2016 NEW RETIREE BENEFITS REFERENCE GUIDE

Transcription

WELLNESS
made
S i m p le
2016
NEW
RETIREE
BENEFITS
REFERENCE
GUIDE
2016 Jackson Health System
3
Benefits Directory
4
Enrollment at a Glance
7
Frequently Asked Questions
HEALTHCARE PLANS
12
Important Notice to Medicare Eligible Retirees
14
Medical Monthly Rates • Under 65
15
Medical Under 65 Charts
20
Medical Monthly Rates • 65 and Over
26
Medical 65 and Over Charts
DENTAL PLANS
29
Dental Rates
30
Guardian Dental Charts
VISION PLAN
32
Guardian/Davis Vision Plan
LIFE INSURANCE & LEGAL PLAN
34
Life Insurance Rates for Under age 65 & 65 and Over
35
ARAG® Legal Plans
PET ASSURE COVERAGE
40
Pet Assure Program
NOTICES
42 Rules & Regulations
www.JacksonBenefits.org
2
Benefits Directory
ON-SITE FBMC SERVICE CENTER
1611 N.W. 12th Avenue
Park Plaza West L-109B
Miami, FL 33136-1096
305-585-6512
MEDICAL PROVIDER
AvMed Health Plan
844-439-5378
www.avmed.org/jhs
DENTAL PROVIDER
Guardian DHMO
P.O. Box 2452
Spokane, WA 99210
Member Service: 888-618-2016
Guardian Dental PPO
Guardian Dental Claims
P.O. Box 2859
Spokane, WA 99210
Member Service:
800-541-7846
Guardian Dental Pre-Enrollment
Support
Hot Line
1-888-600-1600
Group Number 00516547
www.GuardianAnytime.com
VISION PROVIDER
Guardian/Davis Vision
Vision Care Processing Unit
P.O. Box 1525
Latham, NY 12110
Member Service: 877-393-7363
www.davisvision.com
Pre-enrollment Support Hot Line:
1-888-600-1600
Group Number 00516547
TAX SHELTER ANNUITY PROVIDERS
403(b) and 457
Nationwide Retirement Solutions 457
P.O. Box 182797
Columbus, OH 43218-2797
877-677-3678
www.nrsforu.com
VOYA Life Insurance & Annuity Company
403(b) and 457
3201 West Commercial Blvd., Suite 212
Ft. Lauderdale, FL 33309
954-486-2236
305-234-3246
www.voya.com
Fidelity Investments Tax Exempt Services Co.
403(b)
P.O. Box 770002
Cincinnati, OH 45277-0089
800-343-0860
www.fidelity.com/workplace
Lincoln National Life Insurance Co.
403(b) and 457
P.O. Box 2340
Fort Wayne, IN 46801
800-254-6265 (403(b))
800-341-0441 (457)
www.lincolnlife.com
AIG/VALIC
(Variable Annuity Life Insurance Company)
403(b) and 457
8000 Governor’s Square Blvd., Suite 300
Miami Lakes, FL 33016
305-817-2250
Local
250 Bird Road, Suite 202
Coral Gables, FL 33146
305-461-5421
Regional Service Center
10008 N. Dale Mabry Hwy, Suite 113
Tampa, FL 33618
800-448-2542 Extension 88573
www.valic.com
OTHER PROVIDERS
Pet Assure
Veterinary Discount Plan for your Pets
415 Cedar Bridge Avenue
Lakewood, NJ 08701
888-789-7387
www.petassure.com
ARAG®
Legal Plan
400 Locust Street, Suite 480
Des Moines, IA 50309
800-247-4184
ARAGLegalCenter.com,
Access Code 17845ret
Provident Life & Accident Insurance
Company (Unum)
Accident Insurance
Customer Service: 800-635-5597
www.unum.com
3
Allstate Benefits
American Heritage Life Insurance Company
(Critical Illness)
800-521-3535
www.allstatebenefits.com
LIFE INSURANCE PROVIDERS
Reliance Standard Life Insurance Company
800-351-7500
www.reliancestandard.com
ReliaStar Life Insurance Company’s Premier
(Universal Life Insurance)
Offered by Voya Financial Employee Benefits
Customer Service
P.O. Box 122, Minneapolis, MN 55440-0122
800-537-5024
www.voya.com
Transamerica Life Insurance Company
888-763-7474
www.transamerica.com
Unum Life Insurance Company of America
(Long-Term Care)
800-331-1538
www.unum.com
Unum Whole Life Insurance
with Long Term Care
(Whole Life Insurance)
Customer Service
Mon - Fri, 8 a.m. - 8 p.m. ET
800-635-5597
www.unum.com
Group Voluntary Hospital Indemnity
Insurance
Allstate Benefits
AHL American Heritage Life Insurance Co.
Group Voluntary Hospital Indemnity
Insurance (Hospital Indemnity Insurance)
Mon - Fri, 8 a.m. - 8 p.m. ET
800-348-4489
www.allstatebenefits.com
ID Commander
Membership Services: 1-855-592-7941
Mon - Fri, 9 a.m. - 6 p.m. ET.
www.idcommander.com
ConstantCredit
Membership Services: 1-888-384-7935
Mon – Fri, 9 a.m. - 6 p.m. ET.
www.constantcredit.com
Important Information
Enrollment at a Glance
Health Trust provided you transition as an active employee
into retirement. You will have 30 days from your separation
date to make or change your election.
In addition to this 2016 New Retiree Participants Reference
Guide you have been provided an enrollment form.
• Complete and return your enrollment form. When
completing the enrollment form, please be sure to note all
benefits you would like to continue into retirement. Your
enrollment form must be submitted at least two weeks
prior to your retirement date.
• Please remember when electing your retiree benefits:
After retiring you may not increase your coverage
elections, you may only cancel coverage. You may not add
coverage, add dependent coverage or increase coverage.
• For all of your eligible dependents, please record their
Social Security number(s) and date(s) of birth on your
enrollment form.
Please direct all questions or comments to Customer Care at
855-56JHS4U (855-565-4748), Monday – Friday, 7 a.m.
– 7p.m. ET.
If you do not take a distribution and decide to defer your
retirement, you will not be considered retired and may
not be entitled to continue your JHS-sponsored health
insurance coverage.
Election Process
To summarize, continuation of coverage is not automatic.
Your employee group coverage is cancelled the last day
of the pay period in which the separation of employment
date falls and for which the employee experiences a regular
insurance deduction or made direct payments to JHS (if on
an unpaid leave of absence).
Coverage under the Retiree Group will not be activated until
the first retiree premium is received. The insurance carriers
will be notified to reinstate your coverage under the Retiree
Group upon receipt of your initial premium payment.
The Benefit Options Available are:
Medical,
Dental,
and Life
Medical,
Dental,
Vision,
and Life
Medical
Only
Medical and
Life
Medical and
Dental
Dental and
Life
Dental Only
Life Only
Medical,
Medical and
Vision, and
Vision
Life
To continue your medical, dental/vision, and basic life
insurance coverage, complete the correct retiree enrollment
form (either under age 65 or 65 and over, based on eligibility)
and submit it within 30 days of your separation date.
Coverage for your eligible dependent(s) may be continued
under the Retiree Group, but only if the dependent was
enrolled immediately prior to your separation date. To
assure a smooth transition, especially if you have scheduled
ongoing treatment or need prescriptions filled, submit the
enrollment form and initial premium within 10 days of your
separation date. Once the initial retiree premium is received,
medical, dental/vision, and/or life insurance (if elected)
become effective retroactive to the date your coverage
as an active employee expired (without a gap), assuming
premiums were paid through that date. Your enrollment form
must be received by FBMC no later than 30 days following
your separation date, otherwise you forfeit Retiree Group
coverage. If the Retiree Group election period lapses, you
may still exercise your rights under COBRA; please refer to
the COBRA section in this handbook.
Medical,
Dental, and
Vision
Choosing the Right Enrollment Form —
Under age 65 or 65 and Over
The New Retiree Reference Guide explains your available
benefits in separate sections based on whether you are under
65 or 65 and over, including any eligible dependents. The
benefits (except life insurance) for 65 and over also apply
if you and/or your eligible dependent are under 65, but
Medicare eligible.
If you wish to elect Retiree coverage please complete and
return the correct enrollment form:
• Under 65 and/or not Medicare A and B eligible
• 65 and Over and/or Medicare Eligible
Please note: you may not elect continuation of medical
coverage under COBRA if you are entitled/enrolled in
Medicare Part A & B.
You are eligible to continue coverage under the Retiree
Group if you retire from Jackson Health System/Public
4
Leave of Absence
Optional Life Insurance
The same election process applies to employees on leave
of absence (or no-pay status) who terminate Jackson Health
System employment without physically returning to work.
Group insurance coverage will end as of the last day of the
pay period in which the separation of employment date
falls, assuming premiums were paid through that date. If
coverage is cancelled for non-payment of premiums, while
on leave status, you will not have the opportunity to continue
coverage under the Retiree Group or COBRA.
Optional life coverage is not available through the Retiree
Group. If enrolled at the time of your retirement, you may
elect to convert this coverage to an individual policy. The
policy is available to you without medical approval, but will
be provided by Reliance Standard Life Insurance Company at
their prevailing individual insurance rates. You may convert
up to the amount of coverage in force at retirement. Contact
the insurance carrier to obtain rates and policy options.
Reliance Standard Life Insurance Company
1-800-866-2301
Coverage Available
Basic Life Insurance for Retirees Under Age 65
JHS doesn’t contribute the employer portion on your behalf;
consequently, you will pay the full monthly premium cost.
Your dependent spouse or domestic partner (DP) and/or
children including the children of a DP, currently covered
under your medical and/or dental/vision plan as of the date
you retire, may continue under your coverage at retirement.
The group basic life insurance coverage provided to active
employees at no cost may be continued at retirement, at
your expense. The coverage amount for retirees under age
65 is equivalent to their pre-retirement annual base salary.
As long as the coverage was in force prior to retirement, the
benefit may be continued.
Changing Health Plans
Remember to ensure that your beneficiary designations
are current. A new beneficiary may be named at any
time. To update your beneficiary call the FBMC Service
Center at 855-56JHS4U (855-565-4748) and request
a life insurance beneficiary update form. Make sure your
beneficiary designation form is legible and contains no
erasures or cross-out marks. Specify the percentage of
benefits for each named beneficiary to receive. The total
percent allocation among the beneficiaries must add up to
100 percent. Please be sure your beneficiary is aware of the
benefit and knows how to contact our office in the event
of your death.
At the time of retirement and within 30 days of your
separation date, you will have a one-time opportunity to
change plans or enroll in the retiree insurance plan offered
that you previously declined. Once you submit your election
form, you cannot change plans until the annual retiree
open enrollment period, unless you move out of the plan’s
geographic service area.
Electing Health Coverage Under Your
Spouse/DP ’s Plan
If your spouse/DP is a JHS employee, you have the option
of enrolling as a dependent under your spouse/DP’s JHS
medical and/or dental/vision plan. Your spouse/DP must
submit the Change in Status forms (CIS) within 30 days
of your separation date. For the necessary forms visit the
FBMC Service Center at 1611 N.W. 12th Ave., Park Plaza
West L-109B Miami, FL 33136-1096. You can transfer your
medical/dental/vision coverage to the Retiree Group at a
later date as a CIS, as long as you have been continuously
covered under a JHS-sponsored medical/dental/vision plan
without a break, since your retirement.
Important Note: Continuation of basic life insurance cannot
be postponed. You must elect the coverage at retirement
otherwise you forfeit the coverage.
5
Basic Life Insurance for Retirees Age 65+
COBRA
Retirees age 65+ may elect either $15,000 or $20,000 of
life insurance coverage.
Federal law (COBRA) provides that insured employees and
their covered dependents may elect to continue group health
coverage for up to 18 months from the date employment
terminates or until the employee is covered under another
group plan, whichever comes first. We are required by law
to notify you of your COBRA rights, and as a result, you
will receive a COBRA mailing in addition to information
regarding Retiree Group coverage. You can only maintain
COBRA coverage for a limited time, whereas you may
continue health and basic life coverage indefinitely under
the Retiree Group.
Remember to maintain your beneficiary designation
current. A new beneficiary may be named at any time. To
update your beneficiary call the FBMC Customer Service
Center at 855-56JHS4U (855-565-4748) and request
a Life Insurance Beneficiary Update Form. Make sure
your beneficiary designation form is legible and contains
no erasures or cross-out marks. Specify the percentage of
percent allocation among the beneficiaries must add up to
100 percent. Please be sure your beneficiary is aware of the
benefit and knows how to contact our office in the event
of your death.
You may elect continuation of medical/dental/vision
coverage under COBRA instead of participating under the
Retiree Group. The choice is yours to make. However, the
election period for the Retiree Group coverage expires 30
days from your separation date. The COBRA election period
expires 60 days from the date benefits terminate under the
active group. You have 45 days from your COBRA election
date to pay the first premium. Your life insurance coverage
may be converted directly with Reliance Standard Life
Insurance Company, at their prevailing rates.
PayFlex will mail the COBRA information packets directly
to the retiree’s home address, usually within 14 days from
the date your final check is processed. Group medical,
dental/vision, and basic/optional life insurance coverage (if
enrolled) cease the last day of the pay period in which the
retirement date falls and for which the employee experiences
a regular insurance deduction or made direct payments to
PayFlex (if on an unpaid leave of absence). Contact a COBRA
Specialist at 305-585-6512 for information regarding
COBRA.
Medicare Part A & B.
6
Q. What medical/dental/vision insurance
plans are available for retirees and/or
eligible dependents under age 65 (not
Medicare eligible)?
A.
Q. I am under the age of 65, but enrolled
for Medicare Parts A & B due to disability.
May I remain enrolled in the POS plan?
A. Yes, you can remain in the POS plan until age 65, but
Medicare will be the primary payor. This will apply whether
you are enrolled in the POS or HMO plan.
Medical Plans
Q. Are over age dependents eligible?
A. A provision in the new Patient Protection and Affordable
AvMed Jackson First HMO
JHS Select HMO
Care Act (PPACA) allows for an employee’s child to be
covered under the employee’s healthcare plan through age
26. Coverage applies whether the child is/is not married or
is/is not a student.
In the State of Florida anyone up to the age of 30 may
be considered a dependent for the purposes of “health”
insurance eligibility and access. For all health coverage
offered under your employer’s plan, you may continue to
cover your dependent child under the medical plan until
the end of the calendar year in which the child reaches the
age of 30 if the child:
• Is unmarried and does not have a dependent of his or her own
(and is age 26 - 30);
• Is a resident of Florida or a full-time or part-time student;
• Is not provided coverage as a named subscriber, insured,
enrollee, or covered person under any other group,
blanket, or franchise health insurance policy or individual
health benefits plan, or is not entitled to benefits under
Title XVIII of the Social Security Act; and
• Has not had gap in “creditable coverage” of more than
63 days.
AvMed Standard HMO
AvMed Point of Service (POS)
Dental Plans
Guardian PPO Standard or Enriched Dental (Indemnity)
Guardian DHMO Standard or Enriched Dental (Prepaid)
Vision Plan
Guardian/Davis Plan
Q. What medical/dental/vision insurance
plans are available for retirees and/or
eligible dependents age 65 and over
(Medicare A&B enrolled)?
A.
Medical Plans
(must be enrolled in Medicare Parts A & B)
AvMed High Option
* Please Note: If you reside outside of the State of Florida
and have a dependent who meets the above criteria, they are
eligible for coverage. This includes any dependents covered,
regardless of the above until the end of the calendar year in
which the dependent reaches age 26.
AvMed High Option w/No Rx
Dental Plans
Guardian PPO Standard or Enriched Dental (Indemnity)
Q. If enrolled in an HMO plan, may I
utilize providers outside the South Florida
network and still receive HMO coverage?
A. Yes, if enrolled under the Standard Option HMO. Guardian DHMO Standard or Enriched Dental (Prepaid)
Vision Plan
Guardian/Davis Plan
AvMed contracts with PHCS National Network to provide
nationwide coverage for members residing outside of the
service area. As a retiree, if you utilize a participating
provider within the appropriate network you will receive
the same HMO benefits. 7
Q. May I change my medical and dental
plan if I relocate outside the Tri-County area?
A. If you plan to relocate, be aware that Guardian DHMO
Go to www.avmed.org/jhs to check on the participating
status of your provider in the JHS Elite Access Network
(AvMed and provider). If your doctor is not participating in
the network, you may call AvMed Member Services, 24/7,
at 844-439-5378 to request that AvMed contact your doctor
about joining the network.
dental coverage is not available outside Florida. If relocating
your permanent address, please go to www.avmed.org/jhs
to check on the participating status of your providers in the
JHS Elite Access Network (AvMed and PHCS). If your doctor
is not participating in the network, you may call AvMed
Member Services, 24/7, at 844-439-5378 to request that
AvMed contact your doctor about joining the network. If
in-network benefits are not available in your area, your only
option is to switch to the Point-of Service (POS) medical and
Guardian PPO Plan, to access out-of-network benefits. You
must request a Change in Status form within 30 days from the
relocation date. Proof of permanent residence change will
be required (new service utility bill, rental agreement, etc.).
Q. What benefits am I eligible for if I am
under 65 and receiving disability benefits
through the Social Security Administration?
A. If you are under age 65, deemed disabled by the Social
Security Administration and have qualified for Medicare Parts
A, B and D, you may be eligible for the options available to
Medicare eligible retirees described in this Reference Guide.
For more information, contact your Benefits Specialist at
305-585-6512. Be aware that once you qualify for Medicare,
your retiree medical coverage becomes secondary, even if
you elect to continue with your current coverage (HMO or
POS) until age 65 instead of enrolling in one of the Medicare
supplement plans.
Retirees traveling outside their geographic service areas for
extended periods should contact AvMed Member Services to inquire about the “Away From Home Program.”
Q. How do I update my life insurance
beneficiary information?
A. To update your beneficiary information call
Q. What happens to the medical and/
or dental/vision coverage for my covered
dependent(s) if I should die?
A. If you die, dependents covered under your retiree
855-56JHS4U (855-565-4748) and request a Life
Insurance Beneficiary Update Form. Make sure your
beneficiary designation form is legible and contains no
erasures or cross-out marks. Specify the percentage of
percent allocation among the beneficiaries must add up
to 100 percent. Please be sure your beneficiary is aware
of the benefit and knows how to contact our office in the
event of your death.
medical insurance may continue their coverage as long as
timely premium payments are received. Your spouse/DP can
continue indefinitely and your dependent children until the
limiting age. Dependents covered under your retiree dental
/vision insurance may continue their coverage under COBRA
for 36 months.
Q. What happens to the medical and/
or dental/vision coverage for my covered
dependent(s) if I cancel only my coverage
upon becoming eligible for Medicare?
A. If you cancel your coverage upon becoming eligible for
Q. Can my insurance under the Retiree
Group be cancelled?
A. You may cancel your medical, dental, vision or life
insurance coverage at any time. The insurance carriers and/or
Jackson Health System will not cancel your coverage unless:
• Any premiums payable by you are not received within
30 days following the premium due date. If this happens,
a cancellation notice will be mailed to you. You are
responsible for notifying FBMC if there is a change in
your mailing address.
Medicare, dependents covered under your retiree medical
insurance may continue their coverage as long as timely
premium payments are received. Your under age 65 spouse/
DP can continue indefinitely and your dependent children
until the limiting age. Dependents covered under your retiree
dental/vision insurance may continue their coverage under
COBRA up to 18 months.
8
• The group insurance coverage under the Master Contract
for your particular type of insurance is cancelled.
• You are enrolled in an HMO or pre-paid dental plan and
move out of the service area.
• You do not enroll under a Medicare Plan when you
become age 65 and Medicare eligible.
birth certificate or adoption papers, letter from spouse/DP’s
employer certifying termination of insurance benefits, etc.)
must be presented. Dependents cannot be added during the
retiree open enrollment.
Note: You may make a written request to delete your
dependent(s) at anytime. This change will be effective at
the end of the month the request is made or received. If
cancelling coverage due to divorce, your spouse will be
eligible for continuation of coverage under COBRA for 36
months or until age 65, whichever occurs first.
All cancellations are irrevocable. Once cancelled, coverage
may not be requested again.
Q. If I cancel my medical coverage,
may I retain the dental, vision and/or
life insurance? When will the change in
premium take effect?
A. Yes, you may cancel the medical coverage without
Q. May I make a change to my enrollment
after I have completed and returned my
enrollment form?
A. You will have the opportunity to enroll in the Retiree
disrupting your dental, vision and/or life insurance. Simply
submit a written request to a Retiree Benefits Specialist,
indicating the plan (or plans) you wish to cancel. The
premium reduction will take effect the first of the month
following receipt of your cancellation request. Premiums
must be paid through the cancellation date. Cancellations
are irrevocable. Once cancelled, the coverage will not be
reinstated.
Group medical, dental, vision and/or life insurance with
the HR retirement coordinator within 30 days following
your separation date; otherwise you forfeit Retiree Group
coverage. You will also have the option to meet with the HR
retirement counselor to make any changes to your initial
insurance election during that same period.
Once your Retiree Group medical and/or dental/vision
become effective, you must submit a Change in Status
(CIS)/Election Form and supporting documentation (must be
original or government certified) to FBMC Service Center,
PPW L-109B within 30 days of a qualifying event. The
requested change must be consistent with the event. The
request must be submitted to the FBMC Service Center with
the appropriate documentation within 30 days of the event. If
your covered dependent(s) become ineligible during the plan
year, you must notify the FBMC Service Center immediately.
Q. May I add a dependent during the
retiree open enrollment?
A. No. During the annual open enrollment you will only
be allowed to change plans, and only eligible enrolled
dependents will be allowed to continue coverage under
the retiree group.
Q. May I add or drop an eligible dependent
to my benefits after retirement?
A. Yes, you may only add eligible dependents in cases of
You may cancel your medical, dental, vision and/or life
insurance coverage or delete dependents at any time. All
cancellations are irrevocable. Once cancelled, coverage
may not be requested again. Apart from the annual open
enrollment, no changes will be accepted after the deadline
unless you experience a qualifying event. You may call 305585-6512 or visit the FBMC Service Center at 1611 N.W.
12 Ave., Park Plaza West L-109B Miami, FL 33136-1096 to
request and complete a new enrollment form.
qualifying events (QE) such as marriage, entering into a
new domestic partnership, birth (or adoption/placement)
of a child, eligible dependent’s loss of employment, or loss
of other coverage, etc. You must request a Change in Status
form within 30 days of the date of the qualifying event at
the FBMC Service Center or by calling (305) 585-6512. To
add the dependent, original documentation of eligibility
(i.e., marriage certificate, certificate of domestic partnership,
9
Q. How will I be billed for Retiree Group
coverage?
A. Upon applying for retirement, you must submit a Retiree
Form and submit it to FBMC with your enrollment form,
or with your first premium payment. Deductions begin
approximately 60 days thereafter. You are responsible for
sending your check payments directly to FBMC Benefits
Management, Inc., Direct Bill, P.O. Box 10789, Tallahassee,
FL 32302-2789, until deductions begin. Insurance premiums
are deducted from your pension benefit in advance, to pay
for the upcoming month’s insurance coverage. The insurance
deductions will be reflected on your check stub or statement.
Insurance Election form within 30 days of your separation
date. FBMC will mail you a Billing Statement. This billing
statement will include a monthly premium breakdown for
the calendar year. You will be responsible for paying your
insurance premiums through the current billing month.
Your coverage is not reinstated under the Retiree Group
until receipt of your initial premium payment. Thereafter,
premiums are due on the first of each month. For that reason,
we recommend that you budget for approximately three
months of insurance premiums, since your first pension
check may not arrive for approximately 60 days from the
date of retirement. If you and/or your covered dependent
turn 65, subsequent to your retirement, there will be a
change in your premium due to Medicare and/or life
insurance coverage. If a medical plan election is required
you will receive information from us approximately three
months prior to your or your spouse/DP’s 65th birthday. No
election is required if you don’t have medical coverage;
you will be sent a new billing calendar prior to the month
your premium changes. When you turn 70 or 75, your life
insurance premium will be adjusted if you are maintaining
this coverage. You will receive a new billing calendar prior
to the month your premium changes.
Q. What is the Health Insurance Subsidy?
A. Eligible retirees receive $5 per month for each year of
service credit earned at retirement. The subsidy is at least
$30per month, but no more than $150 per month. It is
intended to help offset the cost of your health insurance
coverage.
The Florida Retirement System mails you a form to
enroll for the subsidy. If you have elected to continue
medical coverage under the Retiree Group, you may
forward your subsidy application, after completing
Part I, to the Retirement Coordinator. We will verify
coverage and forward your completed form to the Division
of Retirement. The subsidy will not appear on your pension
check until approximately 60 days from the date the Division
of Retirement receives it. You may contact the Division of
Retirement at 844-377-1888 for any subsidy questions, or
write to:
Division of Retirement
1317 Winewood Boulevard, Building 8
Tallahassee, Florida 32399-1560
Email: [email protected]
Q. How do I pay for my insurance?
A. You may pay your monthly premium by check, money
order, or through automatic deduction from your pension
check. When you pay by check or money order, the payment
is due on the first day of each month. Accounts are subject
to cancellation, if your payment is not received by the end of
the month for which payment is due. We are unable to accept
cash for security reasons. Make checks payable to FBMC. To
expedite processing, indicate your retiree ID number (refer to
your billing statement) on all checks. The insurance carriers
will be notified to reinstate your coverage under the Retiree
Group upon receipt of your initial premium payment.
The Public Health Trust (PHT) Defined Benefit Retirement
Plan provides employees retiring with PHT service credit
years, health insurance subsidy. The subsidy is considered
and included when the retirement benefit is calculated. The
subsidy is a minimum of $30 per month, but not to exceed
more than $150 per month. It is intended to offset the cost
of your health insurance.
For employees retiring from both FRS & PHT, the subsidy
will not exceed $150.00 per month total between the two
retirement plans.
Note: Coverage cannot be verified if the account is not
current.
To have your insurance premiums deducted from your
pension check, you must complete a Payroll Authorization
10
Q. How do I continue coverage through
the retiree group?
A. To continue medical, dental, vision and/or life
Q. My spouse/DP is also employed by JHS.
Upon my retirement, may I continue basic
life insurance under the Retiree Group
and have my spouse/DP add me as his/her
dependent for medical, dental and/or vision
coverage under the Active Employee Group?
insurance coverage as a retiree, complete, sign, and submit
an enrollment form. To assure a smooth transition, the
application must be received by the Retirement Coordinator
at least two weeks prior to your separation date. Enrollment
forms received more than 30 days after the separation date
will not be accepted; you will only be entitled to health
insurance continuation under COBRA, if applied for within
60 days following your last date of coverage as an active
employee. In the event an employee terminates his/her
employment on a retroactive basis after being on a leave
of absence, the enrollment form must be received within
30 days of the date the retiree’s department processes the
status change.
A. Yes, you may elect to continue basic life insurance only
through the Retiree Group. Your spouse/DP must contact the
on-site FBMC Service Center at 305-585-6512 to complete
the Change in Status (CIS) forms required to add you as a
dependent as soon as possible, but no later than 30 days after
your last day of coverage under the Active Employee Group.
Medicare Part A&B.
Q. May I continue my Optional Life insurance?
A. You can convert this optional benefit directly with the
life insurance carrier. You may apply for an individual life
insurance policy (other than term insurance), which will be
issued without medical examination by Reliance Standard
Life Insurance Company, if you apply for it and the required
payment is made within:
• 31 days from the date benefits were terminated, or
• 15 days from the date this notice is given, if notice is given
more than 15 days from the date benefits were terminated.
In no event will this period extend beyond 91 days from the
date benefits were terminated.
Please contact the Benefits Department at 786-466-8378
to request the Conversion of Group Life Benefits to an
Individual Policy form.
11
2016 Important Notice to Medicare Eligible Retirees
Your Prescription Drug Coverage and Medicare
When can you join a medicare drug plan?
Please read this notice carefully and keep it where you
can find it. This notice has information about your current
prescription drug coverage with Jackson Health System
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. Information
about where you can get help to make decisions about your
prescription drug coverage is at the end of this notice.
You can join a Medicare drug plan when you first become
eligible for Medicare from November 15th through
December 31st, 2016. However, if you decide to drop
your current Jackson Health System medical coverage for
Medicare eligible retirees, since it is employer sponsored
group coverage, you will be eligible for a two-month Special
Enrollment Period (SEP) to join a Medicare drug plan. Be
aware that you may be subject to a higher premium (a
penalty) because you did not have creditable coverage.
There are three important things you need
to know about your current coverage and
Medicare’s prescription drug coverage:
Note: if you are currently enrolled in either the POS or HMO
Plans (which have creditable prescription drug coverage) and
become Medicare eligible, since you are losing creditable
prescription drug coverage you are also eligible for a twomonth Special Enrollment Period (SEP) to join a Medicare
drug plan.
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.Jackson Health System has determined that the prescription
drug coverage offered by the Jackson Health System Plans
for Medicare eligible retirees (and Medicare eligible
dependents), is, on average for all plan participants,
NOT expected to pay out as much as standard Medicare
prescription drug coverage pays and is considered NonCreditable Coverage.
This is important, because most likely, you will get more
help with your drug costs if you join a Medicare drug plan,
than if you only have prescription drug coverage through
the Jackson Health System medical plan.
3.You can keep your current coverage from Jackson
Health System. However, because your coverage is noncreditable, you have decisions to make about Medicare
prescription drug coverage that may affect how much you
pay for that coverage, depending on if and when you join
a drug plan. When you make your decision, you should
compare your current coverage, including what drugs are
covered, with the coverage and cost of the plans offering
Medicare prescription drug coverage in your area. Read
this notice carefully - it explains your options.
Since coverage under the Jackson Health System Plans
for Medicare eligible retirees is not creditable, depending
on how long you go without creditable prescription drug
coverage, you may pay a penalty to join a Medicare drug
plan. Starting with the end of the last month that you were
first eligible to join a Medicare drug plan but didn’t join,
if you go 63 continuous days or longer without creditable
prescription drug coverage, your monthly premium may go
up by at least one percent of the Medicare base beneficiary
premium per month, for every month that you did not have
that coverage. For example, if you go 19 months without
creditable coverage, your premium may be at least 19
percent more than the Medicare base beneficiary premium.
You may have to pay this higher premium (penalty) as long as
you have Medicare prescription drug coverage. In addition,
you may have to wait until the following November to join.
12
2016 Important Notice to Medicare Eligible Retirees
Your Prescription Drug Coverage and Medicare
What happens to your current coverage if
you decide to join a medicare drug plan?
For more information about your options
under Medicare prescription drug
coverage...
If you (or your dependent) do decide to join a Medicare drug
plan and drop your current health plan for Medicare eligible
retirees, be aware that you (or your dependent whichever
is applicable) will not be able to get Jackson Health System
coverage back. However, if you join a Medicare drug plan
when you first become Medicare eligible, you can select the
certain eligible plans for Medicare eligible retirees (medical
plan without prescription drug coverage), and continue to
receive coverage for other medical services through Jackson
Health System.
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 (800-633-4227). TTY users should
call 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 800-7721213 (TTY 800-325-0778).
Date: Plan Year 2016
Name of Entity/Sender: Jackson Health System
Contact–Position/Office: Human Resources, Benefits
Address: 1801 NW 9th Avenue, 7th Floor, Miami, FL 33136
Phone Number: 786-466-8378
13
Medical Monthly Rates • Under 65
What AvMed medical plans are offered?
Standard HMO
• Jackson First HMO
• JHS Select HMO
• Standard HMO
• Point of Service (POS)
Plan offers no referral access to an expanded network
of providers. The plan provides 100 percent benefits
for covered charges after the applicable copayments.
Members are encouraged, but not required, to select a
primary care physician.
Jackson First HMO
Plan offers no referral access to the Jackson-only network.
Retiree and covered dependents must reside in Miami-Dade,
Broward and Palm Beach Counties. The plan provides 100
percent benefits for services performed at Jackson Health
System and University of Miami facilities (except emergency
care). Members are encouraged but not required to select a
primary care physician.
Point of Service (POS)
• In-network
Plan offers “no referral” access to an expanded network of
providers in the state of Florida and a nationwide network
for those residing outside of the service area. The plan
provides 100 percent benefits for covered charges after
the applicable copayments. Members are encouraged, but
not required, to select a primary care physician.
• Out-of-network
A fee for service program that provides you the freedom
to use any physician or accredited hospital of your choice
outside of the network. Payments are based on Maximum
Allowable Payment (MAP) charges. Providers who do
not participate in the network may balance bill you for
the amount which exceeds MAP. Coverage is subject to
deductibles and coinsurance.
JHS Select HMO
Plan offers no referral access to the Select HMO Network
of providers. Retiree and covered dependents must reside
in Miami-Dade, Broward and Palm Beach Counties. The
plan provides 100 percent benefits for covered charges
after applicable copays. Members are encouraged but not
required to select a primary care physician.
AvMed Retiree, Spouse/DP &
Dependents Monthly Premiums
JACKSON
FIRST HMO
JHS SELECT
HMO
STANDARD
HMO
POINT OF
SERVICE
Retiree Only
$387.42
$419.23
$466.16
$1,118.58
Retiree & Spouse/DP Under 65
$881.73
$948.46
$1,046.98
$2,165.28
Retiree & Child(ren)†
$811.01
$872.85
$964.11
$2,086.71
$1,096.37
$1,177.78
$1,297.92
$2,638.67
Retiree & Spouse/DP 65 and Over on Medicare Eligible High No Rx Plan
N/A
N/A
$710.20
$1,362.62
Retiree & Spouse/DP 65 and Over on Medicare High Plan
N/A
N/A
$1,027.62
$1,680.04
Retiree & Spouse/DP Under 65, plus Child(ren)†
† Option also applies to Adult Children (AC) between 26 through 30 years of age, children of Domestic Partners (DP) and/or eligible dependents.
14
AvMed Jackson First (HMO) Chart • Under 65
Visit our website at www.avmed.org/jhs
Jackson First (HMO)
COVERAGE PLAN DESCRIPTION
HMO plan offered to Jackson Health System employees, covered dependents and retirees under age 65 who reside in Miami-Dade, Broward
and Palm Beach counties. Members who enroll in the Jackson First HMO plan must receive all medical care except for emergency and
urgent care services through a contracted Jackson First network provider. DEDUCTIBLES/COPAYMENTS
COPAYMENTS - No copayments and/or deductibles for primary care physician or specialist services in the network. For services performed
out-of-network, the member will be responsible 100%; $25 copayment Emergency Room (waived if admitted). $25/$50 copayment
Urgent Care. $15/$25/$35 prescription for 30-day supply based on formulary. $0 copayment for Generics drugs at Jackson Pharmacy.
$30/$50/$70 Mail order prescriptions available for 90-day supply based on formulary.
PHYSICIANS
Access any primary care physician or specialist from the Jackson First HMO Network. Members are encouraged but not required to select
a primary care physician. Covered family members may choose their own primary care physician.
A. IN-HOSPITAL PHYSICIAN SERVICES
Surgery/Visits and Consultations
Anesthesiologist
Benefits payable at 100% when received at participating hospitals (Jackson Health System and University of Miami) and rendered by
participating physicians.
B. OUT-PATIENT PHYSICIAN SERVICES
PCP Office Visits
Specialist Office Visits
Preventive Services
Pediatrician
Routine Physical
Obstetrical/Gynecological
Maternity
Preventive Services Mammogram/Pap Smears
No charge
No charge
No charge
No charge
No charge
No charge
No charge
No charge
HOSPITALIZATION
Benefits covered at 100% at Jackson Health System and University of Miami. HOSPITAL/SURGICAL REQUIREMENTS
Precertification of hospital confinements
Handled by admitting physician.
DRUG & ALCOHOL TREATMENT
Inpatient
Outpatient
No charge
No charge
MENTAL & NERVOUS DISORDERS
Inpatient
Outpatient
No charge
No charge
OTHER SERVICES
Ambulance
Vision
No charge when pre-authorized or in case of emergency.
Coverage provided for diseases of the eye and/or injuries to the eye. Eye exams for children under age 18 covered 100%. AvMed offers adult vision
discount through a preferred network of providers listed in the provider directory. Eye Exams, glasses, contact lenses not covered.
PRESCRIPTION DRUGS
$15 Generic/$25 Brand/$35 Non-Preferred for 30 day supply, including prescription contraceptives, at participating pharmacies nationwide.
If member/physician select Brand when Generic is available, member pays difference in cost plus Brand copayment. See plan literature for
other participating pharmacies. Mail order: 2x copay for 90-day supply. Generic contraceptives will be no charge. No charge for generic
medications under the Jackson First Plan for employee using the Jackson Pharmacy.
DURABLE MEDICAL EQUIPMENT (DME)
$50 copayment per episode of illness. Please refer to brochure for limitations and restrictions.
OUT-OF-AREA
1) Emergency
2) Non-Emergency
$25 copay, waived if admitted, 100% thereafter. $25/$50 urgent care center copay.
Not covered if provider is out-of-network.
This comparison is not a contract. For specific information on benefits, exclusions and limitations, please see the Summary of Benefits & Coverage (SBC). Maximum lifetime benefits is unlimited in-network.
15
JHS Select (HMO) Chart • Under 65
JHS SELECT (HMO)
HMO plan offered to JHS employees, covered dependents and retirees under 65 who reside in Miami-Dade, Broward and Palm Beach
counties. Members who enroll in the Select Network plan must receive all medical care except for emergency and urgent care services
through an AvMed contracted JHS Select Provider Network.
DEDUCTIBLES/COPAYMENTS
COPAYMENTS
$15 Primary Care Physician/$30 Specialty office visit/services. 100% Hospital admission coverage - no copayment. $25 copayment
Emergency Room (waived if admitted). $25/$50 copayment Urgent Care. $15/ $25/ $35 prescription for 30-day supply based on formulary.
$30/$50/$70 Mail order prescription available for 90-day supply based on formulary.
PHYSICIANS
Access any primary care physician or specialist from the Select Network. Members are encouraged but not required to select a primary care
physician. Covered family members may choose their own primary care physician.
Anesthesiologist
Benefits payable at 100% when received at participating hospitals and rendered by participating physicians.
PCP Office Visits
Preventive Services
Pediatrician
Routine Physical
Maternity
Preventive Services Mamogram/Pap Smears
$15 copayment/visit
$30 copayment/visit
No charge
$15 copayment/visit
No charge
$30 copayment/visit
$30 copayment/visit; subsequent visits no charge
No charge
HOSPITALIZATION
Benefits payable at 100%. Please confirm provider has hospital privileges at a Select JHS participating hospital.
HOSPITAL/SURGICAL REQUIREMENTS
Inpatient
Outpatient
No charge
$15 per visit
Inpatient
Outpatient
No charge
$15 per visit
OTHER SERVICES
Ambulance
Vision
Coverage provided for diseases of the eye and/or injuries to the eye. Eye exams for children under age 18 covered 100%, after $15
copayment. AvMed offers adult vision discounts through a preferred network of providers listed in the Provider Directory. Eye exams, glasses,
contact lenses not covered.
PRESCRIPTION DRUGS
$15 Generic/$25 Brand/$35 Non-Preferred for 30 day supply, including prescription contraceptives, at participating pharmacies nationwide.
If member/physician select Brand when Generic is available, member pays difference in cost plus Brand copayment. See plan literature for
other participating pharmacies. Mail order: 2x copay for 90-day supply. Generic contraceptives will be no charge. DURABLE MEDICAL EQUIPMENT (DME)
$50 copayment per episode of illness. Please refer to brochure for limitations and restrictions.
OUT OF AREA
1) Emergency
2) Non-Emergency
$25 copay, waived if admitted, $25 participating urgent care, $50 non-participating urgent care, 100% thereafter.
16
AvMed Standard (HMO) Chart • Under 65
Standard (HMO)
COVERAGE PLAN DESCRIPTIO
AvMed offers Jackson Health System employees, covered dependents and retirees under age 65 “no referral” access to an expanded network of
providers in the state of Florida. In addition, AvMed offers a nationwide network for those residing outside of the service area. The plan provides
100% benefits for covered charges, after applicable copayments. Members are encouraged, but not required, to select a primary care physician.
AvMed offers Member Service, Nurse on Call hot lines, discounted health and wellness programs, discounted Mail Order Prescriptions and
more.
COPAYMENTS
$15 Primary Care Physician/$30 Specialty office visit/services. 100% Hospital admission coverage - no copayment. $25 copayment Emergency
Room (waived if admitted). $25/$50 copayment Urgent Care. $15/ $25/ $35 prescription for 30-day supply based on formulary. $30/$50/$70
Mail order prescription available for 90-day supply based on formulary
PHYSICIANS
Access any primary care physician or specialist from the Elite Access Network. Members are encouraged but not required to select a primary care
Anesthesiologist
PCP Office Visits
Preventive Services
Pediatrician
Routine Physical
Maternity
Preventive Services Mamogram/Pap Smears
$15 copayment/visit
$30 copayment/visit
No charge
$15 copayment/visit
No charge
$30 copayment/visit
$30 copayment/visit; subsequent visits no charge
No charge
HOSPITALIZATION
Benefits payable at 100%.
Inpatient
Outpatient
No charge
$15 per visit
Inpatient
Outpatient
No charge
$15 per visit
OTHER SERVICES
Ambulance
Vision
PRESCRIPTION DRUGS
Coverage provided for diseases of the eye and/or injuries to the eye. Eye exams for children under age 18 covered 100%, after $15 copayment.
AvMed offers adult vision discounts through a preferred network of providers listed in the Provider Directory. Eye exams, glasses, contact lenses
not covered.
$15 Generic/$25 Brand/$35 Non-Preferred for 30 day supply, including prescription contraceptives, at participating pharmacies nationwide. If
member/physician select Brand when Generic is available, member pays difference in cost plus Brand copayment. See plan literature for other
participating pharmacies. Mail order: 2x copay for 90-day supply. Generic contraceptives will be no charge. DURABLE MEDICAL EQUIPMENT (DME) $50 copayment per episode of illness. Please refer to brochure for limitations and restrictions.
OUT OF AREA
1) Emergency
2) Non-Emergency
$25 copay, waived if admitted, $25 participating urgent care, $50 non-participating urgent care, 100% thereafter.
17
AvMed (POS) Chart • Under 65
This plan allows you to use both in and out-of-network providers. For purposes of this summary, the two will be discussed separately.
IN-NETWORK
AvMed offers Jackson Health System employees, covered dependents and retirees under age 65 “no referral” access to an expanded network of
providers in the state of Florida. In addition, AvMed offers a nationwide network for those residing outside of the service area. The plan provides
100% benefits for covered charges, after applicable copayments. Members are encouraged, but not required, to select a primary care physician.
AvMed offers Member Service, Nurse on Call hot lines, discounted health and wellness programs, discounted Mail Order Prescriptions and more.
COPAYMENTS
$15 Primary Care Physician/$30 Specialist office visit, 100% Hospital admission coverage - no copay, $50 Emergency Room (waived if admitted),
$15/$25/$35 Prescriptions for 30 day supply
Mail Order: $30/$50/$70 for 90 day supply.
PHYSICIANS
Access any primary care physician or specialist from the Elite Access Network. Members are encouraged but not required to select a primary care
Anesthesiologist
PCP Office Visits
Specialist Office Visitsy
Preventive Services,
Pediatrician
Routine Physical
Maternity
Preventive Services Mammogram/Pap Smears
$15 copayment /visit
No charge
No charge
$30 copayment /visit; subsequent visits no charge
No charge.
HOSPITALIZATION
Benefits payable at 100% at affiliated hospitals when admitted with PCP authorization.
Inpatient
Outpatient
No charge
$15 per visit
Inpatient
Outpatient
No charge
$15 per visit
OTHER SERVICES
Ambulance
Vision
Coverage provided for diseases of the eye and/or injuries to the eye. Eye exams for children under age 18 covered 100%, after $15 copayment.
AvMed offers adult vision discounts through a preferred network of providers listed in the Provider Directory. Eye exams, glasses, contact lenses not
covered.
PRESCRIPTION DRUGS
$15 Generic/$25 Preferred Brand/$35 Non-Preferred Brand prescriptions for 30 day supply including prescription contraceptives at participating
pharmacies nationwide. See plan literature for participating pharmacies. Mail order: 2x copay for 90-day supply. Generic contraceptives will be
no charge.
DME and Orthotic covered at 100%. External prosthetic appliance - No charge after $200 deductible per contract year.
OUT OF AREA
1) Emergency
2) Non-Emergency
$50 copay, waived if admitted/100% thereafter.
Out-of-network applies: 70% of maximum allowable payment (MAP) after deductible is met.
18
AvMed (POS) Chart • Under 65
This plan allows you to use both in and out-of-network providers. For purposes of this summary, the two will be discussed separately.
OUT-OF-NETWORK
A fee for service program that provides you the freedom to use any physician or accredited hospital of your choice outside of the network.
Payments are based on maximum allowable payment (MAP) charges. Providers who do not participate in the network may balance bill you
for the amount which exceeds MAP. Coverage is subject to deductibles and coinsurance.
$200 per individual; $500 per family, $50 Emergency Room Copayment (waived if admitted).
Same in-network prescription benefits apply if participating, pharmacy is used. Benefits payable at 70% of coinsurance after deductible is
met.
PHYSICIANS
Choose any licensed physician; covered charges payable at MAP after deductible is met.
Anesthesiologist
30% coinsurance after deductible.
Office Visits for Illness
Office Visits for Injury
Diagnostic X-Rays, Lab Tests,
X-Ray Treatments
Pediatrician
1) Medically Necessary
2) Preventive Care Birth through
age 15 (Well-Baby)
Routine Preventive Care for children and adults
HOSPITALIZATION
Plan pays 70% coinsurance, after deductible is met.
1) 70% of MAP, after deductible is met.
2) Plan pays 70% of MAP, after deductible is met.
Plan must be notified within 24 hours after date of admission.
Pre-certification is required.
Inpatient
Outpatient
Plan pays 70% coinsurance, after deductible is met.*
Inpatient
Outpatient
Plan pays 70% coinsurance, after deductible is met..*
OTHER SERVICES
Ambulance
Vision
Coverage provided for diseases and/or injuries of the eye subject to deductible/coinsurance.
PRESCRIPTION DRUGS
$15 Generic Drug/$25 Preferred Brand/$35 Non-Preferred Brand up to a 30 day supply at any participating network pharmacy. 90
day supply at Mail Order available fro 2x copayment. Generic contraceptives no charge. See plan literature or visit website for more
information.
Plan pays 70% of MAP after deductible for DME and orthotics. External prosthetic appliance not covered out-of-network. OUT OF AREA
1) Emergency
2) Non-Emergency
100% after $50 copayment, waived if admitted (worldwide).
* This comparison is not a contract. For specific information on benefits, exclusions and limitations, please see the Summary of Benefits & Coverage (SBC). Maximum lifetime benefits is unlimited in-network and outof-network. Non-participating out-of-network providers have not agreed to accept AvMed’s MAP as payment in full for covered services. Therefore, if a nonparticipating provider is used the member is also responsible
for the difference between MAP and the non-participating provider’s actual charges.
19
Medical Monthly Rates • 65 and Over
The medical chart pages are intended to highlight the plans available and do not constitute a contract. Precise benefits
will be governed by the contracts and not by these charts. Please review details of any modification in benefits in the plan
literature, or seek clarification through the health plan.
Health plans are on an ongoing basis renegotiating contracts with affiliated providers (doctors, hospitals, etc.). As a result,
providers may be added to or deleted from the participating provider listing of the various plans during the plan year. We
highly recommend verifying if your preferred provider still participates in the program prior to seeking use of their services.
AvMed Retiree, Spouse/DP & Dependents
Monthly Rates
AVMED
High Plan
AVMED High W/No Rx
Plan
Retiree 65 and Over Only
$561.46
$244.04
Retiree 65 and Over & Spouse/DP 65 and Over
$1,101.90
$478.97
Retiree 65 and Over & Spouse/DP 65 & Over plus Child(ren)† on
AvMed POS Plan
$2,070.03
N/A
Retiree 65 and Over & Spouse/DP 65 & Over plus Child(ren)† on
AvMed Standard HMO
$1,393.22
N/A
Retiree 65 and Over & Child(ren)† on AvMed POS Plan
$1,529.59
$1,212.17
Retiree 65 and Over & Child(ren)† on AvMed Standard HMO
$1,059.41
$741.99
Retiree 65 and Over & Spouse/DP Under 65 on AvMed POS Plan
$1,680.04
$1,362.62
Retiree 65 and Over & Spouse/DP Under 65 on AvMed Standard
HMO
$1,027.62
$710.20
Retiree 65 and Over & Spouse/DP Under 65, Child(ren)†
on AvMed POS Plan
$2,081.55
N/A
Retiree 65 and Over & Spouse/DP Under 65, Child(ren)†
on AvMed Standard HMO
$1,393.22
$1,075.80
Jackson
First HMO
PLAN
Select
HMO
Standard
HMO PLAN
POS PLAN
Spouse/DP Under 65†
$387.42
$419.23
$466.16
$1,118.58
Child(ren)†
$423.59
$453.62
$497.95
$968.13
Spouse/DP Under 65 and Child(ren)†
$811.01
$872.85
$964.11
$2,086.71
AvMed Dependent Coverage Monthly Rates
Retiree 65 and Over w/Non-JHS Medicare Plan
† Option also applies to Adult Children (AC) between 26 through 30 years of age, children of DP and/or eligible dependents.
20
AvMed Health Plans HIGH OPTION with Rx • 65 and Over
Visit our website at www.avmed.org/go/mdpht
Benefit Summary
MEDICARE ELIGIBLE RETIREE HIGH OPTION WITH PRESCRIPTION DRUG COVERAGE
JACKSON HEALTH SYSTEM
LIFETIME MAXIMUM
DEDUCTIBLE AMOUNT PER CALENDAR YEAR
Per Individual
CHOICE OF HOSPITALS
MEDICARE PART B DEDUCTIBLE: $147 PER
CALENDAR YEAR
INPATIENT HOSPITAL FACILITY
Covered by Medicare Part A. Medicare covers:
Days 1—60:
All but $1,260
Days 61—90:
All but $315 per day
Days 91—150:
*Days 91—150 are the 60 Lifetime Reserve Days.
Medicare will cease until a new Benefit Period begins.
A new Benefit Period begins after you have been out of
the hospital or facility for at least 60 days. In a new
Benefit Period, all Medicare Part A will renew except
for the Lifetime Reserve Days.
HOSPITAL OUTPATIENT/PHYSICIAN
Covered by Medicare Part B
SKILLED NURSING FACILITIES
Days 1—20: Covered by Medicare Part A
Days 21—100: Covered all but $157.50 per day
SCHEDULE OF BENEFITS
Unlimited
$147 for Private Duty Nursing
$250 for Foreign Travel Emergency Care
Unlimited
Not Covered
100% up to $1,260
100% up to $315 per day
*365 additional lifetime days after Medicare Lifetime
Reserve Days are exhausted
Covered at 100% of Medicare eligible expense
Must be medically necessary
Limiting semi-private room (unless medically necessary) &
board amount
Remainder 20% of Medicare approved amount
Days 1—20:
Not Covered
Days 21—100:
100% up to $157.50 per day
Days 101 & beyond: Not Covered
PHYSICIAN VISITS/ILLNESS
EMERGENCY AND URGENT CARE SERVICES
PHYSICIAN’S OFFICE VISIT
SPECIALIST’S OFFICE VISIT
SURGICAL PROCEDURES
PREVENTIVE CARE
Includes, but is not limited to:
Annual Screening Mammogram
Pap Smear & Pelvic Exam
Bone Mass Measurement
Prostate Cancer Screening
Physical Exam (Yearly “Wellness” Exam)
Colorectal Screening
No Charge
Subject to Preventive Care guidelines outlined in the
“2015 Medicare & You” publication from Centers for
Medicare & Medicaid Services (CMS)
ALLERGY INJECTIONS
SF-JHS RETIREE HIGH W/RX-15
SF-3579 (01/15)
21
Benefit Summary
DURABLE MEDICAL EQUIPMENT
IMMUNIZATIONS
X-RAYS
20% of Medicare approved
MEDICARE
ELIGIBLE
RETIREE HIGH OPTIONRemainder
WITH PRESCRIPTION
DRUGamount
COVERAGE
Covered
by Medicare
Part B
ADVANCED RADIOLOGICAL IMAGING (I.E.
JACKSON
SYSTEM
SCHEDULE
BENEFITS
Remainder
20%OF
of Medicare
approved amount
MRIs,
MRAs,HEALTH
CAT Scans
and PET Scans)
Covered
by Medicare
PartEQUIPMENT
B
DURABLE
MEDICAL
Covered by Medicare
Part
B
PHYSICAL
THERAPY
SERVICES
Covered
by Medicare Part B
IMMUNIZATIONS
TMJ
Covered
by Medicare Part B
X-RAYS
Surgical
Coveredand
by Non-Surgical
Medicare Part B
OTHER
LAB/RADIOLOGY
SERVICES
ADVANCED
RADIOLOGICAL
IMAGING (I.E.
Covered
by Medicare
B and PET Scans)
MRIs, MRAs,
CAT Part
Scans
Covered by Medicare
Part B
SHORT-TERM
REHABILITATION
Covered
by Medicare
Part B
PHYSICAL
THERAPY
SERVICES
Includes:
Limited to$1,940 per calendar year for Physical
TMJ
Therapy
(PT)20%
andofSpeech
Therapy
Language
Pathology
Cardiac
Rehab
Remainder
Medicare
approved
amount
(SLP) services combined
Speech
Therapy
Surgical
and Non-Surgical
Occupational
Therapy
OTHER LAB/RADIOLOGY
SERVICES
Remainder
20% of
amount
Limited
to$1,940
perMedicare
calendarapproved
year for Occupational
Pulmonary
Covered byRehab
Medicare Part B
Therapy (OT) services
Cognitive
TherapyREHABILITATION
SHORT-TERM
Chiropractic
Therapy
(includes
Chiropractors)
AMBULANCE
Covered
Includes:by Medicare Part B
Limited to$1,940 per calendar year for Physical
HOME
CARE
Therapy (PT) and Speech Therapy Language Pathology
CardiacHEALTH
Rehab
No
Charge
When
covered
by Medicare
(SLP)
services combined
Speech
Therapy
Occupational Therapy
Plan
will pay
up to $40
per visit year
limited
$1,600 per
When
not covered
Limited
to$1,940
per calendar
forto
Occupational
Pulmonary
Rehabby Medicare
calendar
Therapyyear.
(OT) services
Cognitive Therapy
80% of Medicare approved amount after $250 calendar year
FOREIGN
TRAVEL/EMERGENCY
CARE
Chiropractic
Therapy (includes Chiropractors)
Not
covered by Medicare
deductible, up to a lifetime maximum of $50,000
AMBULANCE
PRIVATE
NURSING
Covered byDUTY
Medicare
Part B
80% of the Reasonable & Customary charges after $147
Covered
MedicareCARE
Part B
HOMEby
HEALTH
calendar
year deductible
(While
In Medicare
a Hospital or Other Health Care
No Charge
When Inpatient
covered by
Facility Only)
Plan will pay up to $40 per visit limited to $1,600 per
When not covered by Medicare
calendar year.
FOREIGN TRAVEL/EMERGENCY CARE
Not covered by Medicare
PRIVATE DUTY NURSING
calendar year deductible
(While Inpatient In a Hospital or Other Health Care
Facility Only)
Benefit Summary
SF-3579 (01/15)
22
Benefit Summary
MATERNITY SERVICES
Initial Visit to confirm pregnancy
Benefit Summary
All subsequent prenatal and postnatal visits
Covered by Medicare Part A
Delivery, (Inpatient
Hospital
or Birthing Center)
JACKSON
HEALTH
SYSTEM
Days 1 to 60: OF
100%
up to $1,260
SCHEDULE
BENEFITS
Days 61 to 90: 100% up to $315 per day
Days 91 -150: 100% up to $630 per day
MATERNITY SERVICES
ABORTION-NON-ELECTIVE
Covered
bytoMedicare
A
Initial
Visit
confirm Part
pregnancy
Inpatient
OUTPATIENT
SURGICAL
FACILITY\
All
subsequent prenatal
and postnatal
visits
Surgicalby
sterilization
for Vasectomy/Tubal
Covered
Medicare procedures
Part A
Ligations(Inpatient Hospital or Birthing Center)
Delivery,
BLOOD
First three pints of blood not covered by Medicare
OUTPATIENT FACILITY
Coveredby
byMedicare
MedicarePart
PartAB
Covered
Services in Operating and Recovery Room, Procedures
Inpatient
Room and Treatment
OUTPATIENT
SURGICAL FACILITY\
HOSPICE
Inpatientsterilization
Services procedures for Vasectomy/Tubal
Surgical
Ligations
Outpatient Services (same coinsurance level as Home
BLOOD
Health
Care)
First
three
pints of blood not covered by Medicare
INFERTILITY
- OFFICE VISIT FOR DIAGNOSIS
OUTPATIENT FACILITY
Coveredby
byMedicare
MedicarePart
PartBB
Covered
ORGANinTRANSPLANT
Services
Operating and Recovery Room, Procedures
Covered
Medicare Part A
Room
andby
Treatment
EXTERNAL PROSTHESES
HOSPICE
Covered Services
by Medicare Part B
Inpatient
Payable as20%
Inpatient
Remainder
of Medicare approved amount
Days 1 to 60: 100% up to $1,260
First 61
three
pints
of blood
at day
100% of the
Days
to 90:
100%
up tocovered
$315 per
Reasonable
&
Customary
charges
Days 91 -150: 100% up to $630 per day
Payable as Inpatient
Remainder
20% ofofMedicare
approvedbut
amount
Plan pays 100%
amount approved
not paid by
Medicare, when Medicare certification and election
requirements
First
three pintsare
ofmet.
blood covered at 100% of the
Reasonable & Customary charges
Payable as Inpatient Hospital
Plan pays 100% of amount approved but not paid by
requirements are met.
Health Care)
INFERTILITY - OFFICE VISIT FOR DIAGNOSIS
ORGAN TRANSPLANT
EXTERNAL PROSTHESES
SF-3579 (01/15)
23
Benefit Summary
AvMed
Health Plans HIGH OPTION with Rx • 65 and Over
MENTAL HEALTH /SUBSTANCE ABUSE
INPATIENT
Benefit Summary
Mental
Health ELIGIBLE RETIREE HIGH OPTION WITH PRESCRIPTION DRUG COVERAGE
MEDICARE
Acute: based on ratio of 1:1
Partial:
based
on a ratio/SUBSTANCE
of 2:1
MENTAL
HEALTH
ABUSE
INPATIENT
Substance
Covered byAbuse
Medicare Part A
Acute detoxification: requires 24 hour nursing; based on
aMental
ratio ofHealth
1:1
Medicare; if charges not approved by Medicare, there is
no coverage
Acute Inpatient Rehab: requires 24 hour nursing;
based
a ratio
Partial:onbased
onofa 1:1
ratio of 2:1
Partial:
based
on a ratio of 2:1
Substance
Abuse
Acute detoxification: requires 24 hour nursing; based on
Residential:
a ratio of 1:1based on a ratio of 2:1
MENTAL HEALTH/SUBSTANCE ABUSE
OUTPATIENT
HOSPITAL/FACILITY
Acute Inpatient Rehab:
requires 24 hour nursing;
Covered
by
Medicare
based on a ratio of 1:1Part B
EYEGLASSES
Covered
by Medicare
Part
B
Partial: based
on a ratio
of 2:1
PRESCRIPTION DRUG COVERAGE
Residential: based on a ratio of 2:1
Retail
(30-day
supply)
MENTAL
HEALTH/SUBSTANCE
ABUSE
OUTPATIENT HOSPITAL/FACILITY
Specialty
(30-day supply at Participating Specialty
EYEGLASSES
Pharmacy)
Mail Order (90-day supply at Participating Pharmacy)
no coverage
Coverage assumes enrollment in Medicare Part B; Plan pays
remainder of charges approved but not paid by Medicare
Part B and member has $0 responsibility
Not Covered
80% after
$200enrollment
calendar year
deductiblePart B; Plan pays
Coverage
assumes
in Medicare
$100 co-payment per prescription for Specialty drugs
Not Covered
100% after $10 co-payment for Generic
100%
after$200
$20 co-payment
Preferred Brand
80% after
calendar yearfordeductible
100% after $30 co-payment for Non-Preferred Brand
Retail (30-day supply)
Not
Mail
Order(30-day
at Non-Participating
PharmacySpecialty
$100Covered
co-payment per prescription for Specialty drugs
Specialty
supply at Participating
Pharmacy)
FOR ADDITIONAL INFORMATION, PLEASE CALL: 1-844-439-5378
100% after $10 co-payment for Generic
Mail Order (90-day supply at Participating Pharmacy)
100%
after $20
For specific information on benefits,
exclusions
andco-payment
limitations for Preferred Brand
100%
after $30(SPD).
co-payment for Non-Preferred Brand
please see your Summary Plan
Description
Not Covered
Mail Order at Non-Participating Pharmacy
For specific information on benefits, exclusions and limitations
please see your Summary Plan Description (SPD).
SF-3579 (01/15)
24
AvMed Health Plans HIGH OPTION without Rx • 65 and Over
Benefit Summary
MEDICARE ELIGIBLE RETIREE HIGH OPTION WITHOUT PRESCRIPTION DRUG
COVERAGE
LIFETIME MAXIMUM
DEDUCTIBLE AMOUNT PER CALENDAR YEAR
Per Individual
CHOICE OF HOSPITALS
MEDICARE PART B DEDUCTIBLE: $147 PER
CALENDAR YEAR
INPATIENT HOSPITAL FACILITY
Covered by Medicare Part A. Medicare covers:
Days 1—60:
All but $1,260
Days 61—90:
Days 91—150:
*Days 91—150 are the 60 Lifetime Reserve Days.
Medicare will cease until a new Benefit Period begins.
A new Benefit Period begins after you have been out of
the hospital or facility for at least 60 days. In a new
Benefit Period, all Medicare Part A will renew except
for the Lifetime Reserve Days.
HOSPITAL OUTPATIENT/PHYSICIAN
SKILLED NURSING FACILITIES
Days 1—20: Covered by Medicare Part A
Days 21—100: Covered all but $157.50 per day
PHYSICIAN VISITS/ILLNESS
EMERGENCY AND URGENT CARE SERVICES
PHYSICIAN’S OFFICE VISIT
SPECIALIST’S OFFICE VISIT
SURGICAL PROCEDURES
PREVENTIVE CARE
Unlimited
$147 for Private Duty Nursing
$250 for Foreign Travel Emergency Care
Unlimited
Not Covered
100% up to $1,260
*365 additional lifetime days after Medicare Lifetime
Reserve Days are exhausted
Covered at 100% of Medicare eligible expense
Must be medically necessary
Limiting semi-private room (unless medically necessary) &
board amount
Days 1—20:
Days 21—100:
Days 101 & beyond:
Not Covered
100% up to $157.50 per day
Not Covered
Includes, but is not limited to:
Annual Screening Mammogram
Pap Smear & Pelvic Exam
Bone Mass Measurement
Prostate Cancer Screening
Physical Exam (Yearly “Wellness” Exam)
Colorectal Screening
No Charge
Subject to Preventive Care guidelines outlined in the
“2015 Medicare & You” publication from Centers for
Medicare & Medicaid Services (CMS)
SF-JHS RETIREE HIGH W/O RX-15
SF-3577 (01/15)
25
Benefit Summary
AvMed
Health Plans HIGH OPTION without Rx • 65 and Over
Visit our website atCOVERAGE
www.avmed.org/go/mdpht
Benefit Summary
ALLERGY INJECTIONS
DURABLE
MEDICALELIGIBLE
EQUIPMENT
MEDICARE
RETIREE HIGH OPTION
WITHOUT
PRESCRIPTION
DRUG
Remainder
20% of Medicare
approved amount
COVERAGE
IMMUNIZATIONS
X-RAYS
ALLERGY
INJECTIONS
Covered
by Medicare
Part B
Covered by Medicare
Part B
ADVANCED
RADIOLOGICAL
IMAGING (I.E.
DURABLE
Remainder
MRIs,
MRAs,MEDICAL
CAT ScansEQUIPMENT
and PET Scans)
Remainder20%
20%ofofMedicare
Medicareapproved
approvedamount
amount
Covered
by
Medicare
PartBB
Covered by Medicare Part
IMMUNIZATIONS
PHYSICAL
THERAPY SERVICES
Remainder20%
20%ofofMedicare
Medicareapproved
approvedamount
amount
Remainder
CoveredbybyMedicare
MedicarePart
PartBB
Covered
X-RAYS
TMJ
Surgical and Non-Surgical
Remainder20%
20%ofofMedicare
Medicareapproved
approvedamount
amount
Remainder
CoveredbybyMedicare
MedicarePart
PartBB
Covered
ADVANCED
RADIOLOGICAL
IMAGING (I.E.
OTHER
LAB/RADIOLOGY
SERVICES
Remainder
Remainder20%
20%ofofMedicare
Medicareapproved
approvedamount
amount
MRIs, MRAs,
CATPart
Scans
Covered
by Medicare
B and PET Scans)
Covered
by
Medicare
Part
B
SHORT-TERM REHABILITATION
PHYSICAL
THERAPY
Covered
by Medicare
Part BSERVICES
Remainder20%
20%ofofMedicare
Medicareapproved
approvedamount
amount
Remainder
TMJ Surgical and Non-Surgical
Includes:
Remainder
20% of
amount
Limited
to $1,940
forMedicare
Physical approved
Therapy (PT)
and
Covered
by Medicare Part B
Cardiac
Rehab
Speech Therapy Language Pathology (SLP) services
OTHER
LAB/RADIOLOGY SERVICES
Speech
Therapy
combined
Covered by Medicare
Occupational
Therapy Part B
SHORT-TERM
Pulmonary
Rehab REHABILITATION
Limited to $1,940 for Occupational Therapy (OT)
Covered Therapy
by Medicare Part B
Cognitive
services
Chiropractic Therapy (includes Chiropractors)
Includes:
Limited to $1,940 for Physical Therapy (PT) and
AMBULANCE
Cardiac Rehab
Speech Therapy
(SLP) services
Remainder
20% ofLanguage
Medicare Pathology
approved amount
Covered
Medicare Part B
Speech by
Therapy
combined
Occupational
Therapy
HOME
HEALTH
CARE
No Charge
When
covered
by Medicare
Pulmonary
Rehab
Limited to $1,940 for Occupational Therapy (OT)
Cognitive Therapy
services
When
not covered
by Medicare
Chiropractic
Therapy
(includes Chiropractors)
calendar year.
AMBULANCE
80% of
Medicare20%
approved
amountapproved
after $250amount
calendar year
Remainder
of Medicare
Covered
byby
Medicare
Part B
Not
covered
Medicare
HOME HEALTH
CARE
PRIVATE
DUTY NURSING
Nothe
Charge
When covered
by Medicare
80% of
Reasonable & Customary charges after $147
Covered
by Medicare
Part B
When not
covered by Medicare
Facility
Only)
calendar year.
Not covered by Medicare
PRIVATE DUTY NURSING
Facility Only)
SF-3577 (01/15)
26
Benefit Summary
AvMed Health Plans HIGHCOVERAGE
OPTION without Rx • 65 and Over
MATERNITY SERVICES
Initial Visit to confirm pregnancy
Benefit Summary
Remainder
20% of Medicare
approved amount
MEDICARE
ELIGIBLE
RETIREE HIGH OPTION
WITHOUT
PRESCRIPTION
DRUG
All subsequent
prenatal and
postnatal visits
COVERAGE
Delivery, (Inpatient Hospital or Birthing Center)
MATERNITY SERVICES
Initial Visit
to confirm
pregnancy
Covered
by Medicare
Part
A
Inpatient
All subsequent prenatal
and postnatal
visits
OUTPATIENT
SURGICAL
FACILITY
Coveredsterilization
by Medicare
Part A for Vasectomy/Tubal
Surgical
procedures
Delivery,
(Inpatient
Hospital
or Birthing Center)
Ligations
BLOOD
First three pints of blood not covered by Medicare
OUTPATIENT
FACILITY
CoveredbybyMedicare
MedicarePart
PartBA
Covered
Inpatient
Services in Operating and Recovery Room, Procedures
OUTPATIENT
SURGICAL FACILITY
Room
and Treatment
Covered
by
Medicare
Part B
HOSPICE
Surgical
sterilization
procedures
for Vasectomy/Tubal
Inpatient Services
Ligations
BLOOD
Health
Care)
First three pints- of
blood not
covered
by DIAGNOSIS
Medicare
INFERTILITY
OFFICE
VISIT
FOR
OUTPATIENT
FACILITY
CoveredTRANSPLANT
by Medicare Part B
ORGAN
ServicesbyinMedicare
OperatingPart
andARecovery Room, Procedures
Covered
Room and Treatment
EXTERNAL PROSTHESES
HOSPICE
Covered
by Medicare Part B
Inpatient Services
Health Care)
INFERTILITY - OFFICE VISIT FOR DIAGNOSIS
ORGAN TRANSPLANT
EXTERNAL PROSTHESES
Days 1 to 60: 100% up to $1,260
SCHEDULE
BENEFITS
Days
61 to 90: OF
100%
up to $315 per day
Days 91 -150: 100% up to $630 per day
Remainder
20% of Medicare approved amount
Payable
as Inpatient
Days 1 to 60: 100% up to $1,260
Days
61 to
90: of100%
to $315
dayof the
First
three
pints
blood up
covered
at per
100%
Days
91
-150:
100%
up
to
$630
per
day
Payable as Inpatient
First three pints
of blood covered at 100% of the
requirements
are met
Remainder
20% of Hospital
Medicare approved amount
Payable
as Inpatient
requirements are met
SF-3577 (01/15)
27
Benefit Summary
COVERAGE
AvMed Health Plans HIGH OPTION without Rx • 65 and Over
MENTAL HEALTH /SUBSTANCE ABUSE
INPATIENT
Benefit Summary
Mental MEDICARE
Health
ELIGIBLE RETIREE HIGH OPTION WITHOUT PRESCRIPTION DRUG
COVERAGE
Partial: based on a ratio of 2:1
Substance
MENTALAbuse
HEALTH /SUBSTANCE ABUSE
Acute
detoxification: requires 24 hour nursing; based on
INPATIENT
aCovered
ratio of by
1:1Medicare Part A
Plan
pays 100%OF
of BENEFITS
amount approved but not paid by
SCHEDULE
no coverage
Acute
MentalInpatient
Health Rehab: requires 24 hour nursing;
based
a ratio
1:1 of 1:1
Acute:onbased
onofratio
Partial:
Partial: based
based on
on aa ratio
ratio of
of 2:1
2:1
Residential:
based
on
a
ratio
of
2:1
Substance Abuse
assumes enrollment in Medicare Part B; Plan pays
MENTAL
HEALTH/SUBSTANCE
Acute detoxification:
requires 24 hourABUSE
nursing; based on Coverage
no coverage
OUTPATIENT
HOSPITAL/FACILITY
a ratio of 1:1
EYEGLASSES
Acute Inpatient Rehab: requires 24 hour nursing;
Not Covered
Covered
Medicare
based onby
a ratio
of 1:1Part B
Not Covered
Partial: based on a ratio of 2:1
Residential: based on a ratio of 2:1
Coverage assumes enrollment in Medicare Part B; Plan pays
MENTAL HEALTH/SUBSTANCE ABUSE
OUTPATIENT HOSPITAL/FACILITY
EYEGLASSES
Not Covered
Not Covered
SF-3577 (01/15)
28
Dental Rates for Under and Over 65
STANDARD
Monthly
Dental Rates
ENRICHED
GUARDIAN
DHMO*
GUARDIAN
PPO
GUARDIAN
DHMO*
GUARDIAN
PPO
Retiree Only
$8.00
$31.22
$14.57
$40.87
Retiree &
One Dependent†
$13.24
$61.76
$24.15
$80.81
Retiree & Dependents†
$20.22
$99.55
$38.39
$130.30
+ Option also applies to Domestic Partners and/or Children of Domestic Partners and eligible dependents.
*Guardian DHMO plans are not available outside of Florida.
Non-Guardian Dental dentists are reimbursed based on the PPO Fee Schedule instead of the maximum program allowance. As a result members visiting a non-Guardian
Dental dentist may see a change in out-of-pocket costs.
29
Guardian Dental PPO Chart • Under and Over 65
CHOICE OF DENTIST
You’ll likely save most with a dentist who participates in the Guardian DentalGuard PPO network, and you’ll likely save least with
a non-participating dentist. Services provided by out-of-network providers will be reimbursed at the 90th percentile of usual and
customary charges. Percentages below are based on Guardian’s applicable allowances and not necessarily the dentist’s actual charge.
$1,000 per year per person
$50 deductible per year per person; $150 family maximum
$1,500 per year per person
$50 deductible per year per person; $150 family maximum
TYPE I
0150 Comprehensive Oral Evaluation - New or
Established
0120 Periodic Oral Exam
X-Rays
1110/20 Prophylaxis
1203 Fluoride Treatment (children up to the age 19)
1351 Sealant per tooth
1510 Space Maintainers
STANDARD
Plan Pays (No deductible)
100%
100%
100%
100% (Twice per calendar year)
100%, 2x per year
100% to age 16
100% to age 19
ENRICHED
Plan Pays (No deductible)
100%
100%
100%
100% (Twice per calendar year)
100%, 2x per year
100% to age 16
100% to age 19
TYPE II*
Fillings: (silver and white)
2330 One surface
2331 Two surfaces
2332 Three surfaces
2334 Four or more surfaces
Restorative Services:
2930 Prefabricated stainless steel primary tooth
Root canals:
3310 Anterior
3320 Bicuspid
3330 Molar
3410 Apicoectomy
Extractions:
7111 Single tooth
7140 Extraction, erupted tooth or exposed tooth
7210 Surgical extraction of erupted tooth
Periodontics: (gum treatment)
4341 Periodontal scaling & root planing- per quadrant
4210 Gingivectomy/gingivoplasty - per quadrant
4910 Periodontal maintenance procedures
STANDARD
ENRICHED
100% (In PPO Network) / 75% (Out of PPO Network)
75% for children to age 16
75% for children to age 16
75%
75%
75%
75%
75%
75%
75%
75%
75%
75%
75%
75%
75%
75%
75%
75%
75%
75%
75%
75%
STANDARD
ENRICHED
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
MAXIMUM BENEFIT/DEDUCTIBLE
TYPE III*
Crown & Bridge:
2791 Crown full cast predominately base metal
2751 Crown Porcelain fused to base metal
Pontics:
6210 Full cast
6240 Porcelain fused to metal
Prosthodontics (Dentures):
5110 Complete upper
5120 Complete lower
5213/14 Partial upper or lower - cast metal base
ORTHODONTIA
Consultation
Evaluation
Records
Children-Normal Class II
Adult - Normal Class II
8750 Retention
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
VISION
Examination
SINGLE VISION LENSES
Bifocal Lenses
Trifocal Lenses
Contact Lenses - Non-Elective
Contact Lenses - Elective
Frames
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
*All Type II and III charges subject to annual deductible.
30
Adult & Child covered at 50% after
a one time deductible of $50 per person.
$1,000 lifetime maximum benefit
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Guardian DHMO Dental Chart • Under and Over 65
STANDARD (U50)
CHOICE OF DENTIST
Limited to Participating Dentists in Private Practice
MAXIMUM BENEFIT/DEDUCTIBLE
TYPE I
1110/20 Prophylaxis
0120 Periodic Oral Exam
0150 Comprehensive Oral Evaluation - New or Established
1203 Fluoride Treatment (children up to the age 19)
1351 Sealant- per tooth
1510 Space Maintainers
TYPE II
Fillings: (silver)
2140 One surface
2150 Two surfaces
2160 Three surfaces
2161 Four or more surfaces
Root canals:
3310 Anterior
3320 Bicuspid
3330 Molar
3410 Apicoectomy
Extractions:
7111 Single tooth
7140 Extraction, erupted tooth or exposed tooth
7210 Surgical extraction of erupted tooth
Periodontics: (gum treatment)
4210 Gingivectomy/gingivoplastY - per quadrant
4341 Periodontal scaling & root planing - per quadrant
4910 Periodontal maintenance procedures
Two additional every 12 months
TYPE III
Crown & Bridge:
2751 Crown Porcelain fused to base metal
2791 Crown full cast predominately base metal
2930 Prefabricated stainless steel
Prosthodontics (Dentures):
5110 Complete upper
5120 Complete lower
5213/14 Partial upper or lower - cast metal base
ORTHODONTIA
Consultation
Evaluation
Records
Children-Normal Class II
Adult - Normal Class II
8680 Retention
ENRICHED (U60)
No Maximum, No Deductible
STANDARD
You Pay
No Charge
No Charge
No Charge
No Charge
$5.00
$30.00
ENRICHED
You Pay
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
STANDARD
ENRICHED
$5.00
$5.00
$10.00
$13.00
No Charge
No Charge
No Charge
No charge
$75.00
$85.00
$150.00
$100.00
$70.00
$80.00
$140.00
$90.00
$10.00
$10.00
$30.00
$10.00
$10.00
$35.00
$75.00
$30.00
$15.00 each (Twice every 12 months)
$60.00 each
$60.00
$25.00
$15 each (Twice every 12 months)
$60.00 each
STANDARD
ENRICHED
$180.00
$180.00
$15.00
$95.00
$95.00
$10.00
$190.00
$190.00
$220.00
$110.00
$110.00
$130.00
This plan covers orthodontia as follows:
Comprehensive for dependent children
under age 19: $1,500. Adults: $2,800
This plan covers orthodontia as follows:
Comprehensive for dependent children
under age 19: $1,500. Adults: $2,800
31
The Guardian Davis Vision Plan offers a network of providers that service your eyecare needs with only a modest member
copayment shown in the Schedule of Benefits. The out of-network-benefit allows you to select any out of-network provider
and reimburses a fixed dollar amount based on the schedule shown for the out of-network services. The chart below indicates
the benefits the plan pays for the services you receive. For more information, see the Guardian Davis plan literature.
Covered Services
In-Network
Out-Of-Network
$10
N/A
Paid in full
Paid in full
Paid in full
Paid in full
Paid in full
Paid in full
Paid in full
$40-$90
up to $40
up to $40
up to $60
up to $80
N/A
N/A
N/A
N/A
Up to $160 retail In-network
Once every plan year in and out of
network.
up to $50
Once every year
Once every plan year
Covered up to $120 allowance
Covered in full
Covered up to $120
up to $210
Covered in full
N/A
N/A
N/A
Average discount of approximately
25%
N/A
One-time copayment (Applied to first service provided - exam
or materials)
Vision Exam (once every plan year)
Single Lenses (once every plan year)
Bifocal Lenses (once every plan year)
Trifocal Lenses (once every plan year)
Transition Lenses3
Polycarbonate Lenses4
Standard Progressive Lenses
Premium Progressive Lenses
Frames from Davis’ Fashion, Designer, or Premier collections 1
Frequency
Contact lenses
Elected by insured
Medically necessary
Contact Lenses Fitting Fee and Follow-Up
Mail Order Contact Replacement (Treated as out-of-network
provider)
LASIK Surgery (at VCP contracted facilities)
1. During any plan year, the member may elect either the frames and/or lenses covered service or the contact lenses allowance, but not both.
2. Polycarbonate lens option covered in full for dependents under 19 years of age.
3. Tints are covered in network. No coverage out of network.
4. UV protection and Photochromic lenses - In Network: Plastic : $65/Glass: Covered. Out of network: No coverage.
32
Guardian Davis Vision Plan
Vision Monthly Rates
How to use a Guardian Davis Vision Provider
Guardian
1.Obtain a listing of participating optometrists and
ophthalmologists during Open Enrollment or access the
list online at davisvision.com.
2.Identify yourself as an Guardian Davis member when you
make an appointment.
3. The eye doctor's office will handle all claim forms.
Employee Only
$4.14
Employee & One Dependent†
$8.30
Employee & Family†
$15.23
Option also applies to Domestic Partners and/or Children of Domestic Partners and
eligible dependents.
†
How to use a Guardian Davis Vision
Out-Of-Network Doctor
To use an out-of-network provider, the insured will need to pay at
the time the services are rendered and submit the claim form
to Guardian/Davis for reimbursement.
LASIK
Please call Guardian Davis Vision member services: 877393-7363 before making your appointment to ensure the
doctor of your choice is a member of the Davis Vision
network.
33
Life Insurance
Under 65 - Life Insurance
The monthly life insurance rate is 17¢ per thousand dollars of your pre-retirement annual salary.
$__________________________________ x .00017 + = $__________________________________
Annual Salary Rate Monthly Premium
* Your life insurance coverage is reduced when you reach age 65. The coverage options are $15,000 or $20,000.
65 and Over - Life Insurance
Monthly for $15,000 in Coverage
Monthly for $20,000 in Coverage
65-69
$ 8.55
$ 11.40
70-74
$ 14.10
$ 18.80
75+
$ 19.50
$ 26.00
Retirees’ Age
34
ARAG® Legal Plan
The Freedom and Control to Embrace Life’s Opportunities
At Jackson Health System, we want you to embrace life’s opportunities with fewer worries. That’s why we’re excited to
provide you with legal insurance from ARAG. It’s affordable and reliable legal counsel for everyday life matters – like a
dispute with a contractor, buying or selling a home or the need for estate planning. The plan provides you with the peace of
mind knowing that attorney fees for most covered legal matters are 100 percent paid in full when you work with a Network
Attorney. That means you’ll avoid paying high-cost attorney fees, which currently average $323 an hour.
Resolve Your Legal Issues with a Network Attorney by Your Side
When a life event turns into a legal issue, ARAG will be there for you, backed by a nationwide network of more than 10,000
credentialed attorneys. They can review or prepare documents, make follow-up calls or write letters on your behalf, provide
legal advice and consultation, and represent you in court. Rely on legal help and protection with a wide range of covered
services, including:
UltimateAdvisor®
UltimateAdvisor PlusTM
Civil Damage
•
•
Pet-Related Matters
•
•
Auto Repair
•
•
Buying a New or Used Vehicle
•
•
Consumer Fraud
•
•
Consumer Protection for Goods or Services
•
•
Home Improvement/Contractor Issues
•
•
Personal Property Protection
•
•
Credit Records Correction
-
•
Habeas Corpus
•
•
Juvenile Matters
•
•
Misdemeanor Matters
-
•
Bankruptcy (Chapters 7 & 13)
•
•
Debt Collection Matters
•
•
Garnishment
•
•
Adoption
•
•
Domestic Violence
•
•
Guardianship/Conservatorship
•
•
Incapacity
•
•
Civil Damage Claims (Defense)
Consumer Protection Issues
Criminal Matters
Debt-Related Matters
Family Law
35
ARAG® Legal Plan
UltimateAdvisor®
Name Change
•
•
Parental Responsibilities
•
•
Pre-Marital Agreements
•
•
Divorce/Annulment/Separation (uncontested)
•
•
Divorce/Annulment/Separation (up to 10 hours)
•
-
Divorce/Annulment/Separation (up to 15 hours)
-
•
Post-Nuptial Agreements
-
•
Alimony (up to 8 hours)
-
•
Child Custody (up to 8 hours)
-
•
Child Support (up to 8 hours)
-
•
Caregiving (annual check-up)
-
•
School Issues
-
•
Medicare/Medicaid Disputes
•
•
Social Security Disputes
•
•
Veteran’s Benefits Disputes
•
•
Contracts/Lease Agreements as a Tenant
•
•
Eviction as a Tenant
•
•
Security Deposits as a Tenant
•
•
Disputes with a Landlord
•
•
Document Preparation of Deeds, Mortgages,
Affidavits, Demand Letters, Promissory Notes
•
•
Other Coverage (up to 4 hours per year)
-
•
Building Codes/Zoning Variances
•
•
Buying/Selling a Home (primary residence)
•
•
Buying/Selling a Secondary Home
•
•
Foreclosure (primary residence)
•
•
Home Improvement/Contractor Issues
•
•
Neighbor Disputes/Easements (primary residence)
•
•
Neighbor Disputes/Easements (secondary residence)
•
•
Real Estate Disputes (primary residence)
•
•
Government Benefits
Landlord/Tenant Matters
Preventative Legal Services
Real Estate Matters
36
ARAG® Legal Plan
UltimateAdvisor®
Real Estate Disputes (secondary residence)
•
•
Refinancing (primary residence)
•
•
Property Tax (primary residence)
-
•
•
•
IRS Audit Protection
•
•
IRS Collection Defense
•
•
Drivers’ License Suspension, Revocation and
Restoration
•
•
Traffic Tickets (1x per year)
•
•
Traffic Tickets (unlimited)
•
•
Codicil
•
•
Complex Will
•
•
Durable/Financial Power of Attorney
•
•
Estate Administration (up to 9 hours)
•
•
Healthcare Power of Attorney
•
•
Inheritance Rights (up to 6 hours)
•
•
Irrevocable Trust
•
•
Living Will
•
•
Revocable Trust
•
•
Standard Will
•
•
Small Claims Court
Small Claims Court Issues
Tax Issues
Traffic Matters
Wills and Estate Planning
37
ARAG® Legal Plan
Preexisting and personal legal matters not listed above
For any legal matters not covered and not excluded, you can still receive at least 25 percent off the Network Attorney’s
normal hourly rates.
For additional details regarding your plan’s specifically-covered services, visit ARAGLegalCenter.com and enter Access
Code 17845ret.
Call for questions or legal assistance
You can also get assistance from trusted professionals and an award-winning Customer Care Center, with dedicated
representatives who will help you navigate your legal issues. You’ll benefit from the following services:
UltimateAdvisor®
UltimateAdvisor
PlusTM
Call a Network Attorney who can provide legal advice and help you better
understand your covered legal issues and how to address them. Plus, they can
help you review or prepare documents, including a standard will.
•
•
Receive Financial Education and Counseling Services on a wide range of
financial topics - cash and debt management, budgeting, retirement planning,
federal tax information and more - from a certified Financial Counselor.
•
•
With Immigration Services, you can always speak with a Network Attorney
over the phone who can offer legal advice and consultation, file and process
applications or petitions, provide guidance regarding immigration benefits,
asylum, business visas and much more.
•
•
Rely on Identity Theft Services provided by Customer Care Specialists who
have earned the Certified Identity Theft Risk Management Specialist** (CITRMS)
designation. They can guide you through the steps of prevention and are there to
assist you in recovery if your identity is stolen.
•
•
Look to Caregiving Services for legal advice from Network Attorneys who focus
on elder law issues, as well as caregiving services from elder care Specialists to
assist you with your parents’ and grandparents’ everyday lives.
•
Go online to learn more about legal issues
Your path to legal protection starts with easy-to-use online resources at ARAGLegalCenter.com to help you handle legal
issues on your own, including:
UltimateAdvisor®
UltimateAdvisor
PlusTM
The Education CenterTM contains guidebooks, hundreds of articles, newsletters
and more to help you learn more about everyday legal issues.
•
•
DIY Docs® offer the convenience and control of creating your own state-specific,
legally-valid documents online.
•
•
Online Financial Tools help you map out a solid financial strategy with a selfguided money management tool, online chat feature with a Financial Counselor,
educational articles, calculators and more.
•
•
Caregiving Resources inform you about the financial, legal and emotional
aspects of caring for your parents and grandparents.
38
•
ARAG® Legal Plan
Identity Theft Protection provides a formidable front line of protection against identity theft. This service includes:
UltimateAdvisor®
Identity Theft Insurance: Coverage up to $1 million for
expenses associated with restoring your identity.
•
Full Service Identity Restoration: Restoration
Specialists will guide you to help clear your name and restore
your identity.
•
Lost Wallet Services: Restoration
Specialists will help you cancel and reissue credit cards,
driver’s license, etc.
•
Credit Monitoring: Monitors and informs members of changes
to their credit report.
•
Internet Surveillance: Monitors websites and other data points
to alert you if your personal information is being traded and/or
sold.
•
Child Monitoring: Monitors minors’ identity to alert you if their
personal information is being traded and/or sold.
•
Choose a Plan that Empowers You – and Enroll Today!
Take a proactive step toward embracing life’s opportunities, with fewer worries when you enroll in one of the following
legal plans:
Monthly Price
UltimateAdvisor®
Individual
$13.33
$17.08
Family
$17.60
$22.55
Visit ARAGLegalCenter.com and enter Access Code 17845ret to learn more about what these plans offer, research specific
legal topics and more. Or call 800-247-4184 to speak with an ARAG Customer Care Specialist.
Limitations and exclusions apply. Insurance products are underwritten by ARAG Insurance Company of Des Moines, Iowa, GuideOne® Mutual Insurance
Company of West Des Moines, Iowa or GuideOne Specialty Mutual Insurance Company of West Des Moines, Iowa. Service products are provided by
ARAG Services, LLC. This material is for illustrative purposes only and is not a contract. For terms, benefits or exclusions, call our toll-free number.
*Average attorney rates in the United States of $323 per hour for attorneys with 11 to 15 years of experience, The Survey of Law Firm Economics: 2014
Edition, The National Law Journal and ALM Legal Intelligence, July 23, 2014.
**Certified Identity Theft Risk Management Specialist (CITRMS)® is a certification mark owned by the Institute of Consumer Financial Education, Inc.
39
Pet Assure Program
Pet Assure is a post-tax discount program that enables
members to receive discounts on all medical services
provided by network veterinarians.
Monthly Premium:
$7.00
Membership must be for a term of no less than three months.
Note: Monthly premium may be deducted from FRS/PHT Pension Check.
You will save hundreds on your pets’ medical care for only $7 per month. Pet Assure is the nation’s oldest and largest
veterinary discount plan and has been saving pet caretakers
money on pet expenses since 1995.
Using Your Pet Assure Membership is Simple!
Here’s How
Simply present your Pet Assure membership card to any
participating provider when paying for services and receive
instant savings with no paperwork, no deductibles and no
hidden fees. Pet Assure is not insurance, so the veterinarian
applies the discount directly to your bill and you don’t have
to wait for reimbursements or fill out time-consuming claim
forms.
Here’s what your membership includes:
• 25 percent off all medical services each and every time
you visit a network veterinarian. With Pet Assure, you’ll
receive your discount right at the vet’s office. This plan
is not insurance so there are no hassles, no claim forms
and no deductibles. Savings are instant! (See page 23.)
• Any type of pet with absolutely no exclusions can
receive the discounts. There are no exclusions based on
type, breed, age, past medical history, or pre-existing
conditions. Do you have one dog, five cats, a lazy iguana
and a donkey? One Pet Assure membership covers them
all.
• 5 – 35 percent off on pet products and specialty items at
over 1,000 participating national pet product retailers!
(See page 23.)
• 10 – 35 percent savings on pet services, such as boarding,
grooming, training, pet day care, etc. (See page 23.)
• 24/7 Pet Assure Locator Service (PALS). Don’t worry
about your pet getting lost anymore! Every pet that joins
gets enrolled in Pet Assure’s 24/7 Lost Pet Recovery
Service. (See page 23.)
There are dozens of network providers in Miami and the
surrounding areas. For a complete list of participating
veterinary practices and merchants, visit Pet Assure online
at www.petassure.com.
If you have any questions, please call Pet Assure at:
888-789-PETS (7387).
40
Pet Assure Program
What’s included?
What’s not included?
Members receive 25 percent off all in-house medical
services, including:
• Wellness examinations
• Sick visits
• Emergency visits
• Immunizations
• Nutrition counseling
• Geriatric care
• Behavioral counseling
• Orthopedic surgery
• Soft tissue surgery
• Elective surgery
• Routine spay and neuter
• Puppy tail and dewclaw removals
• Tumor removal
• Intensive care cages
• Hospitalization
• Serum chemistries, hematology, serology
• Parasite testing
• Urinalysis
• Complete blood counts
• Dental exams
• Tooth scaling & polishing
• Fluoride application
• Tooth extractions
• Dental X-rays
• Periodontal disease treatment
• Radiology (X-rays)
• Ultrasound
• Electrocardiography (EKG)
And any other medical service provided by the veterinarian
in his office. There are no exclusions! All pets are eligible
for discounts regardless of type, age, health status, previous
health history, or any health related conditions that may arise
in the future. There are no usage limits and you can use your
card as long as you’re an active member.
The practice is not required to discount:
1. Outsourced services, e.g., blood work sent to a lab or an
outside specialist,
2. Non-medical services, e.g., routine grooming and
boarding,
3. Mileage fees and
4. Products taken home, e.g., medications and food. May
not be combined with other discounts, coupons or service
packages. Find a vet near you
Find participating veterinarians in your area on our website at
www.petassure.com. Our network reaches across all 50
states, Washington, D.C. and Puerto Rico. Enter your ZIP
code in the search box on the bottom of every page to
search for providers.
More savings on retail products
Save on food, supplements, medications, toys, kitty litter,
boarding, grooming, pet sitting, training, and so much more.
To locate a participating retail provider near you, log on to
www.petassure.com or call customer service toll free at
888-789-7387.
Lost Pet Recovery Service
For many pet owners, a lost pet is like a lost member of the
family, and in our big world a missing pet can be hard to
find. Each pet enrolled in PALS, Pet Assure’s Locator Service,
receives a unique lightweight Pet ID tag with a unique pet
ID numbers linked to the pet’s confidential information.
PALS has reunited thousands of lost pets with their families.
Join today to start saving!
41
Rules & Regulations
Disclaimer – Health Insurance Benefits
Provided Under Health Insurance Plan(s)
FBMC Privacy Statement
This statement applies to products administered by
FBMC Benefits Management, Inc. and its wholly-owned
subsidiaries, including VISTA Management Company
(collectively “FBMC”). FBMC takes your privacy very
seriously. As a provider of products and services that involve
compiling personal-and sometimes, sensitive-information,
protecting the confidentiality of that information has been,
and will continue to be, a top priority of FBMC. This Privacy
Statement explains how FBMC handles and protects the
personal information we collect. Please note that the
information we collect and the extent to which we use it will
vary depending on the product or service involved. In many
cases, we may not collect all of the types of information
noted below. Note this Privacy Statement is not meant to be a
Privacy Notice as defined by the Health Insurance Portability
and Accountability Act (HIPAA), as amended.
Health Insurance benefits will be provided not by your
Employer’s Flexible Benefits Plan, but by the Health
Insurance Plan(s). The types and amounts of health insurance
benefits available under the Health Insurance Plan(s), the
requirements for participating in the Health Insurance Plan(s)
and the other terms and conditions of coverage and benefits
of the Health Insurance Plan(s) are set forth from time to
time in the Health Insurance Plan(s). All claims to receive
benefits under the Health Insurance Plan(s) shall be subject
to and governed by the terms and conditions of the Health
Insurance Plan(s) and the rules, regulations, policies and
procedures from time to time adopted.
Notice of Administrator’s Capacity
This notice advises insured persons of the identity and
relationship among the contract administrator, the
policyholder and the insurer:
FBMC’s privacy statement is as follows:
I. We collect only the customer information necessary to
consistently deliver responsive services.
FBMC collects information that helps serve your needs,
provide high standards of customer service, and fulfill
legal and regulatory requirements. The sources and types
of information collected generally vary depending on the
products or services you request and may include:
• Information provided on enrollment and related forms - for
example, name, age, address, Social Security number, e-mail
address, annual income, health history, marital status, and
spousal and beneficiary information.
• Responses from you and others such as information relating
to your employment and insurance coverage.
• Information about your relationships with us, such as
products and services purchased, transaction history, claims
history, and premiums.
• Information from hospitals, doctors, laboratories and other
companies about your health condition, used to process
claims and prevent fraud.
1. Contract Administrator. FBMC Benefits Management
(FBMC) has been authorized by your employer to provide
administrative services for your employer’s insurance plans
offered within your benefit program. In some instances,
FBMC may also be authorized by one or more of the
insurance companies underwriting the benefits to provide
certain services, including, but not limited to: marketing;
billing and collection of premiums; and processing insurance
claims payments. FBMC is not the policyholder or the
insurer.
2. Policyholder. This is the entity to whom the insurance
policy has been issued; the employer is the policy holder
for group insurance products and the employee is the
policyholder for individual products. The policyholder is
identified on either the face page or schedule page of the
policy or certificate.
3. Insurer. The insurance companies noted herein have been
selected by your employer, and are liable for the funds to
pay your insurance claims.
If FBMC is authorized to process claims for the insurance
company, we will do so promptly. In the event there are
delays in claims processing, you will have no greater rights
to interest or other remedies against FBMC than would
otherwise be afforded to you by law. FBMC is not an
insurance company.
42
Rules & Regulations
Insurance Coverage after Retirement
II. Under Federal Law you have certain rights with respect
to your protected health information.
Under section 112.0801, Florida Statutes, your employer is
required to offer you or your eligible dependents the option
of continued participation in any employer-sponsored group
insurance plans in which you were participating at your
retirement or at your DROP termination date.
You have rights to see and copy the information, receive an
accounting of certain disclosures of the information and,
under certain circumstances, amend the information. You
also have the right to file a complaint with your Employer
or with the Secretary of the U.S. Department of Health and
Human Services if you believe your privacy rights have
been violated.
As a retiree, your premium cost for health and hospitalization
insurance coverage may not exceed the total employee and
employer premium cost applicable to active employees.
You may lose your eligibility to participate if you choose
not to continue participating in your employer’s group plan
at retirement, initially choose to continue but subsequently
stop participating, defer your retirement to a future date,
or otherwise do not meet your employer’s group plan
requirements. Before you terminate employment, contact
your employer about continuing your employer-sponsored
group insurance coverage. The division has no authority
over or responsibility for employer group health and
hospitalization plans.
III. We maintain safeguards to ensure information security.
We are committed to preventing unauthorized access to
personal information.
We maintain physical, electronic, and procedural safeguards
for protecting personal information. We restrict access
to personal information to those employees, insurance
companies, and service providers who need to know that
information to provide products or services to you.
IV. We limit how, and with whom, we share customer
information.
Income Taxes on Your Retirement Benefit
We do not sell lists of our customers, and under no
circumstances do we share personal health information for
marketing purposes. With the following exceptions, we will
not disclose your personal information without your written
authorization. We may share your personal information
with insurance companies with whom you are applying
for coverage, or to whom you are submitting a claim. We
will share personal information of VISTA 401(k) participants
with the plan’s recordkeeper. We also may disclose personal
information as permitted or required by law or regulation.
For example, we may disclose information to comply with
an inquiry by a government agency or regulator, in response
to a subpoena, or to prevent fraud. If you no longer have
a customer relationship with us, we will still treat your
information under our Privacy Policy, the words “you” and
“customer” are used to mean any individual who obtains
or has obtained an insurance, financial product or service
from FBMC that is to be used primarily for personal or family
purposes.
Each year at the end of January, the division provides you an
IRS Form 1099-R. Your annual taxable income is shown in
the taxable amount box (Box 2a). You should use this form
when you file your income tax return.
43
Office Hours: 7:30 a.m. - 4:30 p.m. Monday - Friday ET.
On-site FBMC Service Center
Benefits Department
Jackson Memorial Hospital
1611 N.W. 12th Avenue
Park Plaza West L-109B
Miami, FL 33136-1096
305-585-6512
Jackson Memorial Hospital
Highland Professional Building
1801 N.W. 9th Avenue, 7th floor
Miami, FL 33136
786-466-8355
Contract Administrator
FBMC Benefits Management, Inc.
P.O. Box 1878 • Tallahassee, Florida 32302-1878
FBMC Service Center 855-56JHS4U (855-565-4748)
www.myFBMC.com
Information contained herein does not constitute an insurance certificate or policy.
Certificates or policies will be provided to participants following the start of the plan year, if
applicable.
FBMC/JHS_NEWRET/1115
© FBMC 2016

2016 NEW RETIREE BENEFITS REFERENCE GUIDE

Transcription

Similar documents

verdugo hills 11-11-15

STATEMENT OF PATIENT PRIVACY RIGHTS

Patient Forms

PDF - National Union of Public and General Employees

SAVE 50%

Coumadin Clinics

ameriflex - Montville.net

Connecticut State Teachers` Retirement Board

Saebo Long Term Care Program

Key Changes with Health Reform - The National Association of State