2016 NEW RETIREE BENEFITS REFERENCE GUIDE
Transcription
2016 NEW RETIREE BENEFITS REFERENCE GUIDE
WELLNESS made S i m p le 2016 NEW RETIREE BENEFITS REFERENCE GUIDE 2016 Jackson Health System 3 Benefits Directory 4 Enrollment at a Glance 7 Frequently Asked Questions HEALTHCARE PLANS 12 Important Notice to Medicare Eligible Retirees 14 Medical Monthly Rates • Under 65 15 Medical Under 65 Charts 20 Medical Monthly Rates • 65 and Over 26 Medical 65 and Over Charts DENTAL PLANS 29 Dental Rates 30 Guardian Dental Charts VISION PLAN 32 Guardian/Davis Vision Plan LIFE INSURANCE & LEGAL PLAN 34 Life Insurance Rates for Under age 65 & 65 and Over 35 ARAG® Legal Plans PET ASSURE COVERAGE 40 Pet Assure Program NOTICES 42 Rules & Regulations www.JacksonBenefits.org 2 Benefits Directory ON-SITE FBMC SERVICE CENTER 1611 N.W. 12th Avenue Park Plaza West L-109B Miami, FL 33136-1096 305-585-6512 MEDICAL PROVIDER AvMed Health Plan 844-439-5378 www.avmed.org/jhs DENTAL PROVIDER Guardian DHMO P.O. Box 2452 Spokane, WA 99210 Member Service: 888-618-2016 Guardian Dental PPO Guardian Dental Claims P.O. Box 2859 Spokane, WA 99210 Member Service: 800-541-7846 Guardian Dental Pre-Enrollment Support Hot Line 1-888-600-1600 Group Number 00516547 www.GuardianAnytime.com VISION PROVIDER Guardian/Davis Vision Vision Care Processing Unit P.O. Box 1525 Latham, NY 12110 Member Service: 877-393-7363 www.davisvision.com Pre-enrollment Support Hot Line: 1-888-600-1600 Group Number 00516547 TAX SHELTER ANNUITY PROVIDERS 403(b) and 457 Nationwide Retirement Solutions 457 P.O. Box 182797 Columbus, OH 43218-2797 877-677-3678 www.nrsforu.com VOYA Life Insurance & Annuity Company 403(b) and 457 3201 West Commercial Blvd., Suite 212 Ft. Lauderdale, FL 33309 954-486-2236 305-234-3246 www.voya.com Fidelity Investments Tax Exempt Services Co. 403(b) P.O. Box 770002 Cincinnati, OH 45277-0089 800-343-0860 www.fidelity.com/workplace Lincoln National Life Insurance Co. 403(b) and 457 P.O. Box 2340 Fort Wayne, IN 46801 800-254-6265 (403(b)) 800-341-0441 (457) www.lincolnlife.com AIG/VALIC (Variable Annuity Life Insurance Company) 403(b) and 457 8000 Governor’s Square Blvd., Suite 300 Miami Lakes, FL 33016 305-817-2250 Local 250 Bird Road, Suite 202 Coral Gables, FL 33146 305-461-5421 Regional Service Center 10008 N. Dale Mabry Hwy, Suite 113 Tampa, FL 33618 800-448-2542 Extension 88573 www.valic.com OTHER PROVIDERS Pet Assure Veterinary Discount Plan for your Pets 415 Cedar Bridge Avenue Lakewood, NJ 08701 888-789-7387 www.petassure.com ARAG® Legal Plan 400 Locust Street, Suite 480 Des Moines, IA 50309 800-247-4184 ARAGLegalCenter.com, Access Code 17845ret Provident Life & Accident Insurance Company (Unum) Accident Insurance Customer Service: 800-635-5597 www.unum.com 3 Allstate Benefits American Heritage Life Insurance Company (Critical Illness) 800-521-3535 www.allstatebenefits.com LIFE INSURANCE PROVIDERS Reliance Standard Life Insurance Company 800-351-7500 www.reliancestandard.com ReliaStar Life Insurance Company’s Premier (Universal Life Insurance) Offered by Voya Financial Employee Benefits Customer Service P.O. Box 122, Minneapolis, MN 55440-0122 800-537-5024 www.voya.com Transamerica Life Insurance Company 888-763-7474 www.transamerica.com Unum Life Insurance Company of America (Long-Term Care) 800-331-1538 www.unum.com Unum Whole Life Insurance with Long Term Care (Whole Life Insurance) Customer Service Mon - Fri, 8 a.m. - 8 p.m. ET 800-635-5597 www.unum.com Group Voluntary Hospital Indemnity Insurance Allstate Benefits AHL American Heritage Life Insurance Co. Group Voluntary Hospital Indemnity Insurance (Hospital Indemnity Insurance) Mon - Fri, 8 a.m. - 8 p.m. ET 800-348-4489 www.allstatebenefits.com ID Commander Membership Services: 1-855-592-7941 Mon - Fri, 9 a.m. - 6 p.m. ET. www.idcommander.com ConstantCredit Membership Services: 1-888-384-7935 Mon – Fri, 9 a.m. - 6 p.m. ET. www.constantcredit.com www.JacksonBenefits.org 2016 Jackson Health System Important Information Enrollment at a Glance Health Trust provided you transition as an active employee into retirement. You will have 30 days from your separation date to make or change your election. In addition to this 2016 New Retiree Participants Reference Guide you have been provided an enrollment form. • Complete and return your enrollment form. When completing the enrollment form, please be sure to note all benefits you would like to continue into retirement. Your enrollment form must be submitted at least two weeks prior to your retirement date. • Please remember when electing your retiree benefits: After retiring you may not increase your coverage elections, you may only cancel coverage. You may not add coverage, add dependent coverage or increase coverage. • For all of your eligible dependents, please record their Social Security number(s) and date(s) of birth on your enrollment form. Please direct all questions or comments to Customer Care at 855-56JHS4U (855-565-4748), Monday – Friday, 7 a.m. – 7p.m. ET. If you do not take a distribution and decide to defer your retirement, you will not be considered retired and may not be entitled to continue your JHS-sponsored health insurance coverage. Election Process To summarize, continuation of coverage is not automatic. Your employee group coverage is cancelled the last day of the pay period in which the separation of employment date falls and for which the employee experiences a regular insurance deduction or made direct payments to JHS (if on an unpaid leave of absence). Coverage under the Retiree Group will not be activated until the first retiree premium is received. The insurance carriers will be notified to reinstate your coverage under the Retiree Group upon receipt of your initial premium payment. The Benefit Options Available are: Medical, Dental, and Life Medical, Dental, Vision, and Life Medical Only Medical and Life Medical and Dental Dental and Life Dental Only Life Only Medical, Medical and Vision, and Vision Life To continue your medical, dental/vision, and basic life insurance coverage, complete the correct retiree enrollment form (either under age 65 or 65 and over, based on eligibility) and submit it within 30 days of your separation date. Coverage for your eligible dependent(s) may be continued under the Retiree Group, but only if the dependent was enrolled immediately prior to your separation date. To assure a smooth transition, especially if you have scheduled ongoing treatment or need prescriptions filled, submit the enrollment form and initial premium within 10 days of your separation date. Once the initial retiree premium is received, medical, dental/vision, and/or life insurance (if elected) become effective retroactive to the date your coverage as an active employee expired (without a gap), assuming premiums were paid through that date. Your enrollment form must be received by FBMC no later than 30 days following your separation date, otherwise you forfeit Retiree Group coverage. If the Retiree Group election period lapses, you may still exercise your rights under COBRA; please refer to the COBRA section in this handbook. Medical, Dental, and Vision Choosing the Right Enrollment Form — Under age 65 or 65 and Over The New Retiree Reference Guide explains your available benefits in separate sections based on whether you are under 65 or 65 and over, including any eligible dependents. The benefits (except life insurance) for 65 and over also apply if you and/or your eligible dependent are under 65, but Medicare eligible. If you wish to elect Retiree coverage please complete and return the correct enrollment form: • Under 65 and/or not Medicare A and B eligible • 65 and Over and/or Medicare Eligible Please note: you may not elect continuation of medical coverage under COBRA if you are entitled/enrolled in Medicare Part A & B. You are eligible to continue coverage under the Retiree Group if you retire from Jackson Health System/Public www.JacksonBenefits.org 4 2016 Jackson Health System Important Information Leave of Absence Optional Life Insurance The same election process applies to employees on leave of absence (or no-pay status) who terminate Jackson Health System employment without physically returning to work. Group insurance coverage will end as of the last day of the pay period in which the separation of employment date falls, assuming premiums were paid through that date. If coverage is cancelled for non-payment of premiums, while on leave status, you will not have the opportunity to continue coverage under the Retiree Group or COBRA. Optional life coverage is not available through the Retiree Group. If enrolled at the time of your retirement, you may elect to convert this coverage to an individual policy. The policy is available to you without medical approval, but will be provided by Reliance Standard Life Insurance Company at their prevailing individual insurance rates. You may convert up to the amount of coverage in force at retirement. Contact the insurance carrier to obtain rates and policy options. Reliance Standard Life Insurance Company 1-800-866-2301 Coverage Available Basic Life Insurance for Retirees Under Age 65 JHS doesn’t contribute the employer portion on your behalf; consequently, you will pay the full monthly premium cost. Your dependent spouse or domestic partner (DP) and/or children including the children of a DP, currently covered under your medical and/or dental/vision plan as of the date you retire, may continue under your coverage at retirement. The group basic life insurance coverage provided to active employees at no cost may be continued at retirement, at your expense. The coverage amount for retirees under age 65 is equivalent to their pre-retirement annual base salary. As long as the coverage was in force prior to retirement, the benefit may be continued. Changing Health Plans Remember to ensure that your beneficiary designations are current. A new beneficiary may be named at any time. To update your beneficiary call the FBMC Service Center at 855-56JHS4U (855-565-4748) and request a life insurance beneficiary update form. Make sure your beneficiary designation form is legible and contains no erasures or cross-out marks. Specify the percentage of benefits for each named beneficiary to receive. The total percent allocation among the beneficiaries must add up to 100 percent. Please be sure your beneficiary is aware of the benefit and knows how to contact our office in the event of your death. At the time of retirement and within 30 days of your separation date, you will have a one-time opportunity to change plans or enroll in the retiree insurance plan offered that you previously declined. Once you submit your election form, you cannot change plans until the annual retiree open enrollment period, unless you move out of the plan’s geographic service area. Electing Health Coverage Under Your Spouse/DP ’s Plan If your spouse/DP is a JHS employee, you have the option of enrolling as a dependent under your spouse/DP’s JHS medical and/or dental/vision plan. Your spouse/DP must submit the Change in Status forms (CIS) within 30 days of your separation date. For the necessary forms visit the FBMC Service Center at 1611 N.W. 12th Ave., Park Plaza West L-109B Miami, FL 33136-1096. You can transfer your medical/dental/vision coverage to the Retiree Group at a later date as a CIS, as long as you have been continuously covered under a JHS-sponsored medical/dental/vision plan without a break, since your retirement. Important Note: Continuation of basic life insurance cannot be postponed. You must elect the coverage at retirement otherwise you forfeit the coverage. 5 www.JacksonBenefits.org 2016 Jackson Health System Important Information Basic Life Insurance for Retirees Age 65+ COBRA Retirees age 65+ may elect either $15,000 or $20,000 of life insurance coverage. Federal law (COBRA) provides that insured employees and their covered dependents may elect to continue group health coverage for up to 18 months from the date employment terminates or until the employee is covered under another group plan, whichever comes first. We are required by law to notify you of your COBRA rights, and as a result, you will receive a COBRA mailing in addition to information regarding Retiree Group coverage. You can only maintain COBRA coverage for a limited time, whereas you may continue health and basic life coverage indefinitely under the Retiree Group. Remember to maintain your beneficiary designation current. A new beneficiary may be named at any time. To update your beneficiary call the FBMC Customer Service Center at 855-56JHS4U (855-565-4748) and request a Life Insurance Beneficiary Update Form. Make sure your beneficiary designation form is legible and contains no erasures or cross-out marks. Specify the percentage of benefits for each named beneficiary to receive. The total percent allocation among the beneficiaries must add up to 100 percent. Please be sure your beneficiary is aware of the benefit and knows how to contact our office in the event of your death. You may elect continuation of medical/dental/vision coverage under COBRA instead of participating under the Retiree Group. The choice is yours to make. However, the election period for the Retiree Group coverage expires 30 days from your separation date. The COBRA election period expires 60 days from the date benefits terminate under the active group. You have 45 days from your COBRA election date to pay the first premium. Your life insurance coverage may be converted directly with Reliance Standard Life Insurance Company, at their prevailing rates. PayFlex will mail the COBRA information packets directly to the retiree’s home address, usually within 14 days from the date your final check is processed. Group medical, dental/vision, and basic/optional life insurance coverage (if enrolled) cease the last day of the pay period in which the retirement date falls and for which the employee experiences a regular insurance deduction or made direct payments to PayFlex (if on an unpaid leave of absence). Contact a COBRA Specialist at 305-585-6512 for information regarding COBRA. Please note: you may not elect continuation of medical coverage under COBRA if you are entitled/enrolled in Medicare Part A & B. www.JacksonBenefits.org 6 Frequently Asked Questions Q. What medical/dental/vision insurance plans are available for retirees and/or eligible dependents under age 65 (not Medicare eligible)? A. Q. I am under the age of 65, but enrolled for Medicare Parts A & B due to disability. May I remain enrolled in the POS plan? A. Yes, you can remain in the POS plan until age 65, but Medicare will be the primary payor. This will apply whether you are enrolled in the POS or HMO plan. Medical Plans Q. Are over age dependents eligible? A. A provision in the new Patient Protection and Affordable AvMed Jackson First HMO JHS Select HMO Care Act (PPACA) allows for an employee’s child to be covered under the employee’s healthcare plan through age 26. Coverage applies whether the child is/is not married or is/is not a student. In the State of Florida anyone up to the age of 30 may be considered a dependent for the purposes of “health” insurance eligibility and access. For all health coverage offered under your employer’s plan, you may continue to cover your dependent child under the medical plan until the end of the calendar year in which the child reaches the age of 30 if the child: • Is unmarried and does not have a dependent of his or her own (and is age 26 - 30); • Is a resident of Florida or a full-time or part-time student; • Is not provided coverage as a named subscriber, insured, enrollee, or covered person under any other group, blanket, or franchise health insurance policy or individual health benefits plan, or is not entitled to benefits under Title XVIII of the Social Security Act; and • Has not had gap in “creditable coverage” of more than 63 days. AvMed Standard HMO AvMed Point of Service (POS) Dental Plans Guardian PPO Standard or Enriched Dental (Indemnity) Guardian DHMO Standard or Enriched Dental (Prepaid) Vision Plan Guardian/Davis Plan Q. What medical/dental/vision insurance plans are available for retirees and/or eligible dependents age 65 and over (Medicare A&B enrolled)? A. Medical Plans (must be enrolled in Medicare Parts A & B) AvMed High Option * Please Note: If you reside outside of the State of Florida and have a dependent who meets the above criteria, they are eligible for coverage. This includes any dependents covered, regardless of the above until the end of the calendar year in which the dependent reaches age 26. AvMed High Option w/No Rx Dental Plans Guardian PPO Standard or Enriched Dental (Indemnity) Q. If enrolled in an HMO plan, may I utilize providers outside the South Florida network and still receive HMO coverage? A. Yes, if enrolled under the Standard Option HMO. Guardian DHMO Standard or Enriched Dental (Prepaid) Vision Plan Guardian/Davis Plan AvMed contracts with PHCS National Network to provide nationwide coverage for members residing outside of the service area. As a retiree, if you utilize a participating provider within the appropriate network you will receive the same HMO benefits. 7 www.JacksonBenefits.org Frequently Asked Questions Q. May I change my medical and dental plan if I relocate outside the Tri-County area? A. If you plan to relocate, be aware that Guardian DHMO Go to www.avmed.org/jhs to check on the participating status of your provider in the JHS Elite Access Network (AvMed and provider). If your doctor is not participating in the network, you may call AvMed Member Services, 24/7, at 844-439-5378 to request that AvMed contact your doctor about joining the network. dental coverage is not available outside Florida. If relocating your permanent address, please go to www.avmed.org/jhs to check on the participating status of your providers in the JHS Elite Access Network (AvMed and PHCS). If your doctor is not participating in the network, you may call AvMed Member Services, 24/7, at 844-439-5378 to request that AvMed contact your doctor about joining the network. If in-network benefits are not available in your area, your only option is to switch to the Point-of Service (POS) medical and Guardian PPO Plan, to access out-of-network benefits. You must request a Change in Status form within 30 days from the relocation date. Proof of permanent residence change will be required (new service utility bill, rental agreement, etc.). Q. What benefits am I eligible for if I am under 65 and receiving disability benefits through the Social Security Administration? A. If you are under age 65, deemed disabled by the Social Security Administration and have qualified for Medicare Parts A, B and D, you may be eligible for the options available to Medicare eligible retirees described in this Reference Guide. For more information, contact your Benefits Specialist at 305-585-6512. Be aware that once you qualify for Medicare, your retiree medical coverage becomes secondary, even if you elect to continue with your current coverage (HMO or POS) until age 65 instead of enrolling in one of the Medicare supplement plans. Retirees traveling outside their geographic service areas for extended periods should contact AvMed Member Services to inquire about the “Away From Home Program.” Q. How do I update my life insurance beneficiary information? A. To update your beneficiary information call Q. What happens to the medical and/ or dental/vision coverage for my covered dependent(s) if I should die? A. If you die, dependents covered under your retiree 855-56JHS4U (855-565-4748) and request a Life Insurance Beneficiary Update Form. Make sure your beneficiary designation form is legible and contains no erasures or cross-out marks. Specify the percentage of benefits for each named beneficiary to receive. The total percent allocation among the beneficiaries must add up to 100 percent. Please be sure your beneficiary is aware of the benefit and knows how to contact our office in the event of your death. medical insurance may continue their coverage as long as timely premium payments are received. Your spouse/DP can continue indefinitely and your dependent children until the limiting age. Dependents covered under your retiree dental /vision insurance may continue their coverage under COBRA for 36 months. Q. What happens to the medical and/ or dental/vision coverage for my covered dependent(s) if I cancel only my coverage upon becoming eligible for Medicare? A. If you cancel your coverage upon becoming eligible for Q. Can my insurance under the Retiree Group be cancelled? A. You may cancel your medical, dental, vision or life insurance coverage at any time. The insurance carriers and/or Jackson Health System will not cancel your coverage unless: • Any premiums payable by you are not received within 30 days following the premium due date. If this happens, a cancellation notice will be mailed to you. You are responsible for notifying FBMC if there is a change in your mailing address. Medicare, dependents covered under your retiree medical insurance may continue their coverage as long as timely premium payments are received. Your under age 65 spouse/ DP can continue indefinitely and your dependent children until the limiting age. Dependents covered under your retiree dental/vision insurance may continue their coverage under COBRA up to 18 months. www.JacksonBenefits.org 8 Frequently Asked Questions • The group insurance coverage under the Master Contract for your particular type of insurance is cancelled. • You are enrolled in an HMO or pre-paid dental plan and move out of the service area. • You do not enroll under a Medicare Plan when you become age 65 and Medicare eligible. birth certificate or adoption papers, letter from spouse/DP’s employer certifying termination of insurance benefits, etc.) must be presented. Dependents cannot be added during the retiree open enrollment. Note: You may make a written request to delete your dependent(s) at anytime. This change will be effective at the end of the month the request is made or received. If cancelling coverage due to divorce, your spouse will be eligible for continuation of coverage under COBRA for 36 months or until age 65, whichever occurs first. All cancellations are irrevocable. Once cancelled, coverage may not be requested again. Q. If I cancel my medical coverage, may I retain the dental, vision and/or life insurance? When will the change in premium take effect? A. Yes, you may cancel the medical coverage without Q. May I make a change to my enrollment after I have completed and returned my enrollment form? A. You will have the opportunity to enroll in the Retiree disrupting your dental, vision and/or life insurance. Simply submit a written request to a Retiree Benefits Specialist, indicating the plan (or plans) you wish to cancel. The premium reduction will take effect the first of the month following receipt of your cancellation request. Premiums must be paid through the cancellation date. Cancellations are irrevocable. Once cancelled, the coverage will not be reinstated. Group medical, dental, vision and/or life insurance with the HR retirement coordinator within 30 days following your separation date; otherwise you forfeit Retiree Group coverage. You will also have the option to meet with the HR retirement counselor to make any changes to your initial insurance election during that same period. Once your Retiree Group medical and/or dental/vision become effective, you must submit a Change in Status (CIS)/Election Form and supporting documentation (must be original or government certified) to FBMC Service Center, PPW L-109B within 30 days of a qualifying event. The requested change must be consistent with the event. The request must be submitted to the FBMC Service Center with the appropriate documentation within 30 days of the event. If your covered dependent(s) become ineligible during the plan year, you must notify the FBMC Service Center immediately. Q. May I add a dependent during the retiree open enrollment? A. No. During the annual open enrollment you will only be allowed to change plans, and only eligible enrolled dependents will be allowed to continue coverage under the retiree group. Q. May I add or drop an eligible dependent to my benefits after retirement? A. Yes, you may only add eligible dependents in cases of You may cancel your medical, dental, vision and/or life insurance coverage or delete dependents at any time. All cancellations are irrevocable. Once cancelled, coverage may not be requested again. Apart from the annual open enrollment, no changes will be accepted after the deadline unless you experience a qualifying event. You may call 305585-6512 or visit the FBMC Service Center at 1611 N.W. 12 Ave., Park Plaza West L-109B Miami, FL 33136-1096 to request and complete a new enrollment form. qualifying events (QE) such as marriage, entering into a new domestic partnership, birth (or adoption/placement) of a child, eligible dependent’s loss of employment, or loss of other coverage, etc. You must request a Change in Status form within 30 days of the date of the qualifying event at the FBMC Service Center or by calling (305) 585-6512. To add the dependent, original documentation of eligibility (i.e., marriage certificate, certificate of domestic partnership, 9 www.JacksonBenefits.org Frequently Asked Questions Q. How will I be billed for Retiree Group coverage? A. Upon applying for retirement, you must submit a Retiree Form and submit it to FBMC with your enrollment form, or with your first premium payment. Deductions begin approximately 60 days thereafter. You are responsible for sending your check payments directly to FBMC Benefits Management, Inc., Direct Bill, P.O. Box 10789, Tallahassee, FL 32302-2789, until deductions begin. Insurance premiums are deducted from your pension benefit in advance, to pay for the upcoming month’s insurance coverage. The insurance deductions will be reflected on your check stub or statement. Insurance Election form within 30 days of your separation date. FBMC will mail you a Billing Statement. This billing statement will include a monthly premium breakdown for the calendar year. You will be responsible for paying your insurance premiums through the current billing month. Your coverage is not reinstated under the Retiree Group until receipt of your initial premium payment. Thereafter, premiums are due on the first of each month. For that reason, we recommend that you budget for approximately three months of insurance premiums, since your first pension check may not arrive for approximately 60 days from the date of retirement. If you and/or your covered dependent turn 65, subsequent to your retirement, there will be a change in your premium due to Medicare and/or life insurance coverage. If a medical plan election is required you will receive information from us approximately three months prior to your or your spouse/DP’s 65th birthday. No election is required if you don’t have medical coverage; you will be sent a new billing calendar prior to the month your premium changes. When you turn 70 or 75, your life insurance premium will be adjusted if you are maintaining this coverage. You will receive a new billing calendar prior to the month your premium changes. Q. What is the Health Insurance Subsidy? A. Eligible retirees receive $5 per month for each year of service credit earned at retirement. The subsidy is at least $30per month, but no more than $150 per month. It is intended to help offset the cost of your health insurance coverage. The Florida Retirement System mails you a form to enroll for the subsidy. If you have elected to continue medical coverage under the Retiree Group, you may forward your subsidy application, after completing Part I, to the Retirement Coordinator. We will verify coverage and forward your completed form to the Division of Retirement. The subsidy will not appear on your pension check until approximately 60 days from the date the Division of Retirement receives it. You may contact the Division of Retirement at 844-377-1888 for any subsidy questions, or write to: Division of Retirement 1317 Winewood Boulevard, Building 8 Tallahassee, Florida 32399-1560 Email: [email protected] Q. How do I pay for my insurance? A. You may pay your monthly premium by check, money order, or through automatic deduction from your pension check. When you pay by check or money order, the payment is due on the first day of each month. Accounts are subject to cancellation, if your payment is not received by the end of the month for which payment is due. We are unable to accept cash for security reasons. Make checks payable to FBMC. To expedite processing, indicate your retiree ID number (refer to your billing statement) on all checks. The insurance carriers will be notified to reinstate your coverage under the Retiree Group upon receipt of your initial premium payment. The Public Health Trust (PHT) Defined Benefit Retirement Plan provides employees retiring with PHT service credit years, health insurance subsidy. The subsidy is considered and included when the retirement benefit is calculated. The subsidy is a minimum of $30 per month, but not to exceed more than $150 per month. It is intended to offset the cost of your health insurance. For employees retiring from both FRS & PHT, the subsidy will not exceed $150.00 per month total between the two retirement plans. Note: Coverage cannot be verified if the account is not current. To have your insurance premiums deducted from your pension check, you must complete a Payroll Authorization www.JacksonBenefits.org 10 Frequently Asked Questions Q. How do I continue coverage through the retiree group? A. To continue medical, dental, vision and/or life Q. My spouse/DP is also employed by JHS. Upon my retirement, may I continue basic life insurance under the Retiree Group and have my spouse/DP add me as his/her dependent for medical, dental and/or vision coverage under the Active Employee Group? insurance coverage as a retiree, complete, sign, and submit an enrollment form. To assure a smooth transition, the application must be received by the Retirement Coordinator at least two weeks prior to your separation date. Enrollment forms received more than 30 days after the separation date will not be accepted; you will only be entitled to health insurance continuation under COBRA, if applied for within 60 days following your last date of coverage as an active employee. In the event an employee terminates his/her employment on a retroactive basis after being on a leave of absence, the enrollment form must be received within 30 days of the date the retiree’s department processes the status change. A. Yes, you may elect to continue basic life insurance only through the Retiree Group. Your spouse/DP must contact the on-site FBMC Service Center at 305-585-6512 to complete the Change in Status (CIS) forms required to add you as a dependent as soon as possible, but no later than 30 days after your last day of coverage under the Active Employee Group. Please note: you may not elect continuation of medical coverage under COBRA if you are entitled/enrolled in Medicare Part A&B. Q. May I continue my Optional Life insurance? A. You can convert this optional benefit directly with the life insurance carrier. You may apply for an individual life insurance policy (other than term insurance), which will be issued without medical examination by Reliance Standard Life Insurance Company, if you apply for it and the required payment is made within: • 31 days from the date benefits were terminated, or • 15 days from the date this notice is given, if notice is given more than 15 days from the date benefits were terminated. In no event will this period extend beyond 91 days from the date benefits were terminated. Please contact the Benefits Department at 786-466-8378 to request the Conversion of Group Life Benefits to an Individual Policy form. 11 www.JacksonBenefits.org 2016 Important Notice to Medicare Eligible Retirees Your Prescription Drug Coverage and Medicare When can you join a medicare drug plan? Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Jackson Health System and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. You can join a Medicare drug plan when you first become eligible for Medicare from November 15th through December 31st, 2016. However, if you decide to drop your current Jackson Health System medical coverage for Medicare eligible retirees, since it is employer sponsored group coverage, you will be eligible for a two-month Special Enrollment Period (SEP) to join a Medicare drug plan. Be aware that you may be subject to a higher premium (a penalty) because you did not have creditable coverage. There are three important things you need to know about your current coverage and Medicare’s prescription drug coverage: Note: if you are currently enrolled in either the POS or HMO Plans (which have creditable prescription drug coverage) and become Medicare eligible, since you are losing creditable prescription drug coverage you are also eligible for a twomonth Special Enrollment Period (SEP) to join a Medicare drug plan. 1.Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2.Jackson Health System has determined that the prescription drug coverage offered by the Jackson Health System Plans for Medicare eligible retirees (and Medicare eligible dependents), is, on average for all plan participants, NOT expected to pay out as much as standard Medicare prescription drug coverage pays and is considered NonCreditable Coverage. This is important, because most likely, you will get more help with your drug costs if you join a Medicare drug plan, than if you only have prescription drug coverage through the Jackson Health System medical plan. 3.You can keep your current coverage from Jackson Health System. However, because your coverage is noncreditable, you have decisions to make about Medicare prescription drug coverage that may affect how much you pay for that coverage, depending on if and when you join a drug plan. When you make your decision, you should compare your current coverage, including what drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. Read this notice carefully - it explains your options. www.JacksonBenefits.org Since coverage under the Jackson Health System Plans for Medicare eligible retirees is not creditable, depending on how long you go without creditable prescription drug coverage, you may pay a penalty to join a Medicare drug plan. Starting with the end of the last month that you were first eligible to join a Medicare drug plan but didn’t join, if you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least one percent of the Medicare base beneficiary premium per month, for every month that you did not have that coverage. For example, if you go 19 months without creditable coverage, your premium may be at least 19 percent more than the Medicare base beneficiary premium. You may have to pay this higher premium (penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to join. 12 2016 Important Notice to Medicare Eligible Retirees Your Prescription Drug Coverage and Medicare What happens to your current coverage if you decide to join a medicare drug plan? For more information about your options under Medicare prescription drug coverage... If you (or your dependent) do decide to join a Medicare drug plan and drop your current health plan for Medicare eligible retirees, be aware that you (or your dependent whichever is applicable) will not be able to get Jackson Health System coverage back. However, if you join a Medicare drug plan when you first become Medicare eligible, you can select the certain eligible plans for Medicare eligible retirees (medical plan without prescription drug coverage), and continue to receive coverage for other medical services through Jackson Health System. More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: • Visit www.medicare.gov • Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help • Call 1-800-MEDICARE (800-633-4227). TTY users should call 877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov or call them at 800-7721213 (TTY 800-325-0778). Date: Plan Year 2016 Name of Entity/Sender: Jackson Health System Contact–Position/Office: Human Resources, Benefits Address: 1801 NW 9th Avenue, 7th Floor, Miami, FL 33136 Phone Number: 786-466-8378 13 www.JacksonBenefits.org Medical Monthly Rates • Under 65 What AvMed medical plans are offered? Standard HMO • Jackson First HMO • JHS Select HMO • Standard HMO • Point of Service (POS) Plan offers no referral access to an expanded network of providers. The plan provides 100 percent benefits for covered charges after the applicable copayments. Members are encouraged, but not required, to select a primary care physician. Jackson First HMO Plan offers no referral access to the Jackson-only network. Retiree and covered dependents must reside in Miami-Dade, Broward and Palm Beach Counties. The plan provides 100 percent benefits for services performed at Jackson Health System and University of Miami facilities (except emergency care). Members are encouraged but not required to select a primary care physician. Point of Service (POS) • In-network Plan offers “no referral” access to an expanded network of providers in the state of Florida and a nationwide network for those residing outside of the service area. The plan provides 100 percent benefits for covered charges after the applicable copayments. Members are encouraged, but not required, to select a primary care physician. • Out-of-network A fee for service program that provides you the freedom to use any physician or accredited hospital of your choice outside of the network. Payments are based on Maximum Allowable Payment (MAP) charges. Providers who do not participate in the network may balance bill you for the amount which exceeds MAP. Coverage is subject to deductibles and coinsurance. JHS Select HMO Plan offers no referral access to the Select HMO Network of providers. Retiree and covered dependents must reside in Miami-Dade, Broward and Palm Beach Counties. The plan provides 100 percent benefits for covered charges after applicable copays. Members are encouraged but not required to select a primary care physician. AvMed Retiree, Spouse/DP & Dependents Monthly Premiums JACKSON FIRST HMO JHS SELECT HMO STANDARD HMO POINT OF SERVICE Retiree Only $387.42 $419.23 $466.16 $1,118.58 Retiree & Spouse/DP Under 65 $881.73 $948.46 $1,046.98 $2,165.28 Retiree & Child(ren)† $811.01 $872.85 $964.11 $2,086.71 $1,096.37 $1,177.78 $1,297.92 $2,638.67 Retiree & Spouse/DP 65 and Over on Medicare Eligible High No Rx Plan N/A N/A $710.20 $1,362.62 Retiree & Spouse/DP 65 and Over on Medicare High Plan N/A N/A $1,027.62 $1,680.04 Retiree & Spouse/DP Under 65, plus Child(ren)† † Option also applies to Adult Children (AC) between 26 through 30 years of age, children of Domestic Partners (DP) and/or eligible dependents. www.JacksonBenefits.org 14 AvMed Jackson First (HMO) Chart • Under 65 Visit our website at www.avmed.org/jhs Jackson First (HMO) COVERAGE PLAN DESCRIPTION HMO plan offered to Jackson Health System employees, covered dependents and retirees under age 65 who reside in Miami-Dade, Broward and Palm Beach counties. Members who enroll in the Jackson First HMO plan must receive all medical care except for emergency and urgent care services through a contracted Jackson First network provider. DEDUCTIBLES/COPAYMENTS COPAYMENTS - No copayments and/or deductibles for primary care physician or specialist services in the network. For services performed out-of-network, the member will be responsible 100%; $25 copayment Emergency Room (waived if admitted). $25/$50 copayment Urgent Care. $15/$25/$35 prescription for 30-day supply based on formulary. $0 copayment for Generics drugs at Jackson Pharmacy. $30/$50/$70 Mail order prescriptions available for 90-day supply based on formulary. PHYSICIANS Access any primary care physician or specialist from the Jackson First HMO Network. Members are encouraged but not required to select a primary care physician. Covered family members may choose their own primary care physician. A. IN-HOSPITAL PHYSICIAN SERVICES Surgery/Visits and Consultations Anesthesiologist Benefits payable at 100% when received at participating hospitals (Jackson Health System and University of Miami) and rendered by participating physicians. B. OUT-PATIENT PHYSICIAN SERVICES PCP Office Visits Specialist Office Visits Preventive Services Pediatrician Routine Physical Obstetrical/Gynecological Maternity Preventive Services Mammogram/Pap Smears No charge No charge No charge No charge No charge No charge No charge No charge HOSPITALIZATION Benefits covered at 100% at Jackson Health System and University of Miami. HOSPITAL/SURGICAL REQUIREMENTS Precertification of hospital confinements Handled by admitting physician. DRUG & ALCOHOL TREATMENT Inpatient Outpatient No charge No charge MENTAL & NERVOUS DISORDERS Inpatient Outpatient No charge No charge OTHER SERVICES Ambulance Vision No charge when pre-authorized or in case of emergency. Coverage provided for diseases of the eye and/or injuries to the eye. Eye exams for children under age 18 covered 100%. AvMed offers adult vision discount through a preferred network of providers listed in the provider directory. Eye Exams, glasses, contact lenses not covered. PRESCRIPTION DRUGS $15 Generic/$25 Brand/$35 Non-Preferred for 30 day supply, including prescription contraceptives, at participating pharmacies nationwide. If member/physician select Brand when Generic is available, member pays difference in cost plus Brand copayment. See plan literature for other participating pharmacies. Mail order: 2x copay for 90-day supply. Generic contraceptives will be no charge. No charge for generic medications under the Jackson First Plan for employee using the Jackson Pharmacy. DURABLE MEDICAL EQUIPMENT (DME) $50 copayment per episode of illness. Please refer to brochure for limitations and restrictions. OUT-OF-AREA 1) Emergency 2) Non-Emergency $25 copay, waived if admitted, 100% thereafter. $25/$50 urgent care center copay. Not covered if provider is out-of-network. This comparison is not a contract. For specific information on benefits, exclusions and limitations, please see the Summary of Benefits & Coverage (SBC). Maximum lifetime benefits is unlimited in-network. 15 www.JacksonBenefits.org JHS Select (HMO) Chart • Under 65 Visit our website at www.avmed.org/jhs JHS SELECT (HMO) COVERAGE PLAN DESCRIPTION HMO plan offered to JHS employees, covered dependents and retirees under 65 who reside in Miami-Dade, Broward and Palm Beach counties. Members who enroll in the Select Network plan must receive all medical care except for emergency and urgent care services through an AvMed contracted JHS Select Provider Network. DEDUCTIBLES/COPAYMENTS COPAYMENTS $15 Primary Care Physician/$30 Specialty office visit/services. 100% Hospital admission coverage - no copayment. $25 copayment Emergency Room (waived if admitted). $25/$50 copayment Urgent Care. $15/ $25/ $35 prescription for 30-day supply based on formulary. $30/$50/$70 Mail order prescription available for 90-day supply based on formulary. PHYSICIANS Access any primary care physician or specialist from the Select Network. Members are encouraged but not required to select a primary care physician. Covered family members may choose their own primary care physician. A. IN-HOSPITAL PHYSICIAN SERVICES Surgery/Visits and Consultations Anesthesiologist Benefits payable at 100% when received at participating hospitals and rendered by participating physicians. B. OUT-PATIENT PHYSICIAN SERVICES PCP Office Visits Specialist Office Visits Preventive Services Pediatrician Routine Physical Obstetrical/Gynecological Maternity Preventive Services Mamogram/Pap Smears $15 copayment/visit $30 copayment/visit No charge $15 copayment/visit No charge $30 copayment/visit $30 copayment/visit; subsequent visits no charge No charge HOSPITALIZATION Benefits payable at 100%. Please confirm provider has hospital privileges at a Select JHS participating hospital. HOSPITAL/SURGICAL REQUIREMENTS Precertification of hospital confinements Handled by admitting physician. DRUG & ALCOHOL TREATMENT Inpatient Outpatient No charge $15 per visit MENTAL & NERVOUS DISORDERS Inpatient Outpatient No charge $15 per visit OTHER SERVICES Ambulance Vision No charge when pre-authorized or in case of emergency. Coverage provided for diseases of the eye and/or injuries to the eye. Eye exams for children under age 18 covered 100%, after $15 copayment. AvMed offers adult vision discounts through a preferred network of providers listed in the Provider Directory. Eye exams, glasses, contact lenses not covered. PRESCRIPTION DRUGS $15 Generic/$25 Brand/$35 Non-Preferred for 30 day supply, including prescription contraceptives, at participating pharmacies nationwide. If member/physician select Brand when Generic is available, member pays difference in cost plus Brand copayment. See plan literature for other participating pharmacies. Mail order: 2x copay for 90-day supply. Generic contraceptives will be no charge. DURABLE MEDICAL EQUIPMENT (DME) $50 copayment per episode of illness. Please refer to brochure for limitations and restrictions. OUT OF AREA 1) Emergency 2) Non-Emergency $25 copay, waived if admitted, $25 participating urgent care, $50 non-participating urgent care, 100% thereafter. Not covered if provider is out-of-network. This comparison is not a contract. For specific information on benefits, exclusions and limitations, please see the Summary of Benefits & Coverage (SBC). Maximum lifetime benefits is unlimited in-network. www.JacksonBenefits.org 16 AvMed Standard (HMO) Chart • Under 65 Visit our website at www.avmed.org/jhs Standard (HMO) COVERAGE PLAN DESCRIPTIO AvMed offers Jackson Health System employees, covered dependents and retirees under age 65 “no referral” access to an expanded network of providers in the state of Florida. In addition, AvMed offers a nationwide network for those residing outside of the service area. The plan provides 100% benefits for covered charges, after applicable copayments. Members are encouraged, but not required, to select a primary care physician. AvMed offers Member Service, Nurse on Call hot lines, discounted health and wellness programs, discounted Mail Order Prescriptions and more. DEDUCTIBLES/COPAYMENTS COPAYMENTS $15 Primary Care Physician/$30 Specialty office visit/services. 100% Hospital admission coverage - no copayment. $25 copayment Emergency Room (waived if admitted). $25/$50 copayment Urgent Care. $15/ $25/ $35 prescription for 30-day supply based on formulary. $30/$50/$70 Mail order prescription available for 90-day supply based on formulary PHYSICIANS Access any primary care physician or specialist from the Elite Access Network. Members are encouraged but not required to select a primary care physician. Covered family members may choose their own primary care physician. A. IN-HOSPITAL PHYSICIAN SERVICES Surgery/Visits and Consultations Anesthesiologist Benefits payable at 100% when received at participating hospitals and rendered by participating physicians. B. OUT-PATIENT PHYSICIAN SERVICES PCP Office Visits Specialist Office Visits Preventive Services Pediatrician Routine Physical Obstetrical/Gynecological Maternity Preventive Services Mamogram/Pap Smears $15 copayment/visit $30 copayment/visit No charge $15 copayment/visit No charge $30 copayment/visit $30 copayment/visit; subsequent visits no charge No charge HOSPITALIZATION Benefits payable at 100%. HOSPITAL/SURGICAL REQUIREMENTS Precertification of hospital confinements Handled by admitting physician. DRUG & ALCOHOL TREATMENT Inpatient Outpatient No charge $15 per visit MENTAL & NERVOUS DISORDERS Inpatient Outpatient No charge $15 per visit OTHER SERVICES Ambulance Vision PRESCRIPTION DRUGS No charge when pre-authorized or in case of emergency. Coverage provided for diseases of the eye and/or injuries to the eye. Eye exams for children under age 18 covered 100%, after $15 copayment. AvMed offers adult vision discounts through a preferred network of providers listed in the Provider Directory. Eye exams, glasses, contact lenses not covered. $15 Generic/$25 Brand/$35 Non-Preferred for 30 day supply, including prescription contraceptives, at participating pharmacies nationwide. If member/physician select Brand when Generic is available, member pays difference in cost plus Brand copayment. See plan literature for other participating pharmacies. Mail order: 2x copay for 90-day supply. Generic contraceptives will be no charge. DURABLE MEDICAL EQUIPMENT (DME) $50 copayment per episode of illness. Please refer to brochure for limitations and restrictions. OUT OF AREA 1) Emergency 2) Non-Emergency $25 copay, waived if admitted, $25 participating urgent care, $50 non-participating urgent care, 100% thereafter. Not covered if provider is out-of-network. This comparison is not a contract. For specific information on benefits, exclusions and limitations, please see the Summary of Benefits & Coverage (SBC). Maximum lifetime benefits is unlimited in-network. 17 www.JacksonBenefits.org AvMed (POS) Chart • Under 65 This plan allows you to use both in and out-of-network providers. For purposes of this summary, the two will be discussed separately. Visit our website at www.avmed.org/jhs IN-NETWORK COVERAGE PLAN DESCRIPTION AvMed offers Jackson Health System employees, covered dependents and retirees under age 65 “no referral” access to an expanded network of providers in the state of Florida. In addition, AvMed offers a nationwide network for those residing outside of the service area. The plan provides 100% benefits for covered charges, after applicable copayments. Members are encouraged, but not required, to select a primary care physician. AvMed offers Member Service, Nurse on Call hot lines, discounted health and wellness programs, discounted Mail Order Prescriptions and more. DEDUCTIBLES/COPAYMENTS COPAYMENTS $15 Primary Care Physician/$30 Specialist office visit, 100% Hospital admission coverage - no copay, $50 Emergency Room (waived if admitted), $15/$25/$35 Prescriptions for 30 day supply Mail Order: $30/$50/$70 for 90 day supply. PHYSICIANS Access any primary care physician or specialist from the Elite Access Network. Members are encouraged but not required to select a primary care physician. Covered family members may choose their own primary care physician. A. IN-HOSPITAL PHYSICIAN SERVICES Surgery/Visits and Consultations Anesthesiologist Benefits payable at 100% when received at participating hospitals and rendered by participating physicians. B. OUT-PATIENT PHYSICIAN SERVICES PCP Office Visits Specialist Office Visitsy Preventive Services, Pediatrician Routine Physical Obstetrical/Gynecological Maternity Preventive Services Mammogram/Pap Smears $15 copayment /visit $30 copayment /visit No charge $15 copayment /visit No charge $30 copayment /visit $30 copayment /visit; subsequent visits no charge No charge. HOSPITALIZATION Benefits payable at 100% at affiliated hospitals when admitted with PCP authorization. HOSPITAL/SURGICAL REQUIREMENTS Precertification of hospital confinements Handled by admitting physician. DRUG & ALCOHOL TREATMENT Inpatient Outpatient No charge $15 per visit MENTAL & NERVOUS DISORDERS Inpatient Outpatient No charge $15 per visit OTHER SERVICES Ambulance No charge when pre-authorized or in case of emergency. Vision Coverage provided for diseases of the eye and/or injuries to the eye. Eye exams for children under age 18 covered 100%, after $15 copayment. AvMed offers adult vision discounts through a preferred network of providers listed in the Provider Directory. Eye exams, glasses, contact lenses not covered. PRESCRIPTION DRUGS $15 Generic/$25 Preferred Brand/$35 Non-Preferred Brand prescriptions for 30 day supply including prescription contraceptives at participating pharmacies nationwide. See plan literature for participating pharmacies. Mail order: 2x copay for 90-day supply. Generic contraceptives will be no charge. DURABLE MEDICAL EQUIPMENT (DME) DME and Orthotic covered at 100%. External prosthetic appliance - No charge after $200 deductible per contract year. OUT OF AREA 1) Emergency 2) Non-Emergency $50 copay, waived if admitted/100% thereafter. Out-of-network applies: 70% of maximum allowable payment (MAP) after deductible is met. This comparison is not a contract. For specific information on benefits, exclusions and limitations, please see the Summary of Benefits & Coverage (SBC). Maximum lifetime benefits is unlimited in-network. www.JacksonBenefits.org 18 AvMed (POS) Chart • Under 65 This plan allows you to use both in and out-of-network providers. For purposes of this summary, the two will be discussed separately. Visit our website at www.avmed.org/jhs OUT-OF-NETWORK COVERAGE PLAN DESCRIPTION A fee for service program that provides you the freedom to use any physician or accredited hospital of your choice outside of the network. Payments are based on maximum allowable payment (MAP) charges. Providers who do not participate in the network may balance bill you for the amount which exceeds MAP. Coverage is subject to deductibles and coinsurance. DEDUCTIBLES/COPAYMENTS $200 per individual; $500 per family, $50 Emergency Room Copayment (waived if admitted). Same in-network prescription benefits apply if participating, pharmacy is used. Benefits payable at 70% of coinsurance after deductible is met. PHYSICIANS Choose any licensed physician; covered charges payable at MAP after deductible is met. A. IN-HOSPITAL PHYSICIAN SERVICES Surgery/Visits and Consultations Anesthesiologist 30% coinsurance after deductible. B. OUT-PATIENT PHYSICIAN SERVICES Office Visits for Illness Office Visits for Injury Diagnostic X-Rays, Lab Tests, X-Ray Treatments Pediatrician 1) Medically Necessary 2) Preventive Care Birth through age 15 (Well-Baby) Routine Preventive Care for children and adults Obstetrical/Gynecological HOSPITALIZATION Plan pays 70% coinsurance, after deductible is met. Plan pays 70% coinsurance, after deductible is met. Plan pays 70% coinsurance, after deductible is met. 1) 70% of MAP, after deductible is met. 2) Plan pays 70% of MAP, after deductible is met. Plan pays 70% coinsurance, after deductible is met. Plan pays 70% coinsurance, after deductible is met. Plan pays 70% coinsurance, after deductible is met. Plan must be notified within 24 hours after date of admission. HOSPITAL/SURGICAL REQUIREMENTS Precertification of hospital confinements Pre-certification is required. DRUG & ALCOHOL TREATMENT Inpatient Outpatient Plan pays 70% coinsurance, after deductible is met.* Plan pays 70% coinsurance, after deductible is met.* MENTAL & NERVOUS DISORDERS Inpatient Outpatient Plan pays 70% coinsurance, after deductible is met..* Plan pays 70% coinsurance, after deductible is met.* OTHER SERVICES Ambulance Vision Plan pays 70% coinsurance, after deductible is met. Coverage provided for diseases and/or injuries of the eye subject to deductible/coinsurance. PRESCRIPTION DRUGS $15 Generic Drug/$25 Preferred Brand/$35 Non-Preferred Brand up to a 30 day supply at any participating network pharmacy. 90 day supply at Mail Order available fro 2x copayment. Generic contraceptives no charge. See plan literature or visit website for more information. DURABLE MEDICAL EQUIPMENT (DME) Plan pays 70% of MAP after deductible for DME and orthotics. External prosthetic appliance not covered out-of-network. OUT OF AREA 1) Emergency 2) Non-Emergency 100% after $50 copayment, waived if admitted (worldwide). Plan pays 70% coinsurance, after deductible is met. * This comparison is not a contract. For specific information on benefits, exclusions and limitations, please see the Summary of Benefits & Coverage (SBC). Maximum lifetime benefits is unlimited in-network and outof-network. Non-participating out-of-network providers have not agreed to accept AvMed’s MAP as payment in full for covered services. Therefore, if a nonparticipating provider is used the member is also responsible for the difference between MAP and the non-participating provider’s actual charges. 19 www.JacksonBenefits.org Medical Monthly Rates • 65 and Over The medical chart pages are intended to highlight the plans available and do not constitute a contract. Precise benefits will be governed by the contracts and not by these charts. Please review details of any modification in benefits in the plan literature, or seek clarification through the health plan. Health plans are on an ongoing basis renegotiating contracts with affiliated providers (doctors, hospitals, etc.). As a result, providers may be added to or deleted from the participating provider listing of the various plans during the plan year. We highly recommend verifying if your preferred provider still participates in the program prior to seeking use of their services. AvMed Retiree, Spouse/DP & Dependents Monthly Rates AVMED High Plan AVMED High W/No Rx Plan Retiree 65 and Over Only $561.46 $244.04 Retiree 65 and Over & Spouse/DP 65 and Over $1,101.90 $478.97 Retiree 65 and Over & Spouse/DP 65 & Over plus Child(ren)† on AvMed POS Plan $2,070.03 N/A Retiree 65 and Over & Spouse/DP 65 & Over plus Child(ren)† on AvMed Standard HMO $1,393.22 N/A Retiree 65 and Over & Child(ren)† on AvMed POS Plan $1,529.59 $1,212.17 Retiree 65 and Over & Child(ren)† on AvMed Standard HMO $1,059.41 $741.99 Retiree 65 and Over & Spouse/DP Under 65 on AvMed POS Plan $1,680.04 $1,362.62 Retiree 65 and Over & Spouse/DP Under 65 on AvMed Standard HMO $1,027.62 $710.20 Retiree 65 and Over & Spouse/DP Under 65, Child(ren)† on AvMed POS Plan $2,081.55 N/A Retiree 65 and Over & Spouse/DP Under 65, Child(ren)† on AvMed Standard HMO $1,393.22 $1,075.80 Jackson First HMO PLAN Select HMO Standard HMO PLAN POS PLAN Spouse/DP Under 65† $387.42 $419.23 $466.16 $1,118.58 Child(ren)† $423.59 $453.62 $497.95 $968.13 Spouse/DP Under 65 and Child(ren)† $811.01 $872.85 $964.11 $2,086.71 AvMed Dependent Coverage Monthly Rates Retiree 65 and Over w/Non-JHS Medicare Plan † Option also applies to Adult Children (AC) between 26 through 30 years of age, children of DP and/or eligible dependents. www.JacksonBenefits.org 20 AvMed Health Plans HIGH OPTION with Rx • 65 and Over Visit our website at www.avmed.org/go/mdpht Benefit Summary MEDICARE ELIGIBLE RETIREE HIGH OPTION WITH PRESCRIPTION DRUG COVERAGE JACKSON HEALTH SYSTEM LIFETIME MAXIMUM DEDUCTIBLE AMOUNT PER CALENDAR YEAR Per Individual CHOICE OF HOSPITALS MEDICARE PART B DEDUCTIBLE: $147 PER CALENDAR YEAR INPATIENT HOSPITAL FACILITY Covered by Medicare Part A. Medicare covers: Days 1—60: All but $1,260 Days 61—90: All but $315 per day Days 91—150: All but $630 per day *Days 91—150 are the 60 Lifetime Reserve Days. Medicare will cease until a new Benefit Period begins. A new Benefit Period begins after you have been out of the hospital or facility for at least 60 days. In a new Benefit Period, all Medicare Part A will renew except for the Lifetime Reserve Days. HOSPITAL OUTPATIENT/PHYSICIAN Covered by Medicare Part B SKILLED NURSING FACILITIES Days 1—20: Covered by Medicare Part A Days 21—100: Covered all but $157.50 per day SCHEDULE OF BENEFITS Unlimited $147 for Private Duty Nursing $250 for Foreign Travel Emergency Care Unlimited Not Covered 100% up to $1,260 100% up to $315 per day 100% up to $630 per day *365 additional lifetime days after Medicare Lifetime Reserve Days are exhausted Covered at 100% of Medicare eligible expense Must be medically necessary Limiting semi-private room (unless medically necessary) & board amount Remainder 20% of Medicare approved amount Days 1—20: Not Covered Days 21—100: 100% up to $157.50 per day Days 101 & beyond: Not Covered PHYSICIAN VISITS/ILLNESS Covered by Medicare Part B EMERGENCY AND URGENT CARE SERVICES Covered by Medicare Part B PHYSICIAN’S OFFICE VISIT Covered by Medicare Part B SPECIALIST’S OFFICE VISIT Covered by Medicare Part B SURGICAL PROCEDURES Covered by Medicare Part B PREVENTIVE CARE Covered by Medicare Part B Remainder 20% of Medicare approved amount Remainder 20% of Medicare approved amount Remainder 20% of Medicare approved amount Remainder 20% of Medicare approved amount Remainder 20% of Medicare approved amount Includes, but is not limited to: Annual Screening Mammogram Pap Smear & Pelvic Exam Bone Mass Measurement Prostate Cancer Screening Physical Exam (Yearly “Wellness” Exam) Colorectal Screening No Charge Subject to Preventive Care guidelines outlined in the “2015 Medicare & You” publication from Centers for Medicare & Medicaid Services (CMS) ALLERGY INJECTIONS Covered by Medicare Part B Remainder 20% of Medicare approved amount SF-JHS RETIREE HIGH W/RX-15 SF-3579 (01/15) 21 www.JacksonBenefits.org Benefit Summary AvMed Health Plans HIGH OPTION with Rx • 65 and Over MEDICARE ELIGIBLE RETIREE HIGH OPTION WITH PRESCRIPTION DRUG COVERAGE Visit our website at www.avmed.org/go/mdpht JACKSON HEALTH SYSTEM SCHEDULE OF BENEFITS DURABLE MEDICAL EQUIPMENT Remainder 20% of Medicare approved amount Covered by Medicare Part B IMMUNIZATIONS Remainder 20% of Medicare approved amount Covered by Medicare Part B X-RAYS 20% of Medicare approved MEDICARE ELIGIBLE RETIREE HIGH OPTIONRemainder WITH PRESCRIPTION DRUGamount COVERAGE Covered by Medicare Part B ADVANCED RADIOLOGICAL IMAGING (I.E. JACKSON SYSTEM SCHEDULE BENEFITS Remainder 20%OF of Medicare approved amount MRIs, MRAs,HEALTH CAT Scans and PET Scans) Covered by Medicare PartEQUIPMENT B DURABLE MEDICAL Remainder 20% of Medicare approved amount Covered by Medicare Part B PHYSICAL THERAPY SERVICES Remainder 20% of Medicare approved amount Covered by Medicare Part B IMMUNIZATIONS Remainder 20% of Medicare approved amount Covered by Medicare Part B TMJ Remainder 20% of Medicare approved amount Covered by Medicare Part B X-RAYS Remainder 20% of Medicare approved amount Surgical Coveredand by Non-Surgical Medicare Part B OTHER LAB/RADIOLOGY SERVICES ADVANCED RADIOLOGICAL IMAGING (I.E. Remainder 20% of Medicare approved amount Covered by Medicare B and PET Scans) Remainder 20% of Medicare approved amount MRIs, MRAs, CAT Part Scans Covered by Medicare Part B SHORT-TERM REHABILITATION Remainder 20% of Medicare approved amount Covered by Medicare Part B PHYSICAL THERAPY SERVICES Remainder 20% of Medicare approved amount Covered by Medicare Part B Includes: Limited to$1,940 per calendar year for Physical TMJ Therapy (PT)20% andofSpeech Therapy Language Pathology Cardiac Rehab Remainder Medicare approved amount Covered by Medicare Part B (SLP) services combined Speech Therapy Surgical and Non-Surgical Occupational Therapy OTHER LAB/RADIOLOGY SERVICES Remainder 20% of amount Limited to$1,940 perMedicare calendarapproved year for Occupational Pulmonary Covered byRehab Medicare Part B Therapy (OT) services Cognitive TherapyREHABILITATION SHORT-TERM Chiropractic Therapy (includes Chiropractors) Remainder 20% of Medicare approved amount Covered by Medicare Part B AMBULANCE Remainder 20% of Medicare approved amount Covered Includes:by Medicare Part B Limited to$1,940 per calendar year for Physical HOME CARE Therapy (PT) and Speech Therapy Language Pathology CardiacHEALTH Rehab No Charge When covered by Medicare (SLP) services combined Speech Therapy Occupational Therapy Plan will pay up to $40 per visit year limited $1,600 per When not covered Limited to$1,940 per calendar forto Occupational Pulmonary Rehabby Medicare calendar Therapyyear. (OT) services Cognitive Therapy 80% of Medicare approved amount after $250 calendar year FOREIGN TRAVEL/EMERGENCY CARE Chiropractic Therapy (includes Chiropractors) Not covered by Medicare deductible, up to a lifetime maximum of $50,000 AMBULANCE Remainder 20% of Medicare approved amount PRIVATE NURSING Covered byDUTY Medicare Part B 80% of the Reasonable & Customary charges after $147 Covered MedicareCARE Part B HOMEby HEALTH calendar year deductible (While In Medicare a Hospital or Other Health Care No Charge When Inpatient covered by Facility Only) Plan will pay up to $40 per visit limited to $1,600 per When not covered by Medicare calendar year. 80% of Medicare approved amount after $250 calendar year FOREIGN TRAVEL/EMERGENCY CARE Not covered by Medicare deductible, up to a lifetime maximum of $50,000 PRIVATE DUTY NURSING 80% of the Reasonable & Customary charges after $147 Covered by Medicare Part B calendar year deductible (While Inpatient In a Hospital or Other Health Care Facility Only) Benefit Summary SF-JHS RETIREE HIGH W/RX-15 SF-3579 (01/15) www.JacksonBenefits.org 22 Benefit Summary MEDICARE ELIGIBLE RETIREE HIGH OPTION WITH PRESCRIPTION DRUG COVERAGE AvMed Health Plans HIGH OPTION with Rx • 65 and Over JACKSON HEALTH SYSTEM MATERNITY SERVICES Covered by Medicare Part B SCHEDULE OF BENEFITS Visit our website at www.avmed.org/go/mdpht Initial Visit to confirm pregnancy Benefit Summary Remainder 20% of Medicare approved amount Remainder 20% of Medicare approved amount All subsequent prenatal and postnatal visits MEDICARE ELIGIBLE RETIREE HIGH OPTION WITH PRESCRIPTION DRUG COVERAGE Covered by Medicare Part A Delivery, (Inpatient Hospital or Birthing Center) JACKSON HEALTH SYSTEM Days 1 to 60: OF 100% up to $1,260 SCHEDULE BENEFITS Days 61 to 90: 100% up to $315 per day Days 91 -150: 100% up to $630 per day MATERNITY SERVICES Covered by Medicare Part B ABORTION-NON-ELECTIVE Covered bytoMedicare A Initial Visit confirm Part pregnancy Inpatient OUTPATIENT SURGICAL FACILITY\ All subsequent prenatal and postnatal visits Covered by Medicare Part B Surgicalby sterilization for Vasectomy/Tubal Covered Medicare procedures Part A Ligations(Inpatient Hospital or Birthing Center) Delivery, BLOOD First three pints of blood not covered by Medicare OUTPATIENT FACILITY ABORTION-NON-ELECTIVE Coveredby byMedicare MedicarePart PartAB Covered Services in Operating and Recovery Room, Procedures Inpatient Room and Treatment OUTPATIENT SURGICAL FACILITY\ HOSPICE Covered by Medicare Part B Inpatientsterilization Services procedures for Vasectomy/Tubal Surgical Ligations Outpatient Services (same coinsurance level as Home BLOOD Health Care) First three pints of blood not covered by Medicare INFERTILITY - OFFICE VISIT FOR DIAGNOSIS OUTPATIENT FACILITY Coveredby byMedicare MedicarePart PartBB Covered ORGANinTRANSPLANT Services Operating and Recovery Room, Procedures Covered Medicare Part A Room andby Treatment EXTERNAL PROSTHESES HOSPICE Covered Services by Medicare Part B Inpatient Payable as20% Inpatient Remainder of Medicare approved amount Remainder 20% of Medicare approved amount Remainder 20% of Medicare approved amount Days 1 to 60: 100% up to $1,260 First 61 three pints of blood at day 100% of the Days to 90: 100% up tocovered $315 per Reasonable & Customary charges Days 91 -150: 100% up to $630 per day Payable as Inpatient Remainder 20% of Medicare approved amount Remainder 20% ofofMedicare approvedbut amount Plan pays 100% amount approved not paid by Medicare, when Medicare certification and election requirements First three pintsare ofmet. blood covered at 100% of the Reasonable & Customary charges Remainder 20% of Medicare approved amount Remainder 20% of Medicare approved amount Payable as Inpatient Hospital Remainder 20% of Medicare approved amount Plan pays 100% of amount approved but not paid by Medicare, when Medicare certification and election requirements are met. Outpatient Services (same coinsurance level as Home Health Care) INFERTILITY - OFFICE VISIT FOR DIAGNOSIS Covered by Medicare Part B ORGAN TRANSPLANT Covered by Medicare Part A EXTERNAL PROSTHESES Covered by Medicare Part B Remainder 20% of Medicare approved amount Payable as Inpatient Hospital Remainder 20% of Medicare approved amount SF-JHS RETIREE HIGH W/RX-15 SF-3579 (01/15) 23 www.JacksonBenefits.org Benefit Summary AvMed Health Plans HIGH OPTION with Rx • 65 and Over MEDICARE ELIGIBLE RETIREE HIGH OPTION WITH PRESCRIPTION DRUG COVERAGE Visit our website at www.avmed.org/go/mdpht JACKSON HEALTH SYSTEM MENTAL HEALTH /SUBSTANCE ABUSE INPATIENT Covered by Medicare Part A SCHEDULE OF BENEFITS Benefit Summary Mental Health ELIGIBLE RETIREE HIGH OPTION WITH PRESCRIPTION DRUG COVERAGE MEDICARE Acute: based on ratio of 1:1 JACKSON HEALTH SYSTEM Partial: based on a ratio/SUBSTANCE of 2:1 MENTAL HEALTH ABUSE INPATIENT Substance Covered byAbuse Medicare Part A Acute detoxification: requires 24 hour nursing; based on aMental ratio ofHealth 1:1 SCHEDULE OF BENEFITS Plan pays 100% of amount approved but not paid by Medicare; if charges not approved by Medicare, there is no coverage Acute: based on ratio of 1:1 Acute Inpatient Rehab: requires 24 hour nursing; based a ratio Partial:onbased onofa 1:1 ratio of 2:1 Partial: based on a ratio of 2:1 Substance Abuse Acute detoxification: requires 24 hour nursing; based on Residential: a ratio of 1:1based on a ratio of 2:1 MENTAL HEALTH/SUBSTANCE ABUSE OUTPATIENT HOSPITAL/FACILITY Acute Inpatient Rehab: requires 24 hour nursing; Covered by Medicare based on a ratio of 1:1Part B EYEGLASSES Covered by Medicare Part B Partial: based on a ratio of 2:1 PRESCRIPTION DRUG COVERAGE Residential: based on a ratio of 2:1 Retail (30-day supply) MENTAL HEALTH/SUBSTANCE ABUSE OUTPATIENT HOSPITAL/FACILITY Covered by Medicare Part B Specialty (30-day supply at Participating Specialty EYEGLASSES Pharmacy) Covered by Medicare Part B PRESCRIPTION DRUG COVERAGE Mail Order (90-day supply at Participating Pharmacy) Plan pays 100% of amount approved but not paid by Medicare; if charges not approved by Medicare, there is no coverage Coverage assumes enrollment in Medicare Part B; Plan pays remainder of charges approved but not paid by Medicare Part B and member has $0 responsibility Not Covered 80% after $200enrollment calendar year deductiblePart B; Plan pays Coverage assumes in Medicare remainder of charges approved but not paid by Medicare Part B and member has $0 responsibility $100 co-payment per prescription for Specialty drugs Not Covered 100% after $10 co-payment for Generic 100% after$200 $20 co-payment Preferred Brand 80% after calendar yearfordeductible 100% after $30 co-payment for Non-Preferred Brand Retail (30-day supply) Not Mail Order(30-day at Non-Participating PharmacySpecialty $100Covered co-payment per prescription for Specialty drugs Specialty supply at Participating Pharmacy) FOR ADDITIONAL INFORMATION, PLEASE CALL: 1-844-439-5378 100% after $10 co-payment for Generic Mail Order (90-day supply at Participating Pharmacy) 100% after $20 For specific information on benefits, exclusions andco-payment limitations for Preferred Brand 100% after $30(SPD). co-payment for Non-Preferred Brand please see your Summary Plan Description Not Covered Mail Order at Non-Participating Pharmacy FOR ADDITIONAL INFORMATION, PLEASE CALL: 1-844-439-5378 For specific information on benefits, exclusions and limitations please see your Summary Plan Description (SPD). SF-JHS RETIREE HIGH W/RX-15 SF-3579 (01/15) www.JacksonBenefits.org 24 AvMed Health Plans HIGH OPTION without Rx • 65 and Over Visit our website at www.avmed.org/go/mdpht Benefit Summary MEDICARE ELIGIBLE RETIREE HIGH OPTION WITHOUT PRESCRIPTION DRUG COVERAGE JACKSON HEALTH SYSTEM LIFETIME MAXIMUM DEDUCTIBLE AMOUNT PER CALENDAR YEAR Per Individual CHOICE OF HOSPITALS MEDICARE PART B DEDUCTIBLE: $147 PER CALENDAR YEAR INPATIENT HOSPITAL FACILITY Covered by Medicare Part A. Medicare covers: Days 1—60: All but $1,260 Days 61—90: All but $315 per day Days 91—150: All but $630 per day *Days 91—150 are the 60 Lifetime Reserve Days. Medicare will cease until a new Benefit Period begins. A new Benefit Period begins after you have been out of the hospital or facility for at least 60 days. In a new Benefit Period, all Medicare Part A will renew except for the Lifetime Reserve Days. HOSPITAL OUTPATIENT/PHYSICIAN Covered by Medicare Part B SKILLED NURSING FACILITIES Days 1—20: Covered by Medicare Part A Days 21—100: Covered all but $157.50 per day PHYSICIAN VISITS/ILLNESS Covered by Medicare Part B EMERGENCY AND URGENT CARE SERVICES Covered by Medicare Part B PHYSICIAN’S OFFICE VISIT Covered by Medicare Part B SPECIALIST’S OFFICE VISIT Covered by Medicare Part B SURGICAL PROCEDURES Covered by Medicare Part B PREVENTIVE CARE Covered by Medicare Part B SCHEDULE OF BENEFITS Unlimited $147 for Private Duty Nursing $250 for Foreign Travel Emergency Care Unlimited Not Covered 100% up to $1,260 100% up to $315 per day 100% up to $630 per day *365 additional lifetime days after Medicare Lifetime Reserve Days are exhausted Covered at 100% of Medicare eligible expense Must be medically necessary Limiting semi-private room (unless medically necessary) & board amount Remainder 20% of Medicare approved amount Days 1—20: Days 21—100: Days 101 & beyond: Not Covered 100% up to $157.50 per day Not Covered Remainder 20% of Medicare approved amount Remainder 20% of Medicare approved amount Remainder 20% of Medicare approved amount Remainder 20% of Medicare approved amount Remainder 20% of Medicare approved amount Includes, but is not limited to: Annual Screening Mammogram Pap Smear & Pelvic Exam Bone Mass Measurement Prostate Cancer Screening Physical Exam (Yearly “Wellness” Exam) Colorectal Screening No Charge Subject to Preventive Care guidelines outlined in the “2015 Medicare & You” publication from Centers for Medicare & Medicaid Services (CMS) SF-JHS RETIREE HIGH W/O RX-15 SF-3577 (01/15) 25 www.JacksonBenefits.org Benefit Summary AvMed Health Plans HIGH OPTION without Rx • 65 and Over MEDICARE ELIGIBLE RETIREE HIGH OPTION WITHOUT PRESCRIPTION DRUG Visit our website atCOVERAGE www.avmed.org/go/mdpht Benefit Summary JACKSON HEALTH SYSTEM SCHEDULE OF BENEFITS ALLERGY INJECTIONS Remainder 20% of Medicare approved amount Covered by Medicare Part B DURABLE MEDICALELIGIBLE EQUIPMENT MEDICARE RETIREE HIGH OPTION WITHOUT PRESCRIPTION DRUG Remainder 20% of Medicare approved amount Covered by Medicare Part B COVERAGE IMMUNIZATIONS Remainder 20% of Medicare approved amount Covered by Medicare Part B JACKSON HEALTH SYSTEM SCHEDULE OF BENEFITS X-RAYS Remainder 20% of Medicare approved amount ALLERGY INJECTIONS Covered by Medicare Part B Remainder 20% of Medicare approved amount Covered by Medicare Part B ADVANCED RADIOLOGICAL IMAGING (I.E. DURABLE Remainder MRIs, MRAs,MEDICAL CAT ScansEQUIPMENT and PET Scans) Remainder20% 20%ofofMedicare Medicareapproved approvedamount amount Covered by Medicare PartBB Covered by Medicare Part IMMUNIZATIONS PHYSICAL THERAPY SERVICES Remainder20% 20%ofofMedicare Medicareapproved approvedamount amount Remainder CoveredbybyMedicare MedicarePart PartBB Covered X-RAYS TMJ Surgical and Non-Surgical Remainder20% 20%ofofMedicare Medicareapproved approvedamount amount Remainder CoveredbybyMedicare MedicarePart PartBB Covered ADVANCED RADIOLOGICAL IMAGING (I.E. OTHER LAB/RADIOLOGY SERVICES Remainder Remainder20% 20%ofofMedicare Medicareapproved approvedamount amount MRIs, MRAs, CATPart Scans Covered by Medicare B and PET Scans) Covered by Medicare Part B SHORT-TERM REHABILITATION PHYSICAL THERAPY Covered by Medicare Part BSERVICES Remainder20% 20%ofofMedicare Medicareapproved approvedamount amount Remainder Covered by Medicare Part B TMJ Surgical and Non-Surgical Includes: Remainder 20% of amount Limited to $1,940 forMedicare Physical approved Therapy (PT) and Covered by Medicare Part B Cardiac Rehab Speech Therapy Language Pathology (SLP) services OTHER LAB/RADIOLOGY SERVICES Speech Therapy Remainder 20% of Medicare approved amount combined Covered by Medicare Occupational Therapy Part B SHORT-TERM Pulmonary Rehab REHABILITATION Limited to $1,940 for Occupational Therapy (OT) Covered Therapy by Medicare Part B Cognitive Remainder 20% of Medicare approved amount services Chiropractic Therapy (includes Chiropractors) Includes: Limited to $1,940 for Physical Therapy (PT) and AMBULANCE Cardiac Rehab Speech Therapy (SLP) services Remainder 20% ofLanguage Medicare Pathology approved amount Covered Medicare Part B Speech by Therapy combined Occupational Therapy HOME HEALTH CARE No Charge When covered by Medicare Pulmonary Rehab Limited to $1,940 for Occupational Therapy (OT) Cognitive Therapy services Plan will pay up to $40 per visit limited to $1,600 per When not covered by Medicare Chiropractic Therapy (includes Chiropractors) calendar year. AMBULANCE 80% of Medicare20% approved amountapproved after $250amount calendar year FOREIGN TRAVEL/EMERGENCY CARE Remainder of Medicare Covered byby Medicare Part B Not covered Medicare deductible, up to a lifetime maximum of $50,000 HOME HEALTH CARE PRIVATE DUTY NURSING Nothe Charge When covered by Medicare 80% of Reasonable & Customary charges after $147 Covered by Medicare Part B calendar year deductible (While Inpatient In a Hospital or Other Health Care Plan will pay up to $40 per visit limited to $1,600 per When not covered by Medicare Facility Only) calendar year. 80% of Medicare approved amount after $250 calendar year FOREIGN TRAVEL/EMERGENCY CARE Not covered by Medicare deductible, up to a lifetime maximum of $50,000 PRIVATE DUTY NURSING 80% of the Reasonable & Customary charges after $147 Covered by Medicare Part B calendar year deductible (While Inpatient In a Hospital or Other Health Care Facility Only) SF-JHS RETIREE HIGH W/O RX-15 SF-3577 (01/15) www.JacksonBenefits.org 26 Benefit Summary MEDICARE ELIGIBLE RETIREE HIGH OPTION WITHOUT PRESCRIPTION DRUG AvMed Health Plans HIGHCOVERAGE OPTION without Rx • 65 and Over Visit our website at www.avmed.org/go/mdpht JACKSON HEALTH SYSTEM MATERNITY SERVICES Covered by Medicare Part B Initial Visit to confirm pregnancy SCHEDULE OF BENEFITS Benefit Summary Remainder 20% of Medicare approved amount Remainder 20% of Medicare approved amount MEDICARE ELIGIBLE RETIREE HIGH OPTION WITHOUT PRESCRIPTION DRUG All subsequent prenatal and postnatal visits COVERAGE Covered by Medicare Part A Delivery, (Inpatient Hospital or Birthing Center) JACKSON HEALTH SYSTEM MATERNITY SERVICES Covered by Medicare Part B ABORTION-NON-ELECTIVE Initial Visit to confirm pregnancy Covered by Medicare Part A Inpatient All subsequent prenatal and postnatal visits OUTPATIENT SURGICAL FACILITY Covered by Medicare Part B Coveredsterilization by Medicare Part A for Vasectomy/Tubal Surgical procedures Delivery, (Inpatient Hospital or Birthing Center) Ligations BLOOD First three pints of blood not covered by Medicare ABORTION-NON-ELECTIVE OUTPATIENT FACILITY CoveredbybyMedicare MedicarePart PartBA Covered Inpatient Services in Operating and Recovery Room, Procedures OUTPATIENT SURGICAL FACILITY Room and Treatment Covered by Medicare Part B HOSPICE Surgical sterilization procedures for Vasectomy/Tubal Inpatient Services Ligations Outpatient Services (same coinsurance level as Home BLOOD Health Care) First three pints- of blood not covered by DIAGNOSIS Medicare INFERTILITY OFFICE VISIT FOR OUTPATIENT FACILITY Covered by Medicare Part B CoveredTRANSPLANT by Medicare Part B ORGAN ServicesbyinMedicare OperatingPart andARecovery Room, Procedures Covered Room and Treatment EXTERNAL PROSTHESES HOSPICE Covered by Medicare Part B Inpatient Services Outpatient Services (same coinsurance level as Home Health Care) INFERTILITY - OFFICE VISIT FOR DIAGNOSIS Covered by Medicare Part B ORGAN TRANSPLANT Covered by Medicare Part A EXTERNAL PROSTHESES Covered by Medicare Part B Days 1 to 60: 100% up to $1,260 SCHEDULE BENEFITS Days 61 to 90: OF 100% up to $315 per day Days 91 -150: 100% up to $630 per day Remainder 20% of Medicare approved amount Payable as Inpatient Remainder 20% of Medicare approved amount Remainder 20% of Medicare approved amount Days 1 to 60: 100% up to $1,260 Days 61 to 90: of100% to $315 dayof the First three pints blood up covered at per 100% Days 91 -150: 100% up to $630 per day Reasonable & Customary charges Payable as Inpatient Remainder 20% of Medicare approved amount Remainder 20% of Medicare approved amount Plan pays 100% of amount approved but not paid by Medicare, when Medicare certification and election First three pints of blood covered at 100% of the requirements are met Reasonable & Customary charges Remainder 20% of Medicare approved amount Remainder 20% of Hospital Medicare approved amount Payable as Inpatient Remainder 20% of Medicare approved amount Plan pays 100% of amount approved but not paid by Medicare, when Medicare certification and election requirements are met Remainder 20% of Medicare approved amount Payable as Inpatient Hospital Remainder 20% of Medicare approved amount SF-JHS RETIREE HIGH W/O RX-15 SF-3577 (01/15) 27 www.JacksonBenefits.org Benefit Summary MEDICARE ELIGIBLE RETIREE HIGH OPTION WITHOUT PRESCRIPTION DRUG COVERAGE AvMed Health Plans HIGH OPTION without Rx • 65 and Over Visit our website at www.avmed.org/go/mdpht SCHEDULE OF BENEFITS JACKSON HEALTH SYSTEM MENTAL HEALTH /SUBSTANCE ABUSE INPATIENT Covered by Medicare Part A Benefit Summary Mental MEDICARE Health ELIGIBLE RETIREE HIGH OPTION WITHOUT PRESCRIPTION DRUG Acute: based on ratio of 1:1 COVERAGE Partial: based on a ratio of 2:1 JACKSON HEALTH SYSTEM Substance MENTALAbuse HEALTH /SUBSTANCE ABUSE Acute detoxification: requires 24 hour nursing; based on INPATIENT aCovered ratio of by 1:1Medicare Part A Plan pays 100%OF of BENEFITS amount approved but not paid by SCHEDULE Medicare; if charges not approved by Medicare, there is no coverage Acute MentalInpatient Health Rehab: requires 24 hour nursing; based a ratio 1:1 of 1:1 Acute:onbased onofratio Partial: Partial: based based on on aa ratio ratio of of 2:1 2:1 Plan pays 100% of amount approved but not paid by Residential: based on a ratio of 2:1 Substance Abuse Medicare; if charges not approved by Medicare, there is assumes enrollment in Medicare Part B; Plan pays MENTAL HEALTH/SUBSTANCE Acute detoxification: requires 24 hourABUSE nursing; based on Coverage no coverage remainder of charges approved but not paid by Medicare OUTPATIENT HOSPITAL/FACILITY a ratio of 1:1 Part B and member has $0 responsibility Covered by Medicare Part B EYEGLASSES Acute Inpatient Rehab: requires 24 hour nursing; Not Covered Covered Medicare based onby a ratio of 1:1Part B PRESCRIPTION DRUG COVERAGE Not Covered Partial: based on a ratio of 2:1 FOR ADDITIONAL INFORMATION, PLEASE CALL: 1-844-439-5378 Residential: based on a ratio of 2:1 Coverage assumes enrollment in Medicare Part B; Plan pays MENTAL HEALTH/SUBSTANCE ABUSE For specific information on benefits, exclusions and limitations remainder of charges approved but not paid by Medicare OUTPATIENT HOSPITAL/FACILITY please see your Summary Plan Description (SPD). Part B and member has $0 responsibility Covered by Medicare Part B EYEGLASSES Not Covered Covered by Medicare Part B PRESCRIPTION DRUG COVERAGE Not Covered FOR ADDITIONAL INFORMATION, PLEASE CALL: 1-844-439-5378 For specific information on benefits, exclusions and limitations please see your Summary Plan Description (SPD). SF-JHS RETIREE HIGH W/O RX-15 SF-3577 (01/15) www.JacksonBenefits.org 28 Dental Rates for Under and Over 65 STANDARD Monthly Dental Rates ENRICHED GUARDIAN DHMO* GUARDIAN PPO GUARDIAN DHMO* GUARDIAN PPO Retiree Only $8.00 $31.22 $14.57 $40.87 Retiree & One Dependent† $13.24 $61.76 $24.15 $80.81 Retiree & Dependents† $20.22 $99.55 $38.39 $130.30 + Option also applies to Domestic Partners and/or Children of Domestic Partners and eligible dependents. *Guardian DHMO plans are not available outside of Florida. Non-Guardian Dental dentists are reimbursed based on the PPO Fee Schedule instead of the maximum program allowance. As a result members visiting a non-Guardian Dental dentist may see a change in out-of-pocket costs. 29 www.JacksonBenefits.org Guardian Dental PPO Chart • Under and Over 65 CHOICE OF DENTIST You’ll likely save most with a dentist who participates in the Guardian DentalGuard PPO network, and you’ll likely save least with a non-participating dentist. Services provided by out-of-network providers will be reimbursed at the 90th percentile of usual and customary charges. Percentages below are based on Guardian’s applicable allowances and not necessarily the dentist’s actual charge. $1,000 per year per person $50 deductible per year per person; $150 family maximum $1,500 per year per person $50 deductible per year per person; $150 family maximum TYPE I 0150 Comprehensive Oral Evaluation - New or Established 0120 Periodic Oral Exam X-Rays 1110/20 Prophylaxis 1203 Fluoride Treatment (children up to the age 19) 1351 Sealant per tooth 1510 Space Maintainers STANDARD Plan Pays (No deductible) 100% 100% 100% 100% (Twice per calendar year) 100%, 2x per year 100% to age 16 100% to age 19 ENRICHED Plan Pays (No deductible) 100% 100% 100% 100% (Twice per calendar year) 100%, 2x per year 100% to age 16 100% to age 19 TYPE II* Fillings: (silver and white) 2330 One surface 2331 Two surfaces 2332 Three surfaces 2334 Four or more surfaces Restorative Services: 2930 Prefabricated stainless steel primary tooth Root canals: 3310 Anterior 3320 Bicuspid 3330 Molar 3410 Apicoectomy Extractions: 7111 Single tooth 7140 Extraction, erupted tooth or exposed tooth 7210 Surgical extraction of erupted tooth Periodontics: (gum treatment) 4341 Periodontal scaling & root planing- per quadrant 4210 Gingivectomy/gingivoplasty - per quadrant 4910 Periodontal maintenance procedures STANDARD ENRICHED 100% (In PPO Network) / 75% (Out of PPO Network) 100% (In PPO Network) / 75% (Out of PPO Network) 100% (In PPO Network) / 75% (Out of PPO Network) 100% (In PPO Network) / 75% (Out of PPO Network) 100% (In PPO Network) / 75% (Out of PPO Network) 100% (In PPO Network) / 75% (Out of PPO Network) 100% (In PPO Network) / 75% (Out of PPO Network) 100% (In PPO Network) / 75% (Out of PPO Network) 75% for children to age 16 75% for children to age 16 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% STANDARD ENRICHED 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% MAXIMUM BENEFIT/DEDUCTIBLE TYPE III* Crown & Bridge: 2791 Crown full cast predominately base metal 2751 Crown Porcelain fused to base metal Pontics: 6210 Full cast 6240 Porcelain fused to metal Prosthodontics (Dentures): 5110 Complete upper 5120 Complete lower 5213/14 Partial upper or lower - cast metal base ORTHODONTIA Consultation Evaluation Records Children-Normal Class II Adult - Normal Class II 8750 Retention Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered VISION Examination SINGLE VISION LENSES Bifocal Lenses Trifocal Lenses Contact Lenses - Non-Elective Contact Lenses - Elective Frames Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered *All Type II and III charges subject to annual deductible. www.JacksonBenefits.org 30 Adult & Child covered at 50% after a one time deductible of $50 per person. $1,000 lifetime maximum benefit Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Guardian DHMO Dental Chart • Under and Over 65 STANDARD (U50) CHOICE OF DENTIST Limited to Participating Dentists in Private Practice MAXIMUM BENEFIT/DEDUCTIBLE TYPE I 1110/20 Prophylaxis 0120 Periodic Oral Exam 0150 Comprehensive Oral Evaluation - New or Established 1203 Fluoride Treatment (children up to the age 19) 1351 Sealant- per tooth 1510 Space Maintainers TYPE II Fillings: (silver) 2140 One surface 2150 Two surfaces 2160 Three surfaces 2161 Four or more surfaces Root canals: 3310 Anterior 3320 Bicuspid 3330 Molar 3410 Apicoectomy Extractions: 7111 Single tooth 7140 Extraction, erupted tooth or exposed tooth 7210 Surgical extraction of erupted tooth Periodontics: (gum treatment) 4210 Gingivectomy/gingivoplastY - per quadrant 4341 Periodontal scaling & root planing - per quadrant 4910 Periodontal maintenance procedures Two additional every 12 months TYPE III Crown & Bridge: 2751 Crown Porcelain fused to base metal 2791 Crown full cast predominately base metal 2930 Prefabricated stainless steel Prosthodontics (Dentures): 5110 Complete upper 5120 Complete lower 5213/14 Partial upper or lower - cast metal base ORTHODONTIA Consultation Evaluation Records Children-Normal Class II Adult - Normal Class II 8680 Retention ENRICHED (U60) No Maximum, No Deductible STANDARD You Pay No Charge No Charge No Charge No Charge $5.00 $30.00 ENRICHED You Pay No Charge No Charge No Charge No Charge No Charge No Charge STANDARD ENRICHED $5.00 $5.00 $10.00 $13.00 No Charge No Charge No Charge No charge $75.00 $85.00 $150.00 $100.00 $70.00 $80.00 $140.00 $90.00 $10.00 $10.00 $30.00 $10.00 $10.00 $35.00 $75.00 $30.00 $15.00 each (Twice every 12 months) $60.00 each $60.00 $25.00 $15 each (Twice every 12 months) $60.00 each STANDARD ENRICHED $180.00 $180.00 $15.00 $95.00 $95.00 $10.00 $190.00 $190.00 $220.00 $110.00 $110.00 $130.00 This plan covers orthodontia as follows: Comprehensive for dependent children under age 19: $1,500. Adults: $2,800 This plan covers orthodontia as follows: Comprehensive for dependent children under age 19: $1,500. Adults: $2,800 31 www.JacksonBenefits.org Guardian/Davis Vision Plan The Guardian Davis Vision Plan offers a network of providers that service your eyecare needs with only a modest member copayment shown in the Schedule of Benefits. The out of-network-benefit allows you to select any out of-network provider and reimburses a fixed dollar amount based on the schedule shown for the out of-network services. The chart below indicates the benefits the plan pays for the services you receive. For more information, see the Guardian Davis plan literature. Covered Services In-Network Out-Of-Network $10 N/A Paid in full Paid in full Paid in full Paid in full Paid in full Paid in full Paid in full $40-$90 up to $40 up to $40 up to $60 up to $80 N/A N/A N/A N/A Up to $160 retail In-network Once every plan year in and out of network. up to $50 Once every year Once every plan year Covered up to $120 allowance Covered in full Covered up to $120 up to $210 Covered in full N/A N/A N/A Average discount of approximately 25% N/A One-time copayment (Applied to first service provided - exam or materials) Vision Exam (once every plan year) Single Lenses (once every plan year) Bifocal Lenses (once every plan year) Trifocal Lenses (once every plan year) Transition Lenses3 Polycarbonate Lenses4 Standard Progressive Lenses Premium Progressive Lenses Frames from Davis’ Fashion, Designer, or Premier collections 1 Frequency Contact lenses Elected by insured Medically necessary Contact Lenses Fitting Fee and Follow-Up Mail Order Contact Replacement (Treated as out-of-network provider) LASIK Surgery (at VCP contracted facilities) 1. During any plan year, the member may elect either the frames and/or lenses covered service or the contact lenses allowance, but not both. 2. Polycarbonate lens option covered in full for dependents under 19 years of age. 3. Tints are covered in network. No coverage out of network. 4. UV protection and Photochromic lenses - In Network: Plastic : $65/Glass: Covered. Out of network: No coverage. www.JacksonBenefits.org 32 Guardian/Davis Vision Plan Guardian Davis Vision Plan Vision Monthly Rates How to use a Guardian Davis Vision Provider Guardian 1.Obtain a listing of participating optometrists and ophthalmologists during Open Enrollment or access the list online at davisvision.com. 2.Identify yourself as an Guardian Davis member when you make an appointment. 3. The eye doctor's office will handle all claim forms. Employee Only $4.14 Employee & One Dependent† $8.30 Employee & Family† $15.23 Option also applies to Domestic Partners and/or Children of Domestic Partners and eligible dependents. † How to use a Guardian Davis Vision Out-Of-Network Doctor To use an out-of-network provider, the insured will need to pay at the time the services are rendered and submit the claim form to Guardian/Davis for reimbursement. LASIK Please call Guardian Davis Vision member services: 877393-7363 before making your appointment to ensure the doctor of your choice is a member of the Davis Vision network. 33 www.JacksonBenefits.org Life Insurance Under 65 - Life Insurance The monthly life insurance rate is 17¢ per thousand dollars of your pre-retirement annual salary. $__________________________________ x .00017 + = $__________________________________ Annual Salary Rate Monthly Premium * Your life insurance coverage is reduced when you reach age 65. The coverage options are $15,000 or $20,000. 65 and Over - Life Insurance Monthly for $15,000 in Coverage Monthly for $20,000 in Coverage 65-69 $ 8.55 $ 11.40 70-74 $ 14.10 $ 18.80 75+ $ 19.50 $ 26.00 Retirees’ Age www.JacksonBenefits.org 34 ARAG® Legal Plan The Freedom and Control to Embrace Life’s Opportunities At Jackson Health System, we want you to embrace life’s opportunities with fewer worries. That’s why we’re excited to provide you with legal insurance from ARAG. It’s affordable and reliable legal counsel for everyday life matters – like a dispute with a contractor, buying or selling a home or the need for estate planning. The plan provides you with the peace of mind knowing that attorney fees for most covered legal matters are 100 percent paid in full when you work with a Network Attorney. That means you’ll avoid paying high-cost attorney fees, which currently average $323 an hour. Resolve Your Legal Issues with a Network Attorney by Your Side When a life event turns into a legal issue, ARAG will be there for you, backed by a nationwide network of more than 10,000 credentialed attorneys. They can review or prepare documents, make follow-up calls or write letters on your behalf, provide legal advice and consultation, and represent you in court. Rely on legal help and protection with a wide range of covered services, including: UltimateAdvisor® UltimateAdvisor PlusTM Civil Damage • • Pet-Related Matters • • Auto Repair • • Buying a New or Used Vehicle • • Consumer Fraud • • Consumer Protection for Goods or Services • • Home Improvement/Contractor Issues • • Personal Property Protection • • Credit Records Correction - • Habeas Corpus • • Juvenile Matters • • Misdemeanor Matters - • Bankruptcy (Chapters 7 & 13) • • Debt Collection Matters • • Garnishment • • Adoption • • Domestic Violence • • Guardianship/Conservatorship • • Incapacity • • Civil Damage Claims (Defense) Consumer Protection Issues Criminal Matters Debt-Related Matters Family Law 35 www.JacksonBenefits.org ARAG® Legal Plan UltimateAdvisor® UltimateAdvisor PlusTM Name Change • • Parental Responsibilities • • Pre-Marital Agreements • • Divorce/Annulment/Separation (uncontested) • • Divorce/Annulment/Separation (up to 10 hours) • - Divorce/Annulment/Separation (up to 15 hours) - • Post-Nuptial Agreements - • Alimony (up to 8 hours) - • Child Custody (up to 8 hours) - • Child Support (up to 8 hours) - • Caregiving (annual check-up) - • School Issues - • Medicare/Medicaid Disputes • • Social Security Disputes • • Veteran’s Benefits Disputes • • Contracts/Lease Agreements as a Tenant • • Eviction as a Tenant • • Security Deposits as a Tenant • • Disputes with a Landlord • • Document Preparation of Deeds, Mortgages, Affidavits, Demand Letters, Promissory Notes • • Other Coverage (up to 4 hours per year) - • Building Codes/Zoning Variances • • Buying/Selling a Home (primary residence) • • Buying/Selling a Secondary Home • • Foreclosure (primary residence) • • Home Improvement/Contractor Issues • • Neighbor Disputes/Easements (primary residence) • • Neighbor Disputes/Easements (secondary residence) • • Real Estate Disputes (primary residence) • • Government Benefits Landlord/Tenant Matters Preventative Legal Services Real Estate Matters www.JacksonBenefits.org 36 ARAG® Legal Plan UltimateAdvisor® UltimateAdvisor PlusTM Real Estate Disputes (secondary residence) • • Refinancing (primary residence) • • Property Tax (primary residence) - • • • IRS Audit Protection • • IRS Collection Defense • • Drivers’ License Suspension, Revocation and Restoration • • Traffic Tickets (1x per year) • • Traffic Tickets (unlimited) • • Codicil • • Complex Will • • Durable/Financial Power of Attorney • • Estate Administration (up to 9 hours) • • Healthcare Power of Attorney • • Inheritance Rights (up to 6 hours) • • Irrevocable Trust • • Living Will • • Revocable Trust • • Standard Will • • Small Claims Court Small Claims Court Issues Tax Issues Traffic Matters Wills and Estate Planning 37 www.JacksonBenefits.org ARAG® Legal Plan Preexisting and personal legal matters not listed above For any legal matters not covered and not excluded, you can still receive at least 25 percent off the Network Attorney’s normal hourly rates. For additional details regarding your plan’s specifically-covered services, visit ARAGLegalCenter.com and enter Access Code 17845ret. Call for questions or legal assistance You can also get assistance from trusted professionals and an award-winning Customer Care Center, with dedicated representatives who will help you navigate your legal issues. You’ll benefit from the following services: UltimateAdvisor® UltimateAdvisor PlusTM Call a Network Attorney who can provide legal advice and help you better understand your covered legal issues and how to address them. Plus, they can help you review or prepare documents, including a standard will. • • Receive Financial Education and Counseling Services on a wide range of financial topics - cash and debt management, budgeting, retirement planning, federal tax information and more - from a certified Financial Counselor. • • With Immigration Services, you can always speak with a Network Attorney over the phone who can offer legal advice and consultation, file and process applications or petitions, provide guidance regarding immigration benefits, asylum, business visas and much more. • • Rely on Identity Theft Services provided by Customer Care Specialists who have earned the Certified Identity Theft Risk Management Specialist** (CITRMS) designation. They can guide you through the steps of prevention and are there to assist you in recovery if your identity is stolen. • • Look to Caregiving Services for legal advice from Network Attorneys who focus on elder law issues, as well as caregiving services from elder care Specialists to assist you with your parents’ and grandparents’ everyday lives. • Go online to learn more about legal issues Your path to legal protection starts with easy-to-use online resources at ARAGLegalCenter.com to help you handle legal issues on your own, including: UltimateAdvisor® UltimateAdvisor PlusTM The Education CenterTM contains guidebooks, hundreds of articles, newsletters and more to help you learn more about everyday legal issues. • • DIY Docs® offer the convenience and control of creating your own state-specific, legally-valid documents online. • • Online Financial Tools help you map out a solid financial strategy with a selfguided money management tool, online chat feature with a Financial Counselor, educational articles, calculators and more. • • Caregiving Resources inform you about the financial, legal and emotional aspects of caring for your parents and grandparents. www.JacksonBenefits.org 38 • ARAG® Legal Plan Identity Theft Protection provides a formidable front line of protection against identity theft. This service includes: UltimateAdvisor® UltimateAdvisor PlusTM Identity Theft Insurance: Coverage up to $1 million for expenses associated with restoring your identity. • Full Service Identity Restoration: Restoration Specialists will guide you to help clear your name and restore your identity. • Lost Wallet Services: Restoration Specialists will help you cancel and reissue credit cards, driver’s license, etc. • Credit Monitoring: Monitors and informs members of changes to their credit report. • Internet Surveillance: Monitors websites and other data points to alert you if your personal information is being traded and/or sold. • Child Monitoring: Monitors minors’ identity to alert you if their personal information is being traded and/or sold. • Choose a Plan that Empowers You – and Enroll Today! Take a proactive step toward embracing life’s opportunities, with fewer worries when you enroll in one of the following legal plans: Monthly Price UltimateAdvisor® UltimateAdvisor PlusTM Individual $13.33 $17.08 Family $17.60 $22.55 Visit ARAGLegalCenter.com and enter Access Code 17845ret to learn more about what these plans offer, research specific legal topics and more. Or call 800-247-4184 to speak with an ARAG Customer Care Specialist. Limitations and exclusions apply. Insurance products are underwritten by ARAG Insurance Company of Des Moines, Iowa, GuideOne® Mutual Insurance Company of West Des Moines, Iowa or GuideOne Specialty Mutual Insurance Company of West Des Moines, Iowa. Service products are provided by ARAG Services, LLC. This material is for illustrative purposes only and is not a contract. For terms, benefits or exclusions, call our toll-free number. *Average attorney rates in the United States of $323 per hour for attorneys with 11 to 15 years of experience, The Survey of Law Firm Economics: 2014 Edition, The National Law Journal and ALM Legal Intelligence, July 23, 2014. **Certified Identity Theft Risk Management Specialist (CITRMS)® is a certification mark owned by the Institute of Consumer Financial Education, Inc. 39 www.JacksonBenefits.org Pet Assure Program Pet Assure is a post-tax discount program that enables members to receive discounts on all medical services provided by network veterinarians. Monthly Premium: $7.00 Membership must be for a term of no less than three months. Note: Monthly premium may be deducted from FRS/PHT Pension Check. You will save hundreds on your pets’ medical care for only $7 per month. Pet Assure is the nation’s oldest and largest veterinary discount plan and has been saving pet caretakers money on pet expenses since 1995. Using Your Pet Assure Membership is Simple! Here’s How Simply present your Pet Assure membership card to any participating provider when paying for services and receive instant savings with no paperwork, no deductibles and no hidden fees. Pet Assure is not insurance, so the veterinarian applies the discount directly to your bill and you don’t have to wait for reimbursements or fill out time-consuming claim forms. Here’s what your membership includes: • 25 percent off all medical services each and every time you visit a network veterinarian. With Pet Assure, you’ll receive your discount right at the vet’s office. This plan is not insurance so there are no hassles, no claim forms and no deductibles. Savings are instant! (See page 23.) • Any type of pet with absolutely no exclusions can receive the discounts. There are no exclusions based on type, breed, age, past medical history, or pre-existing conditions. Do you have one dog, five cats, a lazy iguana and a donkey? One Pet Assure membership covers them all. • 5 – 35 percent off on pet products and specialty items at over 1,000 participating national pet product retailers! (See page 23.) • 10 – 35 percent savings on pet services, such as boarding, grooming, training, pet day care, etc. (See page 23.) • 24/7 Pet Assure Locator Service (PALS). Don’t worry about your pet getting lost anymore! Every pet that joins gets enrolled in Pet Assure’s 24/7 Lost Pet Recovery Service. (See page 23.) There are dozens of network providers in Miami and the surrounding areas. For a complete list of participating veterinary practices and merchants, visit Pet Assure online at www.petassure.com. If you have any questions, please call Pet Assure at: 888-789-PETS (7387). www.JacksonBenefits.org 40 Pet Assure Program What’s included? What’s not included? Members receive 25 percent off all in-house medical services, including: • Wellness examinations • Sick visits • Emergency visits • Immunizations • Nutrition counseling • Geriatric care • Behavioral counseling • Orthopedic surgery • Soft tissue surgery • Elective surgery • Routine spay and neuter • Puppy tail and dewclaw removals • Tumor removal • Intensive care cages • Hospitalization • Serum chemistries, hematology, serology • Parasite testing • Urinalysis • Complete blood counts • Dental exams • Tooth scaling & polishing • Fluoride application • Tooth extractions • Dental X-rays • Periodontal disease treatment • Radiology (X-rays) • Ultrasound • Electrocardiography (EKG) And any other medical service provided by the veterinarian in his office. There are no exclusions! All pets are eligible for discounts regardless of type, age, health status, previous health history, or any health related conditions that may arise in the future. There are no usage limits and you can use your card as long as you’re an active member. The practice is not required to discount: 1. Outsourced services, e.g., blood work sent to a lab or an outside specialist, 2. Non-medical services, e.g., routine grooming and boarding, 3. Mileage fees and 4. Products taken home, e.g., medications and food. May not be combined with other discounts, coupons or service packages. Find a vet near you Find participating veterinarians in your area on our website at www.petassure.com. Our network reaches across all 50 states, Washington, D.C. and Puerto Rico. Enter your ZIP code in the search box on the bottom of every page to search for providers. More savings on retail products Save on food, supplements, medications, toys, kitty litter, boarding, grooming, pet sitting, training, and so much more. To locate a participating retail provider near you, log on to www.petassure.com or call customer service toll free at 888-789-7387. Lost Pet Recovery Service For many pet owners, a lost pet is like a lost member of the family, and in our big world a missing pet can be hard to find. Each pet enrolled in PALS, Pet Assure’s Locator Service, receives a unique lightweight Pet ID tag with a unique pet ID numbers linked to the pet’s confidential information. PALS has reunited thousands of lost pets with their families. Join today to start saving! 41 www.JacksonBenefits.org Rules & Regulations Disclaimer – Health Insurance Benefits Provided Under Health Insurance Plan(s) FBMC Privacy Statement This statement applies to products administered by FBMC Benefits Management, Inc. and its wholly-owned subsidiaries, including VISTA Management Company (collectively “FBMC”). FBMC takes your privacy very seriously. As a provider of products and services that involve compiling personal-and sometimes, sensitive-information, protecting the confidentiality of that information has been, and will continue to be, a top priority of FBMC. This Privacy Statement explains how FBMC handles and protects the personal information we collect. Please note that the information we collect and the extent to which we use it will vary depending on the product or service involved. In many cases, we may not collect all of the types of information noted below. Note this Privacy Statement is not meant to be a Privacy Notice as defined by the Health Insurance Portability and Accountability Act (HIPAA), as amended. Health Insurance benefits will be provided not by your Employer’s Flexible Benefits Plan, but by the Health Insurance Plan(s). The types and amounts of health insurance benefits available under the Health Insurance Plan(s), the requirements for participating in the Health Insurance Plan(s) and the other terms and conditions of coverage and benefits of the Health Insurance Plan(s) are set forth from time to time in the Health Insurance Plan(s). All claims to receive benefits under the Health Insurance Plan(s) shall be subject to and governed by the terms and conditions of the Health Insurance Plan(s) and the rules, regulations, policies and procedures from time to time adopted. Notice of Administrator’s Capacity This notice advises insured persons of the identity and relationship among the contract administrator, the policyholder and the insurer: FBMC’s privacy statement is as follows: I. We collect only the customer information necessary to consistently deliver responsive services. FBMC collects information that helps serve your needs, provide high standards of customer service, and fulfill legal and regulatory requirements. The sources and types of information collected generally vary depending on the products or services you request and may include: • Information provided on enrollment and related forms - for example, name, age, address, Social Security number, e-mail address, annual income, health history, marital status, and spousal and beneficiary information. • Responses from you and others such as information relating to your employment and insurance coverage. • Information about your relationships with us, such as products and services purchased, transaction history, claims history, and premiums. • Information from hospitals, doctors, laboratories and other companies about your health condition, used to process claims and prevent fraud. 1. Contract Administrator. FBMC Benefits Management (FBMC) has been authorized by your employer to provide administrative services for your employer’s insurance plans offered within your benefit program. In some instances, FBMC may also be authorized by one or more of the insurance companies underwriting the benefits to provide certain services, including, but not limited to: marketing; billing and collection of premiums; and processing insurance claims payments. FBMC is not the policyholder or the insurer. 2. Policyholder. This is the entity to whom the insurance policy has been issued; the employer is the policy holder for group insurance products and the employee is the policyholder for individual products. The policyholder is identified on either the face page or schedule page of the policy or certificate. 3. Insurer. The insurance companies noted herein have been selected by your employer, and are liable for the funds to pay your insurance claims. If FBMC is authorized to process claims for the insurance company, we will do so promptly. In the event there are delays in claims processing, you will have no greater rights to interest or other remedies against FBMC than would otherwise be afforded to you by law. FBMC is not an insurance company. www.JacksonBenefits.org 42 Rules & Regulations Insurance Coverage after Retirement II. Under Federal Law you have certain rights with respect to your protected health information. Under section 112.0801, Florida Statutes, your employer is required to offer you or your eligible dependents the option of continued participation in any employer-sponsored group insurance plans in which you were participating at your retirement or at your DROP termination date. You have rights to see and copy the information, receive an accounting of certain disclosures of the information and, under certain circumstances, amend the information. You also have the right to file a complaint with your Employer or with the Secretary of the U.S. Department of Health and Human Services if you believe your privacy rights have been violated. As a retiree, your premium cost for health and hospitalization insurance coverage may not exceed the total employee and employer premium cost applicable to active employees. You may lose your eligibility to participate if you choose not to continue participating in your employer’s group plan at retirement, initially choose to continue but subsequently stop participating, defer your retirement to a future date, or otherwise do not meet your employer’s group plan requirements. Before you terminate employment, contact your employer about continuing your employer-sponsored group insurance coverage. The division has no authority over or responsibility for employer group health and hospitalization plans. III. We maintain safeguards to ensure information security. We are committed to preventing unauthorized access to personal information. We maintain physical, electronic, and procedural safeguards for protecting personal information. We restrict access to personal information to those employees, insurance companies, and service providers who need to know that information to provide products or services to you. IV. We limit how, and with whom, we share customer information. Income Taxes on Your Retirement Benefit We do not sell lists of our customers, and under no circumstances do we share personal health information for marketing purposes. With the following exceptions, we will not disclose your personal information without your written authorization. We may share your personal information with insurance companies with whom you are applying for coverage, or to whom you are submitting a claim. We will share personal information of VISTA 401(k) participants with the plan’s recordkeeper. We also may disclose personal information as permitted or required by law or regulation. For example, we may disclose information to comply with an inquiry by a government agency or regulator, in response to a subpoena, or to prevent fraud. If you no longer have a customer relationship with us, we will still treat your information under our Privacy Policy, the words “you” and “customer” are used to mean any individual who obtains or has obtained an insurance, financial product or service from FBMC that is to be used primarily for personal or family purposes. Each year at the end of January, the division provides you an IRS Form 1099-R. Your annual taxable income is shown in the taxable amount box (Box 2a). You should use this form when you file your income tax return. 43 www.JacksonBenefits.org Office Hours: 7:30 a.m. - 4:30 p.m. Monday - Friday ET. On-site FBMC Service Center Benefits Department Jackson Memorial Hospital 1611 N.W. 12th Avenue Park Plaza West L-109B Miami, FL 33136-1096 305-585-6512 Jackson Memorial Hospital Highland Professional Building 1801 N.W. 9th Avenue, 7th floor Miami, FL 33136 786-466-8355 Contract Administrator FBMC Benefits Management, Inc. P.O. Box 1878 • Tallahassee, Florida 32302-1878 FBMC Service Center 855-56JHS4U (855-565-4748) www.myFBMC.com Information contained herein does not constitute an insurance certificate or policy. Certificates or policies will be provided to participants following the start of the plan year, if applicable. FBMC/JHS_NEWRET/1115 © FBMC 2016