Benefits Decision Guide

Transcription

2016 Benefits
Decision Guide
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Table of Contents
Benefit Eligibility & Enrollment................................................................................................................................................................ 4
Your Medical Plans at a Glance ................................................................................................................................................................. 6
Medical Plan Rates ……...………………………...……………………………………………….……………………………………10
Medical Outline of Benefits ……………………………………………………………………………………………………………...11
Provider Network-WIDS ......................................................................................................................................................................... 15
H.S.A. ..................................................................................................................................................................................................... 16
Flexible Spending Accounts .................................................................................................................................................................... 17
Dental ...................................................................................................................................................................................................... 21
Vision ...................................................................................................................................................................................................... 23
Life and Accidental Death and Dismemberment (AD&D) Insurance ..................................................................................................... 26
Voluntary Life and Voluntary AD&D Insurance .................................................................................................................................... 27
Short Term Disability (STD) .................................................................................................................................................................. 29
Long Term Disability (LTD) ................................................................................................................................................................... 30
401 (k) ..................................................................................................................................................................................................... 30
Insurance Directory/Benefit Resources.................................................................................................................................................... 32
Paid Time Off (PTO) .............................................................................................................................................................................. 33
ProShare................................................................................................................................................................................................... 35
MetLife Personal Property/Liability Insurance ........................................................................................................................................ 37
Appendix
Health Care Reform and Your ProHealth Care Benefits .......................................................................................................................... 39
Notice of Privacy Practice ....................................................................................................................................................................... 42
Newborns’ and Mothers’ Health Protection Act of 1996 ......................................................................................................................... 47
Women’s Health and Cancer Rights Act of 1988 .................................................................................................................................... 47
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) ................................................................ 48
Your Prescription Drug Coverage and Medicare .................................................................................................................................... 51
Notice of COBRA Rights – Employee Assistance Program ................................................................................................................... 53
Wellness Program Disclosure ……………………………………………………………………………………………………………55
Summary of Benefits and Coverage (SBC) ……………………………...…………………………………………………………...….55
Employee Rights and Responsibilities Under the Family Medical Leave Act……...……………………………………………………56
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Benefit Eligibility
Full-Time
Benefit
Medical Plan - You may elect to enroll within 31 days of
(36 hours or
more/week or
72 hours or
more per pay
period)
Regular
Part-Time
(20 -35
hours/week or
40-71
hours/pay
period)
Part-Time
(Less than 20
hours/week)
And Pool
Enrollment
Effective
Date
X
X
A
X
X
A
X
X
A
X
X
A
X
X
A
X
X
B
X
X
B
X
X
B
X
X
B
X
X
B
401(k)
X
X
401(k) - Employer Match
X
X
C
Paid Time Off (PTO)
X
X
C
your date of hire.
Dental Plan - You may elect to enroll within 31 days of
your date hire.
Vision Plan - You may elect to enroll within 31 days of
your date hire.
Health Savings Account – You must be enrolled in
a high deductible health plan. You may enroll or change your
elections at any time.
Flexible Spending Accounts - You may elect to
enroll within 31 days of your date of hire.
Life and AD&D (Accidental Death and
Dismemberment) Insurance - Company
Provided – You will be automatically enrolled.
Life Insurance – Voluntary – You may elect to
enroll within 31 days of your date of hire.
Short -Term Disability - You will be automatically
enrolled.
Long -Term Disability – Company
Provided - You will be automatically enrolled.
Long – Term Disability – Voluntary - You may
elect to enroll within 31 days of your date of hire.
X
C
Enrollment Effective Dates
A - First of the month following hire date
B - First of the month following 90 days of employment
C - Upon hire (minimum age 18 for 401(k) Plan)
ProHealth Care is pleased to offer a comprehensive suite of health and welfare benefits to our
employees, described in this booklet. Please review this material carefully so that you can make an
informed decision and select the benefits that best suit you and your family.
Eligible Dependents
You must enroll in benefits in order to enroll your eligible dependents. If you enroll your dependents,
they may only be enrolled in the same coverage you have for yourself.
Determine your dependents eligibility and required documents before enrolling by reviewing the
criteria below.
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Your eligible dependents include:
Your eligible dependents include:
Legally married spouse
Unmarried children who are not on active military duty and
younger than 19
Physically or mentally disabled and dependent on you
Full-time students (as defined by the college or university )
between the ages of 19 and 25 and not married
Adult children between the ages of 19 and 26 and are not
fulltime students or on active military duty
Health

Benefit Plan
Dental

Vision





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
Provided they meet the requirements above, eligible dependent children (regardless of where they
reside) include:




Your natural children,
Your adopted children or children placed with you for adoption,
Your stepchildren and/or
Children for whom you are the legal guardian.
Dependent children also may be covered under the Medical Plan if they are required to be covered
under a Qualified Medical Child Support Order as an “Alternate Recipient”. You are responsible for
determining the tax dependent status of dependents when you add them to your health insurance
coverage. Consult IRS Publication 501 and IRS Notice 2010-38 for tax dependent guidelines and
tests, or speak with a tax advisor.
Spousal Surcharge
You may choose to cover your spouse under the ProHealth Care Medical Plan; however, you will
pay a surcharge if your spouse is eligible for coverage through his or her employer, regardless of
whether or not that medical coverage was elected. If your spouse is not eligible for medical
coverage through his or her employer, not working, or works for PHC, then you are eligible for a
waiver of the spousal surcharge. The spousal waiver form is available electronically on the Total
Rewards page, as well as on Employee Self-Service.
The biweekly spousal surcharge is $75 after tax. ProHealth will randomly audit employees who
have elected to waive the spousal surcharge.
Enrolling in Your Benefits
You may enroll in benefits in one of four coverage categories:
 Single
 Employee + Child(ren)
 Employee + Spouse

Family
Note: You do not need to enroll in the same coverage level for each benefit. For example, you may
enroll in medical with family coverage, but enroll in dental with single coverage.
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When You Can Change Your Coverage
Open enrollment (typically held in November) is your opportunity to select or make changes to your
benefit coverage. You may make changes other times during the year if you experience a qualifying
event, such as marriage, birth, loss of other coverage, etc.
If you experience a qualifying event, contact Total Rewards within 31 days of the change. You will
need to provide the following information with supporting documentation on the appropriate form:
 The type of status change, divorce, marriage, birth/adoption, spouse loss of coverage
 The date the change occurred
 The new or changed benefit coverage requested
If you do not contact Total Rewards within 31 days of the qualifying status change, you will not be
able to make any changes to your benefit elections until the next annual open enrollment period
(unless you experience another qualifying status change).
Your Medical Plans at a Glance
ProHealth Care offers two medical plan options, both of which emphasize wellness, prevention and
wise health care spending.
The two medical plan options are:

ProHealth PPO Plan This plan operates like a traditional PPO.

ProHealth High-Deductible Plan Under this option ProHealth Care will contribute the
incentive amounts to a Health Savings Account (HSA). You may make before-tax personal
contributions to the Health Savings Account, up to a maximum set annually by the Internal
Revenue Service. At the end of the year, any unused amounts in your Health Savings
Account are rolled over and added to your account for the following year.
The two options are alike in many ways

Both operate like traditional PPO plans, enabling you to seek care from any licensed health
care provider, in-network or out-of-network.

Both pay 100% of the cost of preventive care services at in-network providers, and 90% of
the cost of most other Tier 1 health care services after you meet your deductible.
For more details, see “Medical Outline of Benefits” beginning on page 11.
Paying for Medical Services
The amount you pay for medical services will depend on whether you see an in-network or out-ofnetwork provider. Claims will be submitted on your behalf to the plan administrator if you see an innetwork provider. In most cases, out-of-network providers will submit your claims directly to the plan
administrator. If your provider will not file for you, submit a claim form and documentation of services
to Aetna at the address on the claim form (claim forms can be found at www.aetna.com).
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Out of Area Coverage
Dependents who live outside of the coverage area will receive Tier 1 coverage when obtaining care
from one of Aetna’s providers under the Aetna Open Choice PPO. For more information, contact
Total Rewards at 262-928-4185.
To locate an Aetna in-network national provider:
1. Go to the Aetna website www.aetna.com
2. Under the individuals & Families tab – Click on “Find a Doctor”
3. Click on “Find an Aetna Doctor”
 Do not log into website. No need to enter user name or password
4. Click on “search our public directory”
5. Enter “who or what are your looking for?” information and “Where?” information.
6. Select a Plan: Open Choice® PPO
7. If you have any questions or need assistance please contact Aetna customer service at 1800-414-08766.
The following eight counties are NOT eligible for Out of Network consideration using Aetna’s
providers: Dodge, Jefferson, Milwaukee, Ozaukee, Racine, Walworth, Washington, and Waukesha.
Emergency Care
If you have an emergency condition, go to the nearest emergency room immediately. Emergency
care is covered even out-of-network, although at a different coinsurance amount. In emergent
situations, emergency care is covered at the in-network benefit level even though it may be out-ofnetwork.
Additional Resources
Aetna, the plan administrator of the Medical Plan, offers a variety of tools and resources to help you:
 Make more informed decisions about your care,
 Communicate better with your doctors and
 Save time and money by showing you how to get the right care at the right time.
Aetna’s Informed Health Line makes it possible to talk directly to a registered nurse anytime, 24
hours a day, seven days a week. When you call the Informed Health Line at 1-800-556-1555, you
also can listen to the Audio Health Library, which explains thousands of health conditions.
Aetna’s secure Aetna Navigator member Web site at www.aetna.com gives you access to the
Healthwise Knowledgebase, where you can find out more about a health condition you have or
medications you take. It explains things in terms that are easy to understand.
Coordination of Benefits
If you or your dependents are covered under the ProHealth Care medical and/or dental plan and
another group plan, the two plans may coordinate benefits. Special rules determine which plan will
pay benefits first. Generally speaking, you will not benefit from coverage under more than one plan,
so think carefully about whether it is cost effective for you to participate in both plans.
Under coordination of benefits rules, the combined benefit from both of your plans will not exceed
the benefit you would have received from each medical plan individually. The other plan will be the
primary payer if any of the following conditions are present:
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If the other medical plan is primary, the ProHealth Care plan will pay benefits only up to the amount
you would have received if it were the only plan.
Other rules determine which plan pays first if your children are covered under both the ProHealth
Care plan and a spouse’s medical plan.
Note: You should always check plan documents for coordination of benefit rules.
Prescription Drug Benefit
Both medical plan options include prescription drug coverage. Your share of the prescription cost
will depend on the type of medication you purchase and whether you purchase the drug through an
in-network retail pharmacy or through the mail order program. Drugs are assigned to one of three
tiers; each tier represents a group or category of drugs and has its own co-pays or coinsurance
amount as shown in the benefit outline on page 14. The drug formulary, is a listing of the drugs in
each tier, it is available at www.Aetna.com, select Individuals & Families, then Aetna Pharmacy >
Preferred Drug List > Three Tier Open Formulary. All prescriptions will be filled as generic unless
your physician specifies “Dispense as Written” or “DAW” on each prescription. If your physician
does not specify “Dispense as Written” and you elect the non-generic drug, you will pay your share
of the cost plus the difference in price between the drug chosen and the generic drug.
Specialty Medications
The ProHealth Care pharmacy benefit plan includes coverage for what are considered Specialty
Medications. Specialty drugs treat complex, chronic diseases and because of the complex therapy
needed, a pharmacist or nurse should check in with you often during your treatment. These drugs
may include self-injectable, infused or select oral medications that may require refrigeration and may
not be available at retail pharmacies.
You may obtain one fill of the medication through a retail pharmacy if available. But ongoing refills
will need to be obtained from a participating specialty pharmacy, like Aetna Specialty Pharmacy or
from the onsite pharmacies at the ProHealth Care facilities.
To learn which drugs are considered Specialty drugs, visit www.AetnaSpecialityCareRx.com
The Mail Order Advantage
If you or a family member take preventive medications for a long-term or chronic condition (such as
diabetes, coronary artery disease or arthritis), you can save time and money by obtaining those
medications through the mail order service. You save time by not having to refill your prescription
every month and by having your prescription mailed to your home. You also save money by
obtaining a three-month supply of your medication by mail order for the cost of two co-pays.
Definitions
After-tax: Payroll deductions taken after federal, state, and Social Security taxes are taken out.
Premiums for voluntary life insurance, voluntary accidental death and dismemberment (AD&D)
insurance, and voluntary long term disability insurance are paid with after-tax dollars.
Annual out-of-pocket maximum: A dollar limit on the amount you have to pay for services in
any calendar year. The two Medical Plan options pay 100% of charges for covered services after the
annual out-of-pocket maximum is met.
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Before-tax: Payroll deductions taken before federal, state, and Social Security (FICA) taxes are
taken out. Before-tax deductions reduce your taxable income, therefore reducing your current tax
liability. Employee costs for medical, dental and vision plan are paid with before-tax dollars, as are
contributions to a medical or dependent care flexible spending account (FSA).
Coinsurance: A percentage of the cost of covered services that you must pay after the deductible
is met. The two medical plan options pay 90% of charges for most medical services received in Tier
1 after the deductible is met. You pay 10% of the charges (your coinsurance).
Copay: A flat dollar amount you pay at the time services are received. Under the medical plans, for
example, a specialist office visit under the ProHealth PPO plan requires $35 copay.
Deductible: The amount of money you pay for certain covered services in a calendar year before
the plan pays.
Reasonable and customary: A fee is generally considered to be reasonable and customary
(R&C) if it is consistent with the average or commonly charged fee for a particular service within a
specific geographic area. You are responsible for any out-of-network fees above R&C levels.
Spousal Surcharge: An additional fee charged for spouses enrolled on the PHC medical plan
who are eligible for another employer’s health plan.
Summary of Benefits and Coverage (SBC): The Affordable Care Act (ACA) requires health
plans and health issuers to provide applicants and enrollees with a concise document providing
simple and consistent information about the health plan benefits and coverage. This document is
called a summary of benefits and coverage (SBC).
Employee Health & Wellness Clinics
When you have a health care need, remember that ProHealth Care offers immediate care services
for employees and their dependents age six and older at the employee health & wellness clinics.
Clinics are open from 8 a.m. to 4:30 p.m. and are located at ProHealth Care’s existing occupational
health and employee health locations: Waukesha Memorial Hospital, Mukwonago, Oconomowoc
Physician Center, Watertown, and New Berlin.
The clinics can be used for the following services:

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



Upper respiratory and ear infections
Cuts, scrapes, and lacerations
Sore throat
Persistent cough
Viral symptoms
Pink eye





Bladder infections
Minor stomach ailments
Sprains and strains
Minor rashes
Other conditions that typically would be
seen in urgent care
Employees using this service will be seen by a nurse practitioner or physician assistant. Providers
will diagnose, treat and manage medical conditions that require timely care, but are not serious
enough to warrant an emergency department visit.
Walk-in visits are accepted, though appointments are preferred (call Employee Health at 262-9285900 for an appointment). A $10 copay per visit can be paid by cash, check, or credit card. Bring
your Aetna medical insurance card to your visit (medical insurance is only billed for services outside
of your office visit, such as lab and radiology).
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Health Risk Assessment Rate Guidelines
To be eligible for a discount on your medical premiums, you (and your spouse if enrolling in
coverage) must be tobacco-free.
Health Risk Assessment (HRA) at no cost to all employees who are enrolled or plan to enroll in the
ProHealth Care-Aetna medical plans. By examining your health-related behavior and health history,
an HRA can help you take control of your health, identify and prevent potential health risks, and
begin living a life of enhanced wellness. The HRA includes a biometric screening (height, weight,
blood pressure, fasting lipid profile and glucose and nicotine test) and a short health survey.
In addition to the obvious health benefits, you (and your spouse, where applicable), may be eligible
for an annual discount on your health insurance premiums if you participate in the HRA and meet
the necessary criteria (nicotine-free). Employees and their spouses who enroll in the health plan
may choose not to participate in the HRA; however, they will not be eligible for the insurance
premium reduction.
You must fast and not use tobacco to participate: options do not exist. If you participate in the HRA,
your spouse must participate at the same level in order to receive the premium discount.
The premiums you will see during the online enrollment process reflect the non-discounted rate. By
being tobacco-free and completing the online assessment as well as fasting lipid profile and glucose
test, you may be eligible for an annual discount which will be reflected in your health insurance
premiums. See the i-Net or Employee Self Service (ESS) for more information.
2016 Biweekly Medical Premium Rates
FULL-TIME
EMPLOYEE
PROHEALTH PPO
PROHEALTH HIGH-DEDUCTIBLE PLAN
Non Discounted
Rate
Discounted Rate
Non Discounted
Rate
Discounted Rate
Single
$ 106.30
$76.30
$63.40
$33.40
Employee + Child(ren)
$163.50
$133.60
$88.45
$58.45
Employee + Spouse*
$216.85*
$156.90*
$128.60*
$68.65*
Employee + Family*
Regular Part Time
Employee
$270.50*
$210.55*
$152.00*
$92.10*
PROHEALTH PPO
PROHEALTH HIGH-DEDUCTIBLE PLAN
Non Discounted
Rate
Discounted Rate
Non Discounted
Rate
Discounted Rate
Single
$160.95
$130.95
$87.30
$57.30
$259.20
$229.25
$130.25
$100.30
Employee + Spouse*
$329.15*
$269.15*
$177.70*
$117.75*
Employee + Family*
$421.25*
$361.25*
$218.00*
$158.00*
*PLEASE NOTE: If your spouse is eligible for another employer’s medical plan and you insure him or her under the ProHealth Care plan,
you will pay an after-tax surcharge of $75 biweekly. Benefit deductions will be taken the first two (2) pay dates of the month. Months
with three (3) pay periods will not have deductions on the third pay date. It is your responsibility to review the benefit deductions on your
paycheck stub for accuracy and report any issues to Total Rewards for resolution.
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Medical Outline of Benefits
January 1, 2016
ProHealth Care PPO
Provision/Benefit
Network
Tier 1
Tier 2
Tier 3
Tier 1
Tier 2
Tier 3
ProHealth and
CHW facilities
Non-PHC WIDS
Network
facilities and
physicians*
Out of Network
PHC and CHW
facilities
Non-PHC WIDS
Network
facilities and
physicians*
Out of Network
PHC affiliated
and MCW
physicians*
Annual Deductible Amount
ProHealth Care High Deductible
PHC affiliated
and MCW
physicians*
$600 single
$1,200 single
$1,600 single
$1,500 single
$2,000 single
$2,500 single
$1,200 family
$2,400 family
$3,200 family
$3,000 family
$4,000 family
$5,000 family
If an individual family member meets the single
deductible, that family member will then move to coinsurance. The family deductible (which includes the
individual deductible) then needs to be reached before
other family members move to co-insurance.
The full family deductible must be met before anyone
moves into co-insurance.
Annual Out-of-Pocket Limit
$2,400 single
$4,800 single
$6,000 single
$4,500 single
$5,000 single
$5,500 single
(Includes deductible and medical copays)
$4,800 family
$9,600 family
$12,000 family
$9,000 family
$10,000 family
$11,000 family
If any covered family member meets the individual outof-pocket maximum based on the tier, that family
member will be covered at 100% for the remainder of
the year. The family out-of-pocket maximum (which
includes the individual out-of-pocket maximum) then
needs to be reached before other family members are
covered at 100%.
If any covered family member meets the mandated
ACA individual out-of-pocket maximum $6,850, that
family member will be covered at 100% for the
remainder of the year. The family out-of-pocket
maximum (which includes the individual out-of-pocket
maximum) then needs to be reached before other
family members are covered at 100%.
Waived
Waived
Pre-existing Conditions
Professional Services
Physician (other than Specialist) office visits
$25 copay then
100% of
charges
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
$35 copay, then
100% of
charges
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
$50 copay, then
100% of
charges
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
100% of
charges
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
Radiology, pathology and anesthesiology services
provided and billed by an independent radiologist,
pathologist or anesthesiologist
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
Covered Oral Surgical Services
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
Inpatient, Outpatient and Office Surgery/Surgical
Assists/Anesthesia, other than Independent
Anesthesiologist (Professional Service Fees)
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
100% of
charges
60% after
deductible
50% after
deductible
100% of
charges
60% after
deductible
50% after
deductible
(office visit charge only)
Does not include chiropractic services
Specialist office visits
(office visit charge only)
Urgent Care
(exam charge only)
Inpatient Hospital Physician Visit
Pathologist/Radiologist, other than an Independent
Radiologist or Pathologist
(does not include mammograms and pap smears)
Routine Prenatal Visits
(Does not include delivery charges )
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ProHealth Care PPO
Provision/Benefit
Tier 1
Tier 2
Tier 3
Tier 1
Tier 2
Tier 3
Hospital Services - Does not apply to alcoholism, drug use and nervous or mental disorders
Inpatient Hospital Services
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
Preadmission
certification
required or
confinement will
be subject to a
penalty of 10%
not to exceed
$500
Preadmission
certification
required or
confinement will
be subject to a
penalty of 10%
not to exceed
$1,000
Preadmission
certification
required or
confinement will
be subject to a
penalty of 10%
not to exceed
$1,500
Preadmission
certification
required or
confinement
will be subject
to a penalty of
10% not to
exceed $500
Preadmission
certification
required or
confinement will
be subject to a
penalty of 10%
not to exceed
$1,000
Preadmission
certification
required or
confinement
will be subject
to a penalty of
10% not to
exceed $1,500
Inpatient and Outpatient Radiation, Chemotherapy,
Dialysis, Infusion Therapy
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
Outpatient miscellaneous hospital expenses
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
Outpatient radiology and laboratory services
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
Emergency room visit - emergency room charge
only
$150 copay plus Deductible, then 90% of charges
(waived if admitted)
90% after deductible
Includes x-rays, labs and miscellaneous hospital
expenses
Emergency room services provided during an
emergency room visit
Preventive Services
Routine medical exams, including well baby care
(Exam charge only)
100% of
charges
60% after
deductible
50% after
deductible
deductible waived
Preventive Services, including mammograms and
pap smears
Colonoscopies
(limited to one every five years)
100% of
charges
60% after
deductible
50% after
deductible
60% after
deductible
50% after
deductible
100% of
charges
100% of
charges
60% after
deductible
50% after
deductible
100% of
charges
60% after
deductible
50% after
deductible
60% after
deductible
50% after
deductible
deductible
waived
(If surgery
services
performed,
Outpatient
surgical coverage
applies)
(excludes travel immunizations)
50% after
deductible
deductible
waived
deductible waived
Immunizations
60% after
deductible
deductible
waived
deductible waived
100% of
charges
100% of
charges
(If surgery
services
performed,
Outpatient
surgical
coverage
applies)
60% after
deductible
50% after
deductible
deductible waived
100% of
charges
deductible
waived
Other Covered Health Care Services
Physical, speech, and occupational therapy billed
through clinic - (Evaluation or evaluation and therapy)
Outpatient physical, speech, and occupational
therapy billed through clinic - (Therapy only)
Physical, speech, and occupational therapy billed
through hospital - (Evaluation or evaluation and therapy)
$35 copay then
100% of
charges
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
100% of
charges
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
13 | P a g e
ProHealth Care PPO
Provision/Benefit
Outpatient physical, speech, and occupational
therapy billed through hospital - (Therapy only)
Tier 1
Tier 2
Tier 3
Tier 1
Tier 2
Tier 3
100% of
charges
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
Ambulance services
Prosthetic devices (other than dental prosthetics)
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
Nutritional counseling for morbid obesity and any
other health condition
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
Durable medical equipment
90% after
deductible
No Coverage
No Coverage
90% after
deductible
No Coverage
No Coverage
Dental services:
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
Chiropractic Care (includes office visits,
consultations, therapy, x-rays and other related
diagnostic tests, (Limited to 15 visits per calendar year)
$35 copay, then
100% of
charges
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
Allergy Services
$10 copay, then
100% of
charges
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
100% of
charges
60% after
deductible
50% after
deductible
100% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
(unlimited visits)
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
Skilled nursing services in a licensed skilled nursing
facility (limited 120 days per calendar year)
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
Dialysis treatment of kidney disease
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
TMJ treatment - oral surgical services and nonsurgical treatment
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
see benefit
book for
covered
transplants;
transplantrelated services
subject to Plan's
benefits for the
specific service
60% after
deductible
50% after
deductible
see benefit
book for
covered
transplants;
transplantrelated
services
subject to
Plan's benefits
for the specific
service
60% after
deductible
50% after
deductible
(Limited to $500 per calendar year)
- dental repair of your sound natural teeth due to
an injury,
- extraction of teeth to prepare the jaw for
radiation treatment; and
- sealants on existing teeth to prepare the jaw for
chemotherapy treatment
(vials, injections and medical supplies if no office
visit is charged)
Copayment
applies to each
service
Contraceptives (Generic) - Injections, Implants,
IUD's and Diaphragms (and related services)
Infertility Services
limited to $2,500 lifetime maximum per participant for surgical
and non-surgical treatments; $2,500 lifetime for prescription
drugs
Home Care
(limited to 40 visits per calendar year)
Home Hospice Care
Organ transplants
Note:
All diagnosed transplants (bone marrow/stem cell, heart, lung, heart and lung, liver, pancreas, kidney and pancreas) except cornea and kidney must
undergo a pre-transplant evaluation at Mayo clinic, unless travel is medically contraindicated or a $2,000 penalty will be applied. Patients under age 19 are
not required to participate in this program.
14 | P a g e
ProHealth Care PPO
Provision/Benefit
Tier 1
Tier 2
Tier 3
Tier 1
Tier 2
Tier 3
Treatment of Alcoholism, Drug use and Nervous or Mental Disorders
Nervous & Mental - Inpatient Hospital
Nervous & Mental - Outpatient and Transitional
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
Preadmission
certification
required or
confinement will
be subject to a
penalty of 10%
not to exceed
$500
Preadmission
certification
required or
confinement
will be subject
to a penalty of
10% not to
exceed $1,000
Preadmission
certification
required or
confinement will
be subject to a
penalty of 10%
not to exceed
$1,500
Preadmission
certification
required or
confinement will
be subject to a
penalty of 10%
not to exceed
$500
Preadmission
certification
required or
confinement will
be subject to a
penalty of 10%
not to exceed
$1,000
Preadmission
certification
required or
confinement
will be subject
to a penalty of
10% not to
exceed $1,500
$25 copay
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
Preadmission
certification
required or
confinement will
be subject to a
penalty of 10%
not to exceed
$500
Preadmission
certification
required or
confinement
will be subject
to a penalty of
10% not to
exceed $1,000
Preadmission
certification
required or
confinement will
be subject to a
penalty of 10%
not to exceed
$1,500
Preadmission
certification
required or
confinement will
be subject to a
penalty of 10%
not to exceed
$500
Preadmission
certification
required or
confinement will
be subject to a
penalty of 10%
not to exceed
$1,000
Preadmission
certification
required or
confinement
will be subject
to a penalty of
10% not to
exceed $1,500
$25 copay, then
100% of
charges
60% after
deductible
50% after
deductible
90% after
deductible
60% after
deductible
50% after
deductible
then 100% of
the charges
*Alcoholism & Drug use - Inpatient Hospital
*Alcoholism & Drug use - Outpatient and
Transitional
Prescription Drugs
Retail: 30 day supply
Retail: 30 day supply
Prescription Drugs (including insulin, oral
contraceptives and diabetic supplies)
Tier 1 - $15
Mandatory Generic for both plans
Tier 3 - 50% up to $75
$10 copay for certain preventive medications
Mandatory Specialty – One fill at retail, ongoing refills
need to be obtained from Aetna’s Specialty Pharmacy or
from the onsite pharmacies at ProHealth Care.
Specialty Pharmacy: Injectable medications 30 day
supply
Specialty Pharmacy: Injectable medications 30 day
supply
Tier 2 - 40% up to $50
Tier 2 injectable drugs - $50 copay
Tier 3 injectable drugs - $100 copay
New! Prescription copays count towards your out of
pocket maximum.
Mail Order: 90 day supply
Tier 1 - $30
Tier 2 - 40% up to $100
Tier 3 - 50% up to $150
Deductible then 10%
Deductible then 10%
Mail Order: 90 day supply
Deductible then 10%
$20 copay for certain preventive medications
Every effort has been made to report accurately the coverage, benefits and limitation of the plan.
If there is any difference between this publication and the official plan document, the plan document will govern.
ProHealth Care reserves the right to amend, modify or terminate all or part of the plan.
* PHC - ProHealth Care
CHW – Children’s Hospital of Wisconsin
WIDS – Wisconsin Integrated Delivery System
MCW – Medical College of Wisconsin
15 | P a g e
Provider Network
Find a Participating Provider
The ProHealth Care Employee PPO and High Deductible health plans use the Waukesha Integrated
Delivery System (WIDS) provider network. Participants in the employee health plan should see
participating WIDS providers to receive the preferred, Tier 1 benefit levels.
What is WIDS?
The WIDS Network is a partnership among ProHealth Care hospitals and clinics and closely
affiliated Waukesha County independent medical groups.
Where Can I Find the Directory?
Access the provider directory by going to:



www.WIDSNetwork.com –orOn the iNetTotal Rewards Tab
The Provider Directory lists all of the participants in both Tier 1 and Tier 2 of the network.
Tier 1 Providers includes WMH; OMH; PHC joint venture facilities; Children’s Hospital; ProHealth
Care closely affiliated physicians; and Medical College of Wisconsin physicians.
Tier 2 Providers include all other WIDS contracted participating providers, including Froedtert &
Community Memorial hospitals.
Tier 3 Out-of-Network are all other providers not participating in the WIDS Network.
Non-Network providers do not appear in the directory.
The use of Tier 2 and Tier 3 providers and facilities will result in additional out-of-pocket cost to you.
Important to Remember:

Network preferred providers change periodically. The WIDS on-line directory is updated on
a weekly basis. Since this directory frequently changes, it is important to verify that the
health care provider is in-network prior to receiving services. Otherwise, you will be required
to pay a larger portion of the cost of the covered services by an out-of-network provider.

Physicians who have Medical Staff privileges with ProHealth facilities may or may not be
participants in the WIDS provider network.
If you have a question about a provider listed on the WIDS website, please contact Cara Boyer at
262-928-4767 or by e-mail at [email protected].
16 | P a g e
HSA
Feature
HSA
(ProHealth High-Deductible Plan)
Establishing an Account
Elect to enroll in the HSA and enter the amount you wish to contribute to the account.
Contributions
Company incentive contributions, plus optional before-tax personal contributions up to an annual
maximum set by the IRS. For 2016 you can contribute up to:
• $3,350 (individual coverage) or
• $6,750 (family coverage)
You may contribute an additional $1,000 per year as a “catch-up” contribution if you will be age 55 or
older by year-end and are not enrolled in Medicare. (If your spouse will be 55 or older, is not enrolled
in Medicare and wishes to make a catch-up contribution, he or she will need to open an individual
HSA.) Please note: Employer and employee contributions count towards the annual maximum.
Account Earnings
Accumulated amounts in your HSA earn interest, compounded monthly. In addition, once you have
$2,000 in your account, you may elect to transfer a portion of your HSA to an investment account.
Can I change my
contributions at any time?
Yes. You may contribute by check or electronic funds transfer, and you may stop, change or add to
your contributions at any time (subject to the annual maximum).
Tax Liability
Company incentive contributions are considered a benefit and are not subject to federal or state tax.
Your personal before-tax contributions reduce your current tax liability and are not taxed when
withdrawn if used for a qualified medical expense. Interest earned on your account also is not taxed.
Eligibility
Benefit eligible employees who are not enrolled in any other coverage other than another high
deductible health plan and are not enrolled in Medicare. This includes being covered by a spouse’s
FSA as well.
Using The Money
You will receive an HSA Visa debit card to access your account. You can use the card to pay for your
portion of medical expenses covered under the Plan (e.g., deductibles and coinsurance), as well as
other qualified medical expenses, including dental and vision expenses.
Unqualified Expenses
You can use the HSA for your portion of covered expenses under the Medical Plan as well as other
qualified health care expenses (as with a Flexible Spending Account). You cannot use the HSA to
pay for cosmetic procedures, expenses for which you can be reimbursed under any health care plan,
your Medical Plan premium, or premiums for other health care plans (e.g., Dental or Vision).
Any unspent balance in your account at year-end is rolled over and added to your account for the
following year.
Unspent Balances at YearEnd
Unspent Balances at
Termination
Your HSA belongs to you. If you leave the company or the Plan for any reason, the account remains
in your name and you continue to have access to the money. You also may continue to contribute to
the account, up to the annual IRS maximum.
Health Savings Account (HSA): Individual account that you set up to receive company-funded
incentive amounts, and into which you can make optional before-tax contributions up to an annual
maximum determined by the IRS. You can use the HSA to offset a portion of your costs under the
Medical Plan and to pay for qualified expenses not covered by the Plan such as certain over-thecounter medications. You also can let the account grow and earn interest, and use it for future
medical expenses. If there is money in your account at the end of the year, it carries over into the
next year. The money in your Health Savings Account belongs to you. If you leave the medical plan
or leave employment with ProHealth Care, the dollars will remain in that account and are NOT
forfeited.
17 | P a g e
Flexible Spending Accounts
Flexible Spending Accounts (FSAs) offer an easy way to save money while paying for health care or
dependent care (child care) expenses. You set aside before-tax dollars to pay for eligible out of
pocket expenses during the year — in other words; you get a tax break for putting money aside for
expenses you would have paid for anyway.
Note: Before enrolling in the Medical or Dependent Care (child care/elder care) FSA, it’s important
to understand the following IRS restrictions:



File by the deadline. For 2016, you will have until March 31, 2017, to file claims for any
eligible expenses incurred between January 1, 2016 and December 31, 2016.
Plan your contributions carefully. At the end of the year, unused money in an FSA is
forfeited. To avoid this, estimate your expenses as accurately as possible and be
conservative when electing how much to contribute.
No transfers. You may not transfer money between the Dependent Care (child care) FSA
and the Medical FSA.
Medical Flexible Spending Account (FSA)
The Medical FSA gives you the ability to pay for out of pocket medical, dental, vision and certain
other eligible out-of-pocket expenses with before-tax dollars that you contribute to your flexible
spending account. You can contribute to a Medical FSA whether or not you are enrolled in a
ProHealth Care medical plan.
Contribution Limits for Medical Reimbursement


Minimum annual contribution: $ 100
Maximum annual contribution: $2,550
Eligible Expenses
You can find a list of eligible flexible spending account expenses at www.aetna.com/fsa. In the past,
the Medical FSA could be used to pay for over-the-counter (OTC) drugs. Due to health care reform,
the Medical FSA may no longer be used for OTC drugs without a directive from a medical provider.
Dependent Care (child care/elder care) Account
This account allows participants to pay for eligible dependent care expenses with before-tax dollars.
It may appeal to you if you have predictable expenses associated with the care of a child or disabled
adult that you claim as a dependent on your tax return.
To use this account your eligible dependent must require day care or elder care to allow you to
work. If you are married, you can participate in the Dependent Care FSA only if your spouse is
employed or a full-time student for at least five months during the year while you are working, or
disabled/elderly and unable to provide for his or her own care.
Contribution Limits for Dependent Reimbursement


Minimum annual contribution: $ 100
Maximum annual contribution: $5,000
18 | P a g e
Eligible Dependents
To be eligible, the individual receiving the care must be claimed as a dependent on your tax return
and be a child under the age of 13 or an adult who normally spends at least eight hours in your
home each day and cannot care for himself or herself because of a physical or mental disability.
Eligible Expenses
You can find a list of eligible dependent care account expenses at www.aetna.com/fsa.
You must incur an expense in order to be reimbursed for it from your Dependent Care Account.
Expenses are incurred when the service is rendered — not when they are billed, charged or paid for.
When you pay eligible dependent care expenses, obtain a receipt. Complete the Dependent Care
Reimbursement Claim form and attach the receipt (or have the caregiver sign the form). Send it in
as instructed on the form, and Aetna will reimburse you for your eligible expenses. Claim forms are
available at www.aetna.com or on ProHealth iNet - Total Rewards Tab. You must report the name,
address and Social Security or tax identification number of each dependent care provider when you
submit a request for reimbursement.
Something to Consider
The IRS allows two types of tax advantages for dependent care expenses. You may either file for a
federal tax credit on your annual tax return or you can be reimbursed with before-tax dollars
contributed to the Dependent Care FSA, but you may not do both with the same expense. For
example, if you have two or more eligible dependents and spend at least $6,000 in dependent care
expenses in 2016, you may contribute $5,000 to the dependent Care FSA and take $1,000 as a tax
credit. Depending on your income, either the Dependent Care FSA or the tax credit may be more
advantageous. You may wish to consult a tax advisor before deciding which option is best for you.
A Note about Social Security
Although it is to your advantage to make before-tax contributions to an FSA to pay for out-of-pocket
medical, dental, vision, prescription drug and dependent care expenses, you should be aware that
before-tax contributions reduce the amount of earnings used to determine your Social Security
benefits. Because your ultimate Social Security benefit is based on your earnings, this salary
reduction could cause a slight reduction in the benefit. However, any reduction in your future Social
Security benefits probably would be offset by the current tax savings you receive by participating in
the FSAs
19 | P a g e
FSA Streamline Feature
The FSA Streamline Feature automatically pays any out of pocket eligible medical expenses if there
are dollars available in your health care flexible spending account. To enroll in Streamline, log into
the PayFlex website.
1. Log on to https://payflexdirect.com
2. Click on Financial Center, then click on the drop down arrow to select your account.
3. Click on Health Plan Activity Options located on the left hand side under Health Plan Activity.
4. Click on Health Plan Activity Options.
20 | P a g e
5. Select the plan types you want to be automatically reimbursed from your FSA.
Definitions
Flexible Spending Account (FSA): An account you can use to set aside money before-tax for
specific expenses such as medical, dental, or dependent care. Contributions made within a calendar
year must be used for expenses incurred in that year; unused money at the end of the year is
forfeited.
Limited Flexible Spending Account: A special FSA for individuals who enroll in the ProHealth
High-Deductible Plan. This FSA can be used for dental and vision expenses at any time, but can
only be used for medical expenses after the medical plan deductible is met.
21 | P a g e
Dental
Delta Dental is the largest and oldest dental-benefits specialist in the country. It was built on the
guiding principle that dental benefits should be simple and hassle-free. Delta Dental of Wisconsin
was founded in 1962 with the same goal. Combined, member companies of the Delta Dental Plans
Association serve more than 59 million people in nearly 97,000 groups nationwide.
With some PPO plans, you don’t get much choice of providers. And if you go out of network, your
provider may balance-bill you. But your Delta Dental PPO plan is different. The Delta Dental PPO
network, with more than 165,000 dentist locations nationwide, is backed by Premier network, with
more than 247,000 dentist locations nationwide – almost 80% of the nation’s dentists. Your lowest
out-of-pocket costs come from seeing a Delta Dental PPO dentist, but you’ll also enjoy cost
advantages if you see a Delta Dental Premier dentist. That means savings on out-of-pocket costs
and better choice. Here’s an example:
PPO Savings, With A “Safety Net”
Dentist’s Normal Fee
Allowed Amount
Dentist Fee Adjustment Due to Delta
Agreement
50% Benefit paid by Plan
Patient Responsibility
Delta Dental PPO
Dentist
$720
$590
$130
Delta Dental
Premier Dentist
$720
$680
$ 40
Out-of-Network
Dentist
$720
$680
None
$295
$295
$340
$340
$340
$380
Delta
Dental PPO
Network
Dentist
Delta Dental
Premier
Network
Dentists
Agreed-to fee ceilings (no balance-billing): Dentist agrees to fee ceilings. If his/her
normal charge is higher than the fee ceiling, he/she can't pass the balance on to you.
√
√
Additional fee schedule savings: Dentist agrees to a reduced fee schedule. Saves out
of pocket expenses for you.
√
Convenient claims processing: Dentist is required to file claims on your behalf, saving
you the hassle of doing so yourself. Claims payments go directly to the dentist.
√
√
Treatment guarantees: Examples - Repair or replace dental restorations should they
fail within 24 months.
√
√
Advantages of Delta Dental Network Dentists
Non
contracted
Dentists
Confirming Your Coverage
If you are not sure of the effective date of your coverage, please call Delta at 800-236-3712 before
you have any dental work done.
Also, before scheduling appointments for extensive dental care, you may ask your dentist to send
the treatment plan to Delta Dental. The plan will be reviewed by Delta and a Predetermination of
Benefits form will be returned to you and your dentist. You and your dentist may then discuss the
treatment and your out-of-pocket costs. Delta encourages you to be informed about your dental
care
22 | P a g e
Summary of 2016 ProHealth Care Dental Plan Benefits
Delta PPO*
Delta Premier
In-Network Delta Dental
Preferred Provider
Out-of-Network or Other
Provider
Calendar Year Deductible
$ 50 Single
$100 Family
$ 75 Single
$150 Family
Calendar Year Maximum
$1,500 per individual
$1,000 per individual
100% Covered
100% Covered
80% Covered
80% Covered
Deductible applies
Deductible applies
50% Covered
50% Covered
Deductible applies
Deductible applies
50% Covered
50% Covered
Deductible applies
Deductible applies
$1,500 lifetime maximum
$1,000 lifetime maximum
Benefit Description
Diagnostic & Preventative
 Exams
 Cleanings
 Fluoride Treatments (up to age 19)
 Space Maintainers
 X-rays
 Sealants (up to age 19)
Basic and Major Services
 Emergency Pain Treatment
 Fillings
 Endodontics – Surgical and nonsurgical
 Periodontics – Surgical and nonsurgical
 Extractions – Surgical and nonsurgical
 Other oral surgery
Major Restorative Services
 Crowns, inlays, onlays
 Dentures
 Bridges
 Repairs and adjustments to
bridges and dentures
 Implants
Orthodontia
Orthodontia is covered for enrolled
dependent children under age 19
Special Plan Provisions – Evidence Based Integrated Care: Expanded benefits for persons with medical conditions that have
oral health implications. Conditions include:
 Diabetes
 Pregnancy
 Specific heart conditions that pose a risk of certain types of infection
 Kidney failure or dialysis
 Suppressed immune system
 Cancer therapy
 Periodontal disease
Requires self-enrollment by the patient or his/her dentist at Delta Dental’s website, or by calling 800-236-3712.
Dependent Eligibility – Dependents are eligible through the end of the month in which they attain age 19 and full-time students through the end of
the month in which they attain age 25; except as noted for orthodontics and sealants.
*Your lowest out-of-pocket costs will come from seeing a Delta Dental PPO dentist.
23 | P a g e
2016 Per Pay Period Dental Rates
Full Time
Per Pay Period Employee
Contribution
Regular Part-Time
Per Pay Period Employee Contribution
Single
$ 6.20
$10.70
$13.15
$22.55
Employee + Spouse
$13.80
$23.70
Family
$20.05
$34.45
Dental Rates
Provider Network
www.deltadentalwi.com has a lot to offer. You can use it to obtain coverage
information under your plan, check the status of a claim, find a network dentist, evaluate your oral
health and learn ways to improve and protect it. Benefit Advisors are available every weekday from
7:30 a.m. to 5 p.m. (Central Time) to answer your questions at 800-236-3712.
Vision Plan
ProHealth Care’s vision plan is administered by Vision Service Plan (VSP). VSP has a network of
more than 41,000 quality vision care providers nationwide.

The vision plan is 100% voluntary (i.e., employee-paid only) benefit.
No ID cards are necessary and none will be mailed to you.
At your
appointment, you should tell your provider your vision coverage is through VSP. Your VSP provider
and VSP will handle verifying your coverage.
To locate a provider visit www.vsp.com
24 | P a g e
2016 VSP Basic Vision Benefits Summary
Benefit
WellVision Exam
Description
Copay

Your Coverage with a VSP Provider
Focuses on your eyes and overall wellness





$175 allowance for a wide selection of frames
$195 allowance for featured frame brands
20% savings on the amount over your allowance
Single vision, lined bifocal, and lined trifocal lenses
Polycarbonate lenses for dependent children




Standard progressive lenses
Premium progressive lenses
Custom progressive lenses
Average savings of 20-25% on other lens enhancements



$175 allowance for contacts; copay does not apply
Contact lens exam (fitting and evaluation)
Services related to diabetic eye disease, glaucoma and age-related
macular degeneration (AMD). Retinal screening for eligible
members with diabetes. Limitations and coordination with medical
coverage may apply. Ask your VSP doctor for details.
Prescription Glasses
Frame
Lenses
Lens Enhancements
Contacts
(instead of glasses)
Diabetic Eyecare Plus
Program
Suncare
Extra Savings
Your Monthly
Contribution

$175 allowance for ready-made non-prescription sunglasses instead
of prescription glasses or contacts
Frequency
$10
Every calendar year
$20
See frame and lenses
Included in
Prescription
Glasses
Every other calendar year
Included in
Prescription
Glasses
Every calendar year
$55
$95 - $105
$150 - $175
Every calendar year
Up to $60
Every calendar year
$20
As needed
$20
Glasses and Sunglasses
 Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details
 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12
months of your last WellVision Exam.
Retinal Screening
 No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam
Laser Vision Correction
 Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities
$4.06 Employee Only
$8.10 Employee + spouse
$8.66 Employee + child(ren)
$13.86 Employee + Family
Your Coverage with Out-of-Network Providers
Visit vsp.com for details, if you plan to see a provider other than a VSP network provider.
Exam - up to $45
Single Vision Lenses - up to $30
Lined Trifocal Lenses - up to $65
Contacts - up to $105
Frame - up to $70
Lined Bifocal Lenses - up to $50
Progressive Lenses - up to $50
Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details.
Coverage information is subject to change in the event of a conflict between this information and your organizations contract with VSP, the terms of the contract will prevail.
Based on applicable laws, benefits may vary by location
Contact 800-877-7195 | vsp.com
25 | P a g e
2016 VSP Vision Plus Benefits Summary
Benefit
WellVision Exam
Description
Copay

Your Coverage with a VSP Provider
Focuses on your eyes and overall wellness





$175 allowance for a wide selection of frames
$195 allowance for featured frame brands
20% savings on the amount over your allowance
Single vision, lined bifocal, and lined trifocal lenses
Polycarbonate lenses for dependent children





UV Protection
Polycarbonate Lenses
Anti-Reflective Coatings
Progressive Lenses
Average savings of 20-25% on other lens enhancements



$175 allowance for contacts; copay does not apply
Contact lens exam (fitting and evaluation)
Services related to diabetic eye disease, glaucoma and age-related
macular degeneration (AMD). Retinal screening for eligible
members with diabetes. Limitations and coordination with medical
coverage may apply. Ask your VSP doctor for details.
Prescription Glasses
Frame
Lenses
Lens Enhancements
Contacts
(instead of glasses)
Diabetic Eyecare Plus
Program
Suncare
Extra Savings
Your Monthly
Contribution

$175 allowance for ready-made non-prescription sunglasses instead
of prescription glasses or contacts
Frequency
$10
Every calendar year
$20
See frame and lenses
Included in
Prescription
Glasses
Every calendar year
Included in
Prescription
Glasses
Every calendar year
$0
$15
$30
$50
Every calendar year
Up to $60
Every calendar year
$20
As needed
$20
Glasses and Sunglasses
 Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details
 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12
months of your last WellVision Exam.
Retinal Screening
 No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam
Laser Vision Correction
 Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities
$9.70 Employee Only
$19.44 Employee + spouse
$20.80 Employee + child(ren)
$33.22 Employee + Family
Your Coverage with Out-of-Network Providers
Visit vsp.com for details, if you plan to see a provider other than a VSP network provider.
Exam - up to $45
Single Vision Lenses - up to $30
Lined Trifocal Lenses - up to $65
Contacts - up to $105
Frame - up to $70
Lined Bifocal Lenses - up to $50
Progressive Lenses - up to $50
Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details
Coverage information is subject to change in the event of a conflict between this information and your organizations contract with VSP, the terms of the contract will prevail.
Based on applicable laws, benefits may vary by location
Contact 800-877-7195 | vsp.com
26 | P a g e
Life and Accidental Death & Dismemberment Insurance
ProHealth Care provides life and accidental death and dismemberment (AD&D) insurance to fulltime and regular part-time employees. You can add to your coverage by purchasing voluntary life
insurance for you, your spouse and your dependent children.
If you pass away while you are covered by the company’s life insurance benefits, your beneficiary
will receive a payment equal to the amount of basic life insurance you have plus voluntary life
insurance you buy. If you pass away as a result of a covered accident, your beneficiary will receive
an AD&D benefit in addition to your life insurance benefit.
You will need to designate your beneficiary on-line using Metlife’s MyBenefits website.
1. Log on to www.metlife.com/mybenefits and enter ProHeatlh Care in the Company Name
field. Click the “Next” button.
2. You will then see the “Welcome to MyBenefits” page where you can register as a MyBenefits
user or if you have already registered, enter your name and password.
3. Once you log into MyBenefits, select the “group Life Insurance” link.
4. Across the top page, you will see “Life Summary”, “Learn”, “Calculate”, Beneficiaries”,
Common Questions”, Contact Specialist”. Click on “Beneficiaries” and follow instructions to
complete.
If you have any questions regarding making a beneficiary designation, please contact MetLife at 1866-492-6983.
Basic Life and AD&D Insurance
ProHealth Care pays the full cost of basic life and AD&D insurance for full-time and regular part-time
employees.
Eligibility
Staff
Coverage Effective
Date
Basic Life Insurance
Basic AD&D Coverage
First of the month
following 90 days of
employment
1 times your basic annual
earnings rounded to next
higher $1,000 ($500,000
maximum)
higher $1,000 ($500,000
maximum)
First of the month
following 90 days of
employment
1.5 times your basic
annual earnings rounded
to next higher $1,000
($500,000 maximum)
1.5 times your basic annual
higher $1,000 ($500,000
maximum)
Managers,
Directors
and
Physicians
First of the month
following date of hire
1.5 times your basic
annual earnings rounded
to next higher $1,000
($1,000,000 maximum)
1.5 times your basic annual
higher $1,000 ($500,000
maximum)
Vice
Presidents,
Presidents
and Chiefs
First of the month
following date of hire
higher $1,000 ($1,000,000
maximum)
higher $1,000 ($500,000
maximum)
(Less than 3
years of
service)
Staff
(More than
three years of
service)
This information is meant to answer the most frequently asked questions, and is a summary of the
available benefits. For additional information, a certificate of insurance is available on ProHealth
Care iNet - Total Rewards tab.
27 | P a g e
Company - provided Life and AD&D Insurance for all employees will be reduced by 50% of the
original amount at age 70.
If your coverage begins for company-provided Life and AD&D Insurance at age 70 or older, the
above age reductions will apply to:


Any Guarantee Issue Amount available without evidence of insurability; and
The maximum amount of insurance for which you are eligible.
Imputed Income: The IRS places a value on life insurance coverage in excess of $50,000 that is
provided through before-tax group insurance programs. That value is determined by your age and
the amount of your coverage, and is known as “imputed income.” It is calculated using “uniform
premium levels” established by the IRS. The value of your group life insurance coverage in excess
of $50,000 is added to your gross income for federal tax purposes. The company is required to
withhold federal income tax and FICA from your regular pay based on the amount of imputed
income.
Voluntary Life and Accidental Death and Dismemberment Insurance
As a full-time or regular part-time employee, you can purchase additional term life insurance
coverage in $10,000 increments up to $500,000 maximum for staff and up to $1,000,000 for leaders
and physicians. You can also enroll in up to $300,000 of coverage for yourself with no medical
questions if you apply when you first become eligible.
You may add accidental death and dismemberment (AD&D) coverage to your optional life insurance
amount for an additional premium. Benefits are paid in case of an accidental death or
dismemberment, as outlined in the policy.
Eligibility
Staff
Managers, Directors,
Physicians, Vice Presidents,
Presidents and Chiefs
Employee Voluntary Life
Insurance
$10,000 increments,
$500,000 maximum
Employee Voluntary AD&D
$10,000 increments,
$500,000 maximum
$10,000 increments,
$1,000,000 maximum
$10,000 increments
$500,000 maximum
You pay the full cost of voluntary life insurance. The premium depends on your age and your level
of coverage. See the rate table on page 29. Coverage is reduced by 50% at age 70. All applicants
age 60 and over are required to fill out the Evidence of Insurability form.
Voluntary Spouse and Dependent Life Insurance
You may buy life insurance for your spouse and/or your dependent children, whether or not you
purchase voluntary life insurance for yourself. You are automatically the beneficiary for any
dependent life insurance coverage you purchase for your spouse and/or dependent children.
Coverage for Your Spouse
You may buy insurance for your spouse of up to $50,000 with no medical questions (exception: age
60 and older requires evidence of insurability) if you apply when you first become eligible. Additional
coverage is available in $10,000 increments ($250,000 maximum). Coverage amounts for spouses
over $50,000 are subject to evidence of insurability. Spouse amounts will reduce by 50% when the
spouse reaches age 70. Applicants age 60 and over are required to fill out the Evidence of
Insurability form.
28 | P a g e
Coverage for Your Dependent Children
You also may purchase life insurance to cover your unmarried children. There is no limit to the
number of eligible dependent children who can be covered (and the cost is the same regardless of
the number of children covered). The plan pays the full benefit amount in the event of any covered
dependent child’s death. The coverage is $10,000 for children age 15 days to 26 regardless of
fulltime student or marriage status.
Accelerated Benefit Option (ABO)
A “living benefit” is automatically included on both you and your spouse’s optional life insurance
coverage. The living benefit is designed to help offset expenses due to a terminal illness and is paid
to you (or your spouse) while you are still living. The living benefit provides up to 80% of your Basic
Life amount not to exceed $500,000. The covered person must be diagnosed with a terminal illness
that is expected to result in death within 12 months of the diagnosis.
Portability
The voluntary life insurance coverage for yourself, your spouse and your dependent children is
portable, which means that you can keep your coverage at your current rates even if you leave your
job. Another option is conversion, which means that you and your spouse may apply for an
individual permanent policy with the same coverage without answering any medical questions. A
written application must be made within 31 days of termination of employment or loss of eligibility.
An additional fee may be applied depending on the payment method.
29 | P a g e
2016 Voluntary Employee and Spouse Life Rates
Non-Smoker Rate
Per Pay Period Rate Per $1,000
$0.022/$1,000
$0.022/$1,000
$0.030/$1,000
$0.034/$1,000
$0.034/$1,000
$0.056/$1,000
$0.090/$1,000
$0.169/$1,000
$0.236/$1,000
$0.495/$1,000
$0.905/$1,000
Age
0-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70+
Smoker Rate
$0.025/$1.000
$0.025/$1,000
$0.040/$1,000
$0.045/$1,000
$0.047/$1,000
$0.075/$1,000
$0.115/$1,000
$0.200/$1,000
$0.310/$1,000
$0.5925/$1,000
$1.030/$1,000
Example: $150,000 (coverage amount)/1,000 X .056 (age 45-49 nonsmoker) = $8.40 per pay period.
Voluntary Employee and Spouse AD&D Rates
$0.0075
Example: 150,000/1,000 x $0.0075 = $1.13 per pay period.
Voluntary Dependent Child Life Rates
Per Pay Period Rate
$0.75
Short Term Disability (STD) / Salary Continuation
Short Term Disability/Salary Continuation provides you with income if you become disabled and
unable to work due to a non-work related medical condition. It covers illness or disability after you
missed 7 consecutive calendar days due to a disability. You may use PTO for the first seven
calendar day waiting period. You may also supplement your short term disability with PTO to bring
your compensation up to 100%.
Eligibility
Regular part-time and full-time employees are eligible for this benefit on the first of the month
following 90 days of employment.
Coverage Level and Duration
All Staff, Managers and Directors: 60% of base earnings
You are eligible for up to 6 weeks of STD/Salary Continuance during your first year of employment
and up to 26 weeks after first year of employment. You may use your PTO to supplement up to
100% of bi-weekly salary.
30 | P a g e
If you are disabled and need to apply for Short Term Disability/Salary Continuance or have any
questions about this benefit, contact the MetLife Claims Center at 1-877-638-8269.
Long Term Disability
Long term disability is available to you if you remain disabled and unable to work after a 180 day
waiting period.
Eligibility
Regular part-time and full-time employees are eligible for this benefit on the first of the month
following 90 days of employment. Leaders and physicians are eligible for this benefit, the first of the
month following date of hire.
Coverage Level and Duration
Hourly Staff: 33 1/3 % of salary
Exempt Staff: 66 2/3 % of salary
Voluntary Long-Term Disability Buy-Up
Hourly staff have the option to buy-up to the 66 2/3% benefit as a new hire or at open enrollment.
This additional buy-up is paid for by you.
For additional information on the Long Term Disability insurance and to view and/or print the
insurance certificate, please go to ProHealth Care’s iNet - Total Rewards tab.
Voluntary Long Term Disability Rate:
($.00416 X Annual Salary) / 24 pay periods
401k
The ProHealth Care Retirement Savings Plan 401(k) is a benefit available to eligible employees to
help you save for retirement on a tax-deferred basis. You may contribute from 2% to 75% of your
compensation per payroll period up to the maximum allowed by the IRS. For 2016, eligible
participants under age 50 may contribute up to $18,000 and those over age 50 may contribute an
additional $6,000, for a total maximum contribution of $24,000. Additional information about the
plan can be four on the iNet under Total Rewards/Retirement.
Maximize Your Employer Match
In order to maximize your employer match from ProHealth Care, you should ideally
contribute to the plane ach pay period of the year. For every pay period that you contribute
to the plan, the ProHealth Care employer match is credited to your 401(k) account. If you
stop contributing to the plan, you will not receive a ProHealth Care employer match during
the time you are not making contributions.
Getting Ready to Retire
Transamerica’s team of retirement advisors can help you navigate the road to retirement.
These phone-based experts will work with you one-on-one and can provide guidance,
31 | P a g e
advice, and other services based on your unique situation. If you’re not quite ready but
would like to learn more about ho Transamerica can help you get organized, visit
phc.trsretire.com and click on the Get Ready to Retire tab.
Making Changes/Beneficiary Designations
If you would like to make changes or enroll in the 401(k) plan, please call Transamerica at
800-755-5801 or visit phc.trsretire.com. First-time callers should contact Transamerica at
888-676-5512. Please also contact Transamerica to designate your beneficiary(ies) or to
make changes to your existing beneficiary(ies).
True-Up
At the end of each calendar year, ProHealth Care will complete a calculation to ensure that
you receive the maximum employer contribution you are eligible for, called a true-up. If
applicable, this adjusted contribution will be made in early 2016.


Non-pension plan participants contributing at least 10% of pay across the calendar
year are eligible for a maximum match of 5% of your pay but no greater than $9,000
(if under50) or $12,000 (if over 50).
Pension plan participants contributing at least 4% of pay across the calendar year
are eligible for a maximum match of 2% of your pay but no greater than $9,000 (if
under 50) or $12,000 (if over 50).
Treat Yourself to A Retirement Pay Raise
Consider increasing your contribution to the 401(k) plan during merit time, so you can
expect more money in retirement.
32 | P a g e
Insurance Directory/Benefit Resources
PROVIDER
TELEPHONE
WEB SITE or EMAIL
Member Registration www.aetna.com
Medical/Prescription Drug
Aetna
800-414-0766
Drug Cost Calculation – Log on: RXOnly1
Password: RXonly1
https://member.aetna.com/MbrLanding/login.fcc?
Health Plans Comparison
https://www.aetna.com/planselection/mbrDis.jsp?id=47
4
Medical Provider Network
WIDS
262-928-4767
Flexible Spending Accounts
Aetna
888-678-8242
Dental Plan
Delta Dental
800-275-6230
www.deltadental.com
Vision Plan
Vision Service Plan (VSP)
800-877-7195
www.vsp.com
Company-provided and Voluntary Life
MetLife
262-928-4185
Company-Provided and Voluntary AD&D
(Accidental Death & Dismemberment)
MetLife
262-928-4185
www.widsnetwork.com
www.Payflex.com
[email protected]
[email protected]
Short Term Disability
MetLife Claims Center
877-638-8269
https://mybenefits.metlife.com
LTD (Long Term Disability)
MetLife
877-638-8269
https://mybenefits.metlife.com
Family Medical Leave of Absence (FMLA)
MetLife
877-638-8269
401(k) Plan – Retirement Planning Services
Transamerica
866-616-4191
401(k) Plan (Record Keeper)
Transamerica
800-755-5801
phc.trsretire.com
Benefit Questions
262-928-4185
[email protected]
.
33 | P a g e
Paid Time Off (PTO)
PTO Policy Highlights
The Paid Time Off (PTO) program is a system that provides an accrued bank of hours from which
an employee must draw from to receive pay when they don’t meet their normally scheduled work
hours. This bank combines traditional vacation, holiday and short-duration sick time into a single
paid account, which must be used for planned days off and short illnesses. PTO is not used for jury
duty and bereavement pay. Use of PTO must be properly scheduled and approved in advance by
department management. Employees on Family Medical Leave (FMLA) should consult with
Employee Health Services regarding their use of PTO prior to the leave.

PTO may be used in increments of 15 minutes or more for hourly employees. Exempt
employees may take PTO in increments of 1 hour with a 4 hour minimum.

The first seven consecutive days of a Short Term Disability leave (Qualifying or NonQualifying Family Medical Leave) may be paid from this account for all employees.

Employees with PTO time available are required to use PTO when vacation time, holiday
time, or individual sick days are used.

When an employee is given Approved Time Off (ATO) they are not required to use PTO.
PTO Eligibility
Employees who have a full time equivalent equal and/or greater than a .5 are eligible to accrue paid
time off. RN’s who participate in the weekend only programs are also eligible to accrue paid time
off.
Paid Time Off may be accumulated from year to year, not to exceed the established maximum
number of hours based upon years of service. Once the maximum hours are reached, your accrual
will stop until your balance is below the limit.
Procedure
Time off must be properly scheduled and approved by department management, in advance if
possible, prior to using any PTO. In the case of illness, the employee should notify his/her
department manager as soon as possible and get authorization to use PTO to cover the absence.
Excessive unplanned absences may result in disciplinary action up to and including termination of
employment. Employees receive payment of their accrued PTO hours upon termination.
Approved time off (ATO) is the recognized terminology for cancel time. Employees utilizing ATO will
continue to earn PTO while taking ATO. PTO time does not accrue on short-term disability
payments.
If an employee changes from full-time or regular part-time to part-time status, Pool status or 7/70,
PTO is paid out at the time of the status change. In addition, if a non-management employee moves
into a management role, PTO is paid out at the time of the employment change.
Employees transferring between the PHC entities will carry their balance with them.
34 | P a g e
Holidays
Legal holidays are included in PTO accruals and include New Year’s Day, Memorial Day,
Independence Day, Labor Day, Thanksgiving Day and Christmas Day. During the pay periods in
which these days fall, an employee is required to use appropriate PTO time to ensure they meet
their required scheduled hours. If an employee does not work the legal holiday but accepts an
additional shift, no PTO time is required for use.
PTO is calculated on hours worked times accrual rate based on your years of service. See chart
below.
Example: I am a 10 year employee and work 48 hours in a pay period. (48 hours x .1231 = 5.9088
hours of PTO accrued during the pay period)
Your PTO balance can be found on Employee Self Service (ESS) Website https://ess.phci.org.
0-4
5-9
10-14
15-19
20+
.0885
.1077
.1231
.1347
.1385
PTO Days
23
28
32
35
36
PTO Hours
184
224
256
280
288
Maximum Hours Allowable in PTO bank
184
224
256
280
288
Years of Service
PTO Accrual Rate
(per hour worked)
35 | P a g e
ProShare Bonus Program
The purpose of the ProShare Plan is to provide incentive compensation for eligible employees of
PHCI and its subsidiary companies (collectively, the “System”) which directly relates their financial
reward to the System’s achievement of certain financial and on-financial objectives. The primary
purpose of this plan is to support the System’s mission to achieve continued growth and
demonstrate value through:



A seamless continuum of patient-centered care;
Nationally recognized outcomes;
Responsible and efficient use of health care resources; and
A focus on the health of our community.
We will achieve this vision in partnership with talented and caring employees, physicians and
volunteers who share a passion for our mission. The ProShare Plan shares the System’s success
and rewards participants for their active contributions to that success. ProShare provides motivation
for performance which might not otherwise be achieved. To be most effective, the ProShare Plan
must meet the following specific objectives:






Improve performance by providing a mechanism to set and achieve corporate goals that
reflect outstanding performance.
Maximize the viability of the System, given current and future reimbursement issues, by
emphasizing and reinforcing the importance of quality and cost effectiveness.
Reinforce the System’s planning process, resulting in acting with direction, not reaction.
Increase awareness of the corporate culture by emphasizing teamwork.
Encourage team “systemness” among ProHealth employees through aligned goals and
collaborative efforts.
Help recruit and retain high quality staff.
Participants in this plan must be employed (full time, regular part time, part time or pool) by one of
the following participating entities:







ProHealth Care
Waukesha Memorial Hospital
Oconomowoc Memorial Hospital
ProHealth Care Medical Group
ProHealth Home Care
WMH or OMH Foundation (excluding Development Officers)
Waukesha Health System
The following employees shall not be eligible for the ProShare Plan:







All employees with a title of Manager, Director, Vice President, or Chief
Empathia employees
WMH or OMH Foundation Development officers
Employees of joint ventures and affiliated serviced (i.e. West Wood, National Regency,
ProHealth Aligned, or the Rehabilitation Hospital of Wisconsin)
Employed physicians
Temporary employees
Employees who are on a performance development plan at time of payment
36 | P a g e
Newly hired participants must have been hired into their position prior to the first full pay period in
the fiscal year third quarter to be eligible for the plan. Newly hired participants who started during
the first pay period in the fiscal year third quarter or after will not be eligible to participate in the plan
until the next plan year.
The ProShare Plan is made up of two components:


50% - achievement of System operating margin goals
50% - achievement of patient satisfaction goals
General Payment Guidelines
1. The ProShare goad attainment fund shall be calculated at the end of the fiscal year.
2. Results of the System Operating Margin and System Patient satisfaction shall be calculated
on a consolidated basis for all plan participants.
3. Participant payments shall be determined by dividing the total ProShare Pool attained for the
year by the applicable total Participating Payroll. The result shall be multiplied by the
individual’s yearly Participating Payroll to determine each participant’s gross ProShare
payment.
4. If a payment is calculated to be under $10, there will be no payment. If the payment is
between $10 and $25, it is rounded up to $25.
5. Taxes and other required deductions including 401k contributions will be withheld when
making ProShare payments.
37 | P a g e
Personal Property and Liability Insurance Program
for ProHealth Care Employees
The group auto and home insurance program from MetLife Auto & Home® is available to employees. This program
allows you to apply to purchase quality group auto and home insurance at special group rates. A variety of policies are
available to you through the program, including:
Auto
Home
Landlord’s Rental Dwelling
Condo
Mobile Home
Renter’s
Recreational Vehicle
Boat
Personal Excess Liability (“Umbrella")
By participating in the program, employees may benefit from special group insurance rates that are designed to save them
money. There are also a variety of discounts for which you may be eligible.
For the payment of premiums, MetLife Auto & Home offers several hassle-free options.
Bank account deduction spreads your premiums over the policy term, which makes budgeting for your insurance easier.
(A down payment may be required.) There are no checks to write or dates to remember. Best of all, you won’t receive
any bills in the mail because everything is taken care of automatically. Home billing is also available.
To help you discover if participating in the program makes sense for you, you have access to free insurance reviews and
no-obligation premium quotes with one call to the toll-free MetLife® Benefits Line at 1 800 GET-MET 8 (1-800-4386388) to speak with an insurance consultant. To make the most accurate comparisons, have your current policies with you
when you call.
MetLife Auto & Home is a brand of Metropolitan Property and Casualty Insurance Company and its affiliates: Metropolitan General Insurance Company, Metropolitan
Casualty Insurance Company, Metropolitan Direct Property and Casualty Insurance Company, Metropolitan Group Property and Casualty Insurance Company, Economy
Premier Assurance Company, Economy Preferred Insurance Company, Economy Fire and Casualty Company, and Metropolitan Lloyds Insurance Company of Texas, all
with administrative home offices in Warwick, RI. In some instances, policies are provided by Liberty County Mutual Insurance Company. Coverage, rates, and discounts are
available in most states to those who qualify. L05078J4A(exp0709)MPC-LD
38 | P a g e
Appendix
39 | P a g e
Health Care Reform and Your ProHealth Care Benefits
(PPACA) took effect January 1, 2014, with the goal of making health care available to all Americans,
no matter their medical history or ability to pay.
With these changes on the horizon, you may wonder how it will affect the health care benefits
available to you as a ProHealth Care employee. The short answer is: ProHealth Care will continue
to offer medical coverage in 2016. You will have additional choices from other sources, however,
and it’s important that you understand your options.
A Snapshot of the Changes
Health Care Reform Change
(as of January 1, 2014)
Most Americans will be required to purchase minimum health
insurance or pay a tax penalty. This referred to as the individual
mandate.
Patient protections will be fully implemented. Insurers won’t be able
to deny you coverage because of pre-existing conditions. They can’t
charge you more because of your gender or health status, and you’ll
be able to buy health insurance even if you are seriously ill.
Insurers cannot place lifetime dollar limits on how much they will pay
for essential health benefits.
Insurers can’t make you wait for more than 90 days for coverage to
become effective.
You will be able to shop for health insurance in online health
insurance marketplaces (also called exchanges).
All health plans in the marketplaces must offer essential health
benefits (EHB) – a minimum level of coverage.
What it Means to You
Your ProHealth Care medical plan satisfies the requirement to have
health insurance. If you enroll in a ProHealth Care medical plan, you
will not be subject to a tax penalty.
Your ProHealth Care medical plan already includes these patient
protections.
Neither of the ProHealth Care medical plans includes a lifetime
dollar limit.
Employees who enroll in a ProHealth Care medical plan can be
covered as early as the first of the month following their date of
hire.
You do not have to purchase health insurance through one of the
new marketplaces. You still can purchase medical coverage through
ProHealth Care during Open Enrollment, typically held in October.
ProHealth Care will continue to pay the majority of your medical
plan premium. If you purchase coverage through the marketplace,
you will lose all ProHealth Care all Pro-Health Care contributions
toward the cost of your medical coverage.
Your ProHealth Care medical plans already offer these essential
health benefits – and more.
The creation of health insurance marketplaces (also called exchanges) is a key component of health
care reform. Exchanges are new organizations that create an organized and competitive market for
buying health insurance, and enable you to make an apples-to-apples comparison of options
available in your state.
You still have access to ProHealth Care medical plans, and you don’t have to enroll in a
marketplace option. But, if you want to know more, here are some basic facts:

Insurers will offer comprehensive plans with coverage for doctor, hospital, and other health
care provider services and prescriptions drugs. You’ll be able to compare insurance options
based on price, benefits, quality, and other features.

All marketplace options will cover essential health benefits, and there will be four basic levels
of coverage – bronze, silver, gold, and platinum. The levels will vary in premiums and in the
percentage of medical expenses the plans will cover. For example, bronze plans will have
the lowest monthly premiums but members may pay more out of pocket when they receive
medical care. Platinum plans, at the other end of the spectrum will cover more medical
expenses and have higher monthly premiums and members may pay less out of pocket
when they receive medical care. If you buy through the marketplace, you can choose the
plan that best meets your health needs budget.
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
Insurers won’t be able to refuse to cover you or charge you more just because you have a
chronic or pre-existing condition. They also won’t be able to charge more for women than for
men. They will, however, be able to charge individuals over age 50 up to three times more
than younger individuals.
Health Care Reform Questions and Answers
Q: What is the individual mandate?
A: The individual mandate requires most American to purchase a minimum level of health care
insurance or pay a penalty. You can satisfy the coverage requirement by having coverage through
an employer (such as a ProHealth Care medical plan), coverage you purchase on your own, or
Medicaid. If you cannot afford a health plan, you may qualify for financial aid and you may not have
to pay a penalty.
Q: Who is exempt from the individual mandate penalty?
A: You’ll be considered exempt from the penalty if:






You have insurance through an employer or purchase individual insurance on your own.
You have insurance through Medicare, Medicaid, the Children’s Health Insurance Program
(CHIP), the Veteran’s Administration and/or Tricare (for active duty and retired military),
Indian Health Services, or a health care sharing ministry.
You would have to spend more than 8% of your household income on the least expensive
qualifying health insurance plan, even after tax credits and subsidies.
Your income falls below the threshold for filing a federal income tax return.
You live outside of the United States.
You are an undocumented immigrant, incarcerated, or a member of a Native American tribe,
you qualify for a religious exemption, or you qualify for certain other exemptions.
Q: Am I eligible to receive government help in paying for health insurance?
A: PPACA includes provisions to lower premiums and share certain expenses for people with low
and modest incomes through tax credits and subsidies. These provisions are based on the federal
poverty level, defined as earnings of about $11,490 per year for a single person or $23,550 for a
family of four. However, if you have coverage through ProHealth Care, you already receive a
“credit” to lower your premiums, since ProHealth Care pays the majority of the cost of your
coverage.
Since ProHealth Care offers coverage that is considered affordable (the cost of the coverage is less
than 9.5% of employee income) and meets the standard coverage requirements, if you choose to
purchase coverage from an exchange, you will not be eligible for any ProHealth Care contributions,
federal subsidies, or tax credits to help you pay the cost of health insurance.
Q: Can I still insure my children up to age 26 in the medical plan?
A: Yes, the law lets children up to age 26 stay on their parent’s medical plan.
Q: Will I be taxed for the portion of the health insurance premium that is paid by ProHealth
Care?
A: No. Your contribution for a ProHealth Care medical plan is made pre-tax, so you are not taxed
on that amount. And, although your W-2 form will show you how much ProHealth Care contributes
on your behalf, the reporting is for informational purposes only. Under current law, you won’t be
taxed on that amount.
If you purchase insurance through an insurance marketplace, any unreimbursed medical expenses
(including premium payments) will be tax deductible on to the extent they exceed 10% of your gross
income.
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Q: Can I still have a Health Savings Account (HSA)?
A: Yes. The minimum level of coverage (bronze level) required to meet the individual mandate was
specifically designed to allow for the purchase of a high-deductible health plan that would
complement an HSA. Also, ProHealth Care’s High-Deductible Health Plan will continue to include an
HSA.
Q: If I leave my ProHealth Care medical plan, can I re-enroll at a later date?
A: Yes, You can re-enroll during next year’s Open Enrollment period for 2015 coverage or during
the year if you experience a qualifying life event (e.g., loss of a job, death of a spouse, birth of a
child).
Considering a Marketplace Option?
Here is information you may need if you decide to apply for coverage through the state health
insurance marketplace.
Employer Name: ProHealth Care Inc.
Employer Identification Number (EIN): 39-1486873
Employer Address: N17 W24100 Riverwood Drive, Suite 350
City: Waukesha
State: WI
Zip code: 53188
Who Can We Contact About Employee Health Coverage At This Job: Total Rewards
Phone Number: 262-928-4185
E-Mail Address: [email protected]
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ProHealth Care Health, Dental and Vision Plan
Notice of Privacy Practices
This notice tells how medical information about you may be used and disclosed and how you can get
access to this information. Please review it carefully.
ProHealth Care Health Plan is dedicated to keeping your health information private. When we
release your health information, we will make reasonable efforts to limit the use and release of your
information to only the minimum necessary needed for the specific purpose.
To summarize, we are required by law to maintain the privacy of your health information and to
provide you with this Notice of our legal duties and privacy practices with respect to your health
information. This Notice provides you with the following important information:
 How we use and disclose your protected health information
 Your privacy rights with regard to your protected health information, and
 Our obligation to you concerning the use and disclosure of your protected health information.
How ProHealth Care Health Plan May Use or Disclose Your Health Information.
The following categories describe the ways that the ProHealth Care Health Plan may use and disclose
your health information. For each category of uses and disclosures, we will explain what we mean
and give some examples. Not every use or disclosure in a category will be listed. However, all the
ways we are permitted to use and disclose information will fall in one of the categories.
Without your permission we can use and release your health information for:
1. Payment. We may use and disclose your health information to make or collect payment for
treatment or services you receive. For example, we may use or disclose your health
information to:
 Determine your eligibility for plan benefits
 Obtain premiums
 Make payment for treatment and services you receive from health care providers
 Determine your health plan’s responsibility for benefits
 Coordinate benefits
2. Healthcare Operations. We may use and disclose your health information to operate our
business.
 Underwriting, premium rating, or related functions to create, renew, or to replace health
insurance or benefits
 Quality assessment and improvement activities
 Activities designed to improve health or reduce health care cost
 Clinical guideline and protocol development or case management and care coordination
 Accreditation, certification, licensing or credentialing activities
 Reviews and auditing, including fraud and abuse detection programs, medical reviews,
legal services, audit services, and compliance related programs
 Business planning and development, including cost management and planning, and
related analyses and formulary development
 Submitting claims for stop-loss coverage
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
Business management and general administrative activities, including customer service
efforts and resolution of internal grievances
3. Treatment Alternatives. We may contact you or your health care providers with
information about treatment alternatives and other related programs that may be of interest to
you.
4. Distributing Health Related Benefits and Services. We may use or disclose your health
information to provide information on health-related products and services that may be of
interest to you. If we receive compensation from a third party for providing you with
information about other products or services (other than drug refill reminders or generic drug
availability), we will obtain your authorization to share information with the third party.
5. As Required By Law. We may use or disclose your health information as required by
federal, state, or local law. The use or disclosure will be made in compliance with the law
and will be limited to the requirements of the law. For example, we may disclose medical
information when required by a court order in a legal proceeding, such as a malpractice
action. We are also required to report abuse or neglect of a child.
6. For Public Health Activities. We may need to report your health information to help
prevent or control disease, injury, or disability. This may include information for:
 Reactions to drugs or problems with products and devices
 Reporting exposure to disease or infection
7. For Health Oversight Activities. We may disclose your health information to health
agencies that monitor or regulate providers to be certain that you are given the correct and
proper care.
8. Judicial and Administrative Proceedings. We may disclose your health information in the
course of any administrative or judicial proceeding.
9. To Avoid a Serious Threat to Health or Safety. We may release some of your health
information to people in authority if we think that it will prevent or lessen a serious or
immediate danger to you or the safety or health of other people.
10. For Military or National Security Purposes. We may release your health information to
military and federal officials as required for lawful national security purposes, investigations,
or intelligence activities.
11. For Worker’s Compensation. We may share your health information as allowed by
workers’ compensation laws or other similar programs. These programs may provide
benefits for work-related injuries or illness.
Law Enforcement and Correctional Facilities. We may disclose your health information to law
enforcement officials in response to a court order signed by a judge, warrant or summons. We may
disclose your protected health information if necessary to report suspicious deaths, crimes on our
premises, crimes in an emergency, and for purposes of identifying or locating a suspect or other
person. We may disclose your health information to correctional institutions or law enforcement
personnel for certain purposes if you are an inmate or are in lawful custody.
12. To Those Involved with Your Care. If family members or close friends are helping care for
you, we may give health information about you to the extent necessary for them to help with
your care.
13. Disclosure to Sponsors. We may disclose your health information to the sponsor of your
group health plan for purposes of administering benefits under the plan.
With your written permission we may disclose your health information to anyone for any purpose.
If the reason we share health information is not listed above, we must first get your written
permission. If you sign a permission form, you may withdraw your permission at any time, as long
as you notify us in writing. If you wish to withdraw your permission, please send your written
request to ProHealth Care Total Rewards Department, at N17 W24100 Riverwood Drive, Suite 350,
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Waukesha, WI 53188. If you revoke your authorization, we will no longer be able to use or disclose
health information about you for the reasons covered by your written authorization, though we will
be unable to take back any disclosures we have already made with your permission.
Your authorization is necessary for most uses and disclosures of psychotherapy notes.
Your authorization is necessary for any disclosure of health information in which the ProHealth Care
Health Plan receives compensation.
ProHealth Care Health Plan is prohibited from using or disclosing genetic information for
underwriting purposes, including determination of benefit eligibility. If we obtain any health
information for underwriting purposes and the policy or contract of health insurance or health
benefits is not written with us or not issued by us, we will not use or disclose that health information
for any other purpose, except as required by law.
Some of the uses and disclosures described in this notice may be limited in certain cases by
applicable State laws that are more stringent than Federal laws, including disclosures related to
mental health and substance abuse, developmental disability, alcohol and other drug abuse (AODA),
and HIV testing.
Your Health Information Rights
You have the right to:
1.
Inspect and Copy Your Health Information. You have the right to inspect and receive
an electronic or paper copy of health information about you that may be used to make
decisions about your plan benefits. To inspect and copy such information, you must
contact:
Medical Plan
Aetna
PO Box 981106,
El Paso, TX 79998-1106
2.
3.
4.
Dental Plan
Delta Dental of Wisconsin
P.O. Box 828
Stevens Point, WI 54481-0828
Vision Plan
VSP
P.O. Box 99705
Sacramento, CA 95899-7105
If you request a copy of the information, they may charge you a reasonable fee to cover
expenses associated with your request.
Request to Challenge or Correct Your Health Information. If you believe your health
information is not correct or is incomplete, you may ask us to change/correct the
information. To ask for an amendment, you must make your request including a reason
for your request in writing to the ProHealth Care Total Rewards Department, at N17
W24100 Riverwood Drive, Suite 350, Waukesha, WI 53188. We may deny your request
if we did not create the information you want changed, the information is already accurate
and complete or for certain other reasons. If we deny your request, we will provide you
with a written explanation and information on how you can appeal the denial.
Request Restrictions on Certain Uses and Disclosures. You may ask that we limit how
your health information is used. We are not required to agree to your restriction request.
All requests for restrictions must be in writing to ProHealth Care Total Rewards
Department, at N17 W24100 Riverwood Drive, Suite 350, Waukesha, WI 53188. We
will let you know if we can comply with the request.
As Applicable, Receive Confidential Communication of Health Information. You
have the right to ask that we share your health information with you in different ways or
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5.
6.
7.
places. For example, you may ask that we only communicate with you at a certain phone
number or by mail. We will attempt to meet reasonable requests for confidential
communications, but retain the right to deny such requests. All requests for confidential
communications must be in writing to ProHealth Care Total Rewards Department, at N17
W24100 Riverwood Drive, Suite 350, Waukesha, WI 53188.
Receive a Listing of Disclosures. In some cases, you may ask for a list of those who
received your health information. This list must include the date your health information
was given, to whom it was given, a short description of what was given and why. We
must give you this list within 60 days unless we give you notice that we need an extra 30
days. We may not charge you for the first list, but may charge you if you ask for a list
more than once a year. The list will not include disclosures before April 14, 2003, or
disclosure (a) for payment or health care operations, (b) as authorized by you, and (c) for
certain other activities, including disclosures to you. Your request must be in writing and
should specify a time period of up to six years. The request should be sent to the
ProHealth Care Total Rewards Department, at N17 W24100 Riverwood Drive, Suite 350,
Waukesha, WI 53188.
Obtain a Copy of This Notice. A paper copy of this Notice will be provided to you even
if you have received this Notice by electronic mail (e-mail). Even if you received a copy
of this notice before, you may still be asked to sign that you have received the Notice.
You may ask us to give you a paper or electronic copy of this Notice at any time. To
obtain a paper copy of this Notice, send your written request to the ProHealth Care Total
Rewards Department, at N17 W24100 Riverwood Drive, Suite 350, Waukesha, WI
53188. You may also obtain a copy of this Notice from the iNet or Employee Self-Service
(ESS).
Right to be Notified of a Breach. You will be notified in the event of a breach of your
unsecured health information.
Changes to this Notice and Distribution
We reserve the right to change our Notice of Privacy Practices at any time. Any changes to this
Notice will apply to all the health information we keep, including health information we created or
received before we made the changes, as well as any records we receive or create in the future.
As your health plan, we will provide a copy of our notice upon your enrollment to the plan and will
remind you at least every three years where to find our notice and how to obtain a copy of the notice
if you would like to receive one. If we have more than one Notice of Privacy Practices, we will
provide you with the Notice that pertains to you. The notice is provided to the named insured of the
plan and will pertain to the insured and dependents named under this insured.
As a health plan that maintains a website describing our customer service and benefits, we also post
to our website the most recent Notice of Privacy Practices which will describe how your health
information may be used and disclosed as well as the rights you have to your health information. If
our Notice has a material change, we will post information regarding this change to the website for
you to review. In addition, following the date of the material change, we will include a description of
the change that occurred and information on how to obtain a copy of the revised Notice in our annual
mailing to all individuals then covered by the plan.
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Complaint Filing.
If you believe your privacy rights have been violated, you may file a complaint with the ProHealth
Care Privacy Officer or with the Secretary of the Department of Health and Human Services, Office
of Civil Rights. We will not retaliate against you for filing such a complaint.
You may submit your request in writing to:
 File a complaint or to comment on our privacy practices.
 Amend your health information.
 Access your health information.
 Restrict certain used and disclosures.
 Receive confidential communications.
 Receive a listing of disclosures.
All requests in writing should be sent to ProHealth Care Total Rewards Department at N17 W24100
Riverwood Drive, Suite 350, Waukesha, WI 53188.
You may contact the ProHealth Care Privacy Officer directly at (262) 928-4977, or leave a message
on the ProHealth Care Compliance Hotline at (262) 928-2415.
Please contact the ProHealth Care Privacy Officer if you have any questions about this Notice or if
you want more information about the Privacy Practices at ProHealth Care Plan.
This notice of Privacy Practices is effective September 23, 2015.
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Newborns’ and Mothers’ Health Protection Act of 1996
In accordance with the Newborns’ and Mothers’ Health Protection Act of 1996, the Medical Plan
does not restrict benefits for any hospital length of stay in connection with childbirth for the mother or
newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a
Cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s
attending provider from discharging the mother or her newborn earlier than 48 hours (or 96 hours as
applicable), after consulting with the mother. In any case, the Medical Plan does not require that the
provider obtain authorization for prescribing a length of stay shorter than 48 hours (or 96 hours).
Women’s Health and Cancer Rights Act of 1988
In compliance with the Women’s Health and Cancer Rights Act of 1998, the Medical Plan provides
coverage for the following medical conditions in conjunction with a mastectomy:



Reconstruction of the breast on which the mastectomy was performed.
Surgery and reconstruction of the other breast to produce a symmetrical appearance.
Prosthesis and treatment of physical complications in all stages of mastectomy, including
lymphedemas.
These services will be provided in a manner determined in consultation with the attending physician
and the patient. Coverage is subject to applicable deductibles and coinsurance amount that apply to
other benefits under the Plan.
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Premium Assistance Under Medicaid and the
Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from
your employer, your state may have a premium assistance program that can help pay for coverage,
using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for
Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able
to buy individual insurance coverage through the Health Insurance Marketplace. For more
information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed
below, contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any
of your dependents might be eligible for either of these programs, contact your State Medicaid or
CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you
qualify, ask your state if it has a program that might help you pay the premiums for an employersponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as
eligible under your employer plan, your employer must allow you to enroll in your employer plan if
you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request
coverage within 60 days of being determined eligible for premium assistance. If you have
questions about enrolling in your employer plan, contact the Department of Labor at
www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your
employer health plan premiums. The following list of states is current as of July 31, 2015.
Contact your State for more information on eligibility –
ALABAMA – Medicaid
GEORGIA – Medicaid
Website: www.myalhipp.com
Website: http://dch.georgia.gov/
Phone: 1-855-692-5447
- Click on Programs, then Medicaid, then Health
Insurance Premium Payment (HIPP)
Phone: 404-656-4507
ALASKA – Medicaid
Website:
http://health.hss.state.ak.us/dpa/programs/medicaid/
INDIANA – Medicaid
Website: http://www.in.gov/fssa
Phone: 1-800-889-9949
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
COLORADO – Medicaid
IOWA – Medicaid
Medicaid Website: http://www.colorado.gov/hcpf
Website: www.dhs.state.ia.us/hipp/
Medicaid Customer Contact Center: 1-800-221-3943
FLORIDA – Medicaid
Phone: 1-888-346-9562
KANSAS – Medicaid
Website: https://www.flmedicaidtplrecovery.com/
Website: http://www.kdheks.gov/hcf/
Phone: 1-877-357-3268
Phone: 1-800-792-4884
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KENTUCKY – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-635-2570
NEW HAMPSHIRE – Medicaid
Website:
http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
LOUISIANA – Medicaid
NEW JERSEY – Medicaid and CHIP
Website:
http://dhh.louisiana.gov/index.cfm/subhome/1/n/331
Medicaid Website:
http://www.state.nj.us/humanservices/
Phone: 1-888-695-2447
dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
MAINE – Medicaid
NEW YORK – Medicaid
Website: http://www.maine.gov/dhhs/ofi/publicassistance/index.html
Website:
http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-977-6740
Phone: 1-800-541-2831
TTY 1-800-977-6741
MASSACHUSETTS – Medicaid and CHIP
NORTH CAROLINA – Medicaid
Website: http://www.mass.gov/MassHealth
Website: http://www.ncdhhs.gov/dma
Phone: 1-800-462-1120
Phone: 919-855-4100
MINNESOTA – Medicaid
Website: http://www.dhs.state.mn.us/id_006254
Click on Health Care, then Medical Assistance
Phone: 1-800-657-3739
MISSOURI – Medicaid
Website:
http://www.dss.mo.gov/mhd/participants/pages/hipp.ht
m
NORTH DAKOTA – Medicaid
Website:
http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 1-800-755-2604
OKLAHOMA – Medicaid and CHIP
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
Phone: 573-751-2005
MONTANA – Medicaid
Website: http://medicaid.mt.gov/member
Phone: 1-800-694-3084
OREGON – Medicaid
Website: http://www.oregonhealthykids.gov
http://www.hijossaludablesoregon.gov
Phone: 1-800-699-9075
NEBRASKA – Medicaid
PENNSYLVANIA – Medicaid
Website: www.ACCESSNebraska.ne.gov
Website: http://www.dhs.state.pa.us/hipp
Phone: 1-855-632-7633
Phone: 1-800-692-7462
NEVADA – Medicaid
RHODE ISLAND – Medicaid
Medicaid Website: http://dwss.nv.gov/
Website: http://www.eohhs.ri.gov/
Medicaid Phone: 1-800-992-0900
Phone: 401-462-5300
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SOUTH CAROLINA – Medicaid
VIRGINIA – Medicaid and CHIP
Website: http://www.scdhhs.gov
Medicaid Website:
http://www.coverva.org/programs_premium_assistance.
cfm
Phone: 1-888-549-0820
Medicaid Phone: 1-800-432-5924
CHIP Website:
http://www.coverva.org/programs_premium_assistance.
cfm
CHIP Phone: 1-855-242-8282
WASHINGTON – Medicaid
SOUTH DAKOTA - Medicaid
Website: http://dss.sd.gov
Website:
http://www.hca.wa.gov/medicaid/premiumpymt/pages/
index.aspx
Phone: 1-888-828-0059
Phone: 1-800-562-3022 ext. 15473
TEXAS – Medicaid
WEST VIRGINIA – Medicaid
Website: http://gethipptexas.com/
Website:
http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/
Pages/default.aspx
Phone: 1-800-440-0493
Phone: 1-877-598-5820, HMS Third Party Liability
UTAH – Medicaid and CHIP
WISCONSIN – Medicaid and CHIP
Website:
Website:
Medicaid: http://health.utah.gov/medicaid
https://www.dhs.wisconsin.gov/badgercareplus/p10095.htm
CHIP: http://health.utah.gov/chip
Phone: 1-800-362-3002
Phone: 1-866-435-7414
WYOMING – Medicaid
VERMONT– Medicaid
Website: http://www.greenmountaincare.org/
Website: https://wyequalitycare.acs-inc.com/
Phone: 1-800-250-8427
Phone: 307-777-7531
To see if any other states have added a premium assistance program since July 31, 2015, or for more
information on special enrollment rights, contact either:
U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/ebsa
1-866-444-EBSA (3272)
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
1-877-267-2323, Menu Option 4, Ext. 61565
OMB Control Number 1210-0137 (expires 10/31/2016)
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Important Notice from ProHealth Care, Inc. About
Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about
your current prescription drug coverage with ProHealth Care, Inc. and about your options under
Medicare’s prescription drug coverage. This information can help you decide whether or not you
want to join a Medicare drug plan. If you are considering joining, you should compare your current
coverage, including which drugs are covered at what cost, with the coverage and costs of the plans
offering Medicare prescription drug coverage in your area. Information about where you can get help
to make decisions about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s
prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You
can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage
Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide
at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for
a higher monthly premium.
2. ProHealth Care, Inc. has determined that the prescription drug coverage offered by ProHealth
Care, Inc. is, on average for all plan participants, expected to pay out as much as standard Medicare
prescription drug coverage pays and is therefore considered Creditable Coverage. Because your
existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher
premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from
October 15th to December 7th. However, if you lose your current creditable prescription drug
coverage, through no fault of your own, you will also be eligible for a two (2) month Special
Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current ProHealth Care, Inc. coverage will not be
affected. You can keep this coverage if you elect Part D and this plan will coordinate with Part D
coverage. If you do decide to join a Medicare drug plan and drop your current ProHealth Care, Inc.
coverage, be aware that you and your dependents may not be able to get this coverage back.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with ProHealth Care, Inc. and
don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you
may pay a higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly
premium may go up by at least 1% of the Medicare base beneficiary premium per month for every
month that you did not have that coverage. For example, if you go nineteen months without
creditable coverage, your premium may consistently be at least 19% higher than the Medicare base
beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have
Medicare prescription drug coverage. In addition, you may have to wait until the following October to
join.
52 | P a g e
For More Information About This Notice Or Your Current Prescription Drug Coverage…
Contact the office listed below for further information. NOTE: You’ll get this notice each year. You
will also get it before the next period you can join a Medicare drug plan, and if this coverage through
ProHealth Care, Inc. changes. You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the
“Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from
Medicare. You may also be contacted directly by Medicare drug plans. For more information about
Medicare prescription drug coverage:



Visit www.medicare.gov
Call your State Health Insurance Assistance Program (see the inside back cover of your
copy of the “Medicare & You” handbook for their telephone number) for personalized help
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage
is available. For information about this extra help, visit Social Security on the web at
www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug
plans, you may be required to provide a copy of this notice when you join to show whether or not
you have maintained creditable coverage and, therefore, whether or not you are required to pay a
higher premium (a penalty).
Date:
Name of Entity/Sender:
Contact: Office:
Address:
October 1, 2015
ProHealth Care, Inc.
Total Rewards
N17 W24100 Riverwood Dr., Suite 350
Waukesha, WI 53188-1131
Phone Number: 262-928-4185
53 | P a g e
General Notice Of COBRA Continuation Coverage Rights
Employee Assistance Program EAP
** Continuation Coverage Rights Under COBRA**
Introduction
You are receiving this notice because you have recently become covered under a group employee assistance
plan. This notice contains important information about your right to COBRA continuation coverage, which is a
temporary extension of coverage under the Plan. This notice generally explains COBRA continuation
coverage, when it may become available to you and your family, and what you need to do to protect
the right to receive it.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you
would otherwise lose your group health coverage. It can also become available to other members of your
family who are covered under the Plan when they would otherwise lose their group health coverage. For
additional information about your rights and obligations under the Plan and under federal law, you should
review the Plan’s Summary Plan Description or contact the Plan Administrator.
What is COBRA Continuation Coverage?
COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end
because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this notice.
After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified
beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage
under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect
COBRA continuation coverage must pay or are not required to pay] for COBRA continuation coverage.
If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan
because either one of the following qualifying events happens:


Your hours of employment are reduced, or
Your employment ends for any reason other than your gross misconduct.
If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under
the Plan because any of the following qualifying events happens:





Your spouse dies;
Your spouse’s hours of employment are reduced;
Your spouse’s employment ends for any reason other than his or her gross misconduct;
Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or
You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because any
of the following qualifying events happens:






The parent-employee dies;
The parent-employee’s hours of employment are reduced;
The parent-employee’s employment ends for any reason other than his or her gross misconduct;
The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
The parents become divorced or legally separated; or
The child stops being eligible for coverage under the plan as a “dependent child.”
When is COBRA Coverage Available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator
has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or
reduction of hours of employment, death of the employee, or the employee becomes entitled to Medicare
benefits (under Part A, Part B, or both), the employer ProHealth Care Total Rewards must be notified of the
qualifying event.
54 | P a g e
You Must Give Notice of Some Qualifying Events
For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s
losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 30 days after
the qualifying event occurs.
How is COBRA Coverage Provided?
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation
coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an
independent right to elect COBRA continuation coverage. Covered employees may elect COBRA
continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on
behalf of their children.
COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the
death of the employee, the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both),
your divorce or legal separation, or a dependent child's losing eligibility as a dependent child, COBRA
continuation coverage lasts for up to a total of 36 months. When the qualifying event is the end of
employment or reduction of the employee's hours of employment, and the employee became entitled to
Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified
beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For
example, if a covered employee becomes entitled to Medicare 8 months before the date on which his
employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months
after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36
months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the
employee’s hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18
months. There are two ways in which this 18-month period of COBRA continuation coverage can be
extended.
Disability extension of 18-month period of continuation coverage
If you or anyone in your family covered under the Plan is determined by the Social Security Administration to
be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be
entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29
months. The disability would have to have started at some time before the 60th day of COBRA continuation
coverage and must last at least until the end of the 18-month period of continuation coverage.
Second qualifying event extension of 18-month period of continuation coverage
If your family experiences another qualifying event while receiving 18 months of COBRA continuation
coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA
continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given
to the Plan. This extension may be available to the spouse and any dependent children receiving continuation
coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part
B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan
as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage
under the Plan had the first qualifying event not occurred.
Are There Other Options
There may be other coverage options for you and your family. When key parts of the health care law take
effect, you’ll be able to buy coverage through the Health Insurance Marketplace. In the Marketplace, you
could be eligible for a new kind of tax credit that lowers your monthly premiums right away, and you can see
what your premium, deductibles, and out-of-pocket cost will be before you make a decision to enroll. Being
eligible for COBRA does not limit your eligibility for coverage for a tax credit through the Marketplace.
Additionally, you may qualify for a special enrollment opportunity for another group health plan for which you
are eligible for a special enrollment opportunity for another group health plan for which you are eligible (such
as a spouse’s plan), even if the plan generally does not accept late enrollees, if you request enrollment within
30 days.
If You Have Questions
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the
contact or contacts identified below. For more information about your rights under ERISA, including COBRA,
the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans,
contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security
Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses and phone
numbers of Regional and District EBSA Offices are available through EBSA’s website.)
55 | P a g e
Keep Your Plan Informed of Address Changes
In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the
addresses of family members. You should also keep a copy, for your records, of any notices you send to the
Plan Administrator. Plan contact information: Total Rewards 262-928-4185 or [email protected].
Wellness Program Disclosure
If it is unreasonably difficult due to a medical condition for you to achieve the standards for the
reward under this program, or if it is medically inadvisable for you to attempt to achieve the
standards for the reward under this program, call us at (262) 560-4915 and we will work with you to
develop another way to qualify for the reward.
Summary of Benefits and Coverage (SBC)
The Affordable Care Act (ACA) requires health plans and health issuers to provide applicants and
enrollees with a concise document providing simple and consistent information about the health plan
benefits and coverage. This document is called a Summary of Benefits and Coverage (SBC).
The SBC is available on Employee Self Service (ESS) under Benefit Information and on the I-Net
under the Medical Plan. For a paper copy, e-mail Total Rewards at [email protected] or
call Total Rewards at 262-928-4185.
56 | P a g e
EMPLOYEE RIGHTS AND RESPONSIBILITIES
UNDER THE FAMILY AND MEDICAL LEAVE ACT
Basic Leave Entitlement
a regimen of continuing treatment, or incapacity due to pregnancy, or incapacity due to a
chronic condition. Other conditions may meet the definition of continuing treatment.
FMLA requires covered employers to provide up to 12 weeks of unpaid, jobprotected leave to eligible employees for the following reasons:
Use of Leave
• for incapacity due to pregnancy, prenatal medical care or child birth;
• to care for the employee’s child after birth, or placement for adoption or
foster care;
• to care for the employee’s spouse, son, daughter or parent, who has a serious
health condition; or
• for a serious health condition that makes the employee unable to
perform the employee’s job.
An employee does not need to use this leave entitlement in one block. Leave can be
taken intermittently or on a reduced leave schedule when medically necessary.
Employees must make reasonable efforts to schedule leave for planned medical treatment
so as not to unduly disrupt the employer’s operations. Leave due to qualifying exigencies
may also be taken on an intermittent basis.
Military Family Leave Entitlements
Substitution of Paid Leave for Unpaid Leave
Eligible employees whose spouse, son, daughter or parent is on covered active
duty or call to covered active duty status may use their 12-week leave entitlement
to address certain qualifying exigencies. Qualifying exigencies may include
attending certain military events, arranging for alternative childcare, addressing
certain financial and legal arrangements, attending certain counseling sessions,
and attending post-deployment reintegration briefings.
Employees may choose or employers may require use of accrued paid leave while taking
FMLA leave. In order to use paid leave for FMLA leave, employees must comply with
the employer’s normal paid leave policies.
FMLA also includes a special leave entitlement that permits eligible
employees to take up to 26 weeks of leave to care for a covered servicemember during a single 12-month period. A covered service member is:
(1) a current member of the Armed Forces, including a member of the
National Guard or Reserves, who is undergoing medical treatment,
recuperation or therapy, is otherwise in outpatient status, or is otherwise on
the temporary disability retired list, for a serious injury or illness*; or (2) a
veteran who was discharged or released under conditions other than
dishonorable at any time during the five-year period prior to the first date the
eligible employee takes FMLA leave to care for the covered veteran, and who
is undergoing medical treatment, recuperation, or therapy for a serious injury
or illness.*
*The FMLA definitions of “serious injury or illness” for current
service members and veterans are distinct from the FMLA
definition of “serious health condition”.
Benefits and Protections
During FMLA leave, the employer must maintain the employee’s health
coverage under any “group health plan” on the same terms as if the employee
had continued to work. Upon return from FMLA leave, most employees must
be restored to their original or equivalent positions with equivalent pay,
benefits, and other employment terms.
Use of FMLA leave cannot result in the loss of any employment benefit that
accrued prior to the start of an employee’s leave.
Employee Responsibilities
Employees must provide 30 days advance notice of the need to take FMLA leave when
the need is foreseeable. When 30 days notice is not possible, the employee must provide
notice as soon as practicable and generally must comply with an employer’s normal callin procedures.
Employees must provide sufficient information for the employer to determine if the leave
may qualify for FMLA protection and the anticipated timing and duration of the leave.
Sufficient information may include that the employee is unable to perform job functions,
the family member is unable to perform daily activities, the need for hospitalization or
continuing treatment by a health care provider, or circumstances supporting the need for
military family leave. Employees also must inform the employer if the requested leave is
for a reason for which FMLA leave was previously taken or certified. Employees also
may be required to provide a certification and periodic recertification supporting the need
for leave.
Employer Responsibilities
Covered employers must inform employees requesting leave whether they are eligible
under FMLA. If they are, the notice must specify any additional information required as
well as the employees’ rights and responsibilities. If they are not eligible, the employer
must provide a reason for the ineligibility.
Covered employers must inform employees if leave will be designated as FMLAprotected and the amount of leave counted against the employee’s leave entitlement. If
the employer determines that the leave is not FMLA-protected, the employer must notify
the employee.
Unlawful Acts by Employers
FMLA makes it unlawful for any employer to:
Eligibility Requirements
Employees are eligible if they have worked for a covered employer for at least
12 months, have 1,250 hours of service in the previous 12 months*, and if at
least 50 employees are employed by the employer within 75 miles.
*Special hours of service eligibility requirements apply to airline
flight crew employees.
 interfere with, restrain, or deny the exercise of any right provided under FMLA; and
 discharge or discriminate against any person for opposing any practice made
unlawful by FMLA or for involvement in any proceeding under or relating to FMLA.
Enforcement
An employee may file a complaint with the U.S. Department of Labor or may bring a
private lawsuit against an employer.
Definition of Serious Health Condition
A serious health condition is an illness, injury, impairment, or physical or
mental condition that involves either an overnight stay in a medical care
facility, or continuing treatment by a health care provider for a condition that
either prevents the employee from performing the functions of the employee’s
job, or prevents the qualified family member from participating in school or
other daily activities.
FMLA does not affect any Federal or State law prohibiting discrimination, or supersede
any State or local law or collective bargaining agreement which provides greater family
or medical leave rights.
FMLA section 109 (29 U.S.C. § 2619) requires FMLA covered employers
to post the text of this notice. Regulation 29 C.F.R. § 825.300(a) may
require additional disclosures.
Subject to certain conditions, the continuing treatment requirement may be
met by a period of incapacity of more than 3 consecutive calendar days
combined with at least two visits to a health care provider or one visit and
For additional information:
1-866-4US-WAGE (1-866-487-9243) TTY: 1-877-889-5627
WWW.WAGEHOUR.DOL.GOV
of Labor
U.S. Department of Labor /Wage and Hour Division
57 | P a g e

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