

BASIC LIFE

Eligibility

All full-time and part-time benefit eligible associates are provided employer paid Basic Life/AD&D coverage at

1x annual earnings to a maximum of $1,000,000. Associates are automatically enrolled in Basic Life and AD&D.

AMITA Health provides this benefit at no cost to the Associate. The Prudential Insurance Company of America

provides this insurance.


Coverage is effective the 1st of the month following 30 days of employment.

When Coverage Ends

Coverage will end at the termination of your employment. You may convert your insurance to an individual life

insurance policy issued by the Prudential Insurance Company of America. Please see the Life Plan book for

additional instances when coverage ends.

Basic Life – Key Provisions

• If you are terminally ill, you can get a partial payment of your group life insurance benefit. You can use this

payment as you see fit. The payment to your beneficiary will be reduced by the amount you receive with the

Accelerated Benefit Option.

• Payment of premium can be waived if you are totally disabled for 6 months, you are less than 60 years old when

disability begins, and you continue to be totally disabled. The waiver terminates at normal social

security retirement age. This provision may vary by state.

• Coverage will be reduced as you age – 50% at age 70.

Please refer to the Life plan summary plan description for more information.

Basic Accidental Death & Dismemberment – Key Provisions

• Basic AD&D pays you and your beneficiary a benefit for loss of life or other injuries resulting from a covered

accident. 100% is paid for loss of life. A lesser percentage is paid for other injuries such as loss of sight or

speech, paralysis, and dismemberment of hands or feet.

• Basic AD&D benefits are paid regardless of other coverages you may have.

• You are automatically enrolled for an amount equal to your Basic Life coverage amount. L

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VOLUNTARY LIFE

Eligibility

All full-time and part-time benefit eligible associates may purchase voluntary employee optional life coverage for

1.0 to 7.0 times your covered annual earnings up to a maximum of $2,500,000. You must elect voluntary life insurance

at enrollment. Rates for this insurance are determined by your use of tobacco, which is self-reported. Premiums are

deducted on an after tax basis from your paycheck.



When Coverage Ends

Coverage will end at the termination of your employment. You may port (continue) your group coverage in an

amount equal to or lower than your current benefit amount. Coverage amounts will be subject to maximum of five

times your annual earnings or $1 million, whichever is less. Please see the Life Plan book for additional

instances when coverage ends.

Voluntary Employee Optional Life – (100% Associate Paid)

• Enrollment at time of hire. You can elect a coverage up to the Guaranteed Issue amount of up to the lesser

of 2.0 times your covered annual earnings or $750,000, without providing evidence of insurability to The Prudential

Insurance Company of America. If you enroll in voluntary life any other time outside your hire date or increase your

amount of coverage at open enrollment, you will be required provide evidence of insurability.

• If you are terminally ill, you can get a partial payment of your group life insurance benefit. You can use this payment

as you see fit. In the event of your death, your beneficiary will receive a benefit payout which has been reduced by

the amount you receive.

• Payment of premium can be waived if you are totally disabled for 6 months, you are less than 60 years old when

disability begins, and you continue to be totally disabled. The waiver terminates at social security retirement age.

This provision may vary by state.


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Spouse - Dependent Life (100% Associate Paid)

Spouse Term Life AD&D

Eligibility May purchase only if Associate elects Voluntary

Life.

May purchase only if Associate elects Voluntary

AD&D.

Coverage and Limits 1. Coverage amount cannot be greater than 50%

of the Associate Voluntary coverage amount.

2. May elect $10K to $250K in $25K increments.

Purchase a coverage amount equal to 65% of

the Associate Voluntary AD&D coverage with a

maximum of $1 Million.

Evidence of Insurability At time of hire may elect up to 25K without EOI.

If increased or elected any other time, EOI will be

required.

There are no health requirements.

Age Reduction 50% at age 70 50% at age 70

Portability Coverage will end at the termination of your

employment. You may port (continue) your

group coverage in an amount equal to or lower

than your current benefit amount only if Asso-

ciate average is ported. Coverage amounts will

be subject to maximum of five times your annual

earnings or $1 million, whichever is less.

May be ported only if Associate coverage is

ported.

Child Dependent Life (100% Associate Paid)

Child(ren) Term Life AD&D

Eligibility May purchase only if Associate elects Voluntary

Life. Coverage may begin from live birth and con-

tinues to age 26.

May purchase only if Associate elects Voluntary

AD&D. Coverage may begin from live birth and

continues to age 26.

Coverage and Limits 1. Coverage amount cannot be greater than 50%

of the Associate Voluntary coverage amount.

2. May elect either $5K or $10K for each child.

Purchase a coverage amount equal to 25% of

the Associate Voluntary AD&D coverage with a

maximum of $75K.

Evidence of Insurability There are no health requirements. There are no health requirements.

Portability Coverage will end at the termination of your

employment. You may port (continue) your group

coverage in an amount equal to or lower than the

current coverage level only if Associate average is

ported.

May be ported only if Associate coverage is

ported.

Voluntary Optional Accidental Death & Dismemberment (100% Associate Paid)

Eligibility

All full-time and part-time benefit eligible Associates may purchase coverage for 1.0 to 10.0 times annual earnings to a

maximum of $2,500,000. Premiums are deducted on an after tax basis from your paycheck.

When Coverage Begins and Ends

Coverage is effective the 1st of the month following 30 days of employment. Coverage ends on the last day

of employment.

Voluntary Accidental Death & Dismemberment – Key Provisions

• There are no health requirements for this coverage


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Short-Term Disability

Eligibility

Short-Term Disability (STD) is available to Full-Time and Part-Time benefit eligible associates who are

regularly scheduled 40 hours per pay period.



When Coverage Ends

Coverage ends on the last day of employment or when you cease to be an eligible associate. Please see the

Short Term Disability Plan book for additional instances when coverage ends.

Benefits of the STD Plan

• Full-time associates: There is no cost to you. You are automatically enrolled in this employer paid benefit.

• Part-time associates: Have the option to purchase this coverage and pay 100% of the premium after tax.

• You can have coverage without providing proof of good health.

• This plan provides a benefit for disability, illness or injury that is not work-related, including pregnancy.

• Your plan also includes Rehabilitation benefits that provide services and support targeted at helping you return

to active work.

Pre-existing Condition

STD benefits will not be paid for a disability that begins within 3 months of your coverage effective date and due

to a pre-existing condition. A pre-existing condition is an injury or sickness for which you received medical

treatment, consultation, diagnostic measures, prescribed drugs or medicines, or for which you followed

treatment recommendations during the 12 months prior to your effective date of coverage.

Coverage Waiting Period Elimination Period Benefit Duration

Full-time 1st of the month following

30 days of employment

14 Calendar days of an

injury or illness

70% of pre-disability weekly

earnings, not exceeding

maximum of to $2,500

24 weeks

Part-time 1st of the month following


14 Calendar days of an

injury or illness

60% of pre-disability weekly

earnings, not exceeding

maximum of to $2,500

24 weeks

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Long-Term Disability

Eligibility

Long-Term Disability (LTD) is provided at no charge to all Full-time associates only who are regularly scheduled to work

72 hours or more per pay period.



When Coverage Ends

Coverage ends on the last day of employment or when you cease to be an eligible associate. Please see the

Long Term Disability Plan book for additional instances when coverage ends.

Benefits of the LTD Plan

• Your monthly LTD will be 50% of their monthly pre-disability earnings, up to a maximum of $15,000.

• Provides coverage for on–and-off-the-job accidents.

• Benefits are payable directly to you to be spent any way you choose.

• Pays in addition to any other coverage you may have.

• Benefits may be reduced if receiving other income benefits

• Benefits will not be paid for a disability that begins within 12 months of your coverage effective date and is due to

a pre-existing condition unless you were treatment free for 3 consecutive months after the coverage effective date.

• Fast and accurate claims service.

Coverage Waiting Period Elimination Period Benefit Duration

CORE LTD Employer paid

1st of the month following


180 calendar days 50% up to $15K monthly Later of age 65 or

Social Security Normal

Retirement Age

BUY-UP LTD Associate paid

1st of the month following


180 calendar days 70% up to $15K monthly Later of age 65 or

Social Security Normal

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Voluntary Permanent Whole Life

Eligibility

Voluntary Permanent Whole Life Insurance is an associate paid benefit available to all associates

that work over 20 hours per week.

To supplement your Basic Life AD&D insurance provided by AMITA Health, you may purchase

additional life insurance coverage for yourself, your spouse and dependent children through

Voya.

Voluntary Permanent Life insurance provides a financial benefit that your family can depend on and getting it at work

is easier, more convenient and more affordable than doing it on your own. If you have financial dependents- a spouse,

children or aging parents, having life insurance is a responsible and smart decision. Premiums never increase due to an

increase in age and the coverage is fully portable.

Accelerated Life Benefit Included: A lump sum benefit is paid to you if you are diagnosed with a terminal condition,

as defined by the plan

Medical Evidence of Insurability (EOI) is required if you enroll at a later date, including future Open Enrollments.

Associate Coverage

• Coverage is available for you in $10,000 increments up to $100,000.

• No medical questions asked, if you enroll when initially offered the coverage unless you elect over the guarantee

issue amount.

Spouse Coverage

• Coverage is available for you in $5,000 increments to up $25,000.

• Associates and spouses must elect coverage prior to reaching age 70.

Child(ren) Coverage

• Term Life Insurance

• No medical questions asked, if you enroll in up to the guarantee issue amount when initially offered

the coverage. $5,000-$10,000, 15 days - 24 years.

Associate 15-50 Up to $100,000 ($10,000 increments)

51-65 Up to $50,000 ($10,000 increments)

66-70 Up to $30,000 ($10,000 increments)

Spouse 15-65 Up to $25,000 ($5,000 increments)*

66-70 $5,000 or $10,000*

Dependent Child 15 days-24 years $5,000 or $10,000*

*Spouses and Children are limited to 50% of the Associate face amount for amounts in excess of $5,000

For more information regarding Voluntary Permanent Whole Life Insurance, please call Voya at 1-800-537-5024 or visit www.voya.com

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Accident Insurance

Have you ever dislocated a joint or gotten a deep cut? How about something more severe,

like a concussion or broken bone? Most of us have experienced an accident that needed medical

attention as least once in our lives. Accident Insurance can help relieve some of the financial

stress that goes along with an accidental injury.

Eligibility

Accident Insurance is an associate paid benefit available to all associates that work over 20 hours per week.

What is Accident Insurance?

Accident Insurance pays you benefits for specific injuries and events resulting from a covered accident that occurs

while you are not at work, on or after your coverage effective date. The benefit amount depends on the type of injury

and care received. You have the option to elect Accident Insurance to meet your needs. Accident Insurance is a limited

benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the

Affordable Care Act.

Other features of Accident Insurance include:

• Guaranteed issue: No medical questions or tests are required for coverage.

• Flexible: You can use the benefit payments for any purpose you like.

• Payroll deductions: Premiums are paid through convenient payroll deductions.

• Portable: If you leave your current employer, you can take your coverage with you.

How can Accident Insurance help?

Below are a few examples of how your Accident Insurance benefits could be used:

• Medical expenses, such as deductibles and copays

• Home healthcare costs

• Lost income due to lost time at work

• Everyday expenses like utilities and groceries

Who is eligible for Accident Insurance?

• You—all active associates working 20+ hours per week.

• Your spouse*— Coverage is available only if associate coverage is elected.

• Your children— to age 26. Coverage is available only if associate coverage is elected. *The use of “spouse” in this document means a person insured as a spouse as described in the applicable rider. Please contact your employer for more information.

When is my coverage effective?

The effective date of coverage is the date you are eligible to begin filing claims. The injury must occur on or after the

coverage effective date.

2019 Annual Enrollment • Your coverage becomes effective on January 1, 2019, following the election of coverage.

Coverage for your spouse and/or children becomes effective on the same date as your coverage.

New Hires • If you elect voluntary coverage, that coverage becomes effective at 12:01 AM on the first of the

month after 30 days of continuous employment.

• Coverage for your spouse and/or children becomes effective on the same date as your coverage.

For more information regarding Accident Insurance, please call Voya at 1-800-537-5024 or visit www.voya.com

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Critical Illness Insurance

Do you know someone who has had a serious illness like a heart attack or stroke? You probably

do but don’t expect to ever experience one yourself. The problem is, no one thinks it could

happen to them and when it does, they may not be prepared for the financial ramifications.

On top of the medical bills, there are still everyday expenses to pay for, which can be challenging during

recuperation. Plus, you may need help with day-to-day tasks like house maintenance, child care and

transportation. That’s where Critical Illness Insurance can help.

Eligibility

• You—all active associates working 20+ hours per week.

• Your spouse*— Coverage is available only if associate coverage is elected

• Your children— to age 26. Coverage is available only if associate coverage is elected.

*The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance

or rider. Please contact your employer for more information.

What is Critical Illness Insurance?

Critical Illness Insurance pays a lump-sum benefit if you are diagnosed with a covered illness or condition on or after

your coverage effective date. You have the option to elect Critical Illness Insurance to meet your needs. Critical Illness

Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential

coverage under the Affordable Care Act.

Features of Critical Illness Insurance include: • Guaranteed Issue: No medical questions or tests are required for coverage.

• Flexible: You can use the benefit payments for any purpose you like.

• Payroll deductions: Premiums are paid through convenient payroll deductions.

• Portable: If you leave your current employer, you can take your coverage with you.

For what critical illnesses and conditions are benefits available?

Critical Illness Insurance provides a benefit payment for the following illnesses and conditions. Covered illnesses/

conditions are broken out into groups called “modules”. Benefits are paid at 100% of the Maximum Critical Illness

Benefit amount unless otherwise stated. For a complete description of your benefits, along with applicable provisions,

conditions on benefit determination, exclusions and limitations, see your certificate of insurance and any riders.

Base Module

Heart attack* Major organ failure

Stroke Permanent paralysis

Coronary artery bypass (25%) End stage renal (kidney) failure

Coma

*Cardiac arrest is not a heart attack

Cancer Module

Cancer Carcinoma in situ (25%)

Skin cancer (10%)

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How can Critical Illness Insurance help?

Below are a few examples of how your Critical Illness Insurance benefit could be used (coverage amounts may vary):

• Medical expenses, such as deductibles and copays

• Child care

• Home healthcare costs

• Mortgage payment/rent and home maintenance

When is my coverage effective?

The effective date of coverage is the date you are eligible to begin filing claims. The condition or illness must occur on

or after the coverage effective date.

2019 Annual Enrollment

• Your coverage becomes effective on January 1, 2019, following the election of coverage. Coverage for

your spouse and/or children becomes effective on the same date as your coverage.

New Hires

• If you elect voluntary coverage, that coverage becomes effective at 12:01 AM on the first of the month

following 30 days of continuous employment.

• Coverage for your spouse and/or children becomes effective on the same date as your coverage.

What Maximum Critical Illness Benefit am I eligible for?

For you

• You have the opportunity to purchase a Maximum Critical Illness Benefit of $10,000, $20,000 or $30,000.

For your spouse

• You have the opportunity to purchase a Maximum Critical Illness Benefit of $5,000, $10,000 or $15,000

for your spouse.

For your children

• You have the opportunity to purchase a Maximum Critical Illness Benefit of $5,000, $10,000 or $15,000

for each covered child.

How many times can I receive the Maximum Critical Illness Benefit?

Usually you are only able to receive the Maximum Critical Illness Benefit once for each covered condition. Your plan

includes the Recurrence Benefit, which allows you to receive a benefit for the same condition a second time. It’s

important to note that in order for the second occurrence of the illness to be covered, it must occur after 12 consecutive

months without the occurrence of any covered critical illness named in your certificate, including the illness from the

first benefit payment.

If you have reached the benefit limit by receiving the maximum benefit for each covered condition, you may choose to

end your coverage; however, if you have coverage for your spouse and/or children, you must continue your coverage

in order to keep their coverage active. Please see your certificate of coverage for details.

For more information regarding Critical Illness Insurance, please call Voya at 1-800-537-5024 or visit www.voya.com

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Employee Assistance Programs (EAP)

Practical Solutions for Everyday Concerns.

Confidential Counseling Anxiety

Depression

Emotional Health

Effective Communication

Family & Relationship Difficulties

Grief

Life Transitions

Parenting Concerns

Stress

Substance Abuse

Work-Life Balance Adoption Resources

Career Transition Resources

Child Care Options

Education Resources

Health & Wellness Information

Home Health Care Services

Home Maintenance

Parenting Resources

Pet Care Services

Senior Housing Options

Legal-Financial Fitness Bankruptcy

Credit Report Review

Debt Management

Divorce & Custody Issues

Estate Planning & Will Preparation

Financial Counseling

Financial Planning Resources

Foreclosure

Identity Theft Recovery

Real Estate

Small Claims

Responsive Professional counselors are available to speak with you. Our team of

caring professionals helps clarify the nature of your concern and presents

the best options available to meet your needs.

Confidential Your confidentiality is protected by federal and state law as well as our

professional ethical standards. With very limited exceptions, disclosure

of information to any source without prior written consent is prohibited.

24/7 Access Support is available 24 hours a day, 7 days a week by calling our

toll-free number: 1-877-215-6614

Eligibility Workplace Solutions’ services are available to eligible associates and their

dependents, as well as the eligible associate’s household members.

Cost There is no cost to you or your eligible family members to utilize Workplace

Solutions services.

www.wseap.com 1-877-215-6614

For more information regarding Employee Assistance Programs, please visit https://www.lifeworks.com/us/contact

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http://www.lifeworks.com/us/contact


Legal Plan

Protect yourself with affordable Hyatt Group Legal Services.

Eligibility

The Legal Plan is an associate paid benefit available to all associates that work over 20 hours per week.

Adventist Midwest Health Alexian Brothers Health System Presence Health

Legal matters, both planned and unplanned, are part of life. Enrolling in a Hyatt

Legal Plan gives you the financial and emotional peace of mind to know you will

be covered for expected and unexpected legal events.

The Hyatt Legal Plan provides you, your spouse and dependents with fully cov-

ered legal services from attorneys experienced in estate planning documents,

civil suits, adoption, creditor issues and much more. Sign up for a convenient

payroll deduction of just $8.25 per month for the Associate only Plan or $12.00

per month for the Family Plan, and save hundreds over typical attorney fees...

with no deductibles, no co-pays, no claim forms or usage limits when using a

Network Attorney. We’ll automatically deduct the cost from your paychecks.

Choose from more than 15,000 attorneys nationwide. Receive fully covered legal advice and representation for a wide range of legal

matters. You can consult with your attorney on the phone or in person. You can

also use an out-of-network attorney and get reimbursed for covered services

according to a set fee schedule.*

It’s easy to access the right attorney. Online. By Phone. In Person. Once you’re enrolled, simply go to members.legalplans.com or download our

Mobile App. You can also call Hyatt Legal Plans toll-free at 1-800-821-6400 Mon-

day through Friday from 8 a.m. to 8 p.m. EST.

A representative will confirm your plan eligibility and give you a case number

and the address and phone number of the appropriate attorney(s) near you.

Service is just a click or call away.

Questions? Call l-800-821-6400 Monday-Friday 8:00 a.m.-8:00 p.m. (EST).

Peace of mind for you and your family. For more information, visit: info.legalplans.com and enter access code:

9900669 - Adventist Midwest Health Associate Only Plan 9900670 - Adventist Midwest Health Family Plan 9900665 - Alexian Brothers Health System Associate Only Plan 9900666 - Alexian Brothers Health System Family Plan 9901680 - Presence Health Associate Only Plan

9901681 - Presence Health Family Plan

COVERED SERVICES

• Administrative Hearings

• Uncontested Adoption

• Affidavits, Deeds

• Civil Litigation Defense

• Consumer Protection

Matters

• Debt Collection Defense

• Demand Letters

• Document Review

• Domestic Violence Protection

• Elder Law Matters

• Eviction and Tenant Problems

(for tenants)

• Uncontested Guardianship

• Home Equity Loans

(primary residence)

• Immigration Assistance

• Incompetency Defense

• Juvenile Court Defense

• Living Wills

• Mortgages

• Name Change

• Personal Bankruptcy

• Personal Property Protection

• Powers of Attorney

• Prenuptial Agreement

• Promissory Notes

• Property Tax Assessment

• Restoration of Driving Privileges

• Sale, Purchase or Refinancing

of your Primary Residence

• Tax Audits

• Traffic Ticket Defense

(excludes DUI)

• Trusts

• Wills, Codicils

For more information regarding The Legal Plan, please visit www.legalplans.com or 1-800-423-0300

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Retirement

AMITA Health for 2019 will continue to offer three retirement defined contribution plans for all associates across its

legacy organizations. Associates will participate in the retirement plan offered by their legacy organization. The three

plans are:

Alexian Brothers Health System - Alexian Brothers Health System 401(k) Retirement Savings Plan

Adventist Midwest Health - Adventist Healthcare Retirement Plan 403(b)

Adventist Midwest Management Services -Adventist Midwest Management Services 401(k) Retirement Plan

Below is a brief summary of each plan. For more detail please refer to the plan document.

Alexian Brothers Health System 401(k) Retirement Savings Plan

The Retirement Program is available to all associates who are 21 years of age or more, except leased and independent

contractors. Associates are eligible to participate in the Alexian Brothers Health System 401(k) Retirement Savings Plan

(the “401(k) Plan) effective the first of the month following 30 days of continuous active employment. The 401(k) Plan al-

lows associates to save for their own retirement. In addition, AMITA Health will make contributions to the retirement plan.

Participant’s Savings Account:

Associates are always 100% vested in their own contributions. An associate must enroll to have coverage under the plan.

• Pre-Tax Contributions: Associates can contribute a percentage of 1% to 80% their earnings, up to the limit allowed

by federal law. Associates pay taxes on contributions and earnings when the distribution is taken from the account.

• Catch-Up Contributions: Associates who are at least 50, or who will turn 50 during the Plan Year, may contribute

an additional $6,000 to their Plan.

• After-Tax Roth 401(k) Contributions: Associates may designate some or all contributions as Roth 401(k)

contributions. Associates will not pay taxes on any earnings when they are withdrawn provided the account

distribution occurs at least five years following the year the first Roth 401(k) contribution and have attained age 59

1/2, died or become disabled.

• ENROLL in the 401(k) Plan at www.schwab.com/workplace or call 1-800-724-7526.

Employer Matching Account: If associate contributes to the 401(k) plan, AMITA Health will match $.50 for each dollar on

the first 4% of eligible compensation. Contributions to the Employer Matching Account are made quarterly after an asso-

ciate has achieved 1,000 hours of eligible service.

Retirement Contribution Account: AMITA Health will contribute from 2% to 6% towards an account that is based on prior

year pension eligible earnings and pension years of service. To be eligible for the Retirement Contribution Account an

associate must work at least 1,000 hours per year, have at least one calendar year of employment and one year of ser-

vice, and must be actively employed on December 31 of the Plan Year. Contributions are based upon individual pension

eligible earnings and pension years of service.

Vesting Rules: Based on years of pension service. To accumulate one year of vesting, an associate must work 1,000

hours during the plan year, January 1 through December 31. Associates are always 100% vested in their own contribu-

tions. Employer contributions and their earnings vesting schedule is 0-1 years – 0%, 2 years –25%, 3 years – 50%, 4 years

– 75% and 5 years – 100%.

Investment Options: Associates direct the investing of the funds in all three accounts. Investment options range from

highly conservative money market and stable value funds to aggressive equity funds. Targeted funds for less experienced investors are also available.

Changes: Associates may change their contribution rate or investment allocation at any time. Subject to prospectus re-

quirements, associates may transfer funds at any time.

Rollovers: The 401(k) plan will accept a rollover from another qualified retirement plan. Associates can rollover pre-tax

contributions, match contributions and Roth 401(k) contributions (but not Roth IRA contributions). Associates can initiate the rollover by calling Schwab at 1-800-724-7526.

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Adventist Healthcare Retirement Plan 403(b) and 401(a) Plan

The Adventist Healthcare Retirement Plan (AHRP) is available to all associates at least 18 years of age or more. There is

no waiting period. The 403(b) Plan allows associates to save for their own retirement. In addition, AMITA Health will

make contributions to the AHRP 401(a) retirement plan.

AHRP 403(b) Plan (Participant’s Savings Account):

Associates are always 100% vested in their own contributions. An associate must enroll to have coverage under the

plan.

• Pre-Tax Contributions: Associates can contribute a percentage of their earnings, up to the limit allowed by

federal law. Associates pay taxes on contributions and earnings when the distribution is taken from the account.


an additional $6,000 (in 2019) to their Plan.

• After-Tax Roth 403(b) Contributions: Associates may designate some or all contributions as Roth 403(b)

contributions. Associates will not pay taxes on any earnings when they are withdrawn provided the account

distribution occurs at least five years following the year the first Roth 403(b) contribution and have attained age

59 1/2, died or become disabled.

• ENROLL in the 403(b) Plan at http://AHRP.com or call the AHRP Retirement Center at 1-800-730-2477.

AHRP 401(a) Plan (Employer Matching Contribution): If an associate contributes to the 403(b) plan, AMITA Health will

match $.50 for each dollar on the first 4% of eligible compensation. Contributions to the Employer Matching Account

are made after the end of each calendar year. To be eligible for the Matching Contribution, the associate must have

worked 1000 hours in the plan year.

AHRP 401(a) Plan (Employer Basic Contribution): AMITA Health will contribute 2.6% of prior year eligible earnings, plus

an additional contribution of 1.5% of wages in excess of Social Security Taxable Wage Limit ($128,700 in 2019). To be eligible for the Basic Contribution, the associate must have worked 1,000 hours in the plan year.

Vesting Rules: To accumulate one year of vesting, an associate must work 1,000 hours during the plan year, January

1 through December 31. Effective 3/16/2017, vesting in AHRP requires three years of vesting service credit. Less than

three years the associate is 0% vested. Three or more years the associate is 100% vested. Vesting applies only to the

Employer contributions in the AHRP 401(a) Plan and denotes the associate’s ownership in these contributions.

Investment Options: Associates direct the investment of their contributions and AMITA Health contributions to their

AHRP account. The AHRP offers many investment options to suit different retirement needs. These options span a

range of asset classes and investment approaches. When making your choices, factors to consider include your likely

retirement age, tolerance for risk, the length of time you plan to save, and your financial needs at retirement

Changes: Associates may change their contribution rate or investment allocation at any time. Subject to prospectus

requirements, associates may transfer funds at any time.

Rollovers: The AHRP plan will accept a rollover from another qualified retirement plan. Associates can rollover pre-tax

contributions, match contributions and Roth 401(k) contributions (but not Roth IRA contributions). Associates can initiate

the rollover by calling AHRP at 1-800-730-2477.

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http://ahrp.com/


Adventist Midwest Management Services Associate Retirement Plan

The Adventist Midwest Management Services (AMMS) Employee Retirement Plan 401(k) is available to all associates

at least 18 years of age or more. There is no waiting period. The AMMS Plan allows associates to save for their own

retirement. In addition, AMITA Health will make contributions to the retirement plan for those associates who are benefit

eligible and worked at least 1000 hours during the plan year. Independent contractors and all associates of all

related employers are excluded from the plan.

Participant’s Savings Account:

Associates are always 100% vested in their own contributions. An associate must enroll to have coverage under the

plan.

• Pre-Tax Contributions: Associates can contribute a percentage of their earnings, up to the limit allowed by

federal law. Associates pay taxes on contributions and earnings when the distribution is taken from the account.


an additional $6,000 to their Plan.

• Enrollment in this plan is through paper application obtained through Human Resources and thereafter

changes can be made on the vendor website.

• Enroll in the 401(k) plan by contributing MetLife at 1-800-543-2520

Employer Matching Account: If an associate contributes to the Plan, AMITA Health will match $.50 for each dollar on

the first 4% of eligible compensation. Contributions to the Employer Matching Account are made after the end of each calendar year, provided the associate worked 1000 hours in the plan year.

Retirement Contribution Account (Employer Basic Contribution): AMITA Health will contribute 2.6% of prior year eligible

earnings, plus an additional contribution of 1.5% of wages in excess of Social Security Taxable Wage Limit ($128,700 in 2019). To be eligible for the Basic Contribution, the associate must have worked 1,000 hours in the

plan year.

Vesting Rules: To accumulate one year of vesting, an associate must work 1,000 hours during the plan year, January 1

through December 31. Less than three years of vesting credit service, the associate is 0% vested. Three or more years

the associate is 100% vested. Vesting applies only to the Employer contributions and denotes the associate’s ownership

in these contributions.

Investment Options: Associates direct the investment of their contributions and AMITA Health contributions in their

AMMS account. There are many investment options to suit different retirement needs. These options span a range of

asset classes and investment approaches. When making your choices, factors to consider include your likely retirement

age, tolerance for risk, the length of time you plan to save, and your financial needs at retirement

Changes: Associates may change their contribution rate or investment allocation at any time. Subject to prospectus

requirements, associates may transfer funds at any time. Rollovers: The AMMS plan will accept a rollover from another qualified retirement plan. Associates can initiate the

rollover by contacting their Human Resources Department.

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Diabetes Management, Simplified

Livongo for Diabetes is a new health benefit that will be launching soon. Livongo provides

an advanced blood glucose meter, unlimited strips and lancets, and personalized coaching,

100% paid for by your employer.

It’s all in the meter and on the house.

• Personalized tips with each blood glucose check

• Optional family alerts keep everyone in the loop

• Real-time support when you’re out of range

• Send a health summary report directly from your meter

• Strip reordering, right from your meter

• Automatic uploads mean no more paper logbooks

Unlimited strips. Unlimited lancets. It’s all free for you.

More details and how to register coming soon.

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Commuter Benefits User Guide

Now you can reduce your commuting expenses with Commuter Benefits. Not only does

the benefit save you money on work-related transit and parking expenses by allowing

you to use pre-tax money for these items, it is also simple to use!

Ordering: Where to Begin

Ordering eligible commuter products is easy. Log in to your online account, order your parking or transit passes or

vouchers, and they will be mailed directly to you. Or, if you elect, you may choose to pay your parking provider

directly. The total amount of your purchases will be deducted from your paycheck–tax free–up to the IRS limit!

1. Log In - Log in to your ConnectYourCare online account. If you have not registered before, follow instructions

to set your user name and password. Click on the Transit tab to access the Commuter Portal.

2. Take Action - You may choose to place an order, edit and order, delete an order, update your account,

view FAQs, try out the savings calculator, or see important notices. Your options are presented in a helpful dashboard.

Placing a Transit Order

1. From the side menu in the Commuter Portal dashboard, select ‘Place an Order’.

2. Select your preferred transportation methods, for example, ‘Train’, and click ‘Next’.

3. Enter your home and work zip codes, then click ‘Next’.

4. Select your product or transit authority from the list of options.

5. Enter your order details and set your recurring order preferences. When finished, click ‘Next’.

6. View your cart, and click ‘Proceed to Checkout’.

7. Review your order. If everything is correct, click ‘Place Order’.

8. A confirmation will display that your order has been placed.

Substantial Tax Advantages. Reduce your taxable income by the amount of transit and

parking you purchase, subject to IRS limits.

Simple Ordering Process. Enjoy a quick and easy ordering process and valuable online tools.

Multiple Uses. Use for a number of your work-related transportation and parking expenses, including

trains, buses, subways, ferries, vanpools and parking (if included in your plan).

Wallet Wise and Environmentally Friendly. Save money on gas while improving air quality and reducing

energy consumption, automobile congestion and greenhouse gas emissions.

Please keep in mind that you must place your order by the order deadline (generally the 10th of the month)

for the following month. Orders received by the 10th of the month are processed and mailed no later than the

23rd of that month. Example: Passes ordered by June 10th are for July and are mailed no later than June 23rd.

Please check online to verify your order deadline.

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Smart Card Transit Order

Follow steps 1–3 from Placing a Transit Order, then:

• A list of Smart Card options available for your area will display in the list of product options.

• Provide required information including the amount you want added to your card and your account number

and set your recurring order preferences.

• When finished, click ‘Next’ and follow steps 6-8 from Placing a Transit Order above.

Note: Many Smart Cards, including Chicago’s Ventra, Washington DC’s SmarTrip and San Francisco’s Clipper Card, re-

quire you to obtain the card directly from the transportation authority or participating retail outlet first, then log in to your

online account to add funds to the card. You will need your smart card account number.

Commuter Check Vouchers for Transit

Follow steps 1–3 from Placing a Transit Order, then:

• Select Commuter Check Voucher from the list of product options.

• Enter the quantity and denomination of Commuter Checks needed, and set your recurring order preferences.

• When finished, click ‘Next’ and follow steps 6-8 from Placing a Transit Order above.

Parking Orders If included in your plan, there are a variety of options for parking orders to suit your life style and needs. After

selecting ‘Park’ front the ‘Place an Order’ screen, you will have several options from which to choose. Select the

option that works best for you, and follow the easy online prompts to complete your order.

Commuter Check Prepaid Mastercard®

This convenient reloadable prepaid card can be used for purchasing transit products or paying vanpool fees. You will

receive one card, which is funded monthly with a specified amount. No more waiting in line or saving receipts.

The Commuter Check Prepaid Mastercard is accepted at Transit Agencies, fare vending machines, vanpool providers

and designated transit retail centers where only transit products are sold. Use your Commuter Check Prepaid Master-

card the same way you would use a credit card.*

1. From the side menu select ‘Place an Order’.

2. Select your preferred transportation methods, and click ‘Next’.

3. Enter your home and work zip codes, then click ‘Next’.

4. Select ‘Commuter Check Prepaid Mastercard’ from the list of options.

5. Enter your order details and set your recurring order preferences. When finished, click ‘Next’.

6. View your cart, and click ‘Proceed to Checkout’.

7. Review your order. If everything is correct, click ‘Place Order’.

8. A confirmation will display that your order has been placed.

If you set your order to recur monthly, orders will be repeated automatically each month. If it is a carded order,

funds will be automatically loaded on to your card each month. You won’t have to log back into your account

unless you want to make changes to your order.

After your order has been placed, you may edit or delete your order (up to the 10th of the month in most

cases). You can make changes to your order right from your dashboard. Select your upcoming order, and

click ‘Edit’ or ‘Delete’ under ‘Options’.

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Ride Sharing Services: Lyft Line and uberPOOL

• Open up the Lyft or Uber application on your smartphone.

• Add the Commuter Prepaid MasterCard as a new payment method. On the Uber app,

select Commuter Benefits before adding add your card information.

• When you are ready to schedule your ride, open your app and choose your destination.

• Select the Commuter Prepaid MasterCard as your payment method.

• Select the eligible shared ride option.

• Enjoy your commute!

Frequently Asked Questions

How does this benefit work? There is no need to complete any enrollment forms. Simply log in to your online account, order your transit or parking

and your passes or vouchers will be mailed directly to you, or if you elect, your parking provider will be paid directly.

Your purchase will be deducted automatically from your paycheck.

How does the pre-tax payroll deduction work? The amount that you spend on transit or parking can be paid for with pre-tax money. When you order transit and park-

ing online, the value of your order is automatically deducted from your paycheck. Your yearly taxable income is reduced

by the amount of your purchase. For tax years beginning after January 1, 2018, the IRS allows up to $260 a month pre-

tax for costs and up to $260 a month pre-tax for parking costs. Any amount beyond that becomes a post-tax deduction.

Assuming a total tax rate of 30%, if you spend $260 on commuting and $260 on parking each month, you can save

$1,872 per year. That’s like getting more than 3 and a half months for free!

How can I make changes to my information? • After your order has been placed, you may edit or delete your order (up to the 10th of the month in most cases).

You can make changes to your order right from your dashboard. Select your upcoming order, and click ‘Edit’ or

‘Delete’ under ‘Options’.

• To change personal information, log in to the Commuter Portal and click My Account to update your information.

If you set your order to recur monthly, funds will be loaded onto your card automatically each month. You won’t

have to log back into your account unless you want to make changes to your order.

You can activate or report a problem with your card right from your dashboard. More details about your Com-

muter Check Prepaid Mastercard, such as transaction history, can be found under My Account > Card Manage-

ment.

Your Commuter Check Prepaid Mastercard has a PIN, which

is accessible from the Card Management page in your online account. However, you can bypass the need for

a PIN by selecting the CREDIT option when making a purchase.

After your order has been placed, you may edit or delete your order (up to the 10th of the month in most

cases). You can make changes to your order right from your dashboard. Select your upcoming order, and

click ‘Edit’ or ‘Delete’ under ‘Options.’

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What is cutoff date for ordering transit and parking passes? Your order deadline is displayed prominently on the home page of the Commuter Portal. For most associates and

transit authorities, you must place your order by the 10th of the month for the following month. Orders received by the

10th of the month are processed and mailed no later than the 23rd of that month. Example: Passes ordered by June 10th

are for July and are mailed no later than June 23rd.

However, some employers have modified the order deadline. Additionally, some transit authorities have a different

order deadline. Please check online to verify your order deadlines.

Can I order the exact pass that I use now? Absolutely. We offer more than 100,000 different types of commuter and parking benefits. Most likely, we have exactly

what you need for your transit or parking provider. If you don’t see what you need, contact us and we’ll add it for you.

Do I have to remember to place my order each month? You can set your order up as recurring, meaning that we’ll automatically process it each month until you notify us

otherwise. We can also send you an email each month reminding you that you have an order in the system, and

prompting you to re-enter the site if you need to make a change.

How do I add the Commuter Prepaid Mastercard to the Car Service App? Simply open the app on your smartphone, select payment, and then add credit card. Once on this screen, enter in the

fields from your Commuter Prepaid Mastercard. You will have to ensure this card is selected prior to requesting the car

service. This card may not be used for personal car service requests.

What expenses can be purchased pre-tax? Eligible expenses include public transportation used for your transit to work and many parking expenses. Only your

work commuter expenses are eligible. You may not use this benefit for your spouse’s or dependents’ commuter

expenses. Below are some examples of qualified and unqualified expenses.

Eligible Transit Expenses:

• Buses

• Trains & subways

• Ferries

• Vanpools

• Commuter highway vehicles

• Shared ride card service apps- uberPOOL and Lyft Line

Eligible Parking Expenses (if included in your plan)

• Parking at or near your place of employment

• Parking at a location from which you commute to work

Ineligible Transit and Parking Expenses

• Bridge tolls

• Highway tolls

• Expenses for someone other than you

• Uber and Lyft services not associated with uberPOOL and Lyft Line services

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Additional Benefits

Cafeteria Discount

Eligibility:

All Associates receive a cafeteria discount by presenting their I.D. badge at time of purchase.

Tuition Reimbursement

Tuition Reimbursement is available to Full-Time and Part-Time associates who are regularly scheduled to work 40

hours or more per pay period, and is effective after 6 months of continuous employment. An associate must apply to receive tuition reimbursement.

This program will reimburse tuition only (no books, fees or other expenses) – up to $4,000 a year for Full-Time or

$2,000 a year for Part-Time per calendar year. The associate’s status is determined when the course is completed.

Visit the iAMITA > Departments > Human Resources > Benefits > Tuition Reimbursement.

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Vendor Contact Listing

VENDOR CONTACT LISTING

BENEFIT PLAN VENDOR NAME TELEPHONE NUMBER

WEBSITE

To enroll in Benefits Benefit Express 1-844-593-0328 www.amitahealthbenefits.com

Medical PPO Plan Automated Benefit

Services

1-844-659-2519 Member Portal: www.abs-tpa.com

Provider Lookup:

www.amitahealthproviders.org

Prescription Drugs Cigna 1-800-622-5579 www.mycigna.com

Dental PPO Plan Delta Dental of Illinois 1-800-323-1743 www.deltadentalil.com

Vision Plan VSP 1-800-877-7195 www.vsp.com

Life Claims & Waiver of

Premium

Prudential 1-800-524-0542 www.prudential.com

Life Conversion Prudential 1-877-889-2070 www.prudential.com

Life Portability Prudential 1-800-778-3827 www.prudential.com

Short Term Disability

Customer Service

Full-Time Associates

Sedgwick 1-855-224-4899

Short Term Disability Claims


Sedgwick 1-855-224-4899

Short Term Disability

Customer Service

Part-Time Associates


Short Term Disability Claims

Part-Time Associates


Short Term Disability Tax

Questions Part-Time Associates


Long Term Disability

Customer Service



Long Term Disability Claims

Full Time Associates


Flexible Spending Accounts Connect Your Care 1-833-799-1780 www.connectyourcare.com/amita

Commuter Benefit Connect Your Care 1-833-799-1780 www.connectyourcare.com/amita

401(k) Plan - Alexian Brothers

Health System Associates

Charles Schwab 1-800-724-7526 www.schwab.com/workplace

403(b) & 401(a) Plan - Adventist

Midwest Health Associates

AHRP 1-800-730-2477 http://AHRP.com

401(k) Plan - Adventist Midwest

Management Services

Met Life 1-800-543-2520 www.mlr.metlife.com

Voluntary Critical Illness Voya 1-877-236-7564 www.voya.com

Employee Assistance Programs Workspace Solutions 1-877-215-6614 www.wseap.com

Voluntary Accident Insurance Voya 1-877-236-7564 www.voya.com

Voluntary Whole Life Voya 1-800-537-5024 www.voya.com

Legal Services Hyatt 1-800-821-6400 info.legalplans.com

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http://www.abs-tpa.com/

http://www.amitahealthproviders.org/

http://www.mycigna.com/

http://www.deltadentalil.com/

http://www.vsp.com/

http://www.prudential.com/








http://www.connectyourcare.com/amita

http://www.connectyourcare.com/amita

http://www.schwab.com/workplace

http://ahrp.com/

http://www.mlr.metlife.com/


http://www.wseap.com/




Mobile Applications:

Several of AMITA Health’s benefit partners have mobile applications available for download. These applications

contain information which will help you understand and navigate your benefits. Below is information on relevant

applications:

ConnectYourCare

• Available for Android, iOS and Windows devices.

• View account balance, alerts and transaction history, submit a new claim, make payments with Online Bill Pay

and Click-to-Pay, tap to call Customer Service, upload claim documentation with your device’s camera

Delta Dental

• Access these features without logging in:

i. Find a network dentist

ii. Brush for the recommended 2 minutes with our Toothbrush Timer tool

iii. View a mobile ID card (Log in to save your ID card to the app home screen for easy access.

When saved, the “My ID Card” icon will appear in purple.)

• When you log in with your Delta Dental account:

i. Estimate treatment costs with the Dental Cost Estimator

ii. View your dental benefits

iii. View coverage and claims information

iv. Schedule an appointment with a network dentist

Hyatt Legal

• Available on iTunes® App store and Google Play

• Quickly access coverage details and find attorneys

• Provides informative articles, videos and a Legal Needs Test

VSP

• Available on the App Store and Mobile Site

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IMPORTANT NOTICES

Federal regulations require that plan sponsors, such as AMITA Health, provide various notices to their associates. In keeping with

these requirements, we are providing the copies of the following Notices.

• General Notice of COBRA Continuation Rights

• HIPAA Special Enrollment Notice

• HIPAA Privacy Notice

• Medicare Part D Notice

• Medicaid and the Children’s Health Insurance Program (CHIP) Notice

• Women’s Health and Cancer Rights Notice

• Newborns’ and Mothers’ Health Protection Act of 1996

• Genetic Information Non-discrimination Act of 2008

• Uniform Service Employment & Reemployment Rights Act (USERRA)

• New Health Insurance Marketplace Coverage Options and Your Health Coverage

• Notice Regarding Wellness Program

• The Mental Health Parity and Addiction Equity Act of 2008

If you have any questions regarding any of these Notices, please contact the Human Resources Department at:

Contact--Position/Office: AMITA Health

Address: 2601 Navistar Drive, Lisle, IL 60532

Phone Number: 224-273-1099

General Notice of COBRA Continuation Rights

This Notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what

you need to do to protect the right to receive it. Please read it carefully.

Introduction

You are receiving this Notice because you have recently become covered (or may soon become covered) under a group health plan

(the “Plan”). This Notice contains important information about your rights to COBRA continuation coverage, which is a temporary

extension of coverage under the Plan.

What is COBRA Continuation Coverage? COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event

known as a “qualifying event”. Specific qualifying events are listed later in this Notice. After a qualifying event, COBRA continuation

coverage must be offered to each person who is a “qualified beneficiary”. You, your spouse and your dependent children could

become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficia-

ries who elect COBRA continuation coverage must pay for this coverage.

If you are an associate, you will become a qualified beneficiary if you lose your coverage under the Plan because one of the follow-

ing qualifying events happens:

Your hours of employment are reduced, or

Your employment ends for any reason other than your gross misconduct

General Notice of COBRA Continuation Rights Continued

If you are the spouse of an associate, you will become a qualified beneficiary if you lose your coverage under the Plan because any

of the following qualifying events happen:

Your spouse dies;

Your spouse’s hours of employment are reduced;

Your spouse’s employment ends for any reason other than his or her gross misconduct;

Your spouse becomes entitled to Medicare benefits (under Part A, Part B or both); or,

Your divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because any of the following quali-

fying events happen:

The parent/associate dies;

The parent/associate’s hours of employment are reduced;

The parent/associate’s employment ends for any reason other than his or her gross misconduct;

The parent/associate becomes entitled to Medicare benefits (under Part A, Part B or both;

The parents become divorced or legally separated; or,

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The child is no longer eligible for coverage under the Plan as a “dependent child”.

When is COBRA Coverage Available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a

qualified event has occurred. When the qualifying event is the end of employment or reduction of hours, disability, death of an em-

ployee or the associate’s becoming entitled to Medicare benefits, the employer must notify the Plan Administrator of the qualifying

event.

You Must Give Notice of Some Qualifying Events For the other qualifying events, such as divorce or legal separation or the dependent child losing eligibility under the Plan, you must

notify the Plan Administrator within 60 days of the qualifying event occurring. You must provide this notice, along with any requested

documentation to:




How is COBRA Coverage Provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to

each of the qualifying beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage.

Covered associates may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation

coverage on behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage.

When the qualifying event is the death of the associate, the associate becoming entitled to Medicare benefits, divorce or legal sepa-

ration, or a dependent child losing eligibility under the Plan, COBRA continuation coverage lasts for up to a total of 36 months.

When the qualifying event is the end of employment or reduction in the associate’s hours of employment and the associate became

entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified benefi-

ciaries other than the associate lasts until 36 months after the date of Medicare entitlement. For example, if a covered associate

becomes entitled to Medicare 8 months before the date on which his or her employment terminates, COBRA continuation coverage

for his spouse and dependent children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months

after the date of the qualifying event.

Otherwise, when the qualifying event is the end of employment or reduction of the associate’s hours of employment, COBRA con-

tinuation coverage generally lasts for only up to a total of 18 months. There are two ways in which this 18-month period of COBRA

continuation coverage can be extended.

Disability extension of 18-month period of continuation coverage

If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you

notify the Plan Administrator in a timely fashion, you and any family members covered under the Plan may be entitled to receive up

to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability must have started at

some time before the 60th day of COBRA continuation coverage and must last until the end of the 18-month period of coverage. You

must provide this notice of disability, along with any requested documentation to AMITA Health.

Second qualifying event extension of 18-month period of continuation coverage

If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and

dependent children can receive up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, provided

notice of the second qualifying event is properly given to the Plan. This extension may be available to the spouse and any dependent

children receiving continuation coverage if the associate or former associate dies, becomes entitled to Medicare benefits, becomes

divorced or legally separated or if the dependent child is no longer eligible as a dependent child under the Plan, but only if this

second event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not

occurred.

Questions Questions concerning your Plan or your COBRA coverage continuation rights should be addressed to the Plan contact. For more

information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA) and any

other laws or regulations affecting group health plans, contact the nearest regional or district office of the U.S. Department of Labor’s

Associate Benefits Security Administration (EBSA) or visit the EBSA website at www.dol.gov/ebsa.

Keep the Plan Informed of Any Address Changes In order to protect your rights and the rights of your family, you should keep the Plan Administrator informed of any changes in the

addresses of covered family members. You should also keep a copy for your records of any notices you send to the Plan Administra-

tor.

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Health Insurance Portability and Accountability Act of 1996 - Privacy The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires health plans to maintain the privacy of your health

information and to provide you with a notice of the plan’s legal duties and privacy practices with respect to your health information.

The notice describes how the plan may use or disclose your health information, under what circumstances it may share your health

information without your authorization (generally to carry out treatment, payment, or health care operations), and your rights with

respect to your health information.

As required by HIPAA, AMITA Health maintains the confidentiality of your health information and has policies and procedures in

place to help protect it from improper use and disclosure.

Health Insurance Portability and Accountability Act of 1996 (HIPAA) This notice is being provided to insure that you understand your right to apply for group health insurance coverage. You should read

this notice even if you plan to waive coverage at this time.

Loss of Other Coverage If you are declining coverage for yourself or your dependents (including your spouse) because of other health insurance or group

health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility

for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must

request enrollment within 30 days after you or your dependents’ other coverage ends (or after the employer stops contributing

toward the other coverage).

Example: You waived coverage because you were covered under a plan offered by your spouse’s employer. Your spouse termi-

nates his/her employment. If you notify AMITA Health within 31 days of the date coverage ends, you and your eligible dependents

may apply for coverage under our health plan.

Marriage, Birth, or Adoption If you have a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself

and your dependents. However, you must request enrollment within 31 days after the marriage, birth, or placement for adoption.

Example: When you were hired by us, you were single and chose not to elect health insurance benefits. One year later, you

marry. You and your eligible dependents are entitled to enroll in this group health plan. However, you must apply within 31

days from the date of your marriage.

Medicare Part D Notice of Creditable Coverage

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug

coverage with AMITA Health and about your options under Medicare’s prescription drug coverage. This information can help you

decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current cov-

erage, 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. AMITA Health has determined that the prescription drug coverage offered by the AMITA Health Health and Welfare Plan 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 AMITA Health coverage will be affected. If you decide to elect Part D cover-

age, coverage under the AMITA Health plan will end for the individual and all covered dependents

If you do decide to join a Medicare drug plan and drop your current AMITA Health coverage, be aware that you and your dependents

will not be able to get this coverage back (except during certain open enrollment periods).

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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 AMITA Health and don’t join a Medicare drug plan within

63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least

1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you

go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base

beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage.

In addition, you may have to wait until the following November to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage…

Contact the person listed below for further information. Note that you will receive 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 AMITA Health 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).




Medicaid or 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” op-

portunity, 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).

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http://www.socialsecurity.gov/

http://www.healthcare.gov/

http://www.insurekidsnow.gov/

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


If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The follow-

ing list of states is current as of July 31, 2018. 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/medic-

aid/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.in.gov/fssa/hip/

Phone: 1-877-438-4479

All other Medicaid

Website: http://www.indianamedicaid.com

Phone 1-800-403-0864

COLORADO – Health First Colorado (Colorado’s Medicaid

Program) & Child Health Plan Plus (CHP+) IOWA – Medicaid

Health First Colorado Website: https://www.healthfirstcolora-

do.com/

Health First Colorado Member Contact Center:

1-800-221-3943/ State Relay 711

CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus

CHP+ Customer Service: 1-800-359-1991/

State Relay 711

Website:

http://dhs.iowa.gov/hawk-i

Phone: 1-800-257-8563

KANSAS – Medicaid NEW HAMPSHIRE – Medicaid

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

Phone: 1-785-296-3512

Website: https://www.dhhs.nh.gov/ombp/nhhpp/

Phone: 603-271-5218

Hotline: NH Medicaid Service Center at 1-888-901-4999

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP

Website: https://chfs.ky.gov

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: https://www.health.ny.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: https://dma.ncdhhs.gov/

Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid

Website: http://www.mass.gov/eohhs/gov/departments/mass-

health/

Phone: 1-800-862-4840

Website: http://www.nd.gov/dhs/services/medicalserv/med-

icaid/

Phone: 1-844-854-4825

MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP

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http://myalhipp.com/

http://flmedicaidtplrecovery.com/hipp/

http://myakhipp.com/


http://dhss.alaska.gov/dpa/Pages/medic-

http://dch.georgia.gov/medicaid

http://myarhipp.com/

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

http://www.indianamedicaid.com/

http://dhs.iowa.gov/hawk-i

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

http://www.dhhs.nh.gov/ombp/nhhpp/

http://www.dhhs.nh.gov/ombp/nhhpp/

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

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

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

http://www.health.ny.gov/health_care/medicaid/

http://www.health.ny.gov/health_care/medicaid/

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

http://www.mass.gov/eohhs/gov/departments/mass-

http://www.nd.gov/dhs/services/medicalserv/med-


Website:

https://mn.gov/dhs/people-we-serve/seniors/health-care/

health-care-programs/programs-and-services/other-insurance.

jsp

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/provider/medicalassistance/

healthinsurancepremiumpaymenthippprogram/index.htm

Phone: 1-800-692-7462

NEBRASKA – Medicaid RHODE ISLAND – Medicaid

Website: http://www.ACCESSNebraska.ne.gov

Phone: (855) 632-7633

Lincoln: (402) 473-7000

Omaha: (402) 595-1178

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

Phone: 855-697-4347

NEVADA – Medicaid SOUTH CAROLINA – Medicaid

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

Medicaid Phone: 1-800-992-0900

Website: https://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

TEXAS – Medicaid WEST VIRGINIA – Medicaid

Website: http://gethipptexas.com/

Phone: 1-800-440-0493

Website: http://mywvhipp.com/

Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP

Medicaid Website: https://medicaid.utah.gov/

CHIP Website: 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_premi-

um_assistance.cfm

Medicaid Phone: 1-800-432-5924

CHIP Website: http://www.coverva.org/programs_premium_

assistance.cfm

CHIP Phone: 1-855-242-8282

To see if any other states have added a premium assistance program since July 31, 2018, 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/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

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http://www.insureoklahoma.org/

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

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

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

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

http://www.dhs.pa.gov/provider/medicalassistance/

http://www.accessnebraska.ne.gov/

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

http://dhcfp.nv.gov/

http://www.scdhhs.gov/

http://www.scdhhs.gov/

http://dss.sd.gov/

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

http://gethipptexas.com/

http://mywvhipp.com/

http://health.utah.gov/chip

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

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

http://www.greenmountaincare.org/

http://www.coverva.org/programs_premi-

http://www.coverva.org/programs_premium_

http://www.dol.gov/agencies/ebsa

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


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 infor-

mation 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 cur-

rently 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 informa-

tion, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Of-

fice 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.

Women’s Health and Cancer Rights Act of 1998 If you have had or are going to have a mastectomy, you may be entitled to certain benefits under this Act. For individuals receiving

mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the

patient, for:

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

Surgery and reconstruction of the other breast to produce a symmetrical

appearance; à Prostheses; and

Treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and

surgical benefits provided under this plan.

Newborns’ and Mothers’ Health Protection Act of 1996 The Newborns’ Act and its regulations provide that health plans and insurance issuers may not restrict a mother’s or newborn’s

benefits for a hospital length of stay that is connected to childbirth to less than 48 hours following a vaginal delivery or 96 hours fol-

lowing a delivery by cesarean section. However, the attending provider (who may be a physician or nurse midwife) may decide, after

consulting with the mother, to discharge the mother or newborn child earlier.

The Newborns’ Act, and its regulations, prohibit incentives (either positive or negative) that could encourage less than the minimum

protections under the Act as described above.

A mother cannot be encouraged to accept less than the minimum protections available to her under the Newborns’ Act and an

attending provider cannot be induced to discharge a mother or newborn earlier than 48 or 96 hours after delivery. In any case, plans

and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the issuer for prescribing the

length of stay not in excess of 48 hours or 96 hours, as the case may be.

Genetic Information Non-Discrimination Act of 2008 (GINA) The Genetic Information Non-Discrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from

requesting or requiring genetic information of an individual or family members of the individual, except as specifically allowed by this

law. To comply with this law, AMITA Health will generally never require a benefits participant to provide any genetic information when

responding to any request for medical information in connection with enrollment in any AMITA Health benefits plan or access-

ing any of your AMITA Health plan benefits. Genetic information as defined by GINA, includes an individual’s family medical history,

the results of an individual’s or family member’s genetic test, the fact that an individual or an individual’s family member sought or

received genetic services, and genetic information of a fetus carried by an individual’s family member or an embryo lawfully held by

an individual or family member receiving assistive reproductive services. For more information about GINA, visit www.dol.gov/ebsa/

faqs/faq-GINA.html

Uniformed Services Employment & Reemployment Rights Act (USERRA) The Uniformed Services Employment and Reemployment Rights Act (USERRA) was enacted in 1994 following U.S. military action

in the Persian Gulf. USERRA prohibits discrimination against individuals on the basis of membership in the uniformed services with

regard to any aspect of employment. Since its enactment, USERRA has been modified and expanded by additional federal laws, such

as the Veterans Benefits Improvement Act of 2008.

Maintenance of Benefits During Leave A person who is reemployed upon returning from completion of uniformed service is entitled to the rights and benefits that he or she

would have attained if he or she had remained continuously employed.

Health Benefits

An employer must allow individuals absent due to uniformed services to elect to continue health insurance coverage for themselves

and their dependents. Health insurance coverage must be continued until the earlier of:

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24 months beginning on the date when the absence began; or

The day after the date the associate fails to apply for return to work following completion of their service.

Individuals who are absent from work for less than 31 days may not be required to pay more for coverage than the associate

share charged to associates that are actively at work. Employers may charge all other individuals no more than 102 percent of the

full premium under the plan.

If benefits are cancelled because the associate did not elect to continue coverage or failed to pay premiums, the employer must

restore to the associate benefits equivalent to those the associate would have had if leave had not been taken, including family or

dependent coverage. The associate cannot be required to serve a new pre-existing condition waiting period, wait for open

enrollment or pass a medical examination to obtain reinstatement of coverage.

Exchange Notice Beginning in 2014, there is a new way to buy health insurance: The Health Insurance Marketplace. To assist you as you evaluate

options for you and your family, this notice provides some basic information about the new Marketplace.

What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers

“one-stop shopping” to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that

lowers your monthly premium right away.

The 2019 open enrollment period for health insurance coverage through the Marketplace begins on Nov. 1, 2018 and will end on Dec.

15, 2018. Individuals must have enrolled or changed plans prior to Dec. 15, 2018, for coverage starting as early as Jan. 1, 2018. After

Dec. 15, 2018, you can get coverage through the Marketplace for 2019 if you qualify for a special enrollment period or are applying

for Medicaid or the Children’s Health Insurance Program (CHIP).

Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers cover-

age that doesn’t meet certain standards. The savings on your premium that you’re eligible for depends on your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit

through the Marketplace and may wish to enroll in your employer’s health plan. However, you may be eligible for a tax credit that

lowers your monthly premium or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not

offer coverage that meets certain standards.

If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5 % of your

household income for the year (9.56 % for 2018), or if the coverage your employer provides does not meet the “minimum value” stan-

dard set by the Affordable Care Act, you may be eligible for a tax credit. (An employer-sponsored health plan meets the “minimum

value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs.)

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then

you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution—as well as your

associate contribution to employer-offered coverage—is often excluded from income for federal and state income tax purposes. Your

payments for coverage through the Marketplace are made on an after-tax basis.

How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact or

contact your HR department.

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and

its cost. Please visit HealthCare.gov for more information, as well as an online application for health insurance coverage and contact

information for a Health Insurance Marketplace in your area.

The Mental Health Parity and Addiction Equity Act of 2008 The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires group health plans to apply the same treatment limits

on mental health or substance-related disorder benefits as they do for medical and surgical benefits. The MHPAEA also extends

this parity requirement to inpatient and outpatient services, whether in-network or out-of-network, and to emergency care services

and prescription drugs. MHPAEA revised the definition of “mental health benefits” to include substance use disorder benefits. The

MHPAEA also requires group health plans to apply the same beneficiary financial requirements to mental health or substance use

disorder benefits as they apply for medical and surgical benefits, including limits on deductibles, co-payments and out-of-pocket

expenses. Plan administrators are also required to make the criteria for “medical necessity” determinations with respect to mental

health and substance use disorder benefits available to plan participants, beneficiaries or providers upon request.

NOTICE REGARDING WELLNESS PROGRAM AMITA Health wellness program is a voluntary wellness program. The program is administered according to federal rules permitting

employer-sponsored wellness programs that seek to improve associate health or prevent disease, including the Americans with

Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountabil-

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ity Act, as applicable, among others. If you choose to participate in the wellness program you may be asked to complete a voluntary

personal health assessment that asks a series of questions about your health-related activities and behaviors and whether you have

or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You may also be asked to complete a biometric screening,

which will include a blood test which can provide information on conditions like hyperlipidemia, diabetes, and others. You are not

required to complete the health assessment or to participate in the blood test or other medical examinations.

However, associates who choose to participate in the wellness program may receive an incentive from AMITA Health. Although you

are not required to complete the health assessment or participate in the biometric screening, only associates who do so will receive

an incentive. Additional incentives may also be available throughout the year.

If you are unable to participate in any of the health-related activities required to earn an incentive, you may be entitled to a rea-

sonable accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by

contacting AMITA Health Human Resources.

The information from your health assessment and the results from your biometric screening will be used to provide you with informa-

tion to help you understand your current health and potential risks, and may also be used to offer you services through the wellness

program, such as condition management programs. You also are encouraged to share your results or concerns with your own doctor.

Protections from Disclosure of Medical Information

We are required by law to maintain the privacy and security of your personally identifiable health information. Although the wellness

program and AMITA Health may use aggregate information it collects to design a program based on identified health risks in the

workplace, the wellness program will never disclose any of your personal information either publicly or to AMITA Health, except as

necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as

expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness pro-

gram will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment.

Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to

carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of

your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your

information for purposes of providing you services as part of the wellness program will abide by the same confidentiality require-

ments. The only individual(s) who will receive your personally identifiable health information is (are) health coaches or others directly

involved in the wellness program in order to provide you with services under the wellness program.

In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records,

information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in

making any employment decision. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach

occurs involving information you provide in connection with the wellness program, we will notify you immediately.

You may not be discriminated against in employment because of the medical information you provide as part of participating in the

wellness program, nor may you be subjected to retaliation if you choose not to participate.

If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact

AMITA Health Human Resources.

Benefits Guide 2019 11/1/18

2019 - AMITA Health · 2 Benefits Guide 2019 Welcome to the AMITA Health Benefits Program AMITA...

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