lakeland regional health employee benefits

Transcription

L A K E L A N D R E G I O N A L H E A LT H
EMPLOYEE
BENEFITS PLAN
2015
TOGETHER, OUR PROMISE IS YOUR HEALTH
Together, Our Promise is Your Health.
table of contents
Living our Promises to treasure, nurture and inspire ourselves,
our patients and families, and our community is an integral part
of everything we do. We know that you take these Promises to
heart and do your utmost to provide our patients with exceptional
healthcare experiences.
New for 2015............................................................. 2
Medical Plan Design Summary....................... 6
Enrollment Online Access Guide.................... 8
Benefits: An Overview........................................ 10
2015 Benefit Contributions
Planning Guide.......................................................11
Benefits On Call.....................................................12
Benefits Enrollment Process
and Program Pay.................................................. 13
ETO Days................................................................... 14
Who is Eligible, Definition of
Dependents, Qualified Status Changes.... 15
Medical Plan........................................................... 19
Discounted Premiums....................................... 33
Health Screening Program.............................. 35
Cancer Insurance –
A Supplemental Plan.........................................36
Vision Plan...............................................................38
Dental Plan..............................................................39
Health Care & Dependent Day Care
Flexible Spending Accounts............................42
Short Term Disability..........................................46
Long Term Disability...........................................48
Term Life Insurance............................................50
Accidental Death and
Dismemberment Coverage.............................. 53
Long Term Care.....................................................54
Legal Services........................................................ 55
Employee Assistance Plan,
Educational Assistance..................................... 57
Retirement Plans..................................................58
Customer Service Contacts.............................60
2015 Calendar with
Payroll Days Highlighted...................................61
PPACA Summary of
Benefits Coverage................................................62
Premium Assistance Under
Medicaid and Child Health
Insurance Program.............................................. 76
Annual Notice of Coverage
for Reconstructive Surgery...............................77
Welfare Plan Summary
Annual Reports..................................................... 78
It is our privilege to offer you that same exceptional care with healthcare
tools designed to help you get and remain strong and healthy so that
together we can continue to deliver nationally recognized healthcare,
become the healthiest community in Florida and advance the future of
healthcare.
As we grow and evolve, our employee benefits must do so too. This year
your benefit package has three exciting additions designed to provide
you with the best possible care at the lowest possible cost.
1. Beginning January 1, 2015, Lakeland Regional Health will cover
100% of the cost for preventive and specialty care visits to LRHMG
providers at LRH facilities, as long as you participate in our Cigna
Medical Plan. This benefit includes any dependents enrolled in your
plan. If you or a dependent require specialty care that is not provided
at an LRH or an LRHMG facility, our team will help you coordinate that
care.
We hope you will choose to make Lakeland Regional Health
Medical Group (LRHMG) your medical home. Our LRHMG physicians
and clinicians are available to provide convenient access to quality
and affordable care for you and your dependents. Be sure to check
out the LRHMG Physician Directory in ESS to see a listing of physicians
for more than 25 specialties by location.
If you choose not to take advantage of this opportunity, plan
participants can still seek care from providers outside LRHMG and
receive the same coverage offered last year.
2.A new cost-share program has been implemented to comply
with the Patient Protection and Affordable Care Act (PPACA) for the
Cigna Medical Plan. The PPACA is in place to ensure that affordable
medical coverage is available to all eligible employees. In addition
to complying with PPACA, we have introduced the concept of salary
banding. As a result, employee contributions for single coverage will
be based on the following salary bands:
First Band: earning up to $12.00 per hour
Second Band: earning $12.01 to $15.00 per hour
Third Band: earning $15.01 per hour or greater
There will be no employee contribution increase from the prior
year’s plan for employee + child(ren), employee + spouse, and
employee + family coverage.
3. Finally, we are pleased to offer free employee-only memberships
at the Fontaine Gills Family YMCA (North Lakeland YMCA) and
discounted rates for family members. Upgrades are available for a
joint membership with the North and South Lakeland YMCAs. We will
continue to offer payroll deduction.
Our team is strong because each and every one of us consistently does
our very best. Thank you for all that you do to provide our patients with
exceptional healthcare.
This booklet highlights the Lakeland Regional Health
benefits program. This booklet does not attempt to cover
all the details. The details are contained in the summary
plan descriptions, as well as the official plan documents
and insurance contracts that govern the operation of the
various benefit options within the program. Participation
in Lakeland Regional Health benefits does not give you the
right to be employed by Lakeland Regional Health nor does
it give you the right to claim any benefit not covered by
the official plan documents and insurance contracts. If you
would like more detailed information, refer to the summary
plan descriptions available on Lakeland Regional Health’s
Intranet; or you can request a paper copy by contacting the
Talent Division at 863.687.1100. Lakeland Regional Health
reserves the exclusive right to modify, amend or terminate
any and all plans at this time. In the event of any conflict
between this booklet or the summary plan descriptions
and the official plan documents and insurance contracts,
the terms of the plan documents and insurance contracts
will govern.
NEW for 2015
Make Lakeland Regional Health Medical Group (LRHMG) your Medical Home! Our LRHMG
physicians, clinicians and support staff provide convenient access to quality and affordable
care for you and your dependents.
Starting January 1, 2015, Lakeland Regional Health will cover 100% of the cost for preventive and specialty care
visits to LRHMG providers at LRH facilities, as long as you participate in our Cigna Medical Plan. This benefit
includes any dependents enrolled in your plan. If a specialty you require is not provided at LRHMG, our physicians
and support staff will help coordinate that care.
Medical Cost Sharing
Deductibles, Copays and Coinsurance are Waived When Service is provided at LRH by LRH Providers.
This means that you will not be responsible for copays, deductibles or coinsurance except in the cases of:
EMERGENCY SERVICES
• The PPACA requires all Emergency Services be covered the same, regardless of where the service is performed.
Even if you visit the LRH Medical Center Emergency Department, you will still be responsible for a portion of
the costs.
•Effective January 1, 2015, covered Cigna members will be responsible for 30% of the facility charges (facility
charges will not be subject to the deductible), as well as a $200 copay.
•As in the past, you will be responsible for 25% of the payment of physician professional fees when Emergency
Care is received.
PHYSICIAN PROFESSIONAL FEES
•If care you need is not provided by a LRHMG provider, you will be responsible for a cost-share just as you were
previously.
Deductibles, copays and coinsurance will remain the same for Community Partners, including Watson Clinic and
Radiology and Imaging Specialists, as well as other providers in the Cigna OAP Network.
Annual Reminder Updates
•You will receive new Cigna identification cards if you enroll or re-enroll in medical coverage. REMEMBER: YOU
MUST RE-ENROLL ANNUALLY.
•Employees may only enroll their spouses in the Lakeland Regional Health Cigna medical plan if they do not
have coverage available through their own employers, or if they submit a completed Working Spouse Exception
Request form by December 1, 2014, and are subsequently approved.
[2]
NEW for 2015
Contributions Toward Premiums
•There will be no increase for employees enrolling themselves and at least one dependent (child, children, spouse or
family).
• There will be a decrease for single coverage for employees earning $12 per hour or less*.
•There will be no increase for single coverage for employees earning more than $12 per hour and up to $15 per hour.
•There will be a $2.13 increase per pay period in single coverage for team members making more than $15 per hour.
• There will be no change in dental, vision, disability, life insurance or AD&D premiums.
* This change is partly in response the PPACA requirement to offer affordable coverage to all employees.
Out-of-Pocket (OOP) Maximum to Include Pharmacy Expenses
Effective January 1, 2015, both medical and pharmacy expenses will be applied toward the OOP maximum.
While most employees never reach the OOP maximum, Lakeland Regional Health has put limits in place to ensure
that your healthcare costs are limited. By applying both medical and pharmacy expenses to the OOP maximum,
we are able to provide you with even more financial protection.
•OOP expenses are the costs you pay out of your own pocket in addition to your biweekly medical payroll
contribution. These costs include deductibles, copays, coinsurance and other expenses detailed in your Cigna
Medical Plan.
•If you reach your OOP maximum during the calendar year, you will not be responsible for additional covered
expenses for the rest of the year. However, you will be responsible for expenses that are not covered by the
Cigna Medical Plan.
•2014 OOP maximums will be reduced by $2,800 for single coverage and by $6,100 for family coverage for services
received at LRH from LRH providers. The OOP maximums will increase for Community Partners and all other
providers in the OAP network, as shown.
Effective Jan. 1, 2015 LRH Network
Community Partners
Cigna OAP Network
Single
$500 $4,300 $5,800
Family
$1,000 $8,600 $11,600
LAKELAND REGIONAL HEALTH EMPLOYEE BENEFITS PLAN 2015
[3]
NEW for 2015
100% Coverage of Mammograms and Colonoscopies
Preventive and diagnostic mammograms and colonoscopies will be covered in full at LRH, including the Women’s
Imaging Center (WIC).
With this benefit enhancement, you can take advantage of routine, life-saving screenings without the worry of
financial burden.
Employees may still receive services wherever they choose, however copays, coinsurance and deductibles will
apply at non-LRH providers. Preventive mammograms will continue to be covered in full at any Cigna OAP providers.
New Medical Identification Cards
Cigna will issue new medical identification cards to all Lakeland Regional Health employees who elect medical
coverage for 2015. The new cards reflect $0 copays for LRHMG services at LRH facilities and are effective January 1,
2015. You should receive your card in the mail in late December or early January.
Wellness
FREE Membership at West Central Florida YMCA for LRH Team Members
An exciting new partnership begins with West Central Florida YMCA on December 1, 2014. All LRH employees may
receive a free employee-only membership at the Fontaine Gills Family YMCA, located at 2125 Sleepy Hill Road in
North Lakeland.
• If you wish to upgrade your individual employee membership to include the Lakeland Family YMCA located at
3620 Cleveland Heights Boulevard, you can do so at the reduced rate of $15 per month.
•You can also upgrade to a family membership for $25 per month. A family membership includes 2 adult family
members plus legal dependents, and includes use of the Cleveland Heights location.
•Some programs, such as the use of the YMCA Par 3 golf course, will require additional fees. More information
about these programs is available at the Fontaine Gills YMCA or the Lakeland Family YMCA.
[4]
Healthy Points and the Healthy Awards Account
Healthy Points have been discontinued as of this year. Although you will not be awarded additional Healthy Points
in 2015, you will still have access to the Cigna Living Well program, including the educational series, diabetes
education and resources, eating right, cardiac health, managing stress and more.
• You may continue to accrue Healthy Points through December 31, 2014.
•Healthy Points you earned in 2014 (up to $250) will be available to you through December 31, 2015. They will be
added to any balance you may already have in your Healthy Awards Account (HAA). Points earned in the fourth
quarter of 2014 will be available sometime in the first quarter of 2015.
• Your HAA can be used to offset healthcare costs such as deductibles, copays and coinsurance.
• Any balance remaining in your HAA on January 1, 2016, will be forfeited.
• Additional information about this program will be available on ESS.
Discounts toward your Cigna Medical Plan premiums will continue in 2015. You may receive a credit of up to $30
per pay period, or $780 for the entire year, by attesting to being tobacco-free and nicotine-free, submitting your
health assessment with biometrics, and achieving/maintaining a healthy weight. If you or one of your covered
dependents use tobacco or nicotine, and/or you are not able to receive the award because you are not at a healthy
weight, you may receive the award by successfully completing a designated Cigna program.
Payroll Benefit Deduction Holiday
In December 2014, you will receive a pleasant surprise. Our normal Thursday pay date falls on New Year’s Day, so
paychecks will be issued on Wednesday, December 31, 2014. This means that you will receive 27 paychecks in 2014
instead of the normal 26.
•Since most benefit deductions are based on 26 pay dates per year, we will not deduct for the following: medical,
dental, vision, flexible spending accounts (health or dependent day care), cancer plan, legal plan, life and AD&D
insurance, disability coverage or long term care insurance.
•If you are currently contributing to the 403(b) Plan and you have not reached the maximum allowable contribution
limit, your contributions will be withheld on December 31, 2014, as usual. All other regular deductions will also
be made.
[5]
Where You Obtain Your Medical Services
(under the Cigna -LRH Employee Health Plan)
2015
Plan Design
Summary
LRH (Domestic)1
Community Partners2
Other Cigna OAP Providers3
Summary of Benefits
2015
2014*
2015
2014*
2015
2014*
Annual/Lifetime Limit
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
$0
$0
$500 physician only
$1,500 physician only
$500
$1,500
Medical and Rx
$500
$1,000
Only Medical
$3,300
$7,100
Medical and Rx
$4,300
$8,600
Office Visits
PCP/Specialist
100% (copay waived)
$15/$35 copay
$15/$35 copay
(in office lab/
radiology may be
subject to deductible
and coinsurance)
$25/$50 copay
(in office lab/
radiology may be
subject to deductible
and coinsurance)
Surgery in Physician’s Office
100% (copay waived)
$35 copay
$35 copay
70%6
Allergy Injection4
100% (copay waived)
$10 per shot
$10 copay per shot
$10 copay per shot
All other Physician Services
100% (copay waived)
75% + deductible
(radiologist/
pathologist deductible
waived)
Preventive Care
(includes annual exam, EKG,
PAP test, immunization,
mammogram, PSA)
100% (copay waived)
Deductible4
Per Person
Per Family (3 or more)
Maximum Out-of-Pocket5
Per Person
Per Family (3 or more)
$1,000
$3,000
Only Medical
$3,300
$7,100
75%
Medical and Rx
$5,800
$11,600
Only Medical
$4,800
$10,600
70%6
6,9
100% (copay waived)
100% (copay waived)
75%
70%6
Lab/X-Ray/Advanced
Radiology4
(incl. MRIs, CT and PET Scans)
Professional Fees
(incl. Rad/Path)
100%
75%
Inpatient Hospital Facility
100%
N/A
70%6
Outpatient Hospital Facility
100%
N/A
70%6
X-Ray/Imaging/Lab Facility
100%
75%6
70%6
Physician’s Office
100%
75%
70%6
6
Emergency Services
Emergency Room Copay8
$200
$100
$200
Emergency Room (Facility)
70%
100%
Emergency Room
(Professional)
Urgent Care (Facility)
[6]
$100
$200
$100
N/A
70%
70% + deductible
75%
75%
75%
$100 copay
$100 copay
$100 copay
Urgent Care (Professional)
75%
75%
75%
Ambulance
N/A
N/A
70%6
Where You Obtain Your Medical Services
(under the Cigna -LRH Employee Health Plan)
2015
Plan Design
Summary
LRH (Domestic)1
Community Partners2
Other Cigna OAP Providers3
Summary of Benefits
2015
2014*
2015
2014*
2015
2014*
Annual/Lifetime Limit
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Hospital Inpatient
Facility Charges
Professional Fees
100%
100%7
75% + deductible
NA
75%6,9
70%6
70%6
Outpatient Surgery Center
Facility Charges
Professional Fees
Second Opinion Consultation
100%
100%7
100%7
75% + deductible
$15 (PCP)/
$35 (Specialist)
75%6,9
75%6,9
$15 (PCP)/
$35 (Specialist)
70%6
70%6
$25 (PCP)/
$50 (Specialist)
$15/$35
$15/$35
$25/$50
75% + deductible
75% + deductible
N/A
75%6
75%6
70%6
70%6
70%6
75%
70%
75%
70%
N/A
N/A
70%6
N/A
N/A
100%
N/A
N/A
N/A
N/A
N/A
N/A
100%
100%
100%4
N/A
N/A
100%
Maternity
Initial visit to confirm
pregnancy
Delivery Facility Charge
Prenatal/Postnatal Visits
Physician Hospital Visits
Rehabilitation Services
Physical/Occupational/
Speech/Cognitive/
Pulmonary Therapies
(combined max of 60 per year)
Cardiac
Special Services
Skilled Nursing Facility
(up to 60 days)
Home Health Care
(up to 60 days)
Hospice (Inpatient/Outpatient)
Bereavement
Breast-Feeding Supplies
Durable Medical Equipment
100%7
100%7
100%7
100%7
(radiologist/pathologist
deductible waived)
100%
100%
75%
Pharmacy10
Retail
Generic
Preferred Brand
Non-Preferred Brand
$10 copay per script ($4 copay at Publix Pharmacy at LRH Medical Center)
30% ($75 maximum coinsurance per script)
Mail Order/90-day Supply
Generic
Preferred Brand
Non-Preferred Brand
$10 copay per script ($7 copay at Publix Pharmacy at LRH Medical Center)
1. Domestic Facilities include Lakeland Regional Health Medical Center, Lakeland
Regional Health Cancer Center, Lakeland Regional Health Medical Group
(including Clark & Daughtrey Division), Lakeland Surgical & Diagnostic Center,
Women’s Imaging Center.
2. Community Partners include but are not limited to Watson Clinic, Radiology
& Imaging Specialists (RIS), Lakeland Pathology/Micropath Laboratories,
Women’s Care FL, Pediatrix Group of FL, EmCare, United Surgical Assistants,
Lakeland Dermatology (Leavitt Medical).
3. You must use an LRH, Community Partner or other Cigna OAP Provider. There
is no out-of-network coverage available except for emergencies.
4. Refer to page 25 for service specific notes and exclusions.
5.Includes deductible, copays and coinsurance for ALL covered services (Medical
& Pharmacy).
6. Subject to deductible.
7. Professional charges covered at 100% IF performed by a Lakeland Regional
Health Medical Group physician.
8. $200 copay waived if admitted as an inpatient.
9. Deductible waived for radiologists and pathologists.
10.Step Therapy and Dispense-As-Written (DAW) programs apply; medications
required under healthcare reform preventive services are covered at 100%.
(Details available at www.healthcare.gov.)
*2014 vs 2105 Benefits Comparison. Only those benefits that have changed are
shown.
[7]
Enrollment Online Access Guide
Current Employees:
All Benefits-Eligible Employees Are Required To Enroll Online - October 31, 2014 - December 1, 2014
All benefits-eligible employees must make 2015 benefit elections using Employee Self Service
(ESS) by December 1, 2014. This includes those who do not plan to elect benefits for 2015, are
on a leave of absence, or do not plan to make changes to current benefit elections.
New Hires: All Benefits-Eligible Employees Are Required to Enroll Online within 20 calendar days of
their hire date.
Employees with 48 or more authorized hours per pay period (24 hours per week), are eligible to enroll in all LRH
benefits. Employees with at least 40 authorized hours per pay period (20 hours per week), but less than 48 authorized
hours per pay period, are eligible to enroll in all LRH benefits except for medical.
There are three easy ways to enroll:
> At any Lakeland Regional Health computer connected to the Intranet and a printer
> Two ESS kiosks located in the LRH Medical Center
If you want to enroll from home, simply login to Employee Self Service (ESS) while at work, follow the directions on
the home page on how to download Remote Access to ESS. Please note – Printing from ESS Remote Access is Windows
compatible only. The print function is not available for MAC computers.
HOW TO ACCESS OPEN ENROLLMENT ONLINE
Access the LRMC Intranet site by double
Step 1
clicking the Internet Explorer icon on the
desktop. If the site does not automatically
appear, enter www.lrmcnet.com in the
address bar while on an LRH computer. Note
that you may be required to turn off any popup blockers.
Step 2Access the ESS site under the My LRH tab at
the top of the page.
Step 3
Enter your User Name and Password;
then hit the enter key on your keyboard or
click the “Login” button.
If you are a first time user, your user name = your employee (badge) number, front filled with zeroes, totaling six
characters.
Your password = capital “L” followed by your 4-digit birth year, followed by the last 4 digits of your Social Security
number (ex: L19501234), unless you have previously logged into ESS and changed your password. If you are not able
to login, please contact the HELP desk at extension 4357.
[8]
Employee Self Service (ESS)
Tips and Tricks Access via the
Intranet ESS Dashboard
Step 4Once the Employee Self Service Dashboard appears, click
on the Benefits Enrollment link. The welcome screen will
then appear for you to begin the enrollment process.
Notice the two scroll bars to the right – you may need to
adjust one or both of these up and down.
To View and/or Print your pay stub:
1.
Under Payroll, click on the Pay
Checks link
2.Click on the Payment Date of the
check if you would like to see
more details
3. If you wish to print your pay stub,
click the Printable Pay Stub link
To View your Earned Time Off (ETO)
balance:
1. Under Payroll, click on the ETO/
Personal Illness Bank (PIB)
2. Your ETO balance should be
visible
3. For those eligible for PIB, click on
the PIB tab to see your balance
Before you begin, make sure that you have all of the information
you will need in front of you. This will include birth dates and social
security numbers for your eligible dependents.
> Verify, add or change your address, phone and email preferences.
>
Indicate if you want to receive electronic communications
(important benefits information and/or text messages).
> Click the CONTINUE button once all of your contact information
is current and you have made your electronic communcation
elections.
> Update or add any benefit-eligible dependents. If you add/change
any information, click the UPDATE button to continue.
> The CONTINUE button on each form will take you to the next screen.
> On many forms, the PREVIOUS button will be available to return to
the previously viewed form.
> At any time you may click the EXIT button to stop the enrollment
process. Note: Your elections will NOT be saved and you will have to
start the process over.
> Make your desired election for each benefit. You may click on the
ELECTIONS button to see a snapshot of the benefits you have
elected.
> You must click the SAVE/FINISH button to save your changes.
> Print your elections for reference.
> After the completion of your session, you should click the “Logout”
link in the upper, right hand corner of your screen to protect your
personal, confidential information.
To View and/or Change your W4 tax
withholdings:
1. Under Payroll, click on the Tax
Withholding link
2. Click on the Federal Income Tax
Deduction link
3. Modify your exemptions if desired
4. Scroll down and click the
“Continue” button to continue
(You can also click the “Model”
button to simulate what effect the
change will make. If the change
you make is undesirable, click the
“Back” button to start over.)
To Update Your Address:
1. Under Personal Information, click
on the Home Address link
2. Enter an Effective Date
3. Modify your Address in lines 1
and 2
4. Click on the “Update” button
[9]
An Overview
Lakeland Regional Health (LRH) is pleased to provide you with a benefits program you
can customize. Lakeland Regional Health provides you with certain benefits that are
100% paid by Lakeland Regional Health. You also have a wide range of options you can
purchase to address your distinct individual and dependent benefit needs and interests.
BENEFITS PAID BY LAKELAND REGIONAL
HEALTH AND PROVIDED TO YOU AT NO COST1
OPTIONAL BENEFIT CHOICES YOU CAN PURCHASE1
Basic Life Insurance
> $10,000
> No medical questions – automatic coverage
Medical2,4
> LRH Domestic, Community Partners, Cigna OAP Provider
Network
Accidental Death & Dismemberment
(AD&D)
> $10,000
> Covers loss of life, limb or sight
> Emergency travel assistance provided
worldwide
Dental
> DeltaCare USA Plan
> Delta Dental PPO Plan
Short Term Disability
> 66 ⅔% of your base pay
> Up to 9 weeks of payment
Employee Assistance Plan3
> Confidential counseling, resources and referral
services for you and your family members
> Helps balance life’s challenges from work,
family, financial and legal issues
Health Screening Program3
> Provided by Lakeland Regional Health
Cancer Center
> For all Lakeland Regional Health Employees
and eligible dependents
Educational Assistance Plan
> Up to $5,000 each fiscal year
> For you to pursue your educational goals
Retirement Plan4
> 401(a) Plan: 3% of your gross pay funded
annually
> 403(b) Plan: 2% match funded biweekly
> 3 year vesting
> You direct investments
Supplemental Life Insurance
> Your choice up to 6x pay
Supplemental AD&D
> Your choice up to $300,000
Enhanced Short Term Disability
> 100% of your base pay
> Up to 9 weeks of payment
Long Term Disability
> 50% to 66 ⅔% of your base pay up to age limits
ETO You Can Exchange for Benefit Purchases
> Sell up to 10 ETO days to increase
your Benefits buying power (hourly employees only)
Dependent Life Insurance
> Spouse up to $50,000
> Children up to $15,000
Flexible Spending Accounts (FSA)
> Health Care
> Dependent Day Care
And More
> Vision Plan
> Long Term Care (LTC) Policy
> Cancer Policy
> Legal Services
> 403(b) Tax Deferred Plan with Roth Option4
1 For regular full time and part time employees only (minimum 40 authorized hours per pay period) unless noted otherwise.
2 For regular full time and part time employees (minimum 48 authorized hours per pay period).
3 For all employees regardless of employment status.
4 STEP and part time daily employees may be eligible for the retirement plan and the medical plan if certain eligibility requirements are met.
[10]
2015 BENEFITS CONTRIBUTIONS PLANNING GUIDE
Employee Biweekly Contribution
Cigna - LRH Employee Health Plan
Cost Per Pay Period
Before / After $30 Premium Discount
1
[ ] Employee only (Band 1: Earning up to $12/hr)
$55.20 / $25.20
[ ] Employee only (Band 2: Earning $12.01/hr up to $15.00/hr)
$71.17 / $41.17
[ ] Employee only (Band 3: Earning $15.01/hr or greater)
$73.30 / $43.30
[ ] Employee + child(ren)
$171.43 / $141.43
[ ] Employee + Spouse
$207.42 / $177.42
[ ] Employee + Family (spouse and child(ren))
$258.06 / $228.06
DeltaCare USA Dental Plan
[ ] Employee only
$6.66
[ ] Employee + 2 or more dependents
$16.14
[ ] Employee + 1 dependent
Cost $ ___________________________
$12.41
Delta Dental PPO Dental Plan
[ ] Employee only
$15.63
[ ] Employee + 2 or more dependents
$48.11
[ ] Employee + 1 dependent
Cost $ ___________________________
$30.08
Vision Plan
[ ] Employee only
Cost $ ___________________________
$2.31
[ ] Employee + dependent(s)
$5.79
Plan 1000 - Level 2 Cancer
Cost $ ___________________________
[ ] Employee only
$11.08
[ ] Employee + child(ren)
$12.12
Cost $ ___________________________
[ ] Employee only
$4.62
AD&D
Employee Only / Employee + Dependent(s)
(After Taxes)
Cost $ ___________________________
[ ] Employee + spouse or family
$18.35
Legal Services Plan
[ ] Employee + dependent(s)
$6.00
[ ] $25,000.00
$0.21 / $0.38
[ ] $50,000.00
$0.42 / $0.76
[ ] $100,000.00
$0.83 / $1.52
[ ] $150,000.00
$1.25 / $2.29
[ ] $250,000.00
$2.08 / $3.81
[ ] $200,000.00
[ ] $300,000.00
$1.66 / $3.05
Cost $ ___________________________
$2.49 / $4.57
Cost per pay period formula is shown for the benefits below
Short Term Disability (per $100 of monthly salary)
Annual base salary/12 x rate/$100
Long Term Disability (per $100 of monthly salary)
Annual base salary/12 x rate/$100
[ ] 100% Enhanced Option
[ ] Option 1 - 50% after 3 months
[ ] Option 2 - 66 2/3% after 3 months
[ ] Option 3 - 50% after 6 months
[ ] Option 4 - 66 2/3% after 6 months
Supplemental Employee Life
$5,000 option or 1x to 6x annual salary up to $1,250,000 max
[ ] Under age 30
[ ] 30 - 34
[ ] 35 - 39
[ ] 40 - 44
[ ] 45 - 49
[ ] 50 - 54
[ ] 55 - 59
[ ] 60 - 64
[ ] 65 - 69
Dependent Life
[ ] Spouse ($10,000 / $20,000 / $30,000 / $40,000 / $50,000)
[ ] Child ($5,000 / $10,000 / $15,000)
$0.92
Cost $ ___________________________
$0.231
$0.563
$0.180
$0.452
Per $1,000 of annual base salary
Cost $ ___________________________
$0.018
$0.026
$0.031
$0.046
$0.069
$0.106
$0.180
$0.237
$0.386
$0.693
Cost $ ___________________________
$0.066
(After Taxes)
Cost $ ___________________________
Per $1,000
$0.035
TOTAL: $ ___________________________
2
Employees can obtain up to $30 in premium reductions by: 1) Completing Cigna’s health assessment with numeric biometric screening information, 2) Either
attesting that you and your covered dependent(s) are tobacco-free and nicotine-free or successfully completing Cigna’s Tobacco Cessation program, and 3) Either
maintaining a healthy weight or successfully completing Cigna’s Weight Loss program.
2
Total cost per pay period does not reflect any ETO Sold (only hourly employees are eligible) and/or Flexible Spending Account(s) contributions.
1
[11]
An Overview
Each year, you are given the opportunity to make changes to your Benefits
elections for the upcoming year. Please read the following pages, and make sure
you understand how each of the options work and what they can mean to you.
Once you have the information you need, you are ready to choose a benefits
program designed for you, by you.
Contributions for benefits, if any, will be taken directly out of your
biweekly paycheck. Your contributions have certain tax advantages
because the dollars spent on benefits are tax-free. (For example, they
are not subject to Federal Income or Social Security taxes.) The only
exceptions are the dependent life insurance, long term care and legal
services options that are offered on an after-tax basis as required by
law. What you save in taxes increases your take-home pay!
Please note, since you are
not paying Social Security tax
on these dollars, your Social
Security benefit at retirement
may be slightly reduced by the
government.
PUT YOUR QUESTIONS ON THE LINE…
with Benefits On Call
Benefits On Call is a single phone number you can dial to connect with the customer service
representatives for all of your Lakeland Regional Health benefits and retirement plans. It is fast and
easy to use! Simply dial x1499 if calling from within Lakeland Regional Health, or dial 863-687-1499.
When you call, you will be guided through a menu of the various benefits plans available. You will
respond by pressing the corresponding buttons on your telephone’s keypad.
Most of our benefits and retirement plan carriers offer live customer service Monday through Friday,
from 8:30 am - 4:30 pm. You will need to know your date of birth and type of coverage when calling.
Do not hesitate to use Benefits On Call for questions about coverage or claims, about retirement
plan account balances or contributions, or any other benefit related question that comes up!
Benefits on Call - x1499 from within Lakeland Regional Health or 863-687-1499.
[12]
Enrollment Process
Benefits enrollment at Lakeland Regional Health is completed using the Employee
Self Service (ESS) online portal. For your convenience, you can log on to ESS
remotely (once downloaded) and make your benefits elections from the comfort
of your home, or you can use an ESS Kiosk or other designated Lakeland Regional
Health workstation.
BENEFIT ENROLLMENT PROCESS
IF YOU:
YOU MUST:
> are enrolling during the annual enrollment period for
January 1
> log on to Employee Self Service (ESS) during the
annual enrollment period to enroll for benefits.
> are a new hire
> log on to Employee Self Service (ESS) during the
FIRST 20 DAYS of your employment to enroll for
benefits.
NOTE: YOU MUST COMPLETE YOUR ENROLLMENT WITHIN 20
CALENDAR DAYS FROM YOUR DATE OF HIRE OR YOU WILL NOT BE
ABLE TO ENROLL UNTIL NEXT YEAR’S ANNUAL ENROLLMENT.
> have a qualified life status change
> contact the Talent Division Benefits Department
and complete a Qualified Change in Life Status
form within 30 days of the event
WHEN YOU ARE FINISHED ENROLLING, PRINT A CONFIRMATION STATEMENT FOR YOUR RECORDS.
See page 8 if you want more detailed instructions.
PROGRAM PAY
Program pay is used in determining the value of the ETO days that you sell (for hourly employees only) and for
determining life and disability insurance values. It is defined as described below.
IF YOU:
IT’S YOUR:
> are enrolling during the annual enrollment period for
January 1
> base rate of pay, excluding differentials, times your
authorized annual hours.
> are a new hire
> base rate of pay, excluding differentials, as of your
hire date, times your authorized hours.
> become benefits-eligible because of an employment
status change
> base rate of pay, excluding differentials, as of your
status change effective date, times your authorized
annual hours.
Changes in your pay during the year will not affect your program pay. To determine annualized program pay for life insurance, Lakeland
Regional Health multiplies your annual authorized hours times your base rate of pay rounded to the nearest thousand excluding
differentials.
NOTE: When Short Term and Long Term disability benefits are paid, they are paid based upon your base rate of pay, excluding differentials,
times authorized annual hours as of the date of disability.
[13]
Earned Time Off (ETO)
Each pay period you are credited with ETO hours based on the accrual rates
shown in the chart below. You can use the hours as paid time off or accrue the
hours up to the maximum accrual amount. ETO hours can be used for vacation,
holidays, sick time and other personal reasons. (Use of ETO hours cannot exceed
your authorized hours per pay period).
ETO ACCRUALS AND MAXIMUMS
ETO Accruals by Months
of Service
Accrual Rate Per Paid Hour
(Excludes Overtime Hours)
Maximum Accrual
0 - 48
.096 hours
300 hours
49 - 168
.115 hours
340 hours
169 - 228
.135 hours
380 hours
229 or more
.142 hours
396 hours
Employees in all eligible employment status categories accrue ETO based on paid hours* within a pay period, up to a maximum of 80 hours,
excluding those hours paid at overtime rate. No employee accrues ETO in excess of his/her maximum accrual as defined above.
* ETO hours also accrue on unpaid low census hours.
If you end your employment after six months of service and leave Lakeland Regional Health in good standing, you’ll be
paid for all ETO days earned and unused at that time.
Additional ETO Options for Hourly Employees**
Hourly employees can sell up to 10 ETO days (80 hours) and use their value to offset the cost of other benefits.
> The value of each ETO day that you sell will equal the value of a day’s program pay (eight hours).
Of course, you do not have to use ETO days to buy benefits under the Benefits program. Instead, you can:
> use the hours as paid time off.
> take the hours as cash — but you must have six or more months of service and declare your intent to sell your ETO
prior to the calendar year during which they accrue.
> carry the hours over to the next year, up to the ETO maximum.
**Exempt employees may only utilize ETO as time off.
[14]
Who Is Eligible
As an eligible employee, Lakeland Regional Health provides you with certain
benefits that are at no cost to you depending on your employment classification.
You may also choose from a broad range of supplemental plan options depending
on your eligibility:
Regular Full Time and Part Time Employees
48 or more authorized hours per pay period (or those employees averaging at least
60 hours per pay period or 130 hours per month as required by healthcare reform)
> You are eligible to choose from all of the Lakeland Regional Health Benefits.
Part Time Employees
At least 40 authorized hours, but less than 48 authorized hours per pay period
> You are eligible to choose from all of the Lakeland Regional Health Benefits EXCEPT
the medical plan.
STEP and Part Time Daily Employees
> You may be eligible to participate in the Lakeland Regional Health Retirement and
Medical Plans if certain eligibility requirements are met.
Contract and Temporary Employees
> You are not eligible to participate in Lakeland Regional Health’s Benefits.
Newly Benefit-Eligible Employees
> You are eligible for Benefits starting on the first of the month following one
calendar month of service. However, for coverage to take effect, you must enroll by
the designated time. No Lakeland Regional Health provided coverage, or optional
benefits you elect, are effective during this waiting period, except the EAP. (If you
are hired on the first day of the month, your benefits are effective the first day of
the next month.)
Be sure that you
and your eligible
dependent(s) who
also work at Lakeland
Regional Health
coordinate coverage.
Double coverage will
not provide additional
benefits and can result
in premiums being
deducted from both
paychecks.
Employees who average
at least 130 hours per
month are eligible for
medical coverage under
the PPACA regardless of
authorized hours.
Covering Your Dependent(s)
Benefits offers you the option of adding your eligible dependents to your same
election of medical*, dental, vision, accidental death and dismemberment (AD&D)
insurance, cancer and legal service. In addition, dependent life insurance options
are offered to you.
If you and another of your benefit-eligible dependent(s) (spouse and/or child) are
Lakeland Regional Health employees:
> You cannot elect medical*, dental, vision, AD&D, cancer or legal coverage for
yourself and also be covered as a dependent by another Lakeland Regional Health
employee’s plan.
> Only one of you can cover your eligible dependent(s). There can be no double
coverage for medical, dental, vision, dependent life, AD&D, LTC, cancer or the legal
plan.
* Restrictions apply to covering spouses under Lakeland Regional Health’s medical coverage.
Refer to definitions on page 16.
[15]
Definition of Dependent:
For the Benefits plans, eligible dependents* include:
> The employee’s spouse, as defined by Florida law.
• For a previously recognized common law marriage from another state,
please contact the Benefits Department. Documentation proving your legal
marital relationship will be required.
> The employee’s eligible child, until the end of the month in which the child
turns age 26 for all plans, except the cancer plan.
> For the cancer plan, the employee’s eligible child through age 25. In addition,
such child must be living in the home with the employee in a parent-child
relationship, primarily dependent upon the employee for support, and
eligible to be claimed as a dependent on the employee’s Federal Income
Tax Return.
Medical Plan Attestation
An employee who enrolls
a spouse will be required
to attest that the spouse
is not eligible for medical
coverage under his/her
own employer’s health
plan. (Please contact
the Benefits Department
to determine if you qualify
for an exception.)
> An eligible child is the employee’s natural child, stepchild, or adopted child. Enrollment into the plan during
approved time periods and documentation to prove the relationship to the employee is required prior to
coverage becoming effective.
> An eligible child also includes a child who is placed with the employee by an authorized placement agency
or by judgment, decree, or other order of any court of competent jurisdiction. Such child must be living in the
home with the employee in a parent-child relationship, primarily dependent upon the employee for support,
and eligible to be claimed as a dependent on the employee’s Federal Income Tax Return. For the coverage to
become effective, the child must be enrolled in the plan during approved time periods. Documentation to prove
the relationship to the employee is required.
A Dependent child may be covered only up to the age limit, unless the child is physically or mentally handicapped
at the time coverage would otherwise terminate due to the limiting age. Coverage for a Dependent child may only
be extended beyond the age limit if all of the following requirements are met:
> the Dependent child must be covered under the plan at the time he/she reaches the limiting age;
> the Dependent child became physically or mentally handicapped prior to the end of the month in which he/
she reached the limiting age;
> the Dependent child is unable to earn a living;
> the Dependent child is primarily dependent upon you for support and maintenance;
> an application for an extension of coverage and proof of such handicap is submitted within 30 days of the
Dependent child reaching the limiting age; and
> such application for extension is approved by each carrier.
For further details about covering your dependents under a specific plan, please refer to the Summary Plan
Description, or certificate of coverage for that plan.
*Eligible dependents for the long term care plan are defined on page 54.
[16]
If Your Employment Status Changes
When you start or stop any approved leave, you
must contact the Benefits Department to review
your eligibility for benefits and your benefit election
options. If you are approved for a leave of absence
and you continue to receive a paycheck, your Benefits
participation and payroll deductions will continue as
before. If you are approved for a leave of absence and
do not receive a paycheck, you can continue most of
your coverages if you continue to pay for your benefits
on an after-tax basis (various time limitations apply).
If your authorized hours are reduced to less than 48 hours per pay
period (but remain greater than 40), you will no longer be eligible
to participate in the Cigna medical plan*. Your medical coverage will
continue until the end of the month in which the hour reduction
REMEMBER
If you terminate medical,
dental, or vision coverage,
or if you are removing
a dependent due to a
corresponding qualified
change in status during
the year, COBRA requires
that continuation of health
coverage be offered. A COBRA
enrollment packet will be
mailed within 14 days after
notification is received of the
qualified change in status.
event occurs, and you will be required to continue premium payments
for the entire month. However, your other benefits will continue to
It is your and/or your
dependent’s responsibility
remain in effect.
to notify the COBRA
Administrator that you are
If your authorized hours are reduced to less than 40 hours per pay
period, or if you terminate your employment, you will no longer be
eligible to participate in most benefits*. All benefits, except Short
Term Disability (STD) and Long Term Disability (LTD), will end on the
electing COBRA within the
COBRA time frame, which
is stated in the COBRA
enrollment packet. Elections
last day of the month in which the event occurs. Short Term and/
after the stated COBRA time
or Long Term Disability coverage will end on the day of termination
frame cannot be accepted
with Lakeland Regional Health. You will also be required to continue
and will be denied.
premium payments for the entire month (as applicable).
Life insurance, long term care and cancer coverage may be continued
through an individual policy directly with the insurance carrier.
Participation in medical, dental, vision and the Health Care Flexible
Spending Account may be continued through COBRA. The Dependent
Day Care Flexible Spending Account will end.
*If you met the eligibility requirements for medical coverage based on PPACA
requirements this will not apply to you.
[17]
If You Have A Qualified Change In Status
If you have a qualified change in status (see below), you must
contact the Benefits Department and complete a Benefits
Qualified Change In Status form. If you are currently covered
by the Colonial Life cancer plan, you must also complete
a separate status change form which is available in the
Benefits Department.
These forms must be completed and returned to the Benefits Department
within 30* days of the event. The change will become effective the later
Remember, the only time
you can add or delete a
dependent during the
year is if you have an IRS
approved qualified change
in status (see below left).
For your change to take
effect, you must make
it within 30 days* of the
event.
of the first day of the month following the date the Qualified Change
in Status form is received by the Benefits Department or the date the
coverage is approved by the carrier. The effective date for birth, adoption
or custody change of an eligible dependent and death of a dependent
will occur on the day of the event.
When You Can Change Benefits
Each fall you can change your coverage for the upcoming calendar year.
Once you have made these choices, the IRS requires them to stay
in effect for the entire year unless you experience a corresponding
qualifying event.
Approved qualified changes in status include:
> marriage or divorce
> birth, adoption or custody change of an eligible dependent when
ordered by the court (QMSCO or NMSN)
> death of an eligible dependent or your dependent is no longer eligible
> your spouse or dependent newly meeting (or failing to meet) the plan
eligibility rules
> your spouse’s open enrollment
> if a third-party insurer significantly cuts back coverage, increases the
cost or terminates coverage
> going on/returning from a leave of absence
The government also requires that the change you make be consistent
with the event.
[18]
*Exception for Newborns
Your Dependent child born
while you are covered under
the Lakeland Regional
Health Cigna medical plan
will be enrolled on the date
of his/her birth if you elect
dependent coverage no later
than 60 days after his/her
birth. If you do not enroll
your newborn within 60 days,
coverage will end on the 31st
day. No benefits for expenses
incurred beyond the 31st day
will be payable.
Medical Plan
The Cigna - LRH Employee Health Plan offers you a medical plan covering a broad
range of medical services and supplies. The plan protects you and your family
from the high cost of medical treatment and hospitalization.
Lakeland Regional Health offers medical coverage to all regular full time and part
time employees with 24 or more authorized hours per week. Starting in 2015, under
the Affordable Care Act (ACA), employees who work an average of 30 or more hours
per week – even if they are not regularly scheduled or “authorized” hours – may be
eligible to enroll in medical coverage. If this applies to you, you will be notified.
If you are eligible and elect to participate in Lakeland Regional Health’s medical
plan, each time you have medical services performed, you can choose where to
obtain services.
When you come to Lakeland Regional Health for your medical services, you will
receive high quality care at the best benefit level possible under the Cigna medical
plan. Moreover, starting in 2015, you will not be required to pay any deductible,
coinsurance or copays when utilizing Lakeland Regional Health facilities and
providers* (except Emergency Services).
The Lakeland Regional Health benefit level applies only to procedures and services that:
1) Lakeland Regional Health performs and are
2) Covered by the Lakeland Regional Health Cigna medical plan.
If you choose to utilize the Community Partners (including Radiology Imaging Services
and Watson Clinic) you will still be required to satisfy a deductible, coinsurance and
copays. However, these amounts are considerably lower than what you will pay if
you choose to obtain your medical services from a Cigna Open Access Plus (OAP)
provider. (Please refer to the Plan Design Summary on pages 6 and 7 for further
details). Other providers in Cigna’s OAP Network are still available to you and your
covered dependents for those occasions when you are unable to use Lakeland
Regional Health or Community Partner providers.
The Total Cost Of Medical Coverage
Lakeland Regional Health pays a significant portion of the total medical cost. The
total cost for each of the medical plan options – that is, the cost you would have to
pay if Lakeland Regional Health did not pay for a significant portion – is much higher
than your payroll deduction.
Lakeland Regional
Health providers
give you access to
high quality medical
services, all while
providing you
and your covered
dependents with
no out-of-pocket
expenses (except for
emergency services).
The 2015 Medical
Plan Design Summary
is on pages 6 & 7.
Refer to it often to
understand how
your Cigna Medical
Benefits cover
various services and
procedures by the
provider you select:
LRH, Community
Partners, and OAP.
A listing of Lakeland
Regional Health
providers is available
on the LRH Intranet.
Lakeland Regional Health contributes more toward the cost of single medical coverage
for employees who earn less money. We have chosen to implement what’s often
referred to as “Salary Banding” whereby, we pay more of the cost for employees who
are less likely to be able to afford medical coverage. At Lakeland Regional Health,
we treasure all employees and we are committed to providing affordable access to
healthcare to all employees.
[19]
Medical Plan
ILLUSTRATION
Employee earning up to $12
per hour
Single Coverage Per Pay Before $30
Period
Premium
Discount*
2015 Biweekly Cost of
Medical Plan
Lakeland Regional Health
portion of medical cost
Your contribution
After $30
Premium
Discount*
Employees making between
Employee making more
$12.01 per hour and $15 per hour than $15 per hour
Before $30
Premium
Discount*
After $30
Premium
Discount*
Before $30
Premium
Discount*
After $30
Premium
Discount*
$348.50
$348.50
$348.50
$348.50
$348.50
$348.50
-$293.30
-$323.30
-$277.33
-$307.33
-$275.20
-$305.20
$55.20
$25.20
$71.17
$41.17
$73.30
$43.30
*Refer to page 33 for details of how to qualify for up to $30 in premium discounts per pay period.
As you can see, your share of the cost is only a fraction of Lakeland Regional Health’s actual cost of providing your medical benefits.
LRH
Receive the BEST possible care with no out-of-pocket cost.*
The LRH level of coverage within the Cigna medical plan provides access to
the following medical facilities and physicians:
Facilities – Members have access to LRH owned and affiliated facilities
including:
> Lakeland Regional Health Medical Center (LRHMC)
> Lakeland Regional Health Cancer Center (LRHCC)
> Lakeland Surgical & Diagnostic Center (LSDC)
> Lakeland Regional Health Medical Group (LRHMG)
> Women’s Imaging Center (WIC)
Members utilizing the services of these facilities will have:
> No deductible, coinsurance or copays*
> No out-of-pocket costs*
> No claim forms to file
Physicians – the LRH physicians include employed and staff physicians at LRH
Medical Center, LSDC, WIC, LRHCC, and LRHMG (which includes Clark and Daughtrey
physicians). LRH Emergency Room Physicians are not employed by LRH.
Utilizing LRH will provide members with:
> No Primary Care Physician (PCP) required, but you have the option to choose
a PCP to coordinate your care
> Specialty Care without referrals
> Not out-of-pocket costs*
> No claim forms to file.
*Except for Emergency Services (refer to the 2015 Plan Design Summary on pages 6 and 7)
[20]
Remember, when you
utilize the LRH facilities
and physicians for
your medical services,
procedures and physician
services, you will save the
most money (there are no
out-of-pocket costs), and
you will receive the BEST
possible benefits and care!
Community Partners
The Community Partner level of coverage within the Cigna medical plan provides members with access to providers
such as Radiology & Imaging Specialists (RIS), Watson Clinic, Lakeland Pathology/MicroPath Laboratories, Pedatrix
Medical Group, Women’s Care Florida, Emcare and United Surgical to name a few.
Utilizing these physician providers will result in lower deductibles, copays, and coinsurance than what you would
pay if you choose to receive covered services from any of the other Cigna Open Access Plus (OAP) providers, but
will be more than if you obtain your medical services from LRH.
Utilizing the Community Partner physicians will provide members with:
> No Primary Care Physician (PCP) required, but you have the option to choose a PCP to coordinate your care
> Lower out-of-pocket costs
Cigna Open Access Plus (OAP)
If you do not use a LRH or a Community Partner provider, you must
use a Cigna OAP provider to have your medical care covered (except
in emergency situations, see 2015 Plan Design Summary on pages 6
and 7).
The Cigna OAP plan provides members that utilize this network of
services with:
> A National Network of Cigna Providers
> No Primary Care Physician (PCP) required, but you have the option
to choose a PCP to coordinate your care
> Low out-of-pocket costs
A Cigna OAP Provider is
a physician, hospital,
physician specialist,
ancillary facility or
pharmacy that Cigna has
contracted with to provide
care to their members
within the OAP national
network. When working
with Cigna, be sure to tell
them you are in the OAP.
You may call Cigna’s toll-free Care Line at 800-244-6224 to receive
assistance with:
> Locating a Cigna Network Provider
> Facilitating Away From Home Care
> Medical coverage questions or concerns
> Hospital pre-admission certification/continued stay review
PLEASE NOTE: There is NO coverage for out-of-network providers.
In areas without Cigna OAP Network coverage, members and their
covered dependents will need to contact Cigna about other providers
available to them in the area.
Relocation - In areas with a Cigna network, the OAP Network provides
members and their covered dependents with benefits when they
are temporarily relocated out of their provider area (e.g., students
away at school, children living with an ex-spouse, temporary job
reassignment, vacation).
[21]
Coordination of Benefits (COB)
If You or an Eligible Dependent are Covered by Another
Medical Plan
If you (or a family member) are covered by another
medical plan and our medical plan, there may be some
duplication of coverage. Our medical plan includes a
special provision called Coordination Of Benefits (COB)
that describes how benefits are paid in such cases.
Our medical plan will be the primary plan for you, so it pays benefits first.
Your spouse’s medical plan will be the primary plan for him or her; our
medical plan will be considered secondary for your spouse. The primary
plan pays first, up to that plan’s limits. Secondary coverage pays benefits
after primary coverage.
COB
If your child is covered by
another group health plan
and goes to the doctor,
the “Birthday Rule” will
determine which plan is
primary. If Cigna’s plan is
secondary, any unpaid
amount would then be
considered by Cigna
for payment under
Cigna’s Maintenance
of Benefits Secondary
Payer provisions.
If you and your spouse cover your child(ren) under both medical plans,
the “birthday rule” determines which plan is primary. This rule, which is
established by the National Association of Insurance Commissioners (NAIC), states that the plan of the spouse
whose birthday falls earlier in the year is the primary plan. For example, if your birthday is in July and your
spouse’s birthday is in November, your plan is primary for your child(ren).
If you are divorced or separated and a court decree establishes financial responsibility for medical care of a
child, the plan of the parent assigned that responsibility will be that child’s primary plan. When all the rules do
not resolve which plan is primary, the plan covering the child(ren) the longest is primary. After the plan pays its
benefits or denies a claim, you may file for any unpaid amounts with the secondary plan.
When Cigna Is The Secondary Payer
Here is how benefits are determined when Cigna is the secondary payer:
> Cigna determines the benefit that would be paid if Lakeland Regional Health’s plan were the only plan. This
includes applying any applicable deductibles and all other benefit limitations.
> The amount of benefit paid by the primary plan is subtracted from any benefit amount that our plan would pay.
So when our plan is secondary, it will only pay the difference, if any, between the amount it would have paid and
the amount the primary plan paid.
If you have our medical coverage and are covered by another medical plan, you will never receive more than
what the plan with the highest coverage would pay for the calendar year. In most cases, total reimbursement for
healthcare expenses could be less than 100%.
[22]
myCigna.com
myCigna.com is an online tool for accessing health and benefits
information specifically for and about you, including access to the
Health Assessment. Review your benefits plan information. Refill
prescriptions using the Cigna Home Delivery pharmacy. Find a doctor,
hospital or pharmacy using the online directories. Designate a Primary
Care Physician. Order a new Cigna HealthCare ID card. View the status
of claims submitted in the past 24 months. And, manage your Healthy
Awards Account.
24-Hour Health Information Line
Call the Cigna HealthCare 24-Hour Health Information Line for helpful,
reliable information on a wide range of health topics. The Line is open
24 hours a day, any day of the year. You can depend on it for everyday
health information on all sorts of subjects. Call when you are concerned
about a specific health problem, and talk directly with a registered
nurse who will give you advice about self-care or direct you to the most
appropriate care facility. Or, use it to access the Health Information
Library and listen to audio tapes on a wide variety of health-related
topics. Just call the toll-free number on your Cigna HealthCare ID card.
Lakeland Regional
Health’s
Rock-a-Bye Well Baby
Program
Give your baby-to-be a healthy
start. Enroll today in the
Healthy Babies Program and
receive your free baby gift.
Cigna Your Health First
Offering help for these
chronic conditions:
> Acute Myocardial Infarction
> Angina
> Anxiety
> Asthma
> Bipolar Disorder
Cigna Healthy Rewards Program
The Cigna Healthy Rewards Program offers you and your covered family
member(s) discounted prices on complimentary healthcare services
including acupuncture, massage therapy, chiropractic services, and on
laser vision correction surgery up to 25%. You can also order health and
wellness products through the Healthy Rewards program – and save
up to 40%! The discounted services and products available through
Healthy Rewards are in addition to the health care services covered by
your Cigna plan.
For information visit www.Cigna.com/healthyrewards or call toll-free
at 800-870-3470.
> Chronic Obstructive
Pulmonary Disease (COPD)
> Coronary Artery Disease
> Congestive Heart Failure
> Depression
> Diabetes
> Heart Disease
> Low Back Pain
> Metabolic Syndrome
> Osteoarthritis
Cigna Home Delivery Pharmacy
Cigna Home Delivery Pharmacy is a convenient and hassle-free mail
order prescription program that’s part of your Cigna OAP medical plan.
The Cigna Home Delivery Pharmacy has an extensive product line of
prescription medications that are usually at lower prices than you can
get at a retail pharmacy, especially for maintenance medications. Get
discounted prices on medications and convenient home delivery at no
extra charge. Receive up to a 90-day supply and access the 24-hour
prescription order information line.
> Peripheral Arterial Disease
You can call 855-246-1873 for
a live coach or utilize online
services at www.Cigna.com.
Call 800-835-3784 or go online to www.myCigna.com to place your new,
refill or transfer prescription order(s).
[23]
Definitions for Medical Plan
Annual Deductible — the individual deductible is how much you pay in a calendar year
before benefits are paid for services that are subject to the deductible and coinsurance.
A family deductible is met when three (3) family members separately reach the individual
deductible.
Coinsurance — the percentage you, or LRH, pay for covered services. This percentage
varies depending on where you receive services and the type of expense you incur.
Annual Out-Of-Pocket Maximum — the most money an individual or a family will pay
each year for covered expenses. Once you reach this maximum, the plan will pay 100%
of remaining Cigna - approved medically/clinically necessary eligible expenses for the
rest of the year, except for charges over the Reasonable and Customary (R&C) rate,
or any costs related to an inpatient admission, outpatient service, or medication not
pre-certified or pre-authorized by Cigna as medically/clinically necessary. Starting in
2015, the out-of-pocket maximum will include ALL medical and pharmacy deductibles,
coinsurance and copays.
Copay — set dollar amounts that are required of the member for certain medical
services and prescription costs.
Precertification and Prior Authorization — prevents unnecessary costs to you and the
plan by determining medical/clinical necessity. If an inpatient admission, outpatient
service, or prescribed medication is not approved by Cigna because it is not medically
necessary (regardless of whether LRH is used or not), or a prescribed medication does
not meet Cigna’s Step Therapy protocol or clinical Rx guidelines, all costs related to the
inpatient admission, outpatient service or medication are not covered.
Continued Stay Review — to ensure that your hospital stay will not be longer than
necessary. If the continued stay is deemed not medically necessary by Cigna, the stay
is not covered.
Reasonable and Customary (R&C) Cost — is what Cigna bases their reimbursement on
for the emergency service you receive out-of-network. This is the fee level set by National
Data Services that is considered appropriate for a medical service. It is based on the
typical rate charged for a similar service where you live. Currently, the R&C level is set at
80%, which means that 8 out of 10 providers charge the same or lower amounts. If your
expenses are more than the R&C cost, you will have to pay the additional amount in full.
In addition, these charges won’t apply to your deductible or out-of-pocket maximum.
[24]
Service Specific Notes
When reviewing the 2015 Plan Design Summary on pages 6 and 7, you may
also want to reference the notes below. For additional details on coverage,
limitations and exclusions, you should also review the Cigna Summary Plan
Document (SPD).
1.Once the out-of-pocket maximum is reached, the plan pays 100% of Cigna - approved medically/clinically necessary eligible-charges for the
remainder of the plan year, except for charges over the reasonable and
customary (R&C) rate, or any costs related to an inpatient admission,
outpatient service, or medication not pre-certified or preauthorized by
Cigna as medically/clinically necessary.
Note: Lab/x-ray fees
for services received
at your physician’s
office are in addition
to office visit copays.
2.
Prescription Drugs:
One copay applies per prescription for:
• no more than a 30-day supply for retail
• no more than a 90-day supply at the Publix Pharmacy at LRHMC (this
Publix location only) or mail order
If your prescription exceeds these time frames another copay will be
required. If your prescription is for less than the time frames, the entire
copay is still required. Non-prescription drugs are not covered.
Drugs not listed on the Cigna HealthCare Three-Tiered drug list are not
covered. Some drugs need prior authorization from Cigna before being
considered for dispensing.
3.
Allergy injections are a $10 copay per visit at Community Partner and
OAP providers (there is no copay at Lakeland Regional Health providers).
Any allergy treatment other than injections will require payment of the
applicable specialist copay.
4. A
ll inpatient hospital admissions require Precertification and Continued
Stay Review. If your admission/stay is not authorized there will be a denial
of coverage.
5.Outpatient surgeries and services, including imaging and select medications,
require Cigna Precertification or Prior Authorization to determine medical/
clinical necessity. If your outpatient surgery, service or medication is not
authorized by Cigna, there will be a denial of coverage.
6.
Infertility coverage will be provided for the treatment of an underlying
medical condition up to the point an infertility condition is diagnosed.
Charges for or in connection with in-vitro fertilization, artificial insemination
or any other similar procedure are not covered.
7. Chiropractic office visits, services and treatments are excluded from
coverage.
8. Speech therapy which is not restorative in nature will not be covered.
[25]
Dispense-As-Written (DAW)
Generic Drug Program
There are many generic medications available to treat many conditions. When generics are used
consistently, they can help lower your out-of-pocket costs. The Dispense-as-Written (DAW) Generic
Drug program strongly encourages you to try a generic equivalent medication when it is medically
appropriate. You still have the option to purchase the brand name medication; however, it will cost you
more. Generics are safe, effective and approved by the Food and Drug Administration (FDA). Generics
work just as well as brand name medications - they just cost less.
What is a Brand Medication?
A brand name medication is marketed under a specific brand name or trademark by the pharmaceutical
manufacturer. In most cases, it is under patent protection, meaning the manufacturer has the sole right to sell
the medication.
What is a Generic Medication?
A generic medication is sold under its chemical name or “generic” name, and has the same dosage, safety,
strength, quality and performance of a brand name medication. The color and shape of a generic medication may
be different from its brand name counterpart, but the active ingredients are the same.
How the Program Works:
The best way to understand how the program works is to review some examples.
1. Brand Name Medication Prescribed with Generic Substitution Allowed and You Purchase Generic:
> 30-day supply filled at the onsite Publix Pharmacy at LRH
> Generic Medication Atorvastatin (generic equivalent – of Lipitor) Cost: $22.00
If your prescription is written for a brand name medication, the pharmacist will automatically fill it with the
generic medication if one is available unless you specifically ask for the brand name medication or your doctor
indicates “Medically Necessary” or “Dispense-as-Written (DAW)” on the prescription. Filling your prescription
with a generic medication means that you will pay the lower generic copay.
BRAND NAME MEDICATION PRESCRIBED WITH GENERIC SUBSTITUTION ALLOWED
AND YOU PURCHASE GENERIC
The DAW program will not apply
Generic Equivalent Medication (e.g. Atorvastatin)
[26]
Plan Pays: Difference between total cost and your copay
$18.00 ($22.00 - $4.00)
You Pay: $4.00 Copay at the Publix Pharmacy at LRHMC
$4.00
Total
$22.00
2. Brand Name Medication Prescribed as “DAW” or “Medically Necessary”
> Brand Medication Lipitor (brand name medication with a generic equivalent) Cost: $118.00
If your doctor says the generic is not right for you and writes on your prescription, “Dispense-as-Written”
(DAW) or “Medically Necessary,” your pharmacist will fill your prescription with the brand name medication.
You will be responsible for paying the brand name coinsurance.
BRAND NAME MEDICATION PRESCRIBED AS DAW OR MEDICALLY NECESSARY
(YOU PURCHASE BRAND)
The DAW program will not apply
Brand Name Medication (e.g. Lipitor)
Plan Pays 70% of Brand Cost
$82.60 ($118.00 x 70%)
You Pay 30% Brand Coinsurance
$35.40 ($118.00 x 30%)
Total
$118.00
3. Brand Name Medication Prescribed with Generic Substitution Allowed and You Purchase Brand
> Brand Medication Lipitor (brand name medication with a generic equivalent ) Cost: $118.00
If your doctor does not indicate “Medically Necessary” or “Dispense-as-Written (DAW)” on the prescription,
but you ask for the brand name medication anyway, you will pay the generic copay PLUS the difference
between the actual cost of the generic and the actual cost of the brand medication. (You will never pay more
than the total cost of the brand medication.)
BRAND NAME MEDICATION PRESCRIBED WITH GENERIC SUBSTITUTION ALLOWED,
BUT YOU PURCHASE BRAND
The DAW program will apply
Plan Pays: Same as it would have if you had purchased
the generic (i.e., the difference between the total generic
cost and your generic copay)
$18.00 ($22.00 - $4.00)
You Pay: $4.00 Copay at the Publix Pharmacy at LRHMC
$4.00 Plus
You Pay: The difference in cost between the Brand and
Generic medications
$96.00 (Brand $118 - Generic $22)
Total
$118.00
[27]
Dispense-as-Written (DAW) Generic Drug Program
Are generics as safe and effective as brand name medications?
Generics have to meet the same rigorous U.S. Food and Drug Administration (FDA)
requirements as brand name medications. All generic medication manufacturers are
required by the FDA to demonstrate that a medication will have the same medical
effect as its brand name equivalent. A generic equivalent medication contains the
same active ingredients in the same dosage as the brand name medication. The
strength and purity of generic medications are strictly regulated by the FDA.
Are generic medications right for me?
Only your physician can determine whether a generic medication is right for you. Ask
your physician if there is a generic equivalent for your brand name medication and if
it is an appropriate alternative for you.
What happens if I cannot take a generic medication offered by the pharmacist?
The DAW generic drug program does not apply if your physician requests the brand
name medication. In order for you to fill the brand name prescription without paying
the cost difference, your physician must indicate “Dispense as Written (DAW)” or
“Medically Necessary” on the prescription.
Will I have to get a new prescription to get the generic alternative medication?
Your pharmacist may be able to substitute a generic medication for the brand
counterpart without a new prescription from your physician, unless your physician
has indicated “DAW” or “Medically Necessary” on your original prescription. Be sure
to follow up with your medical providers to advise them of this program and discuss
whether a generic equivalent substitution is appropriate for you.
What if I have questions?
Talk to your physician and ask if generics are an appropriate alternative for you. Call
the customer service number listed on the back of your ID card if you have questions
about your medication benefits.
[28]
Step Therapy for Prescription Drugs
What is Step
Therapy?
Step Therapy is a 3-step Cigna prior authorization program that works with you and your
doctor to take one step at a time when choosing your medication. It encourages the use
of cost-effective, therapeutically appropriate medications, typically generics or low-cost
brands, before other more costly prescription medication options are considered, and helps
you:
> Know your medication choices
> Understand how those choices affect what you pay for your medication
> Make an informed decision with your doctor about the best choice of medication based
on how well it works for you and how much it costs you
What types
of prescription
medications
apply to
Step Therapy?
Step Therapy only applies to prescription medications in these 14 drug classes:
> ACEI/ARB class drugs (typically used to manage/treat blood pressure)
> Proton Pump Inhibitor (PPI) class drugs (typically used to manage/treat acid-related
conditions)
> Statin class drugs (typically used to manage/treat cholesterol)
> Topical Immunomodulators (typically used to manage/treat skin conditions)
> ADD/ADHD: Attention Deficit Hyperactivity Disorder*
> Asthma Nebulizer Solutions (use to manage/treat asthma)
> Atypical Antipsychotic Agent (typically used to manage/treat mental health conditions)*
> Bone Resorption Inhibitors (typically used to manage/treat bone loss disorders)
> Hypnotics (typically used to manage/treat sleep disorders)
> Acute Oral Narcotics (typically used as strong pain relievers)
> Nasal Steroids (typically used to manage/treat allergies)
> Non-Steroidal Anti-Inflammatory (Non-Narcotic Pain Relievers – mild pain relievers)
> Urinary Tract Antispasmodic Agents (typically used to treat overactive bladder condition)
> SSR/SNRI Antidepressants (typically used to manage/treat depression)*
Which
prescription
medications
are included in
the Step Therapy
program?
Step Therapy medications are identified on the Cigna Prescription Drug List on Cigna
websites. To determine if your medication is included in the Step Therapy program, go to the
Pharmacy tab on www.myCigna.com or Cigna.com.
Click on the Cigna Prescription Drug List and enter the name of your medication(s). A “ST”
designation will appear next to your drug if it is included in the Step Therapy program.
You can also use the Cigna Drug Price Quote Tool to compare the potential cost-saving
opportunities of generics and therapeutic alternatives.
What happens
when you fill a Step
Therapy medication
at the Pharmacy?
When you go to the pharmacy to fill a prescription that is on the Step Therapy list, the
prescription will be filled once without authorization. This fill will trigger a letter to be sent
to you and your physician which outlines the Step Therapy program and the actions you will
need to take in order to prevent your medication therapy from being disrupted.
* If currently taking these types of medications, Step Therapy may not be required.
[29]
Step Therapy for Prescription Drugs
How does
Step Therapy
work?
Prescription medications are classified as:
Step 1 medication – generic
Step 2 medication – preferred brand
Step 3 medication – non-preferred brand
When you fill a prescription for a Step Therapy medication that has a lower cost alternative
available, you and your doctor will receive a letter from Cigna explaining what needs to be
done before you fill the medication again. This might include trying a lower cost alternative
or seeking authorization from Cigna for continued coverage of the original medication.
At any time, your doctor can request authorization to continue coverage for a Step Therapy
medication for medical reasons. You will typically pay more for Step 2 or Step 3 medications.
How does
Step 1 work?
Step 1 requires the use of at least one available generic before a Step 2 medication is
eligible for coverage. (Note: some drug classes require the use of two generic drugs.) Step
1 medications are available to you immediately without prior authorization. Generics can
offer a considerable economic benefit to you since your copay is lower than for brand name
drugs.
How does
Step 2 work?
Step 2 requires the use of an available preferred brand before a non-preferred brand is
tried. If you have tried a Step 1 medication and your doctor determines it was not right for
you due to medical reasons, then an alternative Step 1 or a Step 2 medication would be your
next choice.
If a Step 1 medication was already tried, and your doctor determines that a Step 2
medication is required, it would be available without the need for prior authorization, after
documentation is provided to Cigna from your doctor.
What if a
Step 3
medication is
wanted?
If you have tried a Step 1 medication(s) and a Step 2 medication and your doctor determines
it was not right for you due to medical reasons, then a Step 3 medication would be the next
choice, and would be available without the need of prior authorization after documentation
is provided to Cigna from your doctor.
If you have not tried the Step 1 or Step 2 medications, the plan will only cover the Step 3
medication for the initial fill. After that, you will be responsible for the full cost of that Step
3 medication.
However, if your doctor believes your treatment plan requires a Step 3 medication initially,
your doctor can request authorization at any time.
[30]
Cigna Clinical Necessity Management
Programs
Clinical Necessity Management Programs are prior authorization programs managed by Cigna
that work with you and your doctor to help determine clinical necessity for certain services and
medicines. The Programs are as follows:
Migraine
Medication
Management
Prior authorization is required for coverage to help you receive the appropriate medication
to manage migraine-related conditions effectively and safely and to help prevent overuse
of these drugs. Common clinical practice indicates that patients who experience more than
three migraines a month should be treated with preventive medications in addition to the
class of drugs called Triptans (e.g., Amerge, Axert, Imitrex, Maxalt, Migranal and Zomig).
Standard
Appropriateness
of Use and
Quantity Limit
Protocols
Selected medications are subject to prior authorization, quantity limits and age limits.
These include: Actiq, Agrylin, Arava, Avita, Differin, Gleevec, Iressa, Panretin, Penlac, Prosca®,
Pulmozyme, Regranex, Relenza, Tamiflu, Vfend, Zyvox, Accutane, Anzemet, Cipro, Claravis,
Dostinex, Duragesic, Emend, Kytril, Revia, Stadol, Zithromax, Zofran, Lariam, Malarone,
Synarel, Toradol, Avita, and Retin-A.
Nonsteroidal
Anti-inflammatory
Medication
Management
Prior authorization is required for the class of medications known as Cox-2 Inhibitors which
include Celebrex.
Fungus Medication
Management
Prior authorization is required for coverage of anti-fungal medications, such as Lamisil® and
Sporanox®.
Gastrointestinal
Medication
Management
When a PPI has been filled by a Participant with no history of using a generic or preferred
PPI (Prevacid/Protonix), the Participant receives a communication from Cigna and the
prescribing physician receives a patient profile and request for information to support the
continued use of the non-preferred PPI (e.g., Nexium, Aciphex). For patients being treated
for acid reflux, the prescriber is requested to modify therapy to a generic or preferred brand
PPI if the prescriber did not start the patient on such medication. As always, all treatment
decisions are between the doctor and patient.
Daily Dose
Efficiency
Management
(Dacon)
For selected maintenance drugs, the cost of one higher strength tablet of drug “A” is typically
the same or slightly less than the cost of two lower strength tablets of the same drug. Cigna
works with your doctor when you are receiving two or more doses per day of a drug when
it may be clinically appropriate for the patient to receive fewer doses per day of a higher
strength.
The drugs noted above represent the majority of drugs covered by these programs. However, this is not a complete list, and the list is subject
to change over time. Please visit www.myCigna.com and click on the pharmacy tab for more information and to determine if there are clinical
programs or limits that pertain to a drug being prescribed for you.
[31]
Cigna Clinical Necessity Management Programs
Clinical Necessity Management Programs are prior authorization programs managed by Cigna
that work with you and your doctor to help determine clinical necessity for certain services and
medicines. The Programs are as follows:
[32]
Maximum Daily
Dose Review
This Program is to help make sure the medications you receive are appropriate for your
situation. When a prescription is submitted online that exceeds the FDA recommended
maximum daily dose, your network pharmacist can call the prescribing physician and adjust
the dose if appropriate or continue to fill the prescription as originally submitted.
Complex
Psychiatric Case
Management
This outreach is to promote optimal therapies that align treatment decision to member
needs. Focus is on reducing gaps in care by facilitating the connection of your primary
physician with psychiatrists and Cigna Pharmacy to ensure appropriate Rx utilization.
Narcotics Therapy
This focuses on the potential for fraud and abuse of narcotics.
Inpatient
Pre-Certification
Clinical Necessity
Review List
All inpatient admissions and non-obstetric observation stays such as:
>A
cute hospitals
> Skilled nursing facilities
> Rehabilitation facilities
> Long term acute care facilities
> Hospice care
> Transfers between inpatient facilities
> Experimental and investigational procedures
> Cosmetic procedures
> Maternity stays longer than 48 hours (vaginal delivery) or 96 hours (Cesarean section)
Outpatient
Pre-Certification
Clinical Necessity
Review List
Certain outpatient surgical procedures
> High-tech radiology (MRI, CAT scans, PET scans)
> Injectable drugs (other than self-injectable)
> Durable medical equipment (insulin pumps, specialty wheelchairs, etc.)
> Home health care/home infusion therapy
> Dialysis (to direct to a participating facility)
> External prosthetic appliances
> Biofeedback
> Speech therapy
> Cosmetic or reconstructive procedures
> Infertility treatment
> Nuclear cardiology
> Radiation therapy
Together,
Our Promise is
Your Health
Take advantage of
our options for
discounted premiums
and see the savings in
your paycheck!
Together, Our Promise is Your Health: Lakeland Regional Health’s Culture of Health is
designed to reward you for those activities you engage in that improve and maintain your
own personal wellness. Employees who participate in Lakeland Regional Health’s Cigna
medical plan can enjoy discounted medical contributions. All employees (whether you
are covered under the Cigna medical plan or not) can enjoy free or low-cost wellness
related activities, such as fitness classes, health screenings, health education classes,
weight loss classes and much more.
Cigna Participant Options for Discounted Premiums
Employees who participate in Lakeland Regional Health’s Cigna medical plan have the option to engage in three
specific Living Well activities in 2015 that can result in up to a $30 per pay period reduction ($10 each) in medical
contributions (that is up to $780 per year)!
1. Non-Tobacco and Non-Nicotine Use: To qualify for this $10 premium discount per pay period, you must report
via the online enrollment system that you and your covered dependents are tobacco-free and nicotine-free.
• Employees who are unable to satisfy these conditions may successfully complete the Cigna Tobacco Cessation
program with a telephonic health coach to earn this $10 premium discount (reported quarterly); OR
• Employees with medical conditions preventing them from satisfying these requirements may contact the
Benefits Department to receive a form for their physician to complete.
2. Health Assessment with Biometrics: To qualify for this $10 premium discount per pay period, employees must
complete an Online Cigna Health Assessment at www.myCigna.com. To be considered complete, you must
include ALL numeric biometric values with test results that are less than six months old. For those completing
annual benefits enrollment for plan year 2015, a Health Assessment completed no earlier than October 1, 2014,
and no later than December 31, 2014, will qualify the participant for this premium discount. Newly enrolled
employees after January 1, 2015, will be added quarterly after they have completed the Health Assessment.
[33]
Achieving and Maintaining a Healthy Weight:
To qualify for this $10 premium discount per pay period for 2015, employees will be required to:
>Have a Body Mass Index (BMI) of < 30, or a waist circumference of 35“ or less (for females) and 40” or less
(for males) as determined by the biometric information provided on your Health Assessment; OR
>Employees who are unable to satisfy these conditions, may successfully complete the Cigna Healthy Steps
to Weight Loss program to earn this $10 premium discount (reported quarterly); OR
>Employees with medical conditions preventing them from satisfying these requirements may contact the
Benefits department to receive a form for their physician to complete.
BODY MASS INDEX (BMI) TABLE
Find your height and then move across to your weight (in lbs) to determine your BMI
Normal
Overweight
Obese
Extreme Obesity
19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54
4'10
91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 172 177 181 186 191 196 201 205 210 215 220 224 229 234 239 244 248 253 258
4'11" 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 178 183 188 193 198 203 208 212 217 222 227 232 237 242 247 252 257 262 267
5'0"
97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 184 189 194 199 204 209 215 220 225 230 235 240 245 250 255 261 266 271 276
5'1" 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 158 190 195 201 206 211 271 222 227 232 238 243 248 254 259 264 269 275 280 285
5'2" 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 196 202 207 213 218 224 229 235 240 246 251 256 262 267 273 278 284 289 295
5'3" 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 203 208 214 220 225 231 237 242 248 254 259 265 270 278 282 287 293 299 304
5'4" 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 209 215 221 227 232 238 244 250 256 262 267 273 279 285 291 296 302 308 314
5'5" 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 216 222 228 234 240 246 252 258 264 270 276 282 288 294 300 306 312 318 324
5'6" 118 124 130 136 142 148 155 161 167 173 179 276 192 198 204 210 216 223 229 235 241 247 253 260 266 272 278 284 291 297 303 309 315 322 328 334
5'7" 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 230 236 242 249 255 261 268 274 280 287 293 299 306 312 319 325 331 338 344
5'8" 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 236 243 249 256 262 269 276 282 289 295 302 308 315 322 328 335 341 348 354
5'9" 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 243 250 257 263 270 277 285 291 297 304 311 318 324 331 338 345 351 358 365
5'10" 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 250 257 264 271 278 285 292 299 306 313 320 327 334 341 348 355 362 369 376
5'11" 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 257 265 272 279 286 293 301 308 315 322 329 338 343 351 358 365 372 379 386
6'0" 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 265 272 279 287 294 302 309 316 324 331 338 346 353 361 368 375 383 390 397
6'1" 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 272 280 288 295 302 310 318 325 333 340 348 355 363 371 378 386 393 401 408
6'2" 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 280 287 295 303 311 319 326 334 342 350 358 365 373 381 389 396 404 412 420
6'3" 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 287 295 303 311 319 327 335 343 251 359 367 375 383 391 399 407 415 423 431
6'4" 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 267 195 304 312 320 328 336 344 353 361 369 377 385 394 402 210 418 426 435 443
> For people with a BMI > 30, weight loss is recommended.
>For people with a BMI between 25 and 29.9, or who have a waist circumference > 40” for men and 35” for women,
and who have additional risk factors, weight loss is recommended.
>For people with a BMI between 25 and 29.9 who have no risk factors and do not want to lose weight, prevention
of further weight gain is recommended.
Source: Adapted from Clinical Guidelines on the Identification, Evaluation, and Treatment of overweight and Obesity in Adults: the Evidence Report.
[34]
LRH Health
Screening Program
We are pleased to announce that employees and their
dependent will now benefit from an expanded menu of
screening opportunities.
Lakeland Regional Health and the Women’s Imaging Center are committed
to esuring we continue to provide a robust employee screening program
to all LRH employees.
Insurance information will be collected and claims will be filed directly
with Cigna. Health Screenings are provided free to employees and their
dependents without insurance.
Mammography will be provided through the Women’s Imaging Center
(WIC). Employees and their dependents may schedule an appointment
directly through the WIC at 863-688-2334, option #1.
Skin, PSA, DRE with Occult Blood, and Oral Cancer Screening appointments
will be available with an ARNP at LRCC. Employees will call Theresa Barbee
at 863-603-6579 to schedule.
Employees and their dependents will now benefit from an expanded
menu of screening opportunities including a LRH Screening Event which
will be scheduled in the spring at the Women’s Imaging Center. The
following services will be offered at this event:
•
Mammography, Occult Blood & DRE, PSA, Melanoma screening,
osteo screening, simple spirometry, ABI (Ankle – Brachial Index) for
Peripheral Artery Disease screening, BMI, Oral Screening, etc.
[35]
Cancer Insurance – A Supplemental Plan
The cancer plan is offered as a supplement to medical coverage. You may choose this
coverage or waive it.
You can elect cancer coverage if you or the eligible dependent(s)
you’re covering:
> have gone 5 years without diagnosis or treatment for internal cancer
(including melanoma)
> have gone 5 years without diagnosis or treatment for external cancer
(such as skin cancer)
> have gone 2 years treatment free from date of coverage for breast
cancer
Anyone who has been diagnosed or treated for AIDS or an AIDS-related
condition cannot be covered by this plan. In addition, anyone age 70
or older cannot elect this coverage. Cancer coverage is subject to the
insurance company’s approval, even if you elect it for yourself or an
eligible dependent during enrollment. Remember, the cancer plan
does not replace health coverage. Instead, it is a supplement to your
medical plan.
Insurance
Company Rules:
If you enroll for cancer coverage
after first becoming eligible,
there is a 30-day waiting period
after the plan’s effective date
of coverage. Benefits will not be
payable for any cancer diagnosed
during this waiting period.
However, premiums are payable
during this time.
Initial Diagnosis Benefit
Plan 1000 pays a $2,000 benefit to the participant upon diagnosis of internal cancer.
Taxability
Some benefits paid from the cancer insurance plan will be considered taxable income and will be subject
to taxation according to IRS regulations. You will receive a 1099 form from Colonial Life if taxable cancer
benefits are paid.
Before You Enroll
To enroll for cancer coverage, you will need to complete the separate Cancer Application and HIPPA
Authorization. You will need to return it prior to the designated date shown on your enrollment materials,
or coverage will not go into effect.
If an eligible person is applying for coverage and they have previously had skin or internal cancer, they will
also have to complete either a cancer history form and/or a skin cancer exclusion form that would exclude
coverage for skin cancer only for 5 years from the effective date of coverage.
Coverage and premiums will not begin until Lakeland Regional Health receives approval from Colonial Life.
[36]
Cancer Insurance Benefits Summary
Specified Diseases
The plan will pay up to $300 a day for hospital confinement due to Cystic Fibrosis, Lou Gehrig’s Disease,
Muscular Dystrophy, Sickle Cell Anemia, among many other specified diseases. See your policy for details
and payment limitations, or call Colonial with your questions.
If you are enrolling in the Colonial Cancer Insurance for the first time you must fill out a paper application.
You also have to make your election online within 20 days of your start date or during open enrollment.
This application can be obtained on EES or directly from the Colonial Agent Michael Wiggs (813) 737-1620.
You will also need to mail the application directly to Michael Wiggs (P.O. BOX 307, Nichols, FL, 33860) for
processing.
Plan 1000 Features
COVERED SERVICE TO YOU:
PLAN 1000 BENEFITS PAID
Hospital Confinement
Up to $200 a day for the 1st 31 days
Up to $400 a day after 31 days
Ambulance
Up to $200 per trip, limit of 2 trips per confinement
Full time Nursing Services
Up to $150 a day
Anti-nausea Medication (approved for cancer)
Up to $40 a day, limit of $160 per month
(prescribed by physician)
Radiation/Chemotherapy
The amount charged up to $200 a day
(limit amounts vary per month based on procedure)
Wellness
Pays indemnity of $75 once per calendar year
Family Care Money paid to insured when child receives internal pays
cancer treatment; $60 a day
Hair Prosthesis//External Breast ProsthesisThe amount charged up to $200 a year
Home Health Care Services
The amount charged up to $75 per day;
maximum of 30 days per calendar year or twice
the number of days you are hospitalized,
whichever is greater
SurgeryAmount charged up to the amount listed in The Surgical
Schedule section of the Cancer Brochure, up to $3,000
depending on the Procedure performed by a physician
Lakeland Regional Health is not endorsing or recommending this insurance. Choosing Cancer coverage is a personal
decision.
[37]
Vision Plan
To help pay the cost of eye exams and eyewear, Lakeland
Regional Health offers a vision plan. Humana VisionCare PlanVCP is administered by Humana Specialty Benefits.
Each time you receive vision care, you choose whether to receive your care
from in-network providers or to receive your care out-of-network. Humana
VisionCare Plan–VCP network includes participating Private Practice
optometrists, ophthalmologists and retail locations. There is a greater savings
when you use participating providers.
The vision plan helps
cover the cost of eye
exams, eyeglasses and
contact lenses. Network
Retail providers include:
LensCrafters, Pearle Vision,
Sears Optical, Target
Optical and JCPenney.
You will receive an
ID Card package with
your Lakeland Regional
Health vision care benefits
and a small listing of
providers near you.
How To Use The Plan
Thinking about choosing the Vision Plan? Remember network providers offer the greater savings.
> Members simply select any in-network provider. You can locate a provider in your area by calling Benefits On
Call (863-687-1499 or extension 1499 if calling within Lakeland Regional Health), or by calling Humana VisionCare
Plan-VCP directly at 866-537-0229 or through their website, www.humana.com/custom_clients/lrmc. Besides
paying less for eye care, there is another advantage to using the network. When you go to a network provider,
Humana pays the doctor directly. You just pay your copay.
> Members can also choose an out-of-network provider. In this case, you will pay the doctor at the time of the
visit and submit receipts to Humana VisionCare Plan-VCP for reimbursement. Claim forms are also available.
Vision Plan At-A-Glance
If You Have This Service:
This Amount Will Be Covered By A Network Provider:
Or, This Amount Will Be Reimbursed
When You Go Out-Of-Network:
Exams — once every 12 mos.
100% after $10 copay $35 after $10 copay
Lenses — once every 12 mos.
100% after $15 copay (up to plan limits)
up to $100 after $15 copay
Frames — once every 24 mos.
100% after $15 copay (up to plan limits)
up to $40 after $15 copay
Contact Lenses —
> if elective100% of a regular eye exam after $10
copay. $105 allowance for contact lens
fitting, follow-up, and all other services and supplies in lieu of all other benefits
up to $35 of a regular eye exam after
$10 copay and $105 reimbursement for
contact lens fitting, follow-up, and all
other services and supplies in lieu of
all other benefits
> if medically necessary
up to $210/pair
100% after appropriate copay
NOTE: If you receive an exam and materials — lenses, frames or both — in the same visit, you must pay both the $10 exam and
the $15 materials copay. You pay only one $15 materials copay whether you receive lenses, frames or both.
Please note: exclusions apply
[38]
Dental Plans
One of the first things a person notices about you is your smile.
To help keep your smile bright, Benefits allows you to choose
between two separate dental plans. Both plans take a bite out of
the cost of taking care of your teeth!
Delta Dental’s dental plan options are:
> DeltaCare USA Plan
Each dental plan works in
a different way. The Delta
Dental PPO is a PPO,
while the DeltaCare USA
works much like an HMO.
> Delta Dental PPO Plan
DeltaCare USA Plan
Recognizing that some people prefer the savings and reduced paperwork that network care offers, ChoiceBenefits
continues to offer a managed care dental plan, which is called the DeltaCare USA plan. Just like an HMO, DeltaCare
USA features a preselected group of skilled providers. Delta Dental’s dentists render most dental care and offer
special rates. However, choosing DeltaCare USA requires you to use DeltaCare USA dentists and facilities, otherwise
no benefits are paid. There is one exception, and that is if you are traveling more than 35 miles away from any
participating dental facility and have an emergency. In this case, Delta Dental will reimburse you up to $100 per
calendar year for emergency care.
A list of participating dentists is available from Delta Dental directly by dialing Benefits On Call at 863-687-1499, or
at extension 1499 if calling within Lakeland Regional Health or by using their website at www.deltadentalins.com.
DeltaCare USA features:
> you must visit a DeltaCare USA participating dentist, specialist or facility to receive benefits
> covered procedures (nearly 300) have set copays
> you select a dental office upon enrollment - up to three different primary care dentists (PCD) can be selected
per family
> no claim forms required; you only need to pay the specified copayment for covered services at the time of your
visit, but the plan only covers dental treatment rendered by Delta Care USA participating dentists, specialists
and facilities
> children through age 12 may receive services from an in-network Pediatric dentist without a referral
> no annual deductible or annual dollar maximums
[39]
Dental Plans
DeltaCare USA covers the following types of dental care, but it must be rendered by your
DeltaCare USA dentist, and you will pay $5 for every office visit plus various copayments (see
the DeltaCare USA schedule of benefits for a detailed list of covered services):
Preventive Care (after a $5 copayment per office visit) — such as:
> oral examinations
> fluoride treatments
> routine cleanings
> dental x-rays
Basic Care Services (after a $5 office visit copayment plus a service copayment) — such as:
> restorative
> non-surgical extraction of a single tooth
Major Care Services (after a $5 office visit copayment plus a service copayment) — such as:
> surgical extractions
> root canals
> dentures
> crowns and bridges
> resin restoration
Specialist Services (after a $5 office visit copayment plus a service copayment) —
such as:
> orthodontists
> periodontists
Note: All Specialist services require a referral from your PCD except for Pediatric
dentists.
Delta Dental PPO Plan
The Delta Dental PPO Plan allows you to receive dental services from in-network
dentists or out-of-network dentists. With this plan, you will pay a deductible for
certain dental services, but you have the freedom to visit any dentist you wish.
Contracting Delta Dental dentists agree to accept the fee approved by Delta
Dental as payment in full. They may not bill you for more than your share of
the copayment/coinsurance. A non-Delta dentist does not contract with Delta
Dental, so they may bill you the balance up to their full fee. This is why you will
usually save on out-of-pocket costs by visiting a contracting dentist.
Features of this option include:
100% Of Preventive Care — including services such as:
[40]
> oral examinations
> cleanings and scalings (up to two a year)
> fluoride treatments
> dental x-rays
FACTS TO
CONSIDER ABOUT
Delta Care USA
For benefits to be
paid, you must use a
Delta Care USA dentist.
For certain specialists
such as endodontists,
pedodontists and
periodontists, you may
have to travel outside
of Lakeland.
You should call early
when making an
appointment with a
Delta Dental dentist.
Because there is
a limited number
of providers, it can
take time to get an
appointment.
For other dental services, a calendar-year deductible of $50 per person and $100 for a family
must first be satisfied. Once this has been paid, the plan covers these services up to an annual
maximum of $1,500:
80% Of Basic Care Services — such as:
> fillings
> surgical extractions
> root canal therapy
> periodontics
50% Of Major Care Services — such as:
> inlays & outlays
> crowns
> dentures
> bridges
50% Of Orthodontic Services For Children Under Age 19 — up to a lifetime maximum benefit of $1,500
Diagnostic and preventive services (such as exams, x-rays and cleanings) do NOT count toward the $1,500 annual
maximum. This leaves you with more dollars to go toward higher costs services (e.g., crowns) if required.
DENTAL PLANS AT-A-GLANCE
FEATURE
Deductible
DELTACARE USA
In-Network Services Only*
No; but $5 copay for each office visit
Claim Forms
No
Can visit any dentist
No; you must use your selected dentist
Must use participating
dentist
Yes
DELTA DENTAL PPO
In-Network*
Out-of-Network**
Yes; $50/person; $100/family
No
Can visit any
network dentist
Yes
Yes
Yes
No
Preventive Care
Covered 100% after $5 office visit copay
100%* deductible
100%** deductible
waivedwaived
Basic Care Services
Covered after applicable copay and
$5 office visit copay
80%* after
deductible
80%** after
deductible
Major Care Services
Covered after applicable copay and $5 office visit copay
50%* after
deductible
50%** after
deductible
Calendar Year Maximum
None
$1,500 per person
(excluding Diagnostic & Preventive services)
Orthodontic Care
Covered after applicable copay and $5 office
visit copay for adults and children
50%* after
deductible 50%** after
deductible
$1,500 lifetime benefits; only for children under 19
* For more information, see the Delta Dental Evidence of Coverage Certificate.
** Of Reasonable and Customary (R&C) charges (Out-of-Network dentists may bill you for their charges over the R&C rates.)
[41]
Health Care and Dependent Day Care
Flexible Spending Accounts
Wouldn’t it be nice to keep some of the money Uncle Sam takes in taxes each year? Flexible
Spending Accounts are a way to let you do just that. You can save taxes on expenses that you
would have to pay anyway.
With the Flexible Spending Accounts, you can enroll in:
> Health Care Flexible Spending Account — to pay for most non-covered health care expenses, such as copays
and deductibles
> Dependent Day Care Flexible Spending Account — to pay for dependent day care expenses while you and your
spouse (if applicable) are at work
> Either one or both accounts
How These Accounts Work
Here is how these accounts work:
> Tax-free money from each paycheck is deposited into your account(s). These deposits cover eligible expenses
you expect to pay during the year (from January 1 to December 31).
> When you have an eligible Health Care expense, you can use the SHDR Benefit Access Card or pay the bill and
turn in a Claim form with itemized receipts to SHDR. You will be reimbursed with the tax-free dollars from your
account(s).
How Much You Can Deposit
You decide how much to deposit for the upcoming year up to the calendar
year maximum. Deposits come from:
The Flexible Spending
Accounts are administered
by Stanley, Hunt, DuPree &
Rhine (SHDR).
> Voluntary tax-free contributions that you make each pay period, or
> The sale of ETO days under the Benefits program (available to hourly
employees only)
The Health Care Flexible Spending Account is pre-funded by Lakeland
Regional Health at the beginning of the year with the total annual amount
that you elect to contribute. The Dependent Day Care Flexible Spending
Account is funded incrementally at each pay period. Please contact SHDR
at 800-768-4873 if you would like more information.
[42]
With the SHDR Benefit
Access Card, employees
pay for most eligible
Health Care expenses at
the point of service. This
means you can often avoid
paying cash for services,
filling out and submitting
claim forms, and waiting
for a reimbursement check.
The maximum calendar year amount you can deposit into each
account is:
> $2,500* per calendar year for Health Care expenses
> $5,000* per calendar year for Dependent Day Care expenses
*Highly Compensated Employees (as defined by the IRS) may have
lower annual maximum contribution limits. You will be notified if this
applies to you.
For employees who enroll after January 1, the annual amounts are
pro-rated over the total number of paychecks remaining in the
calendar year. The minimum you can deposit into an account is $5
per pay period.
Elections do not automatically roll over from year to year. You must
actively enroll each year you want to participate in either of these
accounts.
How to Use the SHDR Benefit Access Card
FSA Online Account
Employees can register online
at www.shdr.com/flex to get
detailed information about account
balances, current statements and
account history.
1. Once your account is effective go
to www.shdr.com/flex.
2. Login using your last name and
last four digits of your SSN for
your user ID. Your password is
your mailing zip code.
3. The system will prompt you
to change your User ID and
password/pin. You will need both
your User ID and password/pin
for future access to your account.
When you enroll in the Health Care Flexible Spending Account, you
will automatically receive two cards. You can use your SHDR Benefit
Access Card at participating pharmacies and mail-order pharmacies.
You may also use the Card to pay any hospital, doctor, dentist or vision provider that accepts Visa®. In this case,
SHDR uses its auto-substantiation technology to electronically verify the transaction’s eligibility to be reimbursed
from your Health Care FSA according to IRS rules. If the transaction cannot be auto substantiated, paper follow up
will be required, so please always save your itemized receipts.
IRS Over the Counter (OTC) Regulation
FSA funds cannot be used to purchase OTC drugs and medicines (for example, Advil, ibuprofen, cough syrup),
unless you have a prescription from your doctor. If you do get a prescription for an OTC drug or medicine, the IRS
prohibits use of the SHDR Benefit Access Card. You must pay for these expenses and then submit a manual claim
for reimbursement.
You do not need a prescription form to use your FSA funds to purchase OTC items that are not considered a drug
or a medicine (for example, bandages, wound care, contact lens solution). Your SHDR Benefit Access Card can be
used for these purchases.
How to File a Claim
If a service provider does not accept the SHDR Benefit Access Card, you can always submit a claim for reimbursement.
Claim forms are available at www.shdr.com/flex or by calling Benefits On Call at 863-687-1499, or at extension 1499
if calling within Lakeland Regional Health. To be reimbursed for a Dependent Day Care or Health Care expense,
mail or fax a SHDR Claim form along with your receipt to the address or fax number shown on your claim form.
Once the claim is processed, a check will be issued or a direct deposit will be sent to your designated account
(direct deposit forms can be found at www.shdr.com/flex). If there is not enough money in your Dependent
Day Care Flexible Spending Account to cover the claim, the unreimbursed balance will be paid after additional
deposits have been made. Reimbursement of health care expenses will be the actual expense or the amount of
your annual contribution balance, whichever is less.
[43]
Health Care and Dependent Day Care Flexible Spending Accounts
IRS Limitations
Once you decide the amount you want to deposit, you cannot change this contribution amount unless there is a
qualified change in status (see page 18). You will forfeit any unused balance if you do not incur enough eligible
expenses by the end of the year, or you do not file your eligible claims by March 31st of the following year. If you
set up both types of accounts, you cannot transfer money from one account to another. By planning carefully and
keeping receipts, you will avoid forfeitures, and these limitations will not be a problem.
Health Care Flexible Spending Account
This account helps you pay for most health care expenses not covered by
your medical, dental or vision plans. This includes out-of-pocket copays,
coinsurance and deductible payments, as well as amounts over Usual and
Customary charges.
But you cannot use it to pay for expenses such as medical plan premiums,
cosmetic procedures or memberships to a health club. A list of Eligible and
Ineligible expenses can be found at www.shdr.com/flex.
Even if you do not participate in a medical, dental or vision plan, consider
the Health Care Flexible Spending Account to help you pay for eligible health
care expenses not covered by insurance.
For a complete list of the types of medical expenses that are eligible, see IRS
Publication 502, Medical and Dental Expenses. To request a copy, call the IRS at
800-829-3676, or visit www.irs.gov/irs-pdf/p502.pdf.
Dependent Day Care Flexible Spending Account
Families of today do not look like traditional households of the past. But all
of the different arrangements, such as working parents with young children
or those with a disabled dependent (as defined by the IRS) of any age, have
one thing in common — the need for Dependent Day Care. To help you with
the cost of such care, Benefits provides you the option of a Dependent Day
Care Flexible Spending Account.
This option is an alternative to the tax credit you may be eligible for on
your federal income tax return. Generally, you will save more money using
a Dependent Day Care Flexible Spending Account than you would with a tax
credit. However, you should consult a tax advisor to see which method is
better for you.
FSA funds can no longer
be used to purchase OTC
medications unless you have a
prescription from your doctor.
If you experience a
corresponding qualified change
in status and stop contributing
to your Flexible Spending
Account(s), you will not be
reimbursed for charges incurred
after the effective date of your
qualified change.
The Dependent Day Care
Flexible Spending Account is
a tax-free way to pay for the
cost of Dependent Day Care
expenses that enable you and
your spouse (if applicable) to
work.
Using the Dependent Day Care Flexible Spending Account
You can use this account for your children under age 13 and elderly or disabled dependents, regardless of age, who
live with you for more than eight hours a day and are claimed as dependents on your tax return.
Dependent Day Care can be provided in the home or in a day care facility outside the home. Inpatient care charges
will not be reimbursed from this account since the dependent must return to your home each day. The care may
be provided by a babysitter, a licensed day care facility or a relative.
[44]
However, this account may not be used to pay anyone who is considered your dependent for income tax purposes,
such as a grandmother living with you.
To be eligible for reimbursement, the care provider must provide you with an itemized bill or a paid receipt
including the date the services were performed and their tax identification number or social security number.
(Further, this provider must report this income to the IRS because it is subject to taxation.)
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
OUT-OF-POCKET COSTS
ELIGIBLE FOR REIMBURSEMENT
> A licensed child care or adult day care center
OUT-OF-POCKET COSTS
NOT ELIGIBLE PER IRS
> D
ependent Day Care that your spouse, whose work
hours differ from yours, could provide
> A
babysitter in or out of your home
(work-related only)
> Expenses for overnight camp
> E lder care for an IRS-eligible dependent who
lives with you
> E xpenses paid by another organization or services
provided at no cost
> Summer day camp
> T ransportation to or from the Dependent Day Care
location
> P
ayment to a relative who cares for dependents,
as long as that relative is age 19 or older and not your dependent for income tax purposes
> A
gency finder fees and charges for referral to day
care providers
> E xpenses you incur while you are away from work
because of an illness or leave of absence
> Kindergarten
For a complete list of the types of Dependent Day Care expenses that are eligible, see IRS Publication 503, Child and Dependent Day
Care Expenses. To request a copy, call the IRS at 800-829-3676, or visit www.irs.gov/irspdf/p503.pdf.
According to IRS regulations, if you or your spouse go on a leave of absence you will not be reimbursed for
Dependent Day Care expenses incurred during that time and you cannot decrease your contribution, so please
plan accordingly.
REMINDER, the amount of your actual tax savings will vary based on your pay, number of exemptions, tax filing
status and total adjusted gross income.
Consult with your tax advisor for your specific tax circumstances.
Reimbursement After You Leave the Plan
If your participation in the plan ends (for example, if your employment ends, you become ineligible to participate
in the plan or experience a family status change and decide to stop participating), you can be reimbursed only for
eligible health care expenses incurred before the event date.
You may be eligible for COBRA continuation coverage if you have a balance in your Health Care Flexible Spending
Account and eligible expenses at the time of termination. To be eligible for reimbursement for expenses incurred
after the benefit is stopped (but during the remainder of the calendar year), you may continue your coverage
under COBRA by making after-tax contributions. If you do not choose COBRA, you will have 90 days after your
benefit participation stops to submit receipts for reimbursement.
[45]
Short Term Disability Plan
When an illness or injury occurs, you need to replace part of your income until you recover.
Lakeland Regional Health automatically provides Short Term disability coverage at no cost to
you and the option to buy enhanced coverage.
Short Term disability coverage is designed to continue a portion of your income if you cannot work because of
illness, injury or pregnancy. And as part of ChoiceBenefits, you also have the opportunity to buy enhanced Short
Term disability coverage, which will increase the amount of income that will be paid to you.
Short Term Disability Coverage
Lakeland Regional Health automatically provides you with a Short Term disability plan at no cost to you. For each
approved claim, the plan pays 66 ⅔% of your base pay for up to nine weeks if you cannot work due to an accident,
sickness or pregnancy. There is a four-week waiting period before benefits begin. During this waiting period, you
must use your available ETO hours or your available Personal Illness Bank (PIB) hours.
Optional Enhanced Coverage
Because some employees may need a greater percentage of their pay replaced during their disability, ChoiceBenefits
offers an enhanced Short Term disability option that you can buy. With the enhanced option, the benefit paid,
when combined with the basic coverage, will provide you with 100% of your base pay for up to nine weeks following
the four-week waiting period. How much you pay for this plan is based on program pay (program pay is described
on page 13) — not your age.
Pre-existing Condition Limitation
There is no pre-existing condition limitation for the
basic Short Term disability coverage. However, a pre-
For each approved claim, benefits will be
paid after a four-week waiting period.
existing condition limitation will apply to the enhanced
Short Term disability option if you waive this additional
coverage when first eligible and buy it later.
[46]
For more information about the Short Term
disability plan, dial Benefits On Call at
863-687-1499 or extension 1499 if calling
within Lakeland Regional Health.
How Short Term Disability Benefits Will Be
Taxed
The IRS requires that you pay income taxes on
both the Short Term disability benefits provided
by Lakeland Regional Health and on the enhanced
benefits you may purchase. These payments will be
reported as taxable income on a separate W-2 form
issued directly to you from the insurance company.
The insurance company will withhold income taxes
for you.
Benefit Offset
The Short Term disability benefit paid will
be reduced by workers’ compensation
benefits or any other type of income you
may be eligible to receive.
Should You Choose The Enhanced
Short Term Disability Plan?
Before deciding if the enhanced Short Term
disability option is for you, ask yourself:
> W
ould 66 ⅔% of my base pay be enough to meet
daily living expenses if I get sick and cannot
work? Or would my family need 100% of my base
pay continued?
>Do I have any other sources of income if I cannot
work, even for a short time?
> Do I want to pay for additional coverage in return
for 100% of my base pay?
NOTE: You also must take your available Personal
Illness Bank (PIB) hours (not applicable for new
hires) or accrued ETO to make up the difference
in income not provided by the basic Short Term
disability plan.
If you waive coverage now and elect the enhanced
Short Term disability option later on, a pre-existing
condition limitation will apply. At this time, you will
also be required to complete a Personal Health
Application. You will be required to pay for any costs
associated with the Personal Health Application
process. Coverage and premiums will begin upon
approval from the insurance company.
[47]
Long Term Disability Plan
To guard against financial loss from a disability, Benefits offers four Long Term Disability (LTD)
options, so you can tailor this coverage to your needs.
Option: Amount Paid: Option 1 50% of base pay less your primary and family When Benefits Begin:
3 months
Social Security benefit (or other disability income)
Option 2 66 ⅔% of base pay less your primary and family 3 months
Option 3 50% of base pay less your primary and family 6 months
Option 4 66 ⅔% of base pay less your primary and family 6 months
Each option provides a maximum monthly benefit of up to $15,000 and a minimum monthly benefit of $50.
Evidence Of Insurability (EOI)
EOI will not be required if you are electing LTD coverage when you are first eligible for ChoiceBenefits. However, if
you have previously waived LTD coverage and are now electing it, proof of good health will be required before your
LTD election will go into effect. EOI will also be required if you choose to either reduce your elimination period or
increase your coverage.
If EOI is required, a form must be completed. You will be required to pay for any costs associated with the EOI
process. Coverage and premiums will not begin until Lakeland Regional Health receives approval from the carrier.
For further information, call the insurance carrier directly, or simply dial Benefits On Call at 863-687-1499 or at
extension 1499 if calling within Lakeland Regional Health.
Pre-existing Condition Limitation
The LTD Plan has a pre-existing condition limitation. This limitation will apply to
everyone who enrolls. It applies to any disability for which you receive medical
treatment, services or supplies during the 90-day period before your effective
date of insurance, or the effective date of a change in coverage.
Keep in mind that at the time you become disabled, if you have not received
medical care for the disabling condition for 90 consecutive days while insured
under this plan, or you have been continuously insured under this plan for 365
consecutive days, you will have satisfied your pre-existing condition limitation.
[48]
The LTD Plan will
replace a percentage
of your annualized
base pay if you cannot
work because of a total
disability due to illness,
injury or pregnancy.
This limitation applies if you:
> h
ave not satisfied your pre-existing limitation
period before the effective date
> buy this coverage after you first become eligible
> increase coverage from 50% to 66 ⅔%
Short Term and Long Term Disability Coverage:
Putting it All Together
> change to a plan option with a shorter waiting
period
Together, Short and Long Term disability coverage
can give you more complete protection. Here’s
how:
If You Go On A Leave Of Absence
> Assume you elect LTD Option 1 or 2, which has a
three-month wait before benefits begin.
You can continue LTD coverage for up to three
months during an approved leave of absence,
other than a disability leave, by simply paying
the premiums while on leave. If your date of
disability occurs within the three months after
your leave begins, disability claims filed will
be accepted as long as premiums are paid in a
timely manner.
If you are on disability leave, you must still
continue to pay your premiums during any
elimination period.
How Benefits Will Be Taxed
Since you pay for this coverage with tax-free
dollars, the IRS requires you to pay income taxes
on any benefits paid to you for a disability. These
payments will be reported as taxable income on
a separate W-2 form issued to you directly from
the insurance company. The insurance company
can withhold income taxes for you, and they will
give you this option before payments are made.
Benefit Offset
As you can see in the chart below, the LTD benefit
paid will be reduced by certain benefits including
(but not limited to) primary and family Social
Security benefits and workers’ compensation
benefits. However, you will receive a minimum of
$50 a month from the LTD option you select. For
more information about the offsets that would
apply, call Benefits On Call at 863-687-1499 or at
extension 1499 if calling within Lakeland Regional
Health.
> You have basic or enhanced Short Term
disability coverage.
Should you experience a Long Term disability,
benefits would be paid — and part of your salary
would be continued — for the entire time except
for the initial 4-week waiting period. During the
waiting period, you must use your ETO hours (or
available PIB hours) to cover this period. However,
if you select either of the six-month waiting period
LTD options, there will be a three-month period
when no disability income will be paid to you.
LTD Benefit Example
To show you how LTD benefits would be determined and
how the benefit offset works, let us assume that you select
LTD Option 3, which provides you with 50% of base pay (less
offsets), beginning after a six month waiting period. We will
assume that at the time of your disability, your base pay is
$3,200 a month and you qualify for $1,200 in Social Security
disability benefits for you and your family. Here is what you
would receive from these two sources:
Monthly LTD benefit from ChoiceBenefits (50% x $3,200)
(Less Social Security benefits you’ll receive)
$1,600
-1,200
Total Monthly Benefit From ChoiceBenefits LTD Option 3
$ 400
[49]
Term Life Insurance
Having life insurance means your beneficiaries will have some financial protection if something
should happen to you.
Term life insurance is “pure” insurance. This means it does not provide any other financial benefits other than a
payment to your beneficiary if you die while covered by the plan.
Basic Term Life
Lakeland Regional Health automatically provides you with $10,000 of term life insurance at no cost to you. This
amount is paid when your named beneficiary files a valid claim form notifying Lakeland Regional Health of your
death.
Supplemental Term Life
ChoiceBenefits allows you the option to increase the amount your beneficiary will receive by purchasing
supplemental term life insurance. Your options are:
> $5,000 > 4 x annualized program pay
> 1 x annualized program pay > 5 x annualized program pay
> 2 x annualized program pay > 6 x annualized program pay
> 3 x annualized program pay > No supplemental coverage
Annualized program pay is calculated by multiplying your authorized hours times your program pay (see page 13
for a definition of program pay). Life insurance coverage is rounded to the next highest thousand. The maximum
amount of coverage is $1,250,000.
Imputed Income
Federal regulations require you to pay imputed income tax and Social Security
tax on the total value of life insurance in excess of $50,000. The value assigned to
employee life insurance in excess of this amount is considered taxable income,
and appropriate taxes are withheld from your paycheck.
The value of life insurance is determined according to the IRS schedule. The IRS
assigns a higher value to life insurance as you get older. As your age increases,
so does the cost of your life insurance. Keep in mind, life insurance is meant to
provide for your beneficiaries. Even if you are required to pay imputed income
tax, select the coverage level that best reflects the needs of your beneficiaries.
[50]
Changes in your pay
during the year will not
affect your program
pay for life insurance.
To name your
beneficiary for your
term life insurance
coverage, you will
need to complete the
Beneficiary Designation
Form that is available
online or in the
Benefits Department.
Life Insurance Evidence Of Insurability (EOI)
You can increase (or decrease) your coverage during annual
enrollment. But when doing so, you should know when the
insurance company requires evidence of insurability, or medical
proof of good health.
Evidence of Insurability (EOI) will be required if:
> y ou increase coverage by more than one level (for example,
you go from 3 x to 5 x annualized program pay) during annual
enrollment
> t he election you make results in your total coverage exceeding
$500,000
> you waived coverage in the past and elect it in the future
If your election requires evidence of insurability, a form must be
completed. You will be required to pay for any costs associated
with the EOI process. Coverage and premiums will begin when
Lakeland Regional Health receives approval from the insurance
company.
To Change Your Beneficiary
Remember, events such as marriage,
divorce or the birth or death of a
dependent may require a change
in your beneficiary designation.
To change your beneficiary for life
insurance, complete a change form
(available on ESS) and submit it to
the Benefits Department.
If you qualify, your premiums may
be waived if you become disabled
prior to age 60.
Accelerated Benefit
Benefits life insurance coverage for you includes an accelerated
benefit. This provides a one-time advance payment of up to 80%
of your coverage up to $500,000 in the event of a terminal illness
prior to age 60, providing you an additional source of income if
you become terminally ill.
While this option is not Health or Long Term care insurance, it
can help you financially during a difficult time.
To be eligible for this benefit, you must provide satisfactory
proof certified by a doctor to the insurance company that your
life expectancy is 12 months or less. For benefits to be paid, the
insurance company must have accepted this doctor’s proof.
The accelerated benefit is payable only once and will permanently
reduce the amount of life insurance payable to your beneficiary
when you die. For example, if you have a $100,000 policy and
receive $80,000 as an accelerated benefit, your beneficiary will
receive the remaining $20,000 upon your death. You continue to
pay the premiums on the reduced coverage amount.
Before using this option, check with a tax advisor concerning the
taxability of the advance payment of life insurance proceeds. To
apply for this benefit, contact the insurance company.
[51]
Dependent Life Insurance
ChoiceBenefits also provides you with an opportunity to purchase life insurance
on your dependents as follows:
For your spouse For your dependent children
$10,000
$ 5,000
$20,000$10,000
$30,000$15,000
$40,000
$50,000
For dependent children, the total premium amount is the same regardless
of the number of children covered. The definition of a dependent excludes
a child in full time active military service. If you are adding a dependent
during the program year due to a qualified change in status, coverage
will begin on the first day of the month following the date the Qualified
Change in Status form is received by the Benefits Department, as long as
you elect coverage for that person within 30 days of the change. However,
if you are adding a dependent due to birth/adoption or custody change,
coverage will begin on the day the status change occurs, as long as you
elect coverage for that dependent within 60 days of the change.
By law, dependent life insurance purchased through group plans cannot
exceed 50% of your total basic and supplemental life insurance coverage
amounts.
Evidence Of Insurability (EOI)
The insurance company does not require (EOI) for dependent children
or for your spouse if you choose coverage when you are first eligible.
Evidence of insurability for spouse coverage is required if you either
waived coverage in the past or elect more than a one level increase during
annual enrollment.
If your spousal election requires evidence of insurability, a form must be
completed. You will be required to pay for any costs associated with the
EOI process. Coverage and premiums will begin when Lakeland Regional
Health receives approval from the insurance company.
[52]
For a total range of
protection, ChoiceBenefits
offers dependent life
insurance for your
spouse and each eligible
dependent. The IRS
requires you to pay the
premium for this option
with after-tax dollars.
If you qualify, your
dependent premiums may
be waived if you become
disabled prior to age 60.
Accelerated Benefit is also
available if your dependent
becomes terminally ill.
Accidental Death and
Dismemberment Coverage
Taking precautions against accidents is the best way to avoid them. But if the
unavoidable should happen, AD&D coverage is an added financial resource. It
pays benefits if you die or lose a limb, eye, speech, hearing or thumb and index
finger in an accident.
The full benefit amount you elect is paid to your beneficiary if you die, or to
you if you lose two or more limbs, such as a hand and a foot. If you lose a limb,
you will receive half of the full benefit. If you lose a thumb and index finger,
you will receive one-fourth of the full benefit.
Lakeland Regional Health automatically provides $10,000 of AD&D coverage at
no cost to you.
AD&D coverage choices are:
$ 25,000
$200,000
$ 50,000
$250,000
$100,000$300,000
$150,000
No additional coverage
Covering Your Dependents
If you select AD&D coverage for yourself, you may also select it for your
dependent(s). Their coverage will depend on the amount of coverage you have
chosen for yourself and your family status at the time a claim is submitted.
AD&D offers you
another layer of financial
protection.
To name your beneficiary
for the AD&D coverage you
select for yourself, you will
need to complete the
Beneficiary Designation
Form that is available
online or in the Benefits
Department. You are the
named beneficiary for your
dependents.
Dependent Coverage
FAMILY STATUS AT TIME OF CLAIM: AD&D COVERAGE AMOUNT:
Spouse only 50% of your coverage
Spouse and children 40% of your coverage
for your spouse plus 10%
for each child
Children only 15% of your coverage for each child
Additional benefits may also be payable for permanent paralysis, coma and
if the covered loss occurs while wearing a seat belt in an automobile. In the
event of the employee’s accidental death in a covered accident, child and
spouse education benefits and a daycare benefit may be payable.
[53]
Long Term Care Insurance
In 2012, the average annual cost of nursing home care in the United States was $81,030 ($6,752
per month or $222 per day) for a semi-private room. The average annual cost for assisted living
was $42,600 ($3,550 per month or $117 per day). The average cost of a nursing home for one
year is more than the typical family has saved for retirement in a 401(k) or an IRA.1
Designing your John Hancock Custom Care III LTC insurance policy is easy2. Simply choose from each of the following
categories to build a policy that meets your specific needs.
Benefit Amount
Your Benefit Amount represents the amount of money that your policy
will provide to cover your Long Term Care needs on a daily or monthly
basis. If you know where you plan to live after you retire, you should
factor in the cost of care in that area.
Daily Benefit Options: $50–$300 per day
Monthly Benefit Options: $1,500–$9,000 per month
Benefit Period
Your Benefit Period represents the minimum period of time (years) you
can expect your coverage to last: 2 years, 3 years, 4 years, 5 years, 6 years,
or 10 years.
Elimination Period
The Elimination Period on your LTC insurance policy is like a deductible.
You pay for the cost of your care for a certain number of days before the
policy coverage begins. This helps to reduce the annual cost (premium)
of your policy. (30 days, 60 days, 90 days, or 180 days) The longer the
elimination period, the lower the premium.
What is Long Term Care?
Long Term Care is a range of services
and supports you may need to
meet your personal care needs.
Most Long Term Care is not medical
care, but rather assistance with the
basic personal tasks of everyday life,
sometimes called Activities of Daily
Living (ADLs), such as:
> Bathing
> Dressing
> Using the toilet
> Transferring
(to or from bed or chair)
> Caring for incontinence
> Eating
A Traditional Policy could be designed as:
Benefit Amount: $3,600 month
Benefit Period: 3 years
Elimination Period: 90 days
> A 45-year-old married female would have a rate of $38 per pay period.
> A 50-year-old single male would have a rate of $58 per pay period.
> A 60-year-old married male would have a rate of $55 per pay period.
These are sample rates. Each policy is custom designed and based on
age and health.
1. 2012 MetLife Market Survey of Nursing Home, Assisted Living, Adult Day Services, and
Home Care Costs, Metlife Mature Market Institute
2. Lakeland Regional Health is not endorsing or recommending this insurance. Choosing
Long Term Care coverage is a personal decision.
[54]
Additional Stay At Home Benefits
Your policy provides extra
funds to pay for the following
home-based services:
> Home modifications
> Durable medical equipment
> Caregiver training
> Home safety checks
> Provider care checks
> Medical alert systems
Legal Services Plan
When you think of legal services, what comes to mind? Estate
planning? Will preparation? Legal consultations? Whatever
you envision, chances are it is covered by the legal plan. In
fact, the Legal Services Plan can meet most people’s basic
legal needs.
The IRS requires you to
pay for this option with
after-tax dollars.
The Legal Services Plan, which is administered by Hyatt Legal Plans, Inc., provides personal legal services for you
and, if elected, for your spouse and dependent child(ren). If you choose this option, the plan will pay attorney fees
for covered services. You can use:
> one of the participating law firms in Hyatt’s network, which allows Hyatt Legal Plans to make the full payment
for covered matters directly to the attorney
> an attorney of your choice who is not in the network, and the plan will reimburse you for covered services based
on Hyatt’s fee schedule
How It Works
If you need legal counsel, call Hyatt Legal Plans’ Client Service Center by dialing Benefits On Call at 863-687-1499,
or at extension 1499 if calling within Lakeland Regional Health. You will need to identify yourself as a participant
in Lakeland Regional Health’s Legal Services Plan and give your Social Security number. (Your spouse or child will
need to provide your Social Security number for access.)
The Client Service Representative who answers your call will:
> verify your eligibility for services
> make an initial determination of whether, and to what extent, your case is covered (the Hyatt Legal Plan attorney
will make the final determination of coverage)
> give you a case number (you will need a new number for each new case you have)
> answer any questions you have about the Legal Services Plan
Then, you will have these three choices for contacting an attorney:
> The Client Service Representative can give you the telephone numbers of the Plan Attorneys most convenient to
you. You then call the Plan Attorney to schedule an appointment.
> During the call to Hyatt’s Client Service Center, you can request to select your own attorney. If your attorney is
not a member of Hyatt’s network, you will be sent a packet of information including a current fee schedule and
reimbursement form. When you return the reimbursement form with a copy of the attorney’s final fee statement,
covered services will be reimbursed according to the fee schedule. Once Hyatt receives the reimbursement
request form, a check will be sent to you within 10 days.
> You can also visit Hyatt as a Member or as a Guest on their website at www.legalplans.com. The user name and
password for access to legal services is: lrmc. If you are a Member, click on “Members Only” to get a listing of
what benefits are covered, find an attorney on “Attorney Locator” or obtain an authorization number. If you are
thinking about enrolling, click on “Thinking about Enrollment” and use 2290010 as your password for Family Plan
or 2270010 as your password for a Single Plan.
[55]
Legal Services Plan
For Emergency Service
In an emergency situation, you may call the same toll-free hotline, 800-821-6400, between the hours of 8:00 am
and 7:00 pm. Monday through Friday Eastern time. You may also leave a message during non-business hours. Your
call will be returned the next business day.
How Services Are Paid
Attorney fees for all covered services (except personal injury and probate) are paid in full when you use a Plan
Attorney. If you prefer to select an out-of-network attorney, you will receive reimbursement based on a set fee
schedule that Hyatt will send to you after you speak with a Client Service Representative.
If you retain a Plan Attorney to handle a personal injury case, the Plan Attorney’s fee will be a maximum of 25% of
the gross award. If you retain a Plan Attorney to handle a probate matter, the Plan Attorney’s fee will be 10% less
than the prevailing fee. In both circumstances, you are responsible for paying this reduced fee. These reductions
do not apply to out-of-network attorneys.
What The Legal Plan Covers
Here is a brief look at what the legal plan covers. This coverage includes full representation, including complete
coverage for trials; however, certain limits apply. For specific details and benefit definitions, call Hyatt Legal Plans
at 800-821-6400.
LEGAL PLAN SERVICES: IN-NETWORK ATTORNEY FEES COVERED/ OUT-OF-NETWORK
ATTORNEY FEES COVERED UP TO FEE SCHEDULE:
Advice And Consultation Office Consultation • Telephone Advice
Criminal Matters Expungement • Habeas Corpus
Debt Matters Debt Collection Defense • ID Theft Defense • Personal Bankruptcy
Defense Of Civil Lawsuits Administrative Hearing Representation • Civil Litigation Defense
Document Preparation Affidavits • Deeds • Demand Letters • Elder Law Matters • Mortgages • Notes
Document Review Personal Legal Documents
Family Law Name Change • Prenuptial Agreement • Protection From Domestic
Violence • Uncontested Adoption/Uncontested Guardianship
Home Equity Loans Document Preparation or Review for Your Primary Residence Only
Personal Injury (Reduced fees in-network)
Real Estate Matters Eviction Defense • Refinancing Of Home • Sale Or Purchase Of Home
• Tenant Negotiations (as Tenant)
Wills And Estate Planning* Living Trusts • Living Wills • Powers Of Attorney
• Probate (reduced fee in-network) • Wills And Codicils
*Services do not include tax planning.
[56]
Employee Assistance Plan (EAP)
The EAP services are provided through Aetna Resources for Living, an independent organization.
The EAP offers a wide range of confidential services and resources to help you and your family
successfully deal with life’s challenges and time-consuming demands. The EAP benefit is available
to all Lakeland Regional Health employees, regardless of employment status.
You and your family members have access to unlimited short term counseling (1-5 visits per issue; unlimited
issues); counselors are available 24 hours a day, 365 days a year.
Following are examples of the types of confidential counseling offered:
• Stress management
• Emotional issues
• Work/Life balance
• Substance abuse
• Parenting challenges
• Social development
• Anxiety and depression
• Relationships
• Legal and financial matters
For additional information about EAP Services, log onto the EAP website at www.horizoncarelink.com
(login = lrmc, password = lrmc) or call 800-272-7252.
In addition to counseling services, the EAP provides the following memberships and discounts at no cost to
the employee.
Web Service Including Discounts:
Mylifevalues.com – Password: LRMC | Login: LRMC
· Over 5,000 Resources on a Variety of Life Balance Topics
· Over 100 Webinars for Work Life and Home Life Issues
· Discount Center and Shopping Coupons
Legal Services | Financial Services:
· 30 Minutes Free Per Issue – Unlimited Issues
· 25% Discount on the Hourly Rate Thereafter
· Free Online Legal Templates
· Free Online Will Kit
· Online Legal Templates
· Identify Theft Resolution Consultation Services
You are encouraged to take full advantage of all of the services available to you and your dependents under
the Employee Assistance Program.
Educational Assistance Plan
You may be eligible for a reimbursement up to $5,000 per fiscal year (October 1 – September 30) to offset the
cost of continuing your education.
The plan is administered by the Talent Division, Compensation Department. Complete details of this program
are described in the Lakeland Regional Health Education Assistance Policy (#1.32.001). Applications are
available online via Employee Self Service (ESS) and must be completed and approved by the Talent Division
prior to starting classes.
[57]
Retirement Plans
Lakeland Regional Health provides an effective way to supplement your retirement income
by offering you a number of unique opportunities to save for your retirement. The retirement
program includes two separate plans:
1)
The LRHMC 401(a) Retirement Plan, established in 1989, in which Lakeland Regional Health may make
contributions to a special Retirement Plan Account established on your behalf; and
2)
The LRHMC 403(b) Plan, which allows you to make tax-deferred contributions and/or after-tax Roth
contributions. (Matching contributions may also be made by Lakeland Regional Health.)
401(a) Retirement Plan
PLAN ELIGIBILITY Employees must complete 12 consecutive months of service and accumulate at least 1,000
hours of service within the 12-month period. Upon completion of these requirements, you will become an active
participant in this plan on the next January 1st, April 1st, July 1st, or October 1st. If you do not earn 1,000 hours of
service in the first 12 months of employment, you will be eligible to join the Plan on January 1st of the following
Plan year (calendar year) in which you do meet this service requirement.
EMPLOYER CONTRIBUTIONS Once you meet eligibility requirements, Lakeland Regional Health contributes to a
401(a) retirement account on your behalf in the amount of 3% of your eligible earnings subject to the IRS Annual
Compensation Limit.
Eligible employees must be employed by Lakeland Regional Health on the last day of the Plan year (with an
exception for retirement, death and/or disability) and be credited with at least 1,000 hours of service in the Plan
year to receive the 401(a) contribution.
Contributions are made annually to the 401(a) Plan after the close of each Plan year which is December 31st.
VESTING SERVICE Vesting service for the 401(a) Plan starts on your date of hire (not the date you become eligible
to participate). For each plan year (calendar year) that you complete 1,000 hours of service, you will be credited
with one year of vesting service.
Once you have completed three calendar years of vesting service, you will be 100% vested. This means you own
your entire 401(a) plan account balance, including investment earnings, as part of your retirement savings and
have full access to this money if you leave Lakeland Regional Health.
DISTRIBUTION OPTIONS If you choose to sever your employment from Lakeland Regional Health and are fully
vested in the plan, you can take your plan account balance with you. You can roll it into an Individual Retirement
Arrangement (IRA) or another eligible retirement plan without incurring income tax, or you can receive a lump
sum payout subject to withholding taxes and possible early withdrawal penalties.
[58]
403(b) Tax Deferred Plan With Roth Option
Lakeland Regional Health offers a tax-deferred 403(b) contribution option as well as a Roth 403(b) (after-tax) contribution option.
Traditional 403(b) contributions are made on a pre-tax basis. Upon retirement, withdrawals of your contributions and the earnings
on those contributions are taxable.
Contributions to a Roth 403(b) are made on an after-tax basis. Upon retirement, withdrawals of your contributions and the earnings
on those contributions are tax-free.*
PLAN ELIGIBILITY All employees are immediately eligible to
contribute to the 403(b) Plan on a pre-tax and/or after-tax basis.
AUTO-ENROLLMENT (Effective January 1, 2015) New employees
will be automatically enrolled in the 403(b) Plan at a 4% pre-tax
contribution rate 30 days following their date of hire. Employees
can opt-out of participation or change this contribution rate at
any time. Subject to federal regulations, employees who opt out
may withdraw contributions within 90 days of the first salary
reduction contribution. If you wish to contribute at a higher
contribution rate, or if you wish to make after-tax contributions,
you must enroll directly with Fidelity either online or by phone.
AUTO-ESCALATION OF CONTRIBUTIONS (Effective October
2015) The 403(b) Plan tax-deferred option includes an annual
automatic escalation feature of 2%, up to a maximum of 10% of
earnings. Employees can opt-out of participation or change the
contribution percentage at any time.
CONTRIBUTION LIMITS The IRS contribution limit is set annually.
The 2015 limit will be $18,000. Participants may make both pretax and after-tax contributions; your combined contribution
total will count towards the IRS contribution limit. Participants
who are age 50 and older may contribute up to an additional
$6,000 in 2015.
EMPLOYER MATCH Lakeland Regional Health will offer a 50%
match on your contributions into your 403(b) account up to a
maximum of 2%, subject to the IRS Annual Compensation Limit.
Therefore, you will need to contribute at least 4% of your annual
earnings in order to obtain the maximum 2% Employer Match.
Your contributions can be pre-tax, after-tax or any combination
of the two as long as you contribute at least 4%. Lakeland
Regional Health will contribute matching funds into your 403(b)
account each pay period.
ELIGIBILITY FOR EMPLOYER MATCH To be eligible for your 403(b)
Employer Match, you must be an eligible participant in the
401(a) Retirement Plan.
OTHER CONTRIBUTIONS If you have a retirement savings
account from a previous employer, you can immediately rollover
eligible contributions from that plan.
VESTING SERVICE You are always 100% vested in your 403(b)
contributions. Vesting rules for the 403(b) Plan Employer Match
are the same as the 401(a) Retirement Plan vesting rules.
DISTRIBUTION OPTIONS
ROLLOVER Upon termination of employment you can rollover
your 403(b) contributions into an Individual Retirement
Arrangement (IRA) or another eligible plan without incurring
income tax.
LUMP SUM DISTRIBUTION You can receive a lump sum
payout of your pre-tax contributions and any associated
earnings subject to withholding tax and possibly early
withdrawal penalties.
*If you receive a “qualified distribution” of your Roth account, the entire
distribution (that is, your Roth contributions AND the earnings on your Roth
contributions) will not be taxed. A “qualified distribution” is a distribution
that satisfies the “5-year rule” and is made after your attainment of age
59 ½, death or disability. The 5-year rule is met if five calendar years have
passed since you first made a contribution to your Roth 403(b) Salary
Deferral Account.
The same distribution options apply to the Employer Match, provided
you have met the vesting requirements as defined under the 401(a) Plan.
Employer Match is subject to withholding tax and possibly early withdrawal
penalties.
MEET WITH ON-SITE FIDELITY REPRESENTATIVE
Please schedule an appointment with our on-site Fidelity Representative for further guidance. You may schedule
online at www.fidelity.com/reserve or by phone at 800-642-7131. The dates when the on-site Fidelity Representative
will be available are posted on the Intranet Home Page.
[59]
Customer Service Contacts
Simply call Benefits On Call at 863-687-1499 or extension 1499 if calling within Lakeland
Regional Health, to access the various customer service representatives of Lakeland
Regional Health’s Benefits Program, or you may use the following information to contact
them directly.
CUSTOMER SERVICE REPRESENTATIVE
Stanley, Hunt, Dupree and Rhine (SHDR) — for Health Care/Dependent Day Care FSA Accounts
CONTACT INFORMATION:
800-930-2441
www.shdr.com/flex
Cigna Healthcare — for Medical Plan
800-244-6224 www.myCigna.com
Teledrug800-835-3784
Colonial — for the Cancer Plan
Michael Wiggs
800-325-4368 www.coloniallife.com
813-737-1620 (office)
Fidelity Investments — for Retirement Plan
800-343-0860
www.fidelity.com/atwork
Delta Dental for DeltaCare USA dental plan (group 06725) &
DeltaCare USA: 800-422-4234
Delta Dental PPO Plan (group 16033)
Delta Dental PPO: 800-521-2651
www.deltadentalins.com
Humana Specialty Benefits — for the Humana VisionCare Plan-VCP
866-537-0229
www.humana.com/custom_clients/lrmc
The Hartford Life Insurance Company — for Term Life
Insurance, Dependent Life and AD&D Insurance
888-563-1124
www.thehartfordatwork.com
The Hartford Life Insurance Company — for the Short Term
and Long Term Disability Plans
800-445-9057
www.thehartfordatwork.com
Aetna Resources for Living — for the EAP
800-272-7252
www.horizoncarelink.com
Hyatt Legal Services, Inc. — for the Legal Services Plan
800-821-6400
www.legalplans.com
Long Term Care
Jeanetta Bryant
904-651-4822
Aon Hewitt (for dependent verification)800-725-5810 (phone)
877-965-9555 (fax)
[60]
2015 Calendar
January
S M T W T F S
1
23
4 5 6 7 8 9 10
11 12 13 14 1516 17
18 19 20 21 2223 24
25 26 27 28 2930 31
Payroll Pay Days
S
1
8
15
22
February
M T W T F S
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9 10 11 12 13 14
16 17 18 1920 21
23 24 25 2627 28
March
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8 9 10 11 12 13 14
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22 23 24 25 2627 28
29 3031
April
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3
4
5 6 7 8 9 10 11
12 13 14 15 1617 18
19 20 21 22 2324 25
26 27282930
May
S M T W T F S
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3 4 5 6 7 8 9
10 11 12 13 1415 16
17 18 19 20 2122 23
24 25 26 27 2829 30
31
July
S M T W T F S
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3
4
5 6 7 8 9 10 11
12 13 14 15 1617 18
19 20 21 22 2324 25
26 27 28 29 3031
August
S M T W T F S
1
2 3 4 5 6 7 8
9 10 11 12 13 14 15
16 17 18 19 2021 22
23 24 25 26 2728 29
3031
September
S M T W T F S
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6 7 8 9 10 11 12
13 14 15 16 1718 19
20 21 22 23 2425 26
27 282930
October
S M T W T F S
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11 12 13 14 1516 17
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25 26 27 28 2930 31
November
S M T W T F S
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15 16 17 18 1920 21
22 23 24 25 2627 28
2930
December
S M T W T F S
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6 7 8 9 10 11 12
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20 21 22 23 2425 26
27 28293031
June
S M T W T F S
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7 8 9 10 11 12 13
14 15 16 17 1819 20
21 22 23 24 2526 27
28 2930
[61]
The Patient Protection Affordable
Health Act (PPACA)
Dear Lakeland Regional Health Employee,
The Patient Protection Affordable Care Act (PPACA) was passed March 23, 2010. Along with the passing
came a number of new regulations aimed at making health care easier to understand. One such
regulation is the Summary of Benefit Coverage (SBC).
Group health plans such as Lakeland Regional Health’s are required to provide each employee
enrolled and eligible for medical coverage with a copy of the SBC. This SBC document should be
viewed as another valuable tool to help you understand and compare Lakeland Regional Health’s
health plan with any other plans you may be considering and to assist you in making the best benefits choice for you and your family.
In this booklet, you will find a SBC for the Cigna health plan offered by Lakeland Regional Health.
This document is also available online on Employee Self Service (ESS), and you may request additional copies from the Talent Division.
A brief overview of what is included in the SBC:
>S
ummary of Coverage: The SBC summarizes the key features of the plan or coverage, such as the
covered benefits, cost sharing provisions and coverage limitations and exceptions.
>C
overage Examples: The SBC includes “coverage examples,” much like the Nutrition Facts label
required for packaged foods. The coverage examples illustrate how our Cigna health plan will cover
the care for common benefit services such as pregnancy and managing diabetes. The coverage
examples are national estimates only and are not the actual cost of the services provided in the
examples.
>U
niform Glossary of Terms: The glossary is designed to help explain commonly used terms associated with health coverage such as “deductible” and “copayment.”
If you have any questions, please contact Talent Division at 863-867-1205, Monday through Friday,
9:00 am to 5:00 pm.
[62]
[63]
Coverage Period: 01/01/2015 – 12/31/2015
Coverage for: Individual | Plan Type: OAP
No. You don’t need a referral to see a specialist.
Do I need a referral to see a
specialist?
You can see the specialist you choose without permission from this plan.
Are there services this plan
doesn’t cover?
Some of the services this plan doesn’t cover are listed on page 6. See your
Yes.
policy or plan document (summary plan description) for additional
information about excluded services.
Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren’t clear about any of the bolded terms used in this form, see the Glossary.
1 of 8
You can view the Glossary at www.cciio.cms.gov or call 1-800-myCigna.com to request a copy.
Yes. For a list of participating providers, see
www.myCigna.com or call
1-800-Cigna24
If you use an in-network doctor or other health care provider, this plan will
pay some or all of the costs of covered services. Be aware, your in-network
doctor or hospital may use an out-of-network provider for some services.
Plans use the term in-network, preferred, or participating for providers in
their network. See the chart starting on page 2 for how this plan pays
different kinds of providers.
Why this Matters:
You must pay all the costs up to the deductible amount before this plan
LRH (Domestic): $0 person / $0 family
begins to pay for covered services you use. Check your policy or plan
document to see when the deductible starts over (usually, but not always,
Community Partners: $500 person / $1,500 family
January 1st). See the chart starting on page 2 for how much you pay for
covered services after you meet the deductible.
Other CIGNA OAP Providers:
Does not apply to preventive care, office visits, emergency room & urgent
$1,000 person / $3,000 family
care facility visits, prescription drugs.
You don’t have to meet deductibles for specific services, but see the chart
No.
starting on page 2 for other costs for services this plan covers.
LRH (Domestic): $500 person / $1,000 family
The out-of-pocket limit is the most you could pay during a coverage
Community Partners: $4,300 person/ $8,600 family period (usually one year) for your share of the cost of covered services
Other CIGNA OAP Providers:
(includes deductibles, co-payments and coinsurance for medical and
$5,800 person / $11,600 family
pharmacy). This limit helps you plan for health care expenses.
Premiums, balanced-billed charges, out-of-network
Even though you pay these expenses, they don’t count toward the out-ofclaims, penalties for failure to obtain prepocket limit.
authorization for services not covered.
The chart starting on page 2 describes any limits on what the plan will pay
No.
for specific covered services, such as office visits.
Answers
Does this plan use a network
of providers?
Is there an overall annual
limit on what the plan pays?
What is not included in
the out–of–pocket limit?
Is there an out–of–pocket
limit on my expenses?
Are there other deductibles
for specific services?
What is the overall
deductible?
Important Questions
www.myCigna.com or by calling 1-800-Cigna24
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
[64]
If you have a test
If you visit a health
care provider’s office
or clinic
Imaging (CT/PET
scans, MRIs)
Diagnostic test (x-ray,
blood work)
Other practitioner office
visit
Preventive care/
screening/immunization
Specialist visit
Primary care visit to
treat an injury or illness
Services You May
Need
No Charge
25% coinsurance
subject to $500
deductible
25% coinsurance
subject to $500
deductible
No Charge
No Charge
No Charge
Not Covered
$35 copay
$15 copay
Community
Partner
Not Covered
No Charge
No Charge
LRH
(Domestic)
30% coinsurance
subject to $1,000
deductible
Not Covered
Not Covered
Not Covered
No Charge
30% coinsurance
subject to $1,000
deductible
Not Covered
Not Covered
Not Covered
Out-of-Network
Provider
Not Covered
$50 copay
$25 copay
Other OAP InNetwork Provider
Your cost if you use:
See Note above
Note: for all applicable
radiologist/pathologist charges,
your cost is: LRH Provider: No
Charge, Community Partners:
25% coinsurance (no
deductible), Other OAP
Providers: 30% coinsurance
subject to $1,000 deductible
–––––––––––none––––––––––
In-Office Lab/Radiology not
included in co-pay
Chiropractic and Acupuncture
not covered
In-Office Lab/Radiology not
included in co-pay
Limitations & Exceptions
2 of 8
Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s
allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven’t met your
deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed
amount, you may have to pay the difference.. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount
is $1,000, you may have to pay the $500 difference (this is called balance billing).
This plan may encourage you to use participating providers by charging you lower deductibles, co-payments and co-insurance amounts.
Common Medical
Event




3 of 8
NONE
30% coinsurance
subject to $1,000
deductible
N/A
N/A
Per visit copay is
waived if admitted
Inpatient
Facility Fee:
$200 copay plus
30% coinsurance
Physicians:
25% coinsurance
Facility Fee:
$200 copay
plus 30%
coinsurance
Physicians:
25%
coinsurance
NONE
Emergency medical
transportation
30%
coinsurance
subject
to $1,000
deductible
Not Covered
NONE
If you need
immediate medical
attention
30%
coinsurance
subject
to $1,000
deductible
Facility Fee:
$100 copay
Physicians:
25%
coinsurance
Emergency room
services
No Charge
Physician/surgeon fees
25%
coinsurance
subject
to $500
deductible
(ded.
waived for
radiologists
and
pathologists)
Not Covered
Facility Fee:
$100 copay
Physicians: 25%
coinsurance
Facility fee (e.g.,
ambulatory surgery
center)
N/A
–––––––––––none––––––––––
Per visit copay is waived if
admitted Inpatient
Not Covered
Facility Fee:
$200 copay plus
30%coinsurance
Physicians:
25%coinsurance
30%coinsurance
subject to
$1,000
deductible
Not Covered
NONE
25% coinsurance
subject to $500
deductible
25% coinsurance
subject to $500
deductible
Facility Fee:
$200 copay plus
30%coinsurance
Physicians:
25%coinsurance
60% coinsurance
to $200 max
Facility Fee:
$100 copay
Physicians:
25%
coinsurance
No Charge
30%
coinsurance
to $150 max
If you have outpatient
surgery
More information about
prescription drug
coverage is available
at www.myCigna.com.
Not Covered
60% coinsurance
to $200 max
30% coinsurance
subject to $1,000
deductible
30% coinsurance
subject to $1,000
deductible
Facility Fee:
$200 copay plus
30% coinsurance
Physicians:
25% coinsurance
N/A
30% coinsurance
to $75 max
Mail Order/90 days
No Charge
30%
coinsurance
subject to $500
deductible
N/A
Publix at LRMC:
60% coinsurance
to $100 max
Non-Preferred Brand
Retail (30 days):
Physician/
Surgeon fee
Mail Order/90 days:
No Charge
Preferred Brand
Retail (30 days):
Facility fee (e.g.,
hospital room)
30%
coinsurance
subject to $500
deductible
Facility Fee:
$200 copay
plus 30%
coinsurance
Physicians:
25%
coinsurance
N/A
Facility Fee: $100
Copay Physicians:
25% Insurance
LRH Limitations &
Exceptions
Out-ofNetwork
Provider
Facility Fee:
$200 copay
plus 30%
coinsurance
Physicians:
25%
coinsurance
N/A
N/A
30% coinsurance
to $150 max
Publix at LRMC
30% coinsurance
to $75 max
N/A
$7 copay
N/A
N/A
$10 copay
Emergency medical
transportation
Other OAP
In-Network
Provider
Not Covered
Not Covered
25%
coinsurance
subject
to $500
deductible
60% coinsurance
to $100 max
30% coinsurance
to $150 max
30% coinsurance
to $75 max
Not Covered
Not Covered
No Charge
Facility Fee:
$200 copay plus
30% coinsurance
Physicians:
25% coinsurance
$10 copay
Community
Partner
25%
coinsurance
subject
to $500
deductible
Emergency room
services
Urgent Care
–––––––––––none––––––––––
Coverage is limited a 30-day
supply (retail), 90 day retail only
available at Publix at LRMC,
and a 90-day supply (home
delivery).
delivery).
delivery).
No Charge
If you need drugs to
treat your illness or
condition
Common Medical
Event
If you have a
hospital stay
Physician/surgeon
fees
Mail Order/90 days:
Services You May
Need
LRH
(Domestic)
If you need
immediate
medical
attention
LRH Domestic
Facility fee (e.g.,
ambulatory surgery
center)
N/A
Community
Partner
If you have
outpatient
surgery
Services You
May Need
Publix at LRMC
$4 copay
Out-of-Network
Provider
Common
Medical Event
Generic
Retail (30 days):
> Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive
the service.
> Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the
service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment
of 20% would be $200. This may change if you haven’t met your deductible.
> The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges
more than the allowed amount, you may have to pay the difference.. For example, if an out-of-network hospital
Not covered
NONE
NONE
[65]
4 of 8
Not Covered
Not Covered
30% coinsurance
subject to $1,000
deductible
Office Visit: $25
OP Facility:
30%coinsurance
subject to $1,000
deductible
None
30% coinsurance
subject to $1,000
deductible
Not Covered
None
No Charge
25% coinsurance
Habilitation Services
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Eye Exam
Glasses
Dental Check-up
No Charge
No Charge
No Charge
Coverage is limited
to annual max of 60
days
No Charge
Not Covered
None
No Charge
Not Covered
None
Not Covered
Not Covered
None
Not Covered
Not Covered
Not Covered
Not Covered
Prenatal and
postnatal care
N/A
30% coinsurance
subject to $1,000 Not Covered
deductible
If you are pregnant
N/A
None
Not Covered
Substance use
disorder inpatient
services
Hospice Service
N/A
Not Covered
Substance use
disorder outpatient
services
N/A
If you have a hospital
stay
Durable Medical
Equipment
Coverage is limited
to annual max of 60
days
If you have mental
health, behavioral
health, or substance
abuse needs
N/A
Coverage is limited
to annual max of 60
days
30% coinsurance Not Covered
Mental/Behavioral
health inpatient
services
N/A
Mental/Behavioral
health outpatient
services
No Charge
Facility fee (e.g.,
hospital room)
Urgent care
Skilled Nursing Care
25%coinsurance
subject to $500
deductible
Rehabiliation
Services
Not Covered
None
No Charge
No Charge
N/A
N/A
N/A
N/A
No Charge
Facility &
Physician
Fees: 30%
coninsurance
Not Covered
subject to $1,000
deductible
Physician/surgeon fee
Facility Fees: N/A
Physician Fees:
25% coinsurance
subject to $500
deductible
Home Health Care
Applicable PCP/Specialist
copay applies for initial
determination of pregnancy
30% coinsurance
subject to $1,000
deductible
Not Covered
30% coinsurance
subject to $1,000
deductible
None
Facility &
Physician Fees:
No Charge
N/A
Delivery and all
inpatient services
25% coinsurance
subject to $500
deductible
Not Covered
Office Visit: $15
OP Facility:
25%coinsurance
subject to $500
deductible
No Charge
N/A
Not Covered
Not Covered
Not Covered
Office Visit:$25
OP Facility:
30%coinsurance
subject to $1,000
deductible
Office Visit:$25
OP Facility:
30%coinsurance
subject to $1000
deductible
Not Covered
None
30% coinsurance
subject to $1,000
deductible
Office Visit:$15
OP Facility:
25%coinsurance
subject to $500
deductible
–––––––––––none––––––––
–––––––––––none––––––––
–––––––––––none––––––––
–––––––––––none––––––––
30% coinsurance
subject to $1,000
deductible
Not Covered
No Charge
Facility Fee:
$100 copay
Physicians:
25%coinsurance
Facility Fee:
$100 copay
Physicians:
25% coinsurance
If your child needs
dental or eye care
None
Office Visit:$15
OP Facility:
25%coinsurance
subject to $500
deductible
No Charge
Not Covered
Office Visit:$25
OP Facility:
30%coinsurance
subject to $1000
deductible
N/A
Not Covered
Substance use
disorder inpatient
services
Office Visit:$15
OP Facility:
25%coinsurance
subject to $500
deductible
30% coinsurance
subject to $1,000
deductible
No Charge
LRH Limitations &
Exceptions
25%coinsurance
subject to $500
deductible
(ded. waived for
radiologists and
pathologists)
Substance use
disorder outpatient
services
Community
Partner
Common Medical
Event
Services You May
Need
If you need help
recovering or
have other special
health needs
–––––––––––none–––––––
–––––––––––none––––––––
Facility Fee:
$100 copay
Physicians:
25%coinsurance
No Charge
Facility Fee:
$100 copay
Physicians:
25% coinsurance
30% coinsurance
subject to $1,000
deductible
Mental/Behavioral
health inpatient
services
Out-of-Network
Provider
No Charge
Mental/Behavioral
health outpatient
services
Out-ofNetwork
Provider
Other OAP
In-Network
Provider
Community
Partner
LRH Domestic
Prenatal and
Postnatal Care
If you are pregnant
[66]
Services You
May Need
LRH
(Domestic)
If you have
mental health,
behavioral
health, or
substance
abuse needs
–––––––––––none–––––––
Common
Medical Event
None
Eye exam
Glasses
Dental check-up
> Bariatric surgery* N/A
Not Covered
Not Covered
Not Covered
N/A
N/A
Not Covered
Not Covered
Not Covered
N/A
N/A
Not Covered
Not Covered
N/A
25%coinsurance
> Weight loss programs
Hospice service
> Routine foot care
Durable medical
equipment
> Routine eye care (Adults)
Skilled nursing care
> Private-duty nursing
No Charge
> Long-term care
Rehabilitation
services
Habilitation services
> Infertility treatment
Out-of-Network
Provider
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
No Charge
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
No Charge
Not Covered
30% coinsurance
subject to $1,000
deductible
30% co-insurance
No Charge
Facility &
Physician Fees:
30%coinsurance Not Covered
subject to 1,000
deductible
> Hearing aids
N/A
> Habilitation services
> Eye exam (Children)
N/A
> Non-emergency care when traveling outside US
Facility Fees:
N/A
Physician
Fees: 25%
coinsurance
subject to $500
deductible
Community
Partner
> Dental care (Adult/Children)
Home health care
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services
and your costs for these services.
Facility &
Physician
Fees:
No Charge
LRH
(Domestic)
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document (summary
plan description) for other excluded services.)
–––––––––––none–––––––
Excluded Services & Other Covered Services:
If your child needs
dental or eye care
*Subject to approval and clinical necessity
Delivery and all
inpatient services
Services You May
Need
> Cosmetic surgery
If you need help
recovering or have
other special health
needs
Common Medical
Event
> Acupuncture
Coverage Period: 01/01/2015 – 12/31/2015
Coverage: What this Plan | Plan Type: OAP
–––––––––––none––––––––
–––––––––––none––––––––
–––––––––––none––––––––
–––––––––––none––––––––
Coverage is limited to annual
max of 60 days
max of 60 days
max of 60 days
–––––––––––none––––––––––
> Chiropractic
> Rhinoplasty* > Blepharoplasty*
[67]
5 of 8
5 of 8
–––––––––––none––––––––
Coverage Period: 01/01/2015 – 12/31/2015
Coverage: What this Plan | Plan Type: OAP
–––––––––––none––––––––
max of 60 days
Your Rights to Continue Coverage:
–––––––––––none––––––––
–––––––––––none––––––––
max of 60 days
max of 60 days
–––––––––––none––––––––––
–––––––––––none–––––––
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may
provide protections that allow you to keep health coverage. Any such rights may be limited in duration and
Out-of-Network
Provider
will require you to pay a premium, which may be significantly higher than the premium you pay while covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Facility &
Physician Fees:
30%coinsurance Not Covered
subject to 1,000
deductible
under the plan. Other limitations on your rights to continue coverage may also apply.For more information on
your rights to continue coverage, contact the plan at 1-800-Cigna24. You may also contact your state insurance
department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.
Not Covered
Not Covered
Not Covered
No Charge
No Charge
No Charge
Not Covered
30% coinsurance
subject to $1,000
deductible
30% co-insurance
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able
to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Cigna
N/A
Not Covered
Not Covered
Not Covered
Not Covered
25%coinsurance
Facility Fees:
N/A
Physician
Fees: 25%
coinsurance
subject to $500
deductible
Customer service at 1-800-Cigna24. You may also contact the Department of Labor’s Employee Benefits Security
Community
Partner
N/A
N/A
Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
N/A
dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have
N/A
Not Covered
Not Covered
Not Covered
N/A
N/A
Not Covered
N/A
Facility &
Physician
Fees:
No Charge
essential coverage.
No Charge
LRH
(Domestic)
health care coverage that qualifies as “minimum essential coverage”. This health plan does provide minimum
Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value
Hospice service
Durable medical
equipment
Language Access Services:
Home health care
Delivery and all
inpatient services
does meet the minimum value standard for the benefits it provides.
Eye exam
Glasses
Dental check-up
Skilled nursing care
Rehabilitation
services
Services You May
Need
standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health plan
[Spanish (Español): Para obtener asistencia en Español, llame al 1-800-244-6244
Common Medical
Event
[Chinese (中文):如果需要中文的帮助，请拨打这个号码1-800-244-6244
If your child needs
dental or eye care
If you need help
recovering or have
other special health
needs
[Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-244-6244
[Navajo (Dine): Dinek’ehgo shika at’ohwol ninisingo, kwiijigo holne’ 1-800-244-6244
[68]
Excluded Services & Other Covered Services:
These examples show how this plan might cover medical care in given situations. Use these examples to see, in
general, how much financial protection a sample patient might get if they are covered under different plans.
THIS IS NOT A COST ESTIMATOR.
Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.
See the next page for important information about these examples.
Note: These numbers assume enrollment in individual-only coverage.
Having a baby
(normal delivery)
> Amount owed to providers: $7,540
> Plan pays $6,350
> Patient pays $1,190
Sample care costs:
Hospital charges (mother) Routine obstetric care Hospital charges (baby) Anesthesia Laboratory tests Prescriptions Radiology Vaccines, other preventive Total Patient pays:
Deductibles Co-pays Co-insurance Limits or exclusions Total Acupuncture
Chiropractic
Cosmetic surgery
Dental care (Adult/Children)
$7,540





Eye exam (Children)
Hearing aids
Infertility treatment
Long-term care





Non-emergency care when traveling outside US
Private-duty nursing
Routine eye care (Adults)
Routine foot care
Weight loss programs
$500
$40
$800
$1,190
 Bariatric surgery*
*Subject to approval and clinical necessity
$2,100
Rhinoplasty*
$2,700
$900
$900
$500
$200
$200
$40
$30
Managing type 2 diabetes
(routine maintenance of
a well-controlled condition)
> Amount owed to providers: $5,400
> Plan pays $4,680
> Patient pays $720
Sample care costs:
Prescriptions Medical Equipment
and Supplies Office Visits and
Procedures Education Laboratory tests Vaccines, other preventive Total 
Blepharoplasty*
Deductibles Co-pays Co-insurance Limits or exclusions Total Affordable Care Act requires most people to have health care coverage that
qualifies as “minimum essential coverage”. This health plan does provide
minimum essential coverage.
Does this Coverage Provide Minimum Essential Coverage? The
Patient pays:
$1,300
$700
$300
$100
$100
$5,400
$0
$400
$0
$320
$720
[Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-244-6244
[Spanish (Español): Para obtener asistencia en Español, llame al 1-800-244-6244
[Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-244-6244
[Chinese (中文):如果需要中文的帮助，请拨打这个号码1-800-244-6244
$2,900
Language Access Services:
6 of 8
Affordable Care Act establishes a minimum value standard of benefits of a
health plan. The minimum value standard is 60% (actuarial value). This health
plan does meet the minimum value standard for the benefits it provides.
Does this Coverage Meet the Minimum Value Standard? The
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage.
Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the
plan. Other limitations on your rights to continue coverage may also apply.For more information on your rights to continue coverage, contact the plan at 1-800-Cigna24.
You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or
www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your
rights, this notice, or assistance, you can contact Cigna Customer service at 1-800-Cigna24. You may also contact the Department of Labor’s Employee Benefits
Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
Your Rights to Continue Coverage:

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.




Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document (summary plan description) for other excluded
services.)
About these Coverage Examples:
[69]
[70]
Note: These numbers assume enrollment
in individual-only coverage.
See the next page for important information
about these examples.
Don’t use these examples to estimate your
actual costs under this plan. The actual
care you receive will be different from these
examples, and the cost of that care will also
be different.
This is not a cost
estimator.
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
About these Coverage
Examples:
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
$500
$40
$800
$30
$1,190
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
Patient pays:
Deductibles
Co-pays
Co-insurance
Limits or exclusions
Total
 Amount owed to providers: $7,540
 Plan pays $6,350
 Patient pays $1,190
(normal delivery)
Having a baby
Patient pays:
Deductibles
Co-pays
Co-insurance
Limits or exclusions
Total
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
(routine maintenance of
a well-controlled condition)
 Amount owed to providers: $5,400
 Plan pays $4,680
 Patient pays $720
Managing type 2 diabetes
7 of 8
$0
$400
$0
$320
$720
$2,900
$1,300
$700
$300
$100
$100
$5,400
[71]
Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S. Department
of Health and Human Services, and aren’t
specific to a particular geographic area or
health plan.
The patient’s condition was not an excluded or
preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only on
treating the condition in the example.
The patient received all care from innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
 No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your own
costs will be different depending on the care
you receive, the prices your providers
charge, and the reimbursement your health
plan allows.
Does the Coverage Example predict my future
expenses?
 No. Treatments shown are just examples. The
care you would receive for this condition could
be different based on your doctor’s advice,
your age, how serious your condition is, and
many other factors.
Does the Coverage Example predict my own
care needs?
For each treatment situation, the Coverage
Example helps you see how deductibles, copayments, and co-insurance can add up. It also
helps you see what expenses might be left up to
you to pay because the service or treatment isn’t
covered or payment is limited.
What does a Coverage Example show?
8 of 8
Yes. An important cost is the premium you
pay. Generally, the lower your premium, the
more you’ll pay in out-of-pocket costs, such as
co-payments, deductibles, and coinsurance. You should also consider
contributions to accounts such as health
savings accounts (HSAs), flexible spending
arrangements (FSAs) or health
reimbursement accounts (HRAs) that help you
pay out-of-pocket expenses.
Are there other costs I should consider when
comparing plans?
Yes. When you look at the Summary of
Benefits and Coverage for other plans, you’ll
find the same Coverage Examples. When you
compare plans, check the “Patient Pays” box
in each example. The smaller that number,
the more coverage the plan provides.
Can I use Coverage Examples to compare
plans?
Questions: Call 1-800-Cigna24 or visit us at www.myCigna.com. If you aren’t clear about any of the bolded terms used in this form, see the Glossary.
You can view the Glossary at www.cciio.cms.gov or call 1-800-myCigna.com to request a copy.







What are some of the assumptions behind the
Coverage Examples?
Questions and answers about the Coverage Examples:
Glossary of Health Coverage and Medical Terms
•
•
•
This glossary has many commonly used terms, but isn’t a full list. These glossary terms and definitions are intended
to be educational and may be different from the terms and definitions in your plan. Some of these terms also
might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan
governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan
document.)
Bold blue text indicates a term defined in this Glossary.
See page 4 for an example showing how deductibles, co-insurance and out-of-pocket limits work together in a real
life situation.
Allowed Amount
Maximum amount on which payment is based for
covered health care services. This may be called “eligible
expense,” “payment allowance" or "negotiated rate." If
your provider charges more than the allowed amount, you
may have to pay the difference. (See Balance Billing.)
Appeal
A request for your health insurer or plan to review a
decision or a grievance again.
Balance Billing
When a provider bills you for the difference between the
provider’s charge and the allowed amount. For example,
if the provider’s charge is $100 and the allowed amount
is $70, the provider may bill you for the remaining $30.
A preferred provider may not balance bill you for covered
services.
Co-insurance
A fixed amount (for example, $15) you pay for a covered
health care service, usually when you receive the service.
The amount can vary by the type of covered health care
service.
Deductible
The amount you owe for
health care services your
health insurance or plan
covers before your health
insurance or plan begins
Jane pays
Her plan pays
to pay. For example, if
100%
0%
your deductible is $1000,
(See page 4 for a detailed example.)
your plan won’t pay
anything until you’ve met
your $1000 deductible for covered health care services
subject to the deductible. The deductible may not apply
to all services.
Your share of the costs
of a covered health care
service, calculated as a
percent (for example,
20%) of the allowed
amount for the service.
Jane pays
Her plan pays
You pay co-insurance
20%
80%
plus any deductibles (See page 4 for a detailed example.)
you owe. For example,
if the health insurance or plan’s allowed amount for an
office visit is $100 and you’ve met your deductible, your
co-insurance payment of 20% would be $20. The health
insurance or plan pays the rest of the allowed amount.
Durable Medical Equipment (DME)
Complications of Pregnancy
Emergency Room Care
Conditions due to pregnancy, labor and delivery that
require medical care to prevent serious harm to the health
of the mother or the fetus. Morning sickness and a nonemergency caesarean section aren’t complications of
pregnancy.
[72]
Co-payment
Equipment and supplies ordered by a health care provider
for everyday or extended use. Coverage for DME may
include: oxygen equipment, wheelchairs, crutches or
blood testing strips for diabetics.
Emergency Medical Condition
An illness, injury, symptom or condition so serious that a
reasonable person would seek care right away to avoid
severe harm.
Emergency Medical Transportation
Ambulance services for an emergency medical condition.
Emergency services you get in an emergency room.
Emergency Services
Evaluation of an emergency medical condition and
treatment to keep the condition from getting worse.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
Page 1 of 4
Excluded Services
Health care services that your health insurance or plan
doesn’t pay for or cover.
Grievance
A complaint that you communicate to your health insurer
or plan.
Habilitation Services
Health care services that help a person keep, learn or
improve skills and functioning for daily living. Examples
include therapy for a child who isn’t walking or talking at
the expected age. These services may include physical and
occupational therapy, speech-language pathology and
other services for people with disabilities in a variety of
inpatient and/or outpatient settings.
Health Insurance
A contract that requires your health insurer to pay some
or all of your health care costs in exchange for a
premium.
Home Health Care
Health care services a person receives at home.
Hospice Services
Services to provide comfort and support for persons in
the last stages of a terminal illness and their families.
Hospitalization
Care in a hospital that requires admission as an inpatient
and usually requires an overnight stay. An overnight stay
for observation could be outpatient care.
Hospital Outpatient Care
Care in a hospital that usually doesn’t require an
overnight stay.
In-network Co-insurance
The percent (for example, 20%) you pay of the allowed
amount for covered health care services to providers who
contract with your health insurance or plan. In-network
co-insurance usually costs you less than out-of-network
co-insurance.
In-network Co-payment
A fixed amount (for example, $15) you pay for covered
health care services to providers who contract with your
health insurance or plan. In-network co-payments usually
are less than out-of-network co-payments.
Medically Necessary
Health care services or supplies needed to prevent,
diagnose or treat an illness, injury, condition, disease or
its symptoms and that meet accepted standards of
medicine.
Network
The facilities, providers and suppliers your health insurer
or plan has contracted with to provide health care
services.
Non-Preferred Provider
A provider who doesn’t have a contract with your health
insurer or plan to provide services to you. You’ll pay
more to see a non-preferred provider. Check your policy
to see if you can go to all providers who have contracted
with your health insurance or plan, or if your health
insurance or plan has a “tiered” network and you must
pay extra to see some providers.
Out-of-network Co-insurance
The percent (for example, 40%) you pay of the allowed
amount for covered health care services to providers who
do not contract with your health insurance or plan. Outof-network co-insurance usually costs you more than innetwork co-insurance.
Out-of-network Co-payment
A fixed amount (for example, $30) you pay for covered
health care services from providers who do not contract
with your health insurance or plan. Out-of-network copayments usually are more than in-network co-payments.
Out-of-Pocket Limit
The most you pay during a
policy period (usually a
year) before your health
insurance or plan begins to
pay 100% of the allowed
amount. This limit never
Jane pays
Her plan pays
includes your premium,
0%
100%
balance-billed charges or
(See page 4 for a detailed example.)
health care your health
insurance or plan doesn’t cover. Some health insurance
or plans don’t count all of your co-payments, deductibles,
co-insurance payments, out-of-network payments or
other expenses toward this limit.
Physician Services
Health care services a licensed medical physician (M.D. –
Medical Doctor or D.O. – Doctor of Osteopathic
Medicine) provides or coordinates.
Page
of 4
LAKELAND REGIONAL HEALTH EMPLOYEE BENEFITS
PLAN22015
[73]
Plan
A benefit your employer, union or other group sponsor
provides to you to pay for your health care services.
Preauthorization
A decision by your health insurer or plan that a health
care service, treatment plan, prescription drug or durable
medical equipment is medically necessary. Sometimes
called prior authorization, prior approval or
precertification. Your health insurance or plan may
require preauthorization for certain services before you
receive them, except in an emergency. Preauthorization
isn’t a promise your health insurance or plan will cover
the cost.
Preferred Provider
A provider who has a contract with your health insurer or
plan to provide services to you at a discount. Check your
policy to see if you can see all preferred providers or if
your health insurance or plan has a “tiered” network and
you must pay extra to see some providers. Your health
insurance or plan may have preferred providers who are
also “participating” providers. Participating providers
also contract with your health insurer or plan, but the
discount may not be as great, and you may have to pay
more.
Provider
A physician (M.D. – Medical Doctor or D.O. – Doctor
of Osteopathic Medicine), health care professional or
health care facility licensed, certified or accredited as
required by state law.
Reconstructive Surgery
Surgery and follow-up treatment needed to correct or
improve a part of the body because of birth defects,
accidents, injuries or medical conditions.
Rehabilitation Services
Health care services that help a person keep, get back or
improve skills and functioning for daily living that have
been lost or impaired because a person was sick, hurt or
disabled. These services may include physical and
occupational therapy, speech-language pathology and
psychiatric rehabilitation services in a variety of inpatient
and/or outpatient settings.
Skilled Nursing Care
Services from licensed nurses in your own home or in a
nursing home. Skilled care services are from technicians
and therapists in your own home or in a nursing home.
Specialist
The amount that must be paid for your health insurance
or plan. You and/or your employer usually pay it
monthly, quarterly or yearly.
A physician specialist focuses on a specific area of
medicine or a group of patients to diagnose, manage,
prevent or treat certain types of symptoms and
conditions. A non-physician specialist is a provider who
has more training in a specific area of health care.
Prescription Drug Coverage
UCR (Usual, Customary and Reasonable)
Premium
Health insurance or plan that helps pay for prescription
drugs and medications.
Drugs and medications that by law require a prescription.
The amount paid for a medical service in a geographic
area based on what providers in the area usually charge
for the same or similar medical service. The UCR
amount sometimes is used to determine the allowed
amount.
Primary Care Physician
Urgent Care
Prescription Drugs
of Osteopathic Medicine) who directly provides or
coordinates a range of health care services for a patient.
Primary Care Provider
of Osteopathic Medicine), nurse practitioner, clinical
nurse specialist or physician assistant, as allowed under
state law, who provides, coordinates or helps a patient
access a range of health care services.
[74]
Care for an illness, injury or condition serious enough
that a reasonable person would seek care right away, but
not so severe as to require emergency room care.
0%
Her plan pays
more
costs
80%
Her plan pays
more
costs
Out-of-Pocket Limit: $5,000
Jane reaches her $1,500
deductible, co-insurance begins
Jane has seen a doctor several times and
paid $1,500 in total. Her plan pays some
of the costs for her next visit.
Office visit costs: $75
Jane pays: 20% of $75 = $15
Her plan pays: 80% of $75 = $60
20%
Jane pays
Co-insurance: 20%
Jane hasn’t reached her
$1,500 deductible yet
Her plan doesn’t pay any of the costs.
Jane pays: $125
Her plan pays: $0
100%
Jane pays
January 1st
Beginning of Coverage
Period
Jane’s Plan Deductible: $1,500
How You and Your Insurer Share Costs - Example
[75]
100%
Her plan pays
Page 4 of 4
Jane reaches her $5,000
out-of-pocket limit
Jane has seen the doctor often and paid
$5,000 in total. Her plan pays the full
cost of her covered health care services
for the rest of the year.
Jane pays: $0
Her plan pays: $200
0%
Jane pays
December 31st
End of Coverage Period
Premium Assistance Under Medicaid
and the Children’s Health Insurance
Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your employer, your State may have a premium assistance program that can help
pay for coverage.
These States use funds from their Medicaid or CHIP programs to help people who are eligible for these programs, but also have access to health insurance through their employer. If you or your children are not eligible
for Medicaid or CHIP, you will not be eligible for these premium assistance programs.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can
contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your
dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or
dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it
has a program that might help you pay the premiums for an employer-sponsored plan.
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP,
as well as eligible under your employer plan, your employer must permit you to enroll in your employer plan if
you are not already enrolled. This is called a “special enrollment” opportunity, and you must request coverage
within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in
your employer plan, you can contact the Department of Labor electronically at www.askebsa.dol.gov or by calling
toll-free 1-866-444-EBSA (3272).
You may be eligible for assistance paying your employer health plan premiums; you may use Florida’s contact
information listed below to get more information.
FLORIDA – Medicaid Website: www.flmedicaidtplrecovery.com | Phone: 1-877-357-3268
Many states offer this program. If you or one of your dependents live in a state other than Florida, contact
Benefits at 863-687-1205 for more information.
For more information on special enrollment rights, you can contact either:
U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/ebsa
1-866-444-EBSA (3272)
OMB Control Number 1210-0137 (expires 09/30/2013)
[76]
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
1-877-267-2323, Menu Option 4, Ext. 61565
Annual Notification
Of Coverage for
Reconstructive Surgery
When a person covered for benefits under one of the Plans
who has had a mastectomy at any time decides to have
breast reconstruction, based on consultation between the
attending physician and the patient, the following benefits
will be subject to the same coinsurance and deductibles
which apply to other plan benefits:
> Reconstruction of the breast on which the mastectomy
was performed;
> Surgery and reconstruction of the other breast to produce
a symmetrical appearance; and
> Prostheses and physical complications in all stages of
mastectomy, including lymphedema.
This regulation applies to both health care plans for active
and COBRA qualified beneficiaries. If you have any questions about this coverage, please call the Lakeland Regional
Health Benefits Department at (863) 687-1100.
[77]
LRMC 2013 Summary Annual Report
for Benefit Plan Participants
October 20, 2014
Federal law requires that a Summary Annual Report be prepared for plan participants
regarding various aspects of the benefits program. Because the objective of these reports is to
provide some basic financial information, the language and form of the summary are dictated
by the government. Nevertheless, we hope you find the following report to be interesting
and informative. Questions about this report can be directed to the Talent Division Benefits
Department.
Summary Annual Report For Lakeland Regional Medical Center Long Term Disabilty Plan
This is a summary of the annual report of the Lakeland Regional Medical Center Long Term Disability Plan,
Employer Identification Number 59-2650456 for the period of 1/1/13 to 12/31/13. The annual report has been filed
with the Employee Benefits Security Administration, as required under the Employee Retirement Income Security
Act of 1974 (ERISA).
Plan 504 has a contract with The Hartford Life and Accident Insurance Company to pay certain Long Term
Disability insurance claims incurred under the terms of the plan. The total premiums paid for the plan year
ending 12/31/13 were $657,672.
Summary Annual Report For Lakeland Regional Medical Center Medical/Dental Flexible Plan
This is a summary of the annual report of the Lakeland Regional Medical Center Medical/Dental Flexible Plan,
Employer Identification Number 59-2650456 for the period of 1/1/13 to 12/31/13. The annual report has been filed
with the Employee Benefits Security Administration, as required under the Employee Retirement Income Security
Act of 1974 (ERISA).
Lakeland Regional Medical Center has committed itself to pay certain claims incurred under the terms of Plan 505.
Plan 505 has a contract with Colonial Life and Accident Insurance Company to pay certain cancer insurance claims
incurred under the terms of the plan. The total premiums paid for the plan year ending 12/31/13 were $227,005.
Plan 505 has a contract with Delta Dental Insurance Company to pay certain dental insurance claims incurred
under the terms of the plan. The total premiums paid for the plan year ending 12/31/13 were $1,791,504.
Plan 505 has a contract with Humana CompBenefits to pay eligible vision claims incurred under the terms of the
plan. The total premiums paid for the plan year ending 12/31/13 were $266,119.
Plan 505 has a contract with Hyatt Legal Plans of Florida to pay eligible legal services claims incurred under the
terms of the plan. The total premiums paid for the plan year ending 12/31/13 were $89,973.
[78]
Summary Annual Report for Lakeland Regional Medical Center Life Insurance Plan
This is a summary of the annual report of the Lakeland Regional Medical Center Group Term Basic Life,
Supplemental Dependent Life, Supplemental Term Life, and Accidental Death & Dismemberment, Employer
Identification Number 59-2650456 for the period of 1/1/13 to 12/31/13. The annual report has been filed with the
Employee Benefits Security Administration, as required under the Employee Retirement Income Security Act of
1974 (ERISA).
Plan 509 has a contract with The Hartford Life and Accident Insurance Company to pay certain life and AD&D
insurance claims incurred under the terms of the plan. The total premiums paid for the plan year ending 12/31/13
were $1,305,512.
Summary Annual Report For Lakeland Regional Medical Center Flexible Benefits Plan
This is a summary of the annual report of the Lakeland Regional Medical Center Flexible Benefits Plan, Employer
Identification Number 59-2650456 for the period of 1/1/13 to 12/31/13. The annual report has been filed with the
Employee Benefits Security Administration, as required under the Employee Retirement Income Security Act of
1974 (ERISA).
Lakeland Regional Medical Center has committed itself to pay certain flexible healthcare claims incurred under
the terms of Plan 508.
Your Rights to Additional Information
You have the right to receive a copy of the full annual report, or any part thereof, on request. The welfare plan
reports include financial information and information on payments to service providers. To obtain a copy of
the full annual report, or any part thereof, write or call the Lakeland Regional Health Talent Division Benefits
Department, P.O. Box 95448, Lakeland, Florida 33804, telephone 863-687-1100. The charge to cover copying costs
will be 25 cents per page.
You also have the legally protected right to examine the annual report at the main office of the plan, 1324
Lakeland Hills Blvd., Lakeland, Florida, and at the U.S. Department of Labor in Washington, D.C., or to obtain a
copy from the U.S. Department of Labor upon payment of copying costs. Requests to the Department should be
addressed to: Public Disclosure, Room N5638, Pension and Welfare Benefits Administration, U.S. Department of
Labor, 200 Constitution Ave., N.W., Washington, D.C. 20210.
[79]
Notes
[80]
[81]
Notes
[82]
[83]
Notes
[84]
1324 Lakeland Hills Blvd
•
Lakeland, FL 33805

lakeland regional health employee benefits

Transcription

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