important benefits information - Cuyahoga County Department of

COMMISSIONERS
Jimmy Dimora
Timothy F. Hagan
Peter Lawson Jones
IMPORTANT BENEFITS INFORMATION
AN ACTIVE ENROLLMENT WILL BE REQUIRED FOR ALL EMPLOYEES. YOU MUST GO ON LINE TO SIGN
UP FOR YOUR BENEFITS. IF YOU DO NOT DO SO, YOU WILL DEFAULT TO THE METROHEALTH SELECT
PLAN DESCRIBED BELOW. YOU WILL HAVE THAT COVERAGE FOR 2009 REGARDLESS OF WHAT PLAN
YOU HAD IN 2008.
Open enrollment will be held from October 14, 2008 through November 10, 2008. Meetings with employees
will be held at all locations to discuss the new plans and the changes for 2009. This will give all employees to
chance to ask questions and become familiar with the options prior to open enrollment.
Medical Plans for 2009:
We are still offering the same medical plans:
ŠŠ United HealthCare Choice Plus PPO (100% plan)
ŠŠ Medical Mutual SuperMed Plus EPO (SuperMed)
ŠŠ Kaiser
ŠŠ Kaiser MetroHealth Advantage (Metro Advantage) (takes the place of the MetroCentric Plan).
In addition, we have also added 3 new medical plans:
ŠŠ United HealthCare 90% PPO Plan (90% plan) which has lower employee contributions, deductibles
and out of pocket maximums.
ŠŠ United HealthCare HSA Plan (HSA) which has high deductibles ($1250 for single and $2500 for family),
a savings account, employees must pay 10% of the insurance costs and an incentive of $200 for single
and $400 for family will be used to start your savings account.
ŠŠ Medical Mutual MetroHealth Select (Metro Select) Plan which utilizes the MetroHealth network and
is administered by Medical Mutual. Metro has 9 satellite facilities in addition to their main location.
Employees will have one central phone number to make appointments to be filled within 5 days. Employees will have a pharmacy window for their use. There will also be lower co-pays for office visits,
emergency room visits and prescription drugs.
Both the Metro Advantage and the Metro Select plans are free for all employees. In addition, employees who
select these plans will receive a $500 incentive ($250 early in the year and $250 late in the year). The $500
is taxable to employees and will be shown under Other Earnings. Please see the summaries in the attached
booklet for more details.
Prescription Drugs (RX) for 2009:
ŠŠ Caremark is still the RX provider if you have the United HealthCare 100% Plan, the SuperMed plan and
the United HealthCare 90% Plan. The United HealthCare HSA Plan has prescription drug coverage
through United HealthCare only (employee is responsible for paying 10% of the costs of the
drugs).
ŠŠ Retail co-pays: $5 generic, $10 brand, $25 non-formulary (30 day supply) for the current plans for
United HealthCare and Medical Mutual. $5 generic, $25 brand and $40 non-formulary (30 day supply)
for the United HealthCare 90% plan.
Benefits2009
1
ŠŠ Maintenance retail co-pays after 4th refill: : $10 generic, $20 brand, $50 non-formulary (30 day
supply) or $10 generic, $50 brand, $80 non-formulary (90 day supply for the 90% plan).
ŠŠ Mail order co-pays: $10 generic, $20 brand, $50 non-formulary (90 day supply)
ŠŠ Kaiser co-pay ($5); Kaiser Metro Advantage co-pays: $3 generic, $10 brand, $15 non-formulary at
Kaiser or MetroHealth facilities
ŠŠ Medical Mutual Metro Select co-pays: $3 generic, $10 brand, $15 non-formulary at MetroHealth
facilities only; $3 generic, $20 brand, $35 non-formulary at retail locations (administered by
Caremark)
Employees can elect to still receive their maintenance drugs (drugs prescribed on an ongoing continuous
basis) at their retail pharmacy or through mail order. If you continue to use your retail pharmacy, your co-pay
will double starting with your 4th refill and will continue to be doubled. For example, if you take Lipitor,
your co-pay at the drugstore is $10 monthly. The 4th refill at the drugstore will now cost you $20 and
you will be charged $20 monthly if you continue to use the retail pharmacy. If you use the mail order
pharmacy, you will pay $20 for a 90 day (3 month) supply.
Opt out allowances:
Employees who have access to other medical benefits will receive additional money in their paychecks if they
elect not to participate in the County’s medical plans.
ŠŠ Employees who are covered under their spouse’s plan will receive a $100 credit every pay period (net
of all other benefit deductions)
ŠŠ Employees who cover themselves and/or children but not their spouse (spouse has their own
coverage) will receive a $50 credit every pay period (net of all other benefit deductions).
ŠŠ Documentation of coverage for the 2009 period will be required in all cases.
ŠŠ County employees who are married to other County employees and receive benefits administered
by the BOCC will not be eligible for this allowance.
Supplemental Plans for 2009 (Dental/Vision/FSA/Life Insurance):
Anthem will continue as our provider for dental coverage. Union Eye Care Center, Inc. continues to provide
vision coverage. The plan comparison provides more information regarding these plans. AFSCME locals 1746,
2927 and 3366 will continue to receive supplemental benefits, including hearing, only through the AFSCME
Care Plan (which is excluded from the waiver provision).
FSA Plans (Health Care or Dependent Care Reimbursement Accounts):
FSA plans will continue to be administered by Northwest Group Services. Remember that you must enroll
in these plans every year as there is no automatic default. These accounts provide an important tax
advantage that can help you pay health care and dependent care expenses on a pre-tax basis. Employees who
have childcare expenses or who are paying for additional expenses that are not covered by our plans should
consider enrollment in these plans (see more detailed information inside). In order to select dependent care,
your dependent must be 13 years old or younger. Claims incurred after you have terminated coverage in
these plans cannot be reimbursed.
Life Insurance will also be administered by Anthem:
You can increase one level (up to $50,000) without evidence of insurability (EOI) unless you only have $6,000
($10,000 for union local 407). Increases of 1 to 5 times salary or amounts greater than $300,000 require
completion of EOI forms. These forms are provided in the attached materials.
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Benefits2009
IMPORTANT
OPEN ENROLLMENT CHANGES FOR 2009
Open enrollment for benefits for 2009 will again include enrollment on-line using our web-based system.
You must go on line to sign up for benefits. Your logon ID was received in your Charity Choice mailer and this
same logon ID will be used for open enrollment. Another self sealer with your logon ID was included with
your October 3 pay check.
ŠŠ Open enrollment starts 10/14 and ends 11/10/08
ŠŠ Open enrollment will be on our web-based system and is mandatory for all employees (this means you
must go on line or you default to the MetroHealth Select plan for 2009).
ŠŠ Instructions (script) to access web-based system will be on the HR website
https://myhr.cuyahogacounty.us
ŠŠ Kiosks (independent PCs with printers) will be available at locations indicated for those without
computer access
ŠŠ If making no changes, you will still have to go on line
Mail Order Requirements for 2009:
90 day prescription from your doctor for EACH maintenance drug; Caremark mail order form; Method of
payment – either check or credit card number. Drugs will be received at home in about 2 weeks. Discounts
for medications filled for the following conditions: asthma, diabetes, blood pressure and cholesterol
at $0 for generic and $5 less for brand and non-formulary at retail.
Voluntary Supplemental Benefits open enrollment:
ŠŠ Short term disability
ŠŠ Whole life insurance with long term care rider
ŠŠ Accident insurance
ŠŠ Any changes will be effective 2/1/09
ŠŠ Information on line regarding how to sign up for these benefits and also at employee group
meetings
ŠŠ If you have questions about these benefits, contact EBI at 216-264-2709.
Costs:
Kaiser MetroHealth Advantage and Medical Mutual MetroHealth Select plans are free to all employees
(no deductions from your pay check). All other plans have small increases.
Eligibility:
By enrolling in County benefits plans, you agree to comply with the eligibility rules for yourself and for all your
dependents in these plans. The enrolling of ineligible dependents may be considered fraud and could result
in disciplinary action up to and including employment termination. You may also be subject to an eligibility
audit during this benefit year which will require you to supply copies of documentation such as certified
birth certificate(s), marriage certificate(s), income tax returns and/or other related documentation including
affidavits. Employees who are divorced cannot cover ex-spouses under our benefits.
Benefits2009
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Plan Comparison
United HealthCare
Network
Non-Network
United HealthCare 90% / 70%
Network
Non-Network
Access care through any network provider with no referral
Access care through any network provider with no referral
70% coverage
Deductible
Per Individual - none
per family - none
$300 per Individual
$600 per family
$250 Single
$500 Family
$500 Single
$1,000 Family
Annual Out-of-Pocket Maximum
Per Individual - none
per family - none
$3000 per Individual $6000
per family
$1,500 Single
$3,000 Family
$3,000 Single
$6,000 Family
Care Coordination must be
notified prior to admission
Days - unlimited in-patient 70% of eligible expenses after
deductible
Out-patient - 70% of eligible
expenses after deductible
50% of eligible expenses after
deductible if Care Coordination
is not notified
10% after deductible
30% after deductible
100% paid by plan
70% of eligible expenses
after deductible
10% after deductible
30% after deductible
100 Days per calendar year
100% paid by plan
Care Coordination must be
notified prior to admission
70% of eligible expenses after
deductible 50% of eligible expenses after deductible if Care
Coordination is not notified
10% after deductible
30% after deductible
No Copay
100% paid by plan
Refer to Certificate
10% after deductible
30% after deductible
$15 Copay
then covered at 100%
70% of eligible expenses
after deductible
$15 Copay
70% of eligible expenses
after deductible
$15 Copay;
$25 Specialist
30% of eligible expenses
after deductible
$5 generic,
$10 Brand Name,
$25 Non-Formulary
Administered through
Caremark
$5 generic,
$10 Brand Name,
$25 Non-Formulary
Administered through
Caremark
$5 generic,
$25 Brand Name,
$40 Non-Formulary
Administered through
Caremark
$5 generic,
$25 Brand Name,
$40 Non-Formulary
Administered through
Caremark
Days - unlimited
Days of Hospital Room and
Board
in-patient 100% paid by Plan
Out-patient 100% paid by plan
Diagnostic Testing at Doctor’s
Office, Clinic, or Hospital
Days of Skilled Nursing Facility
Care
Surgery
Second Surgical Opinion
Doctor’s Office Visits
Prescription Drugs
Psychiatric Care
In-Hospital
4
90% coverage
70% of eligible expenses after deductible 50% of eligible
100% paid by plan 30 Days per
expenses after deductible if 10% after deductible
calendar year (maximum)
United Behavioral Health is not
notified
30% of eligible expenses after
deductible
* Does not apply to AFSCME locals 1746, 2927 and 3366. See your AFSCME Care Plan booklet if you are covered by one of these bargaining units.
** Services must be provided or arranged by Kaiser Permanente or a plan-affiliated provider.
*** If enrollee request a brand name drug when a generic drug is available, enrollee will be responsible for paying the $10 co-pay as well as the difference
between the cost of the brand and the generic drug.
Benefits2009
United HealthCare HSA Plan
Network
Kaiser Permanente
Non-Network
Access care through any network provider with no referral
Medical Mutual
HMO
MetroHealth
Advantage
SuperMed PLUS
(EPO)
Metrohealth
Select
90% coverage
70% coverage
$1,250 Single
$2,500 Family
$2,500 Single
$5,000 Family
None
None
None
None
$2,500 Single
$5,000 Family
$5,000 Single
$10,000 Family
Consult plan for details
Consult plan for details
None
None
10% after deductible
30% after deductible
Unlimited**
Unlimited**
Unlimited
Unlimited
10% after deductible
30% after deductible
Covered in full**
Covered in full**
100%
100%
10% after deductible
30% after deductible
100 days per calendar
year**
100 days per calendar
year**
100 days
100 days
Covered in full**
Covered in full**
100% (Otherwise, at
Surgical-Provider Office,
$15 copay per surgical
procedure)
$5 copay, then 100%
Covered in full**
Covered in full**
10% after deductible
30% after deductible
10% after deductible
30% of eligible expenses
after deductible
$15 copay.
Then covered at 100%
$5 copay.
Then covered at 100%
$15 copay then 100% (For
Illness/Injury); 100% (For
Preventative care)
$5 copay then 100% (For
Illness/Injury); 100% (For
Preventative care)
$5 generic,
$25 Brand Name,
$40 Non-Formulary
Administered by
United HealthCare
$5 generic,
$25 Brand Name,
$40 Non-Formulary
Administered by
United HealthCare
$5 copay per Generic
up to 62-day supply
Administered through
Caremark
$3, $10, $15 retail
Administered through
Caremark
$5 copay per generic,
$10 Brand Name,
$25 Non-Formulary
Administered through
Caremark
$3/$10/$15 at MetroHealth
facilities only;
$3/$20/$35 at retail
locations (administered by
Caremark)
10% after deductible
30% of eligible expenses
after deductible
$250 admission deductible
then 100%; 30 days per
benefit period (combined
with substance abuse)
100%; 30 days per benefit
period
30 days per calendar year**
30 days per calendar year**
at no charge
(continued next page)
Benefits2009
5
Plan Comparison (continued)
United HealthCare
Network
Non-Network
Access care through any network provider with no referral
Mental Health Services
Out-Patient Visits
Mental Health and
Substance Abuse Care
Inpatient
Durable Medical
Equipment
Emergency Care
United HealthCare 90% / 70%
Network
Non-Network
Access care through any network provider with no referral
90% coverage
70% coverage
70% of eligible expenses
after deductible
50% of eligible expenses after
deductible if United Behavioral
Health is not notified
$25 Copay per visit
30 visits per calendar year
$50 Copay per group service
30% of eligible expenses
after deductible
70% of eligible expenses
after deductible
50% of eligible expenses after
deductible if United Behavioral
Health is not notified
10% after deductible
$25 copay per vivist
30% of eligible expenses
after deductible
100% paid by plan Annual
Maximum - $1500
70% of eligible expenses
after deductible
50% of eligible expenses after
deductible if Care Coordination
is not notified - Limited to
$500 per person per year
10% after deductible
Annual Maximum - $1,500
30% of eligible expenses
after deductible
Annual Maximum - $1,500
$75 Copay
(waived if admitted)
$75 Copay Notify Care Coordination if
admitted, If not, benefits
covered at 50%
(waived if admitted)
$75 Copay
(waived if admitted)
$75 Copay
(waived if admitted)
$15 Copay
then covered at 100%
30 visits per calendar year
100% paid by plan in-patient
30 days per calendar year
(maximum)
out-patient $15 Copay,
then 100% paid by Plan
30 visits per calendar year
*HEARING CARE BENEFIT
Audiometric Testing
Maximum - $40 per exam
Maximum $40 per exam
Maximum - $40 per exam
Maximum $40 per exam
Hearing Aid
Maximum - $400 benefit
Maximum $400 benefit
Maximum - $400 benefit
Maximum $400 benefit
* Does not apply to AFSCME locals 1746, 2927 and 3366. See your AFSCME Care Plan booklet if you are covered by one of these bargaining units.
** Services must be provided or arranged by Kaiser Permanente or a plan-affiliated provider.
*** If enrollee request a brand name drug when a generic drug is available, enrollee will be responsible for paying the $10 co-pay as well as the difference
between the cost of the brand and the generic drug.
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Benefits2009
United HealthCare HSA Plan
Network
Non-Network
Access care through any network provider with no referral
90% coverage
10% after deductible
Kaiser Permanente
HMO
70% coverage
30% of eligible expenses
after deductible
MetroHealth
Advantage
20 Visits maximum
20 Visits maximum
-Individual
$15 copay per visit
-Individual $5 copay per
visit
- Group $7 copay per visit
Group $2 copay per visit
Medical Mutual
SuperMed PLUS
(EPO)
$15 copay, then 100%;
20 visits per benefit
period (combined with
substance abuse)
Metrohealth
Select
$10 copay, then 100% Individual Therapy; $5
copay, then 100%
- Group Therapy;
(each visit counts as a visit
towards maximum);
30 visits per benefit period
10% after deductible
30% of eligible expenses
after deductible
Inpatient - Detoxification in
general hospital, No Charge
-Detoxification in a specialized facility -one(1) admit
per year, No Charge.
Inpatient - Detoxification in
general hospital, No Charge
-Detoxification in a specialized facility -one(1) admit
per year, No Charge.
Inpatient: $250 admission
deductible then 100%;
30 days per benefit period
(combined with Mental
Health);
Inpatient: 100%;
One admit per year for
Detox in a specialized
facility.
Outpatient: $15 copay
Outpatient:
$5 copay per visit
Outpatient 20 visits per
benefit period (Combined
with Mental Health)
Outpatient:
$10 Copay then 100%
10% after deductible
Annual Maximum - $2,500
30% of eligible expenses
after deductible
Annual Maximum - $2,500
Covered in full
Covered in full
when referred by PCP
100%
100%
10% after deductible
$75 Copay
(waived if admitted)
$25 copay
(waived if admitted)
$25 copay
(waived if admitted)
$75 copay, then 100%
(copay waived if admitted)
$25 copay, then 100%
(copay waived if admitted)
Maximum - $40 per exam
Maximum $40 per exam
Covered in Fulll***
Covered in Full**
Maximum - $400 benefit
Maximum $400 benefit
100%
100%
$400 maximum for
one hearing aid every
36 months;
includes Hearing Aid
Evaluation and Conformity
Evaluation once every
36 months
$500 maximum,
per hearing aid per ear
every 36 months;
includes one Hearing Aid
Evaluation and Conformity
Evaluation, once every
36 months
(continued next page)
Benefits2009
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SUPPLEMENTAL BENEFIT PLAN
ANTHEM DENTAL PLAN
PROVISION
Deductible*
Preventive and Diagnostic
Basic Services – Includes Endodontics, Periodontics and Oral Surgery;
Temporomandibular Joint Dysfunction TMJ
Major Services – Includes Major Restorative Services and Prosthodontic
Services
Orthodontic (Dependent to Age 19)
Orthodontic Adult
Orthodontic Lifetime
Maximum (Per Child)
TMJ – Lifetime Maximum
Annual Maximum – Other
IN NETWORK
$0
100%
OUT-OF-NETWORK** $50/person
100%
80%
80%
50%
50%
50%
N/A
50%
N/A
$1,000
$1,000
$1,000
None
$1,000
None
*Deductible does not apply to preventive care.
**UCR = Usual customary & reasonable charge
Dental benefits are paid at the same coinsurance levels and maximums for network and non-network dentists. However, members who use a
network dentist will have lower out-of-pocket expenses and get more services for the dollar maximum due to the discounted fees. Also, members
will be responsible for any difference between the R&C determination and the non-network dentist’s actual charge. Please refer to your Summary of
Benefits for more specific details regarding benefits. Please visit our website www.anthem.com for a listing of participating providers.
The vision coverage, described below, will be included with the dental coverage.
UNION EYE CARE
ITEM
Examination:
Exam w/dilation by Network Optometrist
Exam2 w/dilation by Univ. Ophthalmologist
Contact lens exam
Lenses: standard glass or plastic
Single Vision
Bifocals
Trifocals
Lenticular
Frame:
Contacts: Covered in lieu of eyeglasses
$10 co-pay
$25 co-pay2
$35 allowance
$10 co-pay
$10 co-pay
$10 co-pay
$10 co-pay
$45 allowance
$70 allowance
OUT-OF-NETWORK
one exam per calendar year
$25 allowance
$25 allowance
$25 allowance
one pair per calendar year
$25 allowance
$40 allowance
$50 allowance
$80 allowance
one frame per calendar year
$25 allowance $50 allowance
NETWORK benefits are available at any Union Eye Care Center and many independent provider locations.
OPHTHALMOLOGICAL routine eye examinations are available through University Hospitals Department of Ophthalmology and University Eye Care and Surgery. There is a $25.00 co-pay requirement.
Does not apply to AFSCME Locals 1746, 2927, 3366. See your AFSCME Care Plan booklet if you are covered by one of these bargaining units.
If there are any discrepancies between the plan document and this bulletin, the document will prevail.
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IN-NETWORK1
Benefits2009
MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE
FOR USE ON OR AFTER JUNE 15, 2008
OMB 0938-0990
Important Notice from Cuyahoga County 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 Caremark, Kaiser
Permanente or United HealthCare Insurance Company 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. Cuyahoga County has determined that the prescription drug coverage offered by
Caremark, Kaiser Permanente or United HealthCare Insurance Company 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 November 15th through December 31st.
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.
CMS Form 10182-CC
Updated June 15, 2008
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information
collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather
the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.
1
Benefits2009
9
MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE
FOR USE ON OR AFTER JUNE 15, 2008
OMB 0938-0990
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 Caremark, Kaiser Permanente or United
HealthCare Insurance Company coverage will be affected. For those individuals who elect Part
D coverage, coverage under Caremark, Kaiser Permanente or United HealthCare Insurance
Company plans will end for the individual and all covered dependents.
If you do decide to join a Medicare drug plan and drop your current Caremark, Kaiser Permanente
or United HealthCare Insurance Company 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 Caremark, Kaiser
Permanente or United HealthCare Insurance Company and don’t join a Medicare drug plan
within 63 continuous days after your current coverage ends, you may pay a higher premium (a
penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly
premium may go up by at least 1% of the Medicare base beneficiary premium per month for
every month that you did not have that coverage. For example, if you go nineteen months without
creditable coverage, your premium may consistently be at least 19% higher than the Medicare
base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you
have Medicare prescription drug coverage. In addition, you may have to wait until the following
November to join.
For More Information About This Notice Or Your Current Prescription Drug
Coverage…
Contact the person listed below for further information. NOTE: You’ll get this notice each year.
CMS Form 10182-CC
Updated June 15, 2008
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information
collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather
the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.
10
2
Benefits2009
MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE
FOR USE ON OR AFTER JUNE 15, 2008
OMB 0938-0990
You will also get it before the next period you can join a Medicare drug plan, and if this coverage
through Caremark, Kaiser Permanente or United HealthCare Insurance Company 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:
ŠŠ Visit www.medicare.gov
ŠŠ 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
ŠŠ 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--Position/Office:
Address:
Phone Number:
9/24/08
Cuyahoga County
Benefits Department
1255 Euclid Avenue, 3rd Floor, Cleveland, OH 44115
216-443-3539
CMS Form 10182-CC
Updated June 15, 2008
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information
collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather
the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.
3
Benefits2009
11
YOUR GROUP LIFE INSURANCE OPTIONS
FLEXCOUNT offers a basic level of insurance protection plus flexibility to elect more coverage if you wish. With FLEXCOUNT,
you can choose from several different levels of coverage. You must choose at least the minimum option — you cannot decline
life insurance coverage.
• If you are not covered by the AFSCME bargaining unit agreement, the $6,000 minimum option life insurance coverage the
County provides is at no cost to you. You may choose from five other options: $10,000, $20K, $30K, $40K, or $50K.
• If you are covered by the AFSCME bargaining unit agreement, your basic life insurance coverage is provided by the County
at no cost to you through the AFSCME Care Plan. The amount of basic coverage you have depends on your base pay. Under
FLEXCOUNT, you may choose additional life insurance from four options. This coverage is in addition to the life insurance
provided by the County through the AFSCME Care Plan. Those options are $6,000, $lOK, $20K, or $24K.
Choosing More Life Insurance Coverage
You can elect to purchase additional supplemental life insurance from 1 to 5 times your salary (up to $500,000) on a pretax basis.
AD&D Insurance
Each life insurance option automatically includes $6,000 in Accidental Death and Dismemberment (AD&D) coverage. AD&D
pays a benefit, in addition to your life insurance amount, if you die as the result of an accident. AD&D will also pay if you suffer
certain injuries, like the loss of a limb. The charge for AD&D is part of your life insurance premium.
Evidence of Insurability
An employee wishing to increase their optional life insurance more than one level who does not have at least $10,000 life insurance currently ($20,000 for Union Local 407) must complete a medical evidence of insurability (EOI). Insurability is
also required for employees purchasing supplemental life of 1 to 5 times their annual salary or employees requesting more than
$300,000. An EOI statement will be sent to you with your confirmation statement. Simply complete the statement and return it to
the Benefits Office by the published deadline. No EOI statement will be accepted after 1/31/09. Requesting evidence of insurability is a standard practice in the insurance industry. It protects all employees by helping to control costs. It is a brief statement
that will only take a few minutes for you to complete. For most employees, it does not require medical documentation. However,
in some instances, you may be asked at a later date to have your doctor complete a statement regarding your health. Your total
increase in life insurance coverage and prevailing deduction will be effective the 1st day of the month following approval of your
EOI statement by the County’s life insurance carrier.
Dependent Life Insurance
The County also provides Dependent Life Insurance for your spouse and eligible children at NO COST TO YOU. Dependent
Life Insurance for employees covered by the AFSCME bargaining unit agreement is provided by the County only through the
AFSCME Care Plan.
Dependent Life Insurance for employees NOT covered by the AFSCME bargaining unit agreement pays the following benefit in
the event of the death of a covered dependent:
COVERED DEPENDENT
YOUR SPOUSE
YOUR DEPENDENT CHILD
(From birth, but less than 23 years unless handicapped)
BENEFIT PAID
$1,000
$ 500
Keep in mind, this coverage is provided
at no cost to you
Living Benefit Provision
The County has a special feature in the optional life insurance plan called Accelerated Benefits. Sometimes referred to as “living
benefits”, this rider allows a terminally ill employee to receive up to 75 percent of their life insurance benefit early.
If you have further questions about your life insurance coverage, you may contact the Benefits Office (216-443-3539)
Ohio Relay Service 711.
12
Benefits2009
Beneficiary Form
It is important that each employee have a beneficiary form on file in the Benefits
Office. The beneficiary form allows the employee to state where they want the
proceeds to be paid upon the employee’s death. If you do not have a beneficiary form
on file, proceeds will be paid to your survivors as outlined in your certificate booklet.
Therefore it is important that you have a form on file with the Benefits Office. Also
if there is a change in your marital status, such as divorce, be sure to fill out a new
form, if applicable.
If you are in the AFSCME bargaining unit, you need only fill out a beneficiary form
if you have elected life insurance coverage in addition to your AFSCME policy.
Waiver of Premium
An employee who becomes totally disabled may be eligible for a waiver of insurance premium if
they are under the age of 60. Please contact the Benefits Office for further instructions. The insurance
company will make the ultimate decision on eligibility. Please review your insurance certificate for
complete details.
Conversion
Upon leaving employment, an employee has the right to convert his insurance policy. You have 31 days to
contact the insurance company after your resignation/retirement date to continue the life insurance coverage.
Please review your insurance certificate for complete details.
This document is intended only as a brief summary of the group life insurance benefit. Other plan provisions and
limitations may apply. If there are discrepancies between the actual contract and this summary, the contract
will prevail.
Benefits2009
13
Notes
14
Benefits2009
Class of INS: ____________ AMOUNT CURRENTLY IN FORCE:____________ AMOUNT RQUESTED:___________________
Evidence of
Insurability Form
Group #
00123863
Last Name
Anthem Life Insurance Company
P.O. Box 182361
Columbus, OH 43218-2361
800-551-7265 614-433-8880 Fax
PART A - GENERAL INFORMATION
Please Print in ink or type
First Name
Middle Initial
Name of Employer
State of Birth
Date of Birth
Social Security Number
Height
Weight
Work Phone #
PART B - DEPENDENT INFORMATION
Complete for all dependents (if any) to be covered under this program:
First Name
MI
Last Name
(if different
from Employee)
Birthdate
Height
Weight
Mo . Day Yr.
State
of
Birth
Sex
M or F
Relationship
Full-time
Student
Y or N
Eligible Income
Tax Exemption
Y or N
SPOUSE
PART C - MEDICAL QUESTIONNAIRE
COMPLETE THE FOLLOWING MEDICAL QUESTIONS FOR ALL PERSONS TO BE COVERED: For the purpose of the following medical questions, the
term “medical or social practitioner” includes but is not limited to: a doctor, nurse, psychologist, psychiatrist, social worker, chiropractor, podiatrist, therapist, pathologist, dentist, optometrist, osteopath, clergy, Christian Science practitioner, or any person affiliated with a self-help program such as Alcoholics Anonymous, a substance abuse program, or a weight loss program.
1. Are you or any of your dependents currently
pregnant?
YES
NO
If yes, who? Expected due date: 2. Do you or any of your dependents smoke or use
tobacco?
YES
NO
If yes, who? Type? 3. In the past 10 years, has anyone ever:
a. had high blood pressure or high cholesterol?
If yes, last three readings:
YES
NO
b. had heart disease, cancer, diabetes, arthritis, or
asthma?
YES
NO
c. had counseling by a medical or social
practitioner for an emotional, mental or nervous
condition?
YES
NO
d. been treated for alcohol or chemical
dependency, or been convicted for driving while
intoxicated?
YES
NO
4. Has anyone ever been diagnosed by, or received
treatment from, a member of the medical profession
for Acquired Immune Deficiency Syndrome (AIDS)
or AIDS-Related Complex (ARC), or tested positive
for antibodies to the Human Immune Deficiency
virus?
YES
NO
5. In the past three years has anyone been prescribed
medication?
YES
NO
6. In the past 10 years has anyone had an inpatient
admission and/or outpatient surgery?
YES
NO
YES
NO
YES
NO
YES
NO
7. During the past three years, has anyone sought
medical treatment, or been advised by a medical or
social practitioner to seek treatment for any
condition not indicated by your answers to the
preceding six questions?
8. Has anyone ever been rated or declined for, or
refused reinstatement or renewal of, life or health
insurance?
If yes, name of person, date and reason:
IMPORTANT NOTICE: No person, including an employee or agent
of Anthem Life has the authority to change or omit any of these
medical questions.
9. In the past three years, has anyone been engaged in
or does anyone contemplate being engaged in
sports or hobbies such as aviation, scuba diving, sky
diving, racing, or similar activities? (Please list)
A-306 9612
A-306 9807
(To be detached and retained by applicant)
ANTHEM LIFE INSURANCE COMPANY
NOTICE TO PROPOSED INSURED
(Fair Credit Reporting Notice)
INVESTIGATIVE CONSUMER REPORTS
Under Public Law 91-508, we are required to inform persons proposed for insurance that, as part of our underwriting procedure, an investigative
consumer report may be obtained which will provide information concerning residence, employment, finances, health, character, general reputation, personal characteristics, and mode of living. Such information for the investigative consumer report will be obtained through personal interviews with your friends, neighbors, and associates. This information may also be obtained by telephone interview with you or a member of your
household. You may request to be personally interviewed. You may also request a copy of the investigative report. Upon written request to the
Company’s Underwriting Department, a complete and accurate disclosure of the nature and scope of the investigative consumer report will be
provided. If you question the accuracy of the information in our files, you may request a correction in accordance with the procedures set forth in
the Federal Fair Credit Reporting Act.
N3
(See reverse side)
15
If you answered yes to any questions 3 through 7, provide details below. If additional space is needed, please attach a separate page
including your signature and date.
QUEST.
NO.
NAME OF
INDIVIDUAL
NAME OF
ILLNESS OR INJURY
DATES OF
TREATMENT
ANY REMAINING
EFFECTS
NAME OF
MEDICATION
AND DOSAGE
NAME AND ADDRESS
OF PHYSICIAN/HOSPITAL
AGREEMENT AND AUTHORIZATION
I understand that, in order for Anthem Life Insurance Company to accept or decline this application, all of the information requested on the application must be
completed. In the event that I have not correctly or fully completed this application, my signature shall authorize Anthem Life or its designee to obtain the necessary information for me and to complete that information on this application. I realize that Anthem Life reserves the right to accept or decline this application
(or to accept only certain persons for coverage) and that no right whatsoever is created by this application.
For the purpose of evaluating my application for insurance, I hereby authorize any licensed physician, medical practitioner, hospital, clinic, or other medical or
medically related facility; insurance company; the Medical Information Bureau, Inc.; or other organization, institution or person that has any records or knowlege of me, or my health, or of my family for whom this insurance application is made or their health to give Anthem Life or its reinsurers any such information.
I also authorize Anthem Life or its reinsurers to release any information regarding me or my health, or that of my family for whom insurance application is
made, to the Medical Information Bureau, Inc.; or other life insurance companies in which I have policies or to which I may apply; and other insurers to which
a claim for benefits may be submitted. I understand that this information will be used by Anthem Life to determine eligibility for insurance. This information includes information about drugs, alcoholism or mental illness. This authorization will be valid from the date signed for a period of two-and-one-half years. A
photocopy of this authorization will be as valid as the original. I understand that I may request a photocopy.
I certify that I have read, or have had read to me, the completed application and that all information is true and complete to the best of my knowledge. I understand that any misrepresentation or significant omission may void my coverage. I acknowledge that I have received the Fair Credit Reporting Notice. I also understand that any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement, is guilty of insurance fraud.
SIGNATURE OF APPLICANT
DATE
SIGNATURE OF SPOUSE (If to be covered)
DATE
IMPORTANT NOTICE
The underwriting process is necessary to assure reasonable cost of insurance and provide a mechanism by which policyholders pay their fair
share of the cost. In considering your application, information from various sources is considered, including statements in the application and
any reports we obtain from doctors or medical facilities where you have been attended.
Information regarding your insurability will be treated as confidential. We or our reinsurers may, however, make a brief report to the Medical
Information Bureau, a nonprofit membership organization of life insurance companies, which operates an information exchange on behalf of
its members. If you apply to another Bureau member company for life or health insurance coverage, or a claim for benefits is submitted to
such a company, the Bureau, upon request, will supply such company with the information it may have in its files.
16
Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If you question the accuracy
of information in the Bureau’s file, you may contact the Bureau and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of the Bureau’s information office is: P.O. Box 105, Essex Station, Boston, Massachusetts 02112,
telephone number (617) 426-3660.
We, or our reinsurers, may also release information in our file to other life insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted.
become too much to handle.
difficult times — before they
and your family manage
Anthem Life is here to help you
With -- Resource Advisor,
® Registered marks Blue Cross and Blue Shield Association.
Life and disability products are underwritten by Anthem Life Insurance Company.
Anthem Life and the Anthem Blue Cross and Blue Shield companies are
independent licensees of the Blue Cross and Blue Shield Association.
This product description is intended to be a brief outline of benefits available. It does not include all terms of
coverage offered by Anthem Life. Products may vary and may not be available in all states.
For more information,
visit our Web site at
anthem.com.
It all adds up to a strong,
stable approach to protecting our most
valuable asset — our customers.
Our size and stability allow us to
offer you quality coverage at
affordable group rates.
Our combined life companies form
the nation’s 12th largest group life carrier
with nearly six million life and
disability members.
You can feel confident
placing your trust in us.
About Anthem Life
AL-9038 (Rev. 3/06)
anthem.com
Wrap Your Arms Around
You and Your Family Can
Reliable Support Services
Resource Advisor
Beneficiaries dealing with the loss of an
employee with Life coverage qualify for up to
three visits with a licensed mental health
professional as well as up to three consultations
with a legal and/or financial professional. Each
consultation requires a separate concern. These
services are available for up to six months after
the qualifying event.
If you have disability coverage and become
disabled, Resource Advisor provides up to three
face-to-face sessions with a licensed mental
health professional during the six month period
following the onset of your disability.
Counseling and consultation services
in a time of need
In today’s fast-paced world, you may feel more
and more stress at home and at work. And, as
you know, stress in one environment can lead
to stress in another. Anthem Life Resource
Advisor is designed to improve your well-being
by helping you manage problems before they
become too overwhelming — emotionally and
financially.
Support for you and your family
— no cost, confidential
assistance.
much it costs?
without worrying about how
finding the support you need —
What could be better than
Security When You Need It Most
Resource Advisor offers you a consultation with
a legal or financial professional at no cost. You
can access legal or financial services for up to
three consultations. Each consultation requires
a separate concern. (Family members are not
eligible for this service.)
Personal assistance with legal and
financial matters
• online legal tools and library
• self-assessments
• online financial calculators and tools
• advice on handling difficult life events, like
losing a loved one
• tips on dealing with emotions
• parenting information and services
• consumer education and services
• child and elder care provider databases
Anthem Life and the Anthem Blue Cross and Blue Shield companies are independent licensees of the
Blue Cross and Blue Shield Association. ® Registered marks Blue Cross and Blue Shield Association.
www.resourceadvisor.Anthem.com
Call (888) 209-7840 or visit
For toll-free, 24/7 telephone consultation
and referral services:
Anthem Life Resource Advisor
For easy access to Resource Advisor, cut out and carry the wallet card below.
additional information.
if you have questions or need
See your human resources contact
Certain limitations and exclusions apply to this
service. All benefits end at retirement.
Eligibility, limitations and exclusions
Remember that you can reach Anthem Life Resource
Advisor toll free from anywhere in the United States.
For free, confidential help 24 hours a day, seven days
a week, simply call (888) 209-7840 or visit
www.resourceadvisor.Anthem.com.
With Anthem Life Resource Advisor, you
and your family members will also have free and
confidential access to extensive work/life
resources, including:
• community resources
Accessing Resource Advisor
Helping you find balance
• Resource Advisor web site resources at
www.resourceadvisor.Anthem.com
• toll-free, 24/7 telephone consultation and
referral services from anywhere in the
United States – (888) 209-7840
In addition, you and your family members
will appreciate ongoing access to convenient
support:
Staying connected
Life Insurance Coverage Checklist
How much coverage do I need?
If Employee Dies
If Spouse Dies
Annual Income ________ x Desired Number of Years
___________________
__________________
Mortgage Loan Balance
___________________
__________________
Auto Loan Balances
___________________
__________________
Children’s Educational Fund
___________________
__________________
Credit Card Balances
___________________
__________________
Other Loan Balances
___________________
__________________
Funeral Expenses
___________________
__________________
Emergency Fund
___________________
__________________
___________________
__________________
Employer Sponsored Group Life Insurance
___________________
___________________
Individual Insurance
___________________
___________________
___________________
___________________
___________________
___________________
MINUS (-) ___________________
___________________
___________________
___________________
Employee
___________________
___________________
Spouse
___________________
___________________
Children
___________________
___________________
Total Cash Needs
Current Life Insurance
Total Insurance In-force
Additional Insurance needs
Total Cash Needs
Total Insurance In-Force
Additional Life Insurance Necessary
Voluntary Group Life Insurance Monthly Cost
Total Monthly Cost
From No. 94604
$ _________________
(REV. 7/03)
Benefits2009
19
PAYMENT ACCOUNTS
HOW TO SAVE MONEY FOR CHILDCARE AND MEDICAL CARE
Many of us pay for childcare expenses out of our paychecks each month. We also use the money from our paychecks to pay medical
expenses that aren’t covered by our medical plan. Our paychecks have already been reduced by income taxes before we ever receive
them. That means that for every dollar we use to pay our medical and childcare expenses, we’ve had to earn even more to pay taxes.
The Payment Account program is a special benefit giving all eligible full-time employees the chance to pay those expenses without first
paying taxes.
How do the Payment Accounts work?
Basically, it’s set up much like a bank with checking accounts. You may deposit a certain amount of your pre-tax earnings through
payroll deduction in one or two separate accounts each pay period. The money that goes into the accounts can be your leftover Benefit
Allowance (if you have any), or your own money through payroll deductions. You get paid that money back when you have eligible
medical expenses and dependent care expenses. The money you put into the accounts lowers your taxable earnings, so you end up
paying fewer taxes.
Changes to the Payment Account:
Effective for the 2009 plan year, employees in the payment account can have expenses reimbursed that were incurred in 2008. It works
like this. An employee who has a 2008 payment account can submit health or dependent care expenses incurred from 1/1/09 through
3/15/09 (grace period). These will be paid from their 2008 account balance. Once their 2008 account balances reaches zero, any expenses
incurred during the 2009 grace period that were not already paid can then be paid from their 2009 account (if they have one).
What expenses may I put through the Medical Payment Account?
Many health care expenses are eligible for payment through the MPA. You may be reimbursed for expenses such as:
• the deductibles and co-payments you are required to pay under the medical plan you choose.
• routine physical exams.
• part of bills not paid by the plan for eye examinations, contact lenses, frames and lenses.
• orthodontia (braces).
• dental expenses the plan does not pay.
There are many more expenses that are eligible for reimbursement under the Medical Payment Account. You’ll find a list of eligible
expenses on a separate flyer in your enrollment package. Everything on that list is an eligible expense as long as it is not paid by your
medical plan, some other medical plan or taken as a deduction on your tax return. Certain expenses require a letter of medical need from
your healthcare provider.
How do I decide how much to deposit?
The first step in calculating your deposits to the Payment Accounts is to estimate what your expenses will be for the coming year.
Once your likely medical and dental expenses are identified, add them together to come up with a total. That total is the amount you may
want to consider depositing in the Medical Payment Account. The total of your likely dependent care expenses is the amount you may
want to consider depositing in the Dependent Care Payment Account.
Of course, the decision is yours. You can deposit as much or as little as you choose (within plan limits) in each Payment Account. But
remember, by using the Payment Accounts, you can pay the expenses you’ve listed with tax-free dollars.
The intention of the Payment Accounts is to result in a tax savings for you. Contact your tax advisor to help determine whether a
Payment Account is beneficial to you.
How do I get the money out of the Accounts?
It’s pretty easy. Your tax-free deposits go into the Payment Accounts every paycheck. Then, when you have an eligible expense, you
will submit a claim, including an Explanation of Benefits form for medical expenses or a receipt for dependent care expenses. The Plan
Administrator will then send you a check for that amount (up to the maximum you deposit for the year for medical expenses). Cancelled
checks are no longer eligible as a receipt. Claims incurred after you have terminated coverage in these plans cannot be reimbursed.
Are there any special rules?
The Federal government has a rule about money left in your account at the end of the year. Because you get to put the money in tax-free,
you lose any money that is left after you submit all of your claims for the year. That means you can’t get the money back.
It is very important that you figure out how much money to put into each Payment Account. Once you’ve established a certain amount
of deduction, it can’t be changed except as qualified status changes allow.
20
Benefits2009
DEPENDENT CARE PAYMENT ACCOUNT
Eligible dependent care expenses include those which allow you (and your spouse if you are married) to work, look for work or attend school
full‑time. Your Payment Account pays child care expenses for children under 13 years old. Day-care services can be provided in or out of your
home, as long as the sitter is not a dependent you claim on your income tax.
Your Payment Account may also be used to pay for the care of an incapacitated adult who is dependent on you for 50% of his/her support and
who needs care while you work. Nursing home expenses do NOT qualify.
To decide what your Dependent Care Payment Account deposits should be, you will need to estimate your dependent care costs for the next Plan
Year. You will also want to verify that your expenses and dependents meet the eligibility requirements for the Account.
Dependent care expenses are usually easy to predict. You usually know ahead of time what your expenses are going to be. Looking at what you
have spent this year in dependent care expenses may be helpful to you in determining your expenses for the next Plan Year. Be sure to consider
only the cost of services actually delivered during the year, regardless of when you’ll get the bill.
In deciding how much you want to deposit in the Dependent Care Payment Account, you should also consider whether the Federal tax credit for
eligible dependent care expenses offers you even more savings than our Payment Account. You may want to contact a tax advisor or financial
advisor to help you make that decision. Generally if your earnings are more than $24,000 a year, the Dependent Care Payment Account probably
offers more advantages for you than the Federal tax credit.
You cannot take the tax credit for the same expenses that you have submitted to the Dependent Care Payment Account. However, you may use
both the tax credit and the Payment Account for different dependent care expenses. If you are reimbursed from the Dependent Care Payment
Account for more expenses than the tax credit allows, you may not use the tax credit at all.
There are some rules about how much you can deposit in the Dependent Care Payment Account. The minimum you can deposit is $5.00 each
pay period. Most employees can deposit up to $192.00 each pay period in a whole dollar amount. However, there are two circumstances under
which the maximum you may deposit is less than $192.00
ŠŠ
ŠŠ
If you are married and file a single tax return, the most you can deposit is $96.00 each pay period.
If you and your spouse both work (or attend school full‑time) and one of you makes less than $5,000 a year, there is a different
maximum. That maximum each pay period is the lower annual salary divided by 26. A full‑time student is considered to make $2,400
a year with one child or $4,800 a year with more than one child.
What expenses can I pay through the Dependent Care Payment Account?
Most of us have childcare expenses because we work and our spouses also work or attend school full-time. Single parents also may have childcare expenses so they can work. These are exactly the kind of expenses the Dependent Care Payment Account is meant for. Some common
expenses include:
l DAYCARE l AFTER-SCHOOL CARE
Other dependent care expenses may be eligible for payment under the Account, too (for example, nursery school tuition). All expenses must
meet the following rules to be eligible:
ŠŠ
ŠŠ
ŠŠ
The services may be provided inside or outside your home, but not by one of your other dependents, like an older child.
The services must be so you and your spouse can work, look for work or attend school full‑time.
If your child goes to a daycare facility that cares for six or more children at the same time, it must be a licensed daycare center.
You can be reimbursed for these kinds of expenses if they are for care of your dependent children under age 13. See IRS code for details.
The expenses can also be for dependents who are over age 13 (such as an elderly parent) as long as the dependent meets two requirements. First,
that dependent must be physically or mentally unable to care for himself or herself. And, second, he or she must be claimed as your dependent
for income tax purposes.
How can I save on taxes?
Let’s look at an example of how you can save on Federal income taxes. Keep in mind that the same idea works with state income taxes. Let’s say Sue
and Bob both expect to have $800 in childcare expenses for the year. They are both in the 15 % Federal income tax bracket. Sue decides to set aside
$800 a year in the Dependent Care Payment Account to cover those expenses. Bob decides not to put any money in the Dependent Care Payment
Account. He’s going to continue paying his Day Care Provider from the money in his paycheck, just as he always has.
Without the Payment Account
Bob has to earn $941 ($800 for the childcare expenses and $141 for Federal income taxes) to pay his Day Care Provider. He pays the $141 in
taxes before he ever sees the $800 in his paycheck.
With the Payment Account
Sue has to earn only $800 to pay $800 in expenses. Because Sue pays her $800 in expenses through the Dependent Care Payment Account, she
saves the $141 in Federal income taxes.
The tax savings for the Medical Payment Account work in the same way.
Benefits2009
21
MEDICAL PAYMENT ACCOUNT
You may deposit between $5 and $80 each pay period into the medical payment account.
Consider the medical and dental expenses you expect to have in the coming year. To be eligible for reimbursement, the
expenses must be for services you actually receive in the Plan Year, regardless of when you get or pay the bill.
Be careful to deposit an amount only equal to your expenses that will not be covered by the medical plan you’ve
chosen or by any other medical plan. For example. let’s assume, you expect to have $1,500 next year in expenses for
your child’s braces. If you choose a dental plan that would pay $750 during the year for those expenses, you should only
list the remaining $750 that you would have to pay. Through the Medical Payment Account, you could pay the $750 with
tax-free dollars and save money.
Be sure to check the list of expenses that are considered eligible (reverse side) and non-eligible (below) on this flyer.
Examples of non-Eligible Health Care Expenses
(Specifically Disallowed by the IRS or Courts)
yy Payment to domestic help, companion, babysitter, etc, who
primarily render services of a non-medical nature (may be
allowed under Dependent Care Payment Account)
yy Nursemaids or practical nurses who render general care for
healthy infants (allowed under Dependent Care payment
Account)
yy Chauffeur services
yy Tattoos and ear-piercing
yy Religious cult de-programming
yy Expenses of divorce where doctor or psychiatrist recommend
divorce
yy Fees for exercise, athletic, or health club membership where
there is no specific health reason for needing the membership
yy Physical treatments unrelated to a specific health problem (e.g.
massage for general well-being)
yy Payments for Church of Scientology auditing and processing
yy Marriage counseling provided by clergyman
yy Weight reduction programs for general well-being
yy Any illegal treatment
yy Payment for which the childcare credit is taken under Section
44A
yy Psychoanalysis undertaken to satisfy curriculum requirements
of student
yy Cost of toiletries, cosmetics, and sundry items (e.g., soap,
toothbrushes)
yy Cost of illegal drugs or non-prescription drugs
yy Cost of special foods taken as a substitute for regular diet,
where the special diet is not medically necessary or taxpayer
cannot justify cost is excess of cost of a normal diet
yy Teeth Bleaching
yy Dermatologist fees (for cosmetic procedures)
yy Cosmetic Procedures
22
Benefits2009
yy Maternity clothes
yy Premiums for provision of indemnification for hospital,
surgical and other medical expenses under other health
coverage
yy Diaper services
yy Wigs, where not medically necessary for mental health
yy Distilled water purchased to avoid drinking fluoridated city
water supply
yy Installation of power steering in automobile
yy Pajamas purchased to wear in hospital
yy Mobile telephone used for personal calls as well as calls to doctor
yy Vacuum cleaner purchased by individual with dust allergy
yy Mechanical exercise device not specifically prescribed by
doctor
yy Insurance against loss of income, loss of life, limb or sight
yy Any portion of premium charge which represents a tax
yy Union dues for sick benefits for member
yy Auto insurance providing medical coverage for all persons
injured in or by the taxpayer’s automobile, where amount
allocable to taxpayer and dependent is not stated separately
yy Contributions to state disability fund
yy Dancing and swimming lessons where doctor recommends for
general well-being
yy Vacations or trips taken for general well-being, even if made
on doctor’s advice
yy Premiums for reimbursement of cost of prescription drugs
under other health coverage
yy Premiums voluntarily paid for Medical coverage where a
taxpayer would not otherwise be entitled to such coverage
yy Vitamins, Nutritional Supplements or Dietary Aids
MEDICAL PAYMENT ACCOUNT
Examples of Eligible Health Care Expenses
(Specifically Approved by the IRS or Courts)
yy Deductible or Coinsurance for medical and dental plans
yy Physician’s fees
yy Obstetrical expenses
yy X-Ray treatments
yy Hospital services
yy Long-distance telephone tolls for psychiatric counseling
conducted over the phone
yy Fee to use swimming pool for exercises prescribed by physician to alleviate specific medical condition such as rheumatoid
arthritis
yy Chiropractor for services within scope of license
yy Prescription drugs or insulin
yy Artificial teeth or limbs
yy Nursing services for care of specific medical ailment
yy Cost of Braille books and magazines in excess of cost of
regular editions
yy Cost of a nurse’s room and board if paid by the taxpayers where
nurse’s services qualify
yy Eyeglasses and/or Contact Lenses
yy Surgical or diagnostic services
yy Seeing-eye dog (cost of buying, training, and maintaining)
yy X-Rays
yy Hearing-trained cat or other animal to assist deaf person (cost
of buying, training, and maintaining)
yy Services of chiropractors and osteopaths
yy Household visual alert system for deaf person
yy Services of psychotherapists, psychiatrists, and psychologists
yy Excess cost of specifically equipping automobile for handicapped person over cost of ordinary automobile; device for
lifting handicapped person into automobile
yy Psychiatric therapy for sexual problems
yy Anesthesiologist’s fees
yy Dermatologist’s fees (office visits)
yy Optometrist’s or ophthalmologist’s fees
yy Wheelchair or autoette
yy Crutches
yy Gynecologist’s fees
yy Wigs (where necessary to mental health of individual who
loses hair because of disease)
yy Laboratory fees
yy Birth control drugs (prescribed)
yy Vaccinations
yy Hearing aids
yy Acupuncture
yy Cost of special diet, but only if taxpayer can show that it is medically necessary and only to the extent that cost exceeds
that of a normal diet
yy Treatment for alcoholism and drug dependency
yy Sterilization
yy Legal abortion
yy Special mattress and plywood boards prescribed to alleviate
arthritis
yy Physical therapy
yy Cost of fluoridation of home water supply advised by dentist
yy Expenses of services connected with donating an organ
yy Oxygen equipment and oxygen used to alleviate heart
condition
yy Cost of note-taker for a deaf child in school
yy Legal fees directly related to mental commitment of mentally
ill person
yy Cost of computer storage of medical records
yy Smoking Cessation Programs - by Prescription only
yy Prescription drugs to alleviate nicotine withdrawal
yy Excess cost of orthopedic shoes over cost of ordinary shoes
yy Braces, orthodontic devices
yy Special devices, such as tape recorder and typewriter, for blind
person
yy Insurance for replacement of lost or damaged contact lenses
yy Over the counter medicines and drugs (antacids, allergy, pain
and cold medications)
yy Tuition fees to a special school for a child who has severe
learning disabilities caused by mental or physical handicap, if
attendance was recommended by a doctor
yy Parking garage fees while on doctor’s office visit
yy Radial Keratotomy
yy Over the counter contact lens cleaners and solutions
yy exercise/health club membership if doctor’s prescription
accompanies it
Benefits2009
23
Northwest Group Services, Inc.
Over-the-Counter Drug List
Eligible/Ineligible
Thisȱinformationȱrepresentsȱaȱcommonlyȱunderstoodȱinterpretationȱofȱtheȱregulations,ȱ
andȱaddressesȱtheȱfullȱrangeȱofȱexpensesȱtheȱIRSȱconsidersȱeligibleȱforȱreimbursement.ȱ
Yourȱcompanyȱplanȱmayȱbeȱmoreȱrestrictive.ȱ
ELIGIBLEȱ
ȱȱȱȱTYPEȱOFȱEXPENSEȱ
AllergyȱMedicine:ȱ
Pillsȱ
Dropsȱ
Spraysȱ
Asthmaȱ
ColdȱRelief:ȱ
Pills,ȱSprays,ȱLozenges,ȱ
Rubsȱ
ColdȱSoreȱReliefȱ
DiabeticȱTreatmentȱ
EyeȱandȱEarȱTreatment:ȱ
Dropsȱ
FootȱTreatments:ȱ
AthletesȱFoot,ȱAntiȱFungalȱ
Solutions,ȱBunions/ȱSpursȱ
HemorrhoidȱReliefȱ
JockȱItchȱ
LiceȱTreatmentȱ
PainȱRelievers:ȱ
Arthritis,ȱBackȱPainȱ
Headaches,ȱMenstrual,ȱ
UrinaryȱPainȱReliefȱ
SmokingȱCessation:ȱ
Devices,ȱPatches,ȱ
Gumȱ&ȱLozengesȱ
StomachȱRemedies:ȱ
Antacid,ȱAcidȱReducers,ȱ
AntiȱDiarrhea,ȱLaxatives,ȱ
GasȱRelief,ȱLactoseȱIntolerantȱ
Pills,ȱMotionȱSicknessȱPillsȱ
Actifed,ȱAdvil,ȱAfrin,ȱAlavert,ȱBenadryl,CholorȬ
Trimeton,ȱClaritin,ȱTavist,ȱTylenol,ȱSudafed,ȱ
Vicks,ȱDiphedryl,ȱStoreȱBrandsȱ
Bronkaid,ȱInhalers,ȱInhalerȱRefills,ȱStoreȱBrandsȱ
Actifed,ȱDimetapp,ȱDrixoral,ȱRobitussin,ȱ
Sudafed,ȱTriminic,ȱAdvil,ȱComtrex,ȱTheraflu,ȱ
TylenolȱFlu,ȱChloraseptic,ȱStoreȱBrandsȱ
Novitra,ȱAbreva,ȱStoreȱBrandsȱ
Insulin,ȱGlucoseȱtabletsȱ
RULINGȱ
Eligibleȱ
Eligibleȱ
Eligibleȱ
Eligibleȱ
Eligibleȱ
Visine,ȱOcuȱHist,ȱSwimȬear,ȱStoreȱBrandsȱ
Eligibleȱ
Micatin,ȱFungiȱCare,ȱLotrimin,ȱStoreȱBrandsȱ
Eligibleȱ
Hemroid,ȱAnusol,ȱPreparationȱH,ȱNupercainal,ȱ
Tucks,ȱStoreȱBrandsȱ
Tinactin,ȱMicatin,ȱLotriminȱAF,ȱLamisilȱAT,ȱ
Cruex,ȱStoreȱBrandsȱ
LiceFree,ȱRid,ȱPronto,ȱStoreȱBrandsȱ
Eligibleȱ
Eligibleȱ
Eligibleȱ
Aspirin,ȱIbuprofen,ȱAdvil,ȱMidol,ȱMotrin,ȱBayer,ȱ
Doan’s,ȱAleve,ȱExcedrin,ȱPamprin,ȱPremsynȱPMS,ȱ Eligibleȱ
Azo,ȱProdium,ȱTylenol,ȱStoreȱBrandsȱ
Endit,ȱLite’nȱup,ȱSmokeȱAway,ȱVenturi,ȱ
Nicorette,ȱNicoDermȱCQ,ȱ
Nicotrol,ȱStoreȱBrandsȱ
AxidȱAR,ȱPepcid,ȱPrilosec,ȱTagamet,ȱZantac,ȱ
Tums,ȱRolaids,ȱAlkaȬSeltzer,ȱMaalox,ȱMylanta,ȱ
PeptoȬBismol,ȱPhillips,ȱGaviscon,ȱGasȬX,ȱStoreȱ
Brands,ȱLactaidȱpills,ȱStoreȱBrands,ȱBonine,ȱ
Dramamine,ȱEmetrolȱ
Eligibleȱ
Eligibleȱ
Toothacheȱ
Orajel,ȱZilactin,ȱRedȱCross,ȱOrabase,ȱDenȱTek,ȱ
Dents,ȱStoreȱBrandsȱ
Eligibleȱ
TopicalȱProducts:ȱ
Ointments,ȱCreamsȱ
Antiseptics,ȱSpraysȱ
NOTȱCosmeticsȱ
BenGay,ȱArthȬRX,ȱDr.Holt’s,ȱFlexall,ȱIcyHot,ȱ
Jointflex,ȱJointȬRitis,ȱPR5,ȱMentholatum,ȱStopain,ȱ
HydrogenȱPeroxide,ȱBactine,ȱNeosporin,ȱ
Polysporin,ȱIodine,ȱDestinȱDiaperȱRash,ȱBalmax,ȱ
BenadrylȱAntiȬitchȱcream,ȱDermarest,ȱItchȬX,ȱ
StoreȱBrandsȱ
CompoundȱW,ȱDr.Scholl’s,ȱPedifix,ȱWartȬoff,ȱ
StoreȱBrandsȱ
Monistat,ȱVagistateȱ3,ȱVaginex,ȱMycelex3ȱ
Eligibleȱ
WartȱTreatmentȱ
YeastȱInfectionȱ
24
EXAMPLESȱ
Benefits2009
Eligibleȱ
Eligibleȱ
INELIGIBLEȱ
Cosmetics:ȱ
FaceȱCreams,ȱLotions,ȱMakeȬupȱ
NailȱCare,ȱTeethȱWhiteningȱ
ȱ
ȱ
Olay,Aveeno,ȱJergens,ȱSt.Ives,ȱL’Oreal,ȱ
Neutrogena,ȱAlmay,ȱCoverGirl,ȱMaybelline,ȱ
Cutex,ȱRevlon,ȱSallyȱHansen,ȱStoreȱBrandsȱ
ȱ
ȱ
ȱ
Ineligibleȱ
IllegallyȱProcuredȱ
Marijuanaȱ
SunȱBlockȱ
Coppertone,ȱHawaiianȱTropics,ȱBullȱFrogȱ
Ineligibleȱ
Ineligibleȱ
Toiletries:ȱ
Toothpaste,ȱMouthwash,ȱȱ
Shampoo,ȱConditionerȱ
Soap,ȱDeodorant/Antiperspirantȱ
ShavingȱCream,ȱPowderȱ
Colgate,ȱCrest,ȱAquafresh,ȱSensodyne,ȱScope,ȱ
Listerine,ȱDial,ȱCaress,ȱCoast,ȱDove,ȱL’Oreal,ȱ
Pantene,ȱThermasilk,ȱDenorex,ȱHeadȱ&ȱ
Shoulders,ȱBabyȱPowder,ȱShowerȱtoȱShower,ȱ
Gillette,ȱBarbasol,ȱSkintimate,ȱArrid,ȱBan,ȱDegree,ȱ
Mitchumȱ
Ineligibleȱ
ȱ
AceneȱMedicine:ȱ
Soapsȱ
Creamsȱ
Pillsȱ
ȱ
Stridex,ȱCleanȱandȱClear,ȱNeutrogena,ȱLomaLux,ȱ
Clearasil,ȱStoreȱBrandsȱ
Dietaryȱsupplements,ȱȱ
includingȱherbal,ȱ
ȱhomeopathicȱorȱȱ
naturopathicȱremedies,ȱȱ
minerals,ȱnutrients,ȱ
vitamins,ȱaminoȱacidsȱ
hormones,ȱenzymesȱ
HairȱGrowthȱTreatmentȱ
Ensure,ȱAcidophilus,ȱCoenzyme,ȱQȬ10,ȱDHEA,ȱ
FishȱOils,ȱGlucosamineȱandȱChondroitin,ȱLȬ
Carnitine,ȱLecithin,ȱMelatonin,ȱMSM,ȱOmegaȬ3,ȱ
SAMȬe,ȱSharkȱCartilage,ȱEchinacea,ȱFlaxȱSeedȱoil,ȱ
Garlic,ȱGinkgoȱBiloba,ȱHerbs,ȱLutein,ȱMenopauseȱ
Supplements,ȱCalcium,ȱChromiumȱPicolinate,ȱ
Iron,ȱLysine,ȱMagnesium,ȱPotassium,ȱSelenium,ȱ
Zinc,ȱA’s,ȱB’s,ȱD’s,ȱE’s,ȱAntioxidants,ȱC’s,ȱ
Children’s,ȱE’s,ȱFolicȱAcid,ȱMultiȬVitamins,ȱ
Niacin,ȱPrenatalȱorȱSeniorȱVitaminsȱ
NuȱHair,ȱRogaine,ȱStoreȱBrandsȱ
ȱ
Ineligibleȱasȱaȱcosmeticȱ
procedureȱ
Toȱbecomeȱeligible.ȱClaimȱ
mustȱbeȱsupportedȱbyȱaȱ
doctorȱ
Ineligibleȱasȱanȱexpenseȱ
forȱgeneralȱhealth.ȱ
ȱ
ȱ
Toȱbecomeȱeligible,ȱclaimȱ
mustȱbeȱsupportedȱbyȱaȱ
doctor’sȱstatementȱ
SleepingȱAidsȱ
Alluna,ȱNatrol,ȱNytol,ȱUnisom,ȱStoreȱBrandsȱ
WeightȬLossȱ
Puralin,ȱCidermax,ȱPatentlean,ȱDexatrim,ȱStoreȱ
Brandsȱ
Ineligibleȱasȱaȱcosmeticȱ
procedureȱ
Toȱbecomeȱeligible,ȱclaimȱ
mustȱbeȱsupportedȱbyȱaȱ
doctor’sȱstatementȱ
ȱ
Ineligibleȱasȱanȱexpenseȱ
forȱtheȱgeneralȱhealthȱ
ȱ
Toȱbecomeȱeligible,ȱclaimȱ
mustȱbeȱsupportedȱbyȱaȱ
doctor’sȱstatementȱ
Ineligibleȱasȱaȱcosmeticȱ
procedureȱ
ȱ
Toȱbecomeȱeligible,ȱclaimȱ
mustȱbeȱsupportedȱbyȱaȱ
doctor’sȱstatementȱ
ȱ
Thisȱisȱnotȱanȱexhaustiveȱlistȱandȱisȱintendedȱtoȱgiveȱexamplesȱofȱsomeȱofȱtheȱmostȱcommonȱcategoriesȱandȱ
brandȱnamesȱoverȬȱtheȬcounterȱdrugs.ȱThisȱinformationȱisȱnotȱintendedȱtoȱprovideȱlegalȱorȱtaxȱadvice.ȱYouȱ
shouldȱconsultȱyourȱlegalȱandȱtaxȱadvisorsȱtoȱensureȱcomplianceȱwithȱapplicableȱlaw.ȱȱȱȱȱȱȱȱȱȱ
ȱ
ȱ
NorthwestȱGroupȱServices,ȱInc.ȱ
1910ȱIndianwoodȱCircleȱ
Maumee,ȱOHȱ43537ȱ
[email protected]ȱ–Phone:ȱȱ419Ȭ887Ȭ1215ȱ–ȱFax:ȱȱ419Ȭ887Ȭ1214ȱ
TollȱFree:ȱȱ888Ȭ808Ȭ3008ȱ
Benefits2009
25
United HealthCare Insurance Company
ASO Choice Plus 100 / 70 Plan Non-AFSCME
Cuyahoga County Board of Commissioners
ChoicePlusplangivesyouthefreedomto see any Physician or other health care
professionalfromtheNetwork,includingspecialists,withoutareferral.Withthis
plan, you will receive the highest level of benefits when you seek care from a
network physician, facility or other health care professional. In addition, you do
nothavetoworryaboutanyclaimformsorbills.
You also may choose to seek care outside the Network, without a referral.
However, you should know that care received from a non-network physician,
facility or other health care professional means a higher deductible and
Copayment.Inaddition,ifyou choose to seek care outsidetheNetwork,yourplan
only pays a portion of those charges and it is your responsibility to pay the
remainder.Thisamountyouarerequiredtopay,whichcouldbesignificant,does
not apply to the Out-of-Pocket Maximum. We recommend that you ask the nonnetworkphysicianorhealthcareprofessional about their billed charges before you
receive care.
Some of the Important Benefits of Your Plan:
YouhaveaccesstoaNetworkofphysicians,
facilities and other healthcareprofessionals,
includingspecialists,withoutdesignatinga
PrimaryPhysicianorobtainingareferral.
Benefits are available for office visits and
hospitalcare,aswellasinpatientand
outpatientsurgery.
SM
Care Coordination services are available
tohelpidentifyandpreventdelaysincare
forthosewhomightneedspecializedhelp.
ASXGMCCB02MOD
26
Benefits2009
Emergenciesarecoveredanywhereinthe
world.
Papsmearsarecovered.
Prenatalcareiscovered.
Routinecheck-upsarecovered.
Childhoodimmunizationsarecovered.
Mammogramsarecovered.
Vision and hearing screeningsarecovered.
Choice Plus Benefits Summary: Cuyahoga County Board of
Commissioners
TypesofCoverage
Member/PatientResponsibility
This Benefit Summary is intended only to highlight
Annual Deductible: Noin-networkdeductible
yourBenefitsandshouldnotbereliedupontofully
determinecoverage.Thisbenefitplanmaynotcoverall
ofyourhealthcareexpenses.More complete
descriptions of Benefits and the terms under which
Out-of-Pocket Maximum: NoOut-of-PocketMaximum
they are provided are contained in the Summary
Plan Description that you will receive upon enrolling
in the Plan.
Member/PatientResponsibility
Annual Deductible: $300perCoveredPersonper
calendaryear,nottoexceed$600forallCovered
Personsinafamily.
Maximum Plan Benefit: NoMaximumPlanBenefit.
IfthisBenefitSummaryconflictsinanywaywiththe
SummaryPlanDescriptionissuedtoyouremployer,the
SummaryPlanDescriptionshallprevail.
Maximum Plan Benefit: $1,000,000perCovered
Person.
Out-of-Pocket Maximum:$3,000perCovered
Personpercalendaryear,nottoexceed$6,000for
allCoveredPersonsinafamily.
TermsthatarecapitalizedintheBenefitSummaryare
definedintheSummaryPlanDescription.
WhereBenefitsaresubjecttoday,visitand/ordollar
limits,suchlimitsapplytothecombineduseof
Benefitswhetherin-Networkorout-of-Network,except
wheremandatedbystatelaw.
NetworkBenefitsarepayableforCoveredHealth
Servicesprovidedbyorunderthedirectionofyour
Networkphysician.
*PriorNotificationisrequiredforcertainservices.
1. Ambulance Services - Emergency only
GroundTransportation:NoCopayment
SameasNetworkBenefit
AirTransportation:NoCopayment
2. Dental Services - Accident only
NoCopayment
*Priornotificationisrequiredbeforefollow-uptreatment
begins.
3. Durable Medical Equipment
InNetworkandOutofNetworkcalendaryear
maximumscrossapply.
NoCopayment
4. Emergency Health Services
$75copay(WaiveifAdmitted)
NetworkBenefitsfordurablemedicalequipmentis
limitedto$1,500percalendaryear.
*SameasNetworkBenefit
*Priornotificationisrequiredbeforefollow-up
treatmentbegins.
*30%ofEligibleExpensesafterdeductiblelimited
to$500/person/year
SameasNetworkBenefit
*NotificationisrequiredifresultsinanInpatient
Stay.
5. Eye Examinations
Refractiveeyeexaminationsarelimitedtooneper
calendaryearfromaNetworkProvider.
$15co-payment.
*30%ofEligibleExpensesafterdeductible
6. Hearing Care Benefit
AudiometricTestingforbothNetworkandNon-Networkislimitedto$40perexamperyear
EyeExaminationsforrefractiveerrorsarenot
covered.
HearingAidsforbothNetworkandNon-Networkarelimitedto$400peryear
NoCopayment
7. Home Health Care
NetworkandNon-NetworkBenefitsarelimitedto
60visitsforskilledcareservicespercalendaryear.
*30%ofEligibleExpensesafterdeductible
NoCopayment
8. Hospice Care
NetworkandNon-NetworkBenefitsarelimitedto
360daysduringtheentireperiodoftimeaCovered
PersoniscoveredunderthePlan.
*30%ofEligibleExpensesafterdeductible
NoCopayment
*30%ofEligibleExpensesafterdeductible
9. Hospital - Inpatient Stay
-Unlimited.
10. Injections Received in a Physician’s Office
$15co-payment
NoCopaymentapplieswhenaPhysicianchargeisnot
assessed.
30%ofEligibleExpensesperinjectionafter
deductible
Benefits2009
27
Cuyahoga County Board of Commissioners: YOUR BENEFITS
TypesofCoverage
11. Maternity Services
Member/PatientResponsibility
Same as 8, 11, 12 and 13
NoCopaymentappliestoPhysicianofficevisitsfor
prenatalcareafterthefirstvisit.
12. Outpatient Surgery, Diagnostic and Therapeutic
Services
NoCopayment
OutpatientSurgery
OutpatientDiagnosticServices
Forlabandradiology/Xray:NoCopayment
Member/PatientResponsibility
Same as 8, 11, 12 and 13
*NotificationisrequiredifInpatientStayexceeds
48hoursfollowinganormalvaginaldeliveryor96
hoursfollowingacesareansectiondelivery.
30%ofEligibleExpensesafterdeductible
30%ofEligibleExpensesafterdeductible
Formammographytesting:NoCopayment
OutpatientDiagnostic/TherapeuticServices-CT
Scans,PetScans,MRIandNuclearMedicine
NoCopayment
30%ofEligibleExpensesafterdeductible
OutpatientTherapeuticTreatments
NoCopayment
30%ofEligibleExpensesafterdeductible
$15co-payment.
30%ofEligibleExpensesafterdeductible.
13. Physician’s Office Services
NoCopaymentforPreventiveServices
NoCopaymentforPreventiveServices
NoCopaymentapplieswhenaPhysicianchargeisnot
assessed.
14. Professional Fees for Surgical and Medical
Services
NoCopayment
*30%ofEligibleExpensesafterdeductible
15. Prosthetic Devices
NoCopayment
30%ofEligibleExpensesafterdeductible
16. Reconstructive Procedures
Same as 8, 11, 12, 13 and 14
*Same as 8, 11, 12, 13 and 14
$15copayment
*30%ofEligibleExpensesafterdeductible
18. Skilled Nursing Facility/Inpatient Rehabilitation NoCopayment
Facility Services
NetworkBenefitsarelimitedto100daysper
calendaryear.
*30%ofEligibleExpensesafterdeductible
17. Rehabilitation Services -Outpatient Therapy
NetworkandNon-NetworkBenefitsarelimitedas
follows:20visitsofphysicaltherapy;20visitsof
occupationaltherapy;20visitsofspeechtherapy;
20visitsofpulmonaryrehabilitation;and36visits
ofcardiacrehabilitationpercalendaryear.
19. Transplantation Services
*NoCopayment
–requirespre-authorization
*30%ofEligibleExpensesafterdeductible
Benefitsarelimitedto$30,000pertransplant.
20. Urgent Care Center Services
$15co-payment.
*30%ofEligibleExpensesafterdeductible
$15co-payment.
30%ofEligibleExpensesafterdeductibleupto
30daysperyear(combinedmentalhealthand
substanceabuse).
Additional Benefits
Mental Health and Substance Abuse Services –
Outpatient
MustreceivepriorauthorizationthroughtheMental
Health/SubstanceAbuseDesignee.NetworkBenefits
arelimitedto30visitspercalendaryear.
Upto30visitsperyear(combinedmentalhealthand
substanceabuse)withCaseManagementreferral.
In and Out of Network visit limits cross apply
Mental Health and Substance Abuse Services –
Inpatient and Intermediate
MustreceivepriorauthorizationthroughtheMental
Health/SubstanceAbuseDesignee.NetworkandNonNetworkBenefitsarelimitedto30dayspercalendar
year.
In and Out of Network days limits cross apply
28
Benefits2009
NoCopayment
30daysperyear(combinedmentalhealthandsubstance
abuse)withCaseManagementreferral.
30%ofEligibleExpensesafterdeductibleupto30
daysperyear(combinedmentalhealthand
substanceabuse).
Cuyahoga County Board of Commissioners: YOUR BENEFITS
TypesofCoverage
Member/PatientResponsibility
$15copayment
Spinal Treatment
Benefits include diagnosis and related services and are
limitedtoonevisitandtreatmentperday.Networkand
Non-NetworkBenefitsarelimitedto24visitsper
calendaryear.
AudiometricTesting HearingAid
Member/PatientResponsibility
30%ofEligibleExpensesafterdeductible
Maximum$40PerExamMaximum$40PerExam
Maximum$400BenefitMaximum$400Benefit
Benefits2009
29
Exclusions
ExceptasmaybespecificallyprovidedinSection1oftheSummaryPlanDescription(SPD)or
throughaRidertothePlan,thefollowingarenotcovered:
A. Alternative Treatments
Acupressure;hypnotism;rolfing;massagetherapy;aromatherapy;acupuncture;andotherformsof
alternativetreatment.
B. Comfort or Convenience
Personalcomfortorconvenienceitemsorservicessuchastelevision;telephone;barberorbeauty
service;guestservice;supplies,equipmentandsimilarincidentalservicesandsuppliesforpersonal
comfortincludingairconditioners,airpurifiersandfilters,batteriesandbatterychargers,dehumidifiers
andhumidifiers;devicesorcomputerstoassistincommunicationandspeech.
C. Dental
ExceptasspecificallydescribedascoveredinSection1oftheSPDforservicestorepairasound
naturaltooththathasdocumentedaccident-relateddamage,dentalservicesareexcluded.Thereisno
coverageforservicesprovidedfortheprevention,diagnosis,andtreatmentoftheteeth,jawbonesor
gums(includingextraction,restoration,andreplacementofteeth,medicalorsurgicaltreatmentsof
dentalconditions,andservicestoimprovedentalclinicaloutcomes).Dentalimplantsanddentalbraces
areexcluded.Dentalx-rays,suppliesandappliancesandallassociatedexpensesarisingoutofsuch
dentalservices(includinghospitalizationsandanesthesia)areexcluded,exceptasmightotherwisebe
requiredfortransplantpreparation,initiationofimmunosuppressives,orthedirecttreatmentofacute
traumaticInjury,cancer,orcleftpalate.Treatmentforcongenitallymissing,malpositioned,orsuper
numeraryteethisexcluded,evenifpartofaCongenitalAnomaly.
D. Drugs
Prescriptiondrugproductsforoutpatientusethatarefilledbyaprescriptionorderorrefill.Selfinjectablemedications.Non-injectablemedicationsgiveninaPhysician’sofficeexceptasrequiredin
anEmergency.Over-the-counterdrugsandtreatments.
E. Experimental, Investigational or Unproven Services
Experimental,InvestigationalorUnprovenServicesareexcluded.ThefactthatanExperimental,
InvestigationalorUnprovenService,treatment,deviceorpharmacologicalregimenistheonly
availabletreatmentforaparticularconditionwillnotresultinBenefitsiftheprocedureisconsideredto
beExperimental,InvestigationalorUnproveninthetreatmentofthatparticularcondition.
F. Foot Care
Routinefootcare(includingthecuttingorremovalofcornsandcalluses);nailtrimming,cutting,or
debriding;hygienicandpreventivemaintenancefootcare;treatmentofflatfeetorsubluxationofthe
foot;shoeorthotics.
G. Medical Supplies and Appliances
Devicesusedspecificallyassafetyitemsortoaffectperformanceprimarilyinsports-relatedactivities.
Prescribedornon-prescribedmedicalsuppliesanddisposablesuppliesincludingbutnotlimitedto
elasticstockings,acebandages,gauzeanddressings,ostomysupplies, syringesanddiabeticteststrips.
Orthoticappliancesthatstraightenorre-shapeabodypart(includingcranialbandingandsometypesof
braces).TubingsandmasksarenotcoveredexceptwhenusedwithDurableMedicalEquipmentas
describedinSection1oftheSPD.
H. Mental Health/Substance Abuse
ServicesperformedinconnectionwithconditionsnotclassifiedinthecurrenteditionoftheDiagnostic
andStatisticalManualoftheAmericanPsychiatricAssociation.Servicesthatextendbeyondtheperiod
necessaryforshort-termevaluation,diagnosis,treatment,orcrisisintervention.MentalHealth
treatmentofinsomniaandothersleepdisorders,neurologicaldisorders,andotherdisorderswitha
knownphysicalbasis.
Treatmentofconductandimpulsecontroldisorders,personalitydisorders,paraphiliasandother
MentalIllnessesthatwillnotsubstantiallyimprovebeyondthecurrentleveloffunctioning,orthatare
notsubjecttofavorablemodificationormanagementaccordingtoprevailingnationalstandardsof
clinicalpractice,asreasonablydeterminedbytheMentalHealth/SubstanceAbuseDesignee.
ASO
Physicalconditioningprogramssuchasathletictraining,bodybuilding,exercise,fitness,flexibility,
anddiversionorgeneralmotivation.Weightlossprogramsformedicalandnon-medicalreasons.Wigs,
regardlessofthereasonforthehairloss.
K. Providers
Servicesperformedbyaproviderwithyoursamelegalresidenceorwhoisafamilymemberbybirth
ormarriage,includingspouse,brother,sister,parentorchild.Thisincludesanyservicetheprovider
mayperformonhimselforherself.Servicesprovidedatafree-standingorHospital-baseddiagnostic
facilitywithoutanorderwrittenbyaPhysicianorotherproviderasfurtherdescribedinSection2of
theSPD(thisexclusiondoesnotapplytomammographytesting).
L. Reproduction
Healthservicesandassociatedexpensesforinfertilitytreatments.
Surrogateparenting.Thereversalofvoluntarysterilization.
M. Services Provided under Another Plan
Healthservicesforwhichothercoverageisrequiredbyfederal,stateorlocallawtobepurchasedor
providedthroughotherarrangements,includingbutnotlimitedtocoveragerequiredbyworkers’
compensation,no-faultautomobileinsurance,orsimilarlegislation.Ifcoverageunderworkers’
compensationorsimilarlegislationisoptionalbecauseyoucouldelectit,orcouldhaveitelectedfor
you,BenefitswillnotbepaidforanyInjury,MentalIllnessorSicknessthatwouldhavebeencovered
underworkers’compensationorsimilarlegislationhadthatcoveragebeenelected.
Healthservicesfortreatmentofmilitaryservice-relateddisabilities,whenyouarelegallyentitledto
othercoverageandfacilitiesarereasonablyavailabletoyou.Healthserviceswhileonactivemilitary
duty.
N. Transplants
Healthservicesfororganortissuetransplantsareexcluded,exceptthosespecifiedascoveredin
Section1oftheSPD.Anysolidorgantransplantthatisperformedasatreatmentforcancer.
Healthservicesconnectedwiththeremovalofanorganortissuefromyouforpurposesofatransplant
toanotherperson.Healthservicesfortransplantsinvolvingmechanicaloranimalorgans.
AnymultipleorgantransplantnotlistedasaCoveredHealthServiceinSection1oftheSPD.
O. Travel
Healthservicesprovidedinaforeigncountry,unlessrequiredasEmergencyHealthServices.
Travelortransportationexpenses,eventhoughprescribedbyaPhysician.Sometravelexpensesrelated
tocoveredtransplantationservicesmaybereimbursedatourdiscretion.
P. Vision
Purchasecostofeyeglassesorcontactlenses.Fittingchargeforeyeglassesorcontactlenses.Eye
exercisetherapy.Surgerythatisintendedtoallowyoutoseebetterwithoutglassesorothervision
correctionincludingradialkeratotomy,laser,andotherrefractiveeyesurgery.
Q. Other Exclusions
HealthservicesandsuppliesthatdonotmeetthedefinitionofaCoveredHealthService-seedefinition
inSection10oftheSPD.
Physical,psychiatricorpsychologicalexaminations,testing,vaccinations,immunizationsortreatments
otherwisecoveredunderthePlan,whensuchservicesare:(1)requiredsolelyforpurposesofcareer,
education,sportsorcamp,travel,employment,insurance,marriageoradoption;(2)relatingtojudicial
oradministrativeproceedingsororders;(3)conductedforpurposesofmedicalresearch;or(4)to
obtainormaintainalicenseofanytype.
Healthservicesreceivedasaresultofwaroranyactofwar,whetherdeclaredorundeclaredorcaused
duringserviceinthearmedforcesofanycountry.
Health services received after the date your coverage under the Plan ends, including health services for
medicalconditionsarisingpriortothedateyourcoverageunderthePlanends.
Healthservicesforwhichyouhavenolegalresponsibilitytopay,orforwhichachargewouldnot
ordinarilybemadeintheabsenceofcoverageunderthePlan.
Servicesutilizingmethadonetreatmentasmaintenance,L.A.A.M.(1-Alpha-Acetyl-Methadol),
In the event that a Non-NetworkproviderwaivesCopaymentsand/ortheAnnualDeductiblefora
Cyclazocine,ortheirequivalents.Treatmentprovidedinconnectionwithortocomplywithinvoluntary particularhealthservice,noBenefitsareprovidedforthehealthserviceforwhichCopaymentsand/or
commitments,policedetentionsandothersimilararrangements,unlessauthorizedbytheMental
theAnnualDeductiblearewaived.
Health/SubstanceAbuseDesignee.Residentialtreatmentservices.Servicesorsuppliesthatinthe
ChargesinexcessofEligibleExpensesorinexcessofanyspecifiedlimitation.
reasonablejudgmentoftheMentalHealth/SubstanceAbuseDesigneearenot,forexample,consistent
Servicesfortheevaluationandtreatmentoftemporomandibularjointsyndrome(TMJ),whetherthe
withcertainnationalstandardsorprofessionalresearchfurtherdescribedinSection2oftheSPD.
servicesareconsideredtobemedicalordentalinnature.
I. Nutrition
Megavitaminandnutritionbasedtherapy;nutritionalcounselingforeitherindividualsorgroups.
Enteralfeedingsandothernutritionalandelectrolytesupplements,includinginfantformulaanddonor
breastmilk.
J. Physical Appearance
CosmeticProceduresincluding,butnotlimitedto,pharmacologicalregimens;nutritionalproceduresor
treatments;salabrasion,chemosurgeryandothersuchskinabrasionproceduresassociatedwiththe
removalofscars,tattoos,and/orwhichareperformedasatreatmentforacne.Replacementofan
existingbreastimplantisexcludediftheearlierbreastimplantwasaCosmeticProcedure.
(Replacementofanexistingbreastimplantisconsideredreconstructiveiftheinitialbreastimplant
followedmastectomy.)
UpperandlowerjawbonesurgeryexceptasrequiredfordirecttreatmentofacutetraumaticInjuryor
cancer.Orthognathicsurgery,jawalignment,andtreatmentforthetemporomandibularjoint,exceptas
atreatmentofobstructivesleepapnea.
Surgicaltreatmentandnon-surgicaltreatmentofobesity(includingmorbidobesity).
Growthhormonetherapy;sextransformationoperations;treatmentofbenigngynecomastia(abnormal
breastenlargementinmales);medicalandsurgicaltreatmentofexcessivesweating(hyperhidrosis);
medicalandsurgicaltreatmentforsnoring,exceptwhenprovidedaspartoftreatmentfordocumented
obstructivesleepapnea.Oralappliancesforsnoring.
Custodialcare;domiciliarycare;privatedutynursing;respitecare;restcures.
Psychosurgery.Speechtherapyexceptasrequiredfortreatmentofaspeechimpedimentorspeech
dysfunctionthatresultsfromInjury,strokeorCongenitalAnomaly.
ThissummaryofBenefitsisintendedonlytohighlightyourBenefitsandshouldnotbereliedupontofullydeterminecoverage.Thisplanmaynotcoverallyourhealthcare
expenses.PleaserefertotheSummaryPlanDescriptionforacompletelistingofservices,limitations,exclusionsandadescriptionofallthetermsandconditionsofcoverage.Ifthis
descriptionconflictsinanywaywiththeSummaryPlanDescription,theSummaryPlanDescriptionprevails.TermsthatarecapitalizedintheBenefitSummaryaredefinedinthe
SummaryPlanDescription.
ASXGMCCB02MODAS02I_BS_4ChcPls_KA_091503
30
Benefits2009
United HealthCare Insurance Company
ASO Choice Plus 90/70 Plan- Non AFSCME
ChoicePlusplangivesyouthefreedom to see any Physician or other
health care professional from our Network, including specialists,
withoutareferral.Withthisplan, youwillreceivethehighestlevelof
benefitswhenyouseekcarefromanetworkphysician,facilityorother
health care professional. In addition, you do not have to worry about
anyclaimformsorbills.
You also may choose to seek care outside the Network, without a
referral. However, you should know that care received from a non-
network physician, facility or other health care professional means a
higher deductible and Copayment. In addition, if you choose to seek
care outside the Network, your plan only pays a portion of those
chargesanditisyourresponsibility topaytheremainder.Thisamount
youarerequiredtopay,whichcould besignificant,doesnotapplyto
the Out-of-Pocket Maximum. We recommend that you ask the nonnetworkphysicianorhealthcareprofessional about their billed charges
before you receive care.
Some of the Important Benefits of Your Plan:
YouhaveaccesstoaNetworkofphysicians,
facilitiesandotherhealthcareprofessionals,
includingspecialists,withoutdesignatinga
PrimaryPhysicianorobtainingareferral.
Benefits are available for office visits and
hospitalcare,aswellasinpatientand
outpatientsurgery.
Care CoordinationSM services are available
to help identify and prevent delays in care
forthosewhomightneedspecializedhelp.
ASXGMXXX04
Emergenciesarecoveredanywhereinthe
world.
Papsmearsarecovered.
Prenatalcareiscovered.
Routinecheck-upsarecovered.
Childhoodimmunizationsarecovered.
Mammogramsarecovered.
Visionandhearingscreeningsarecovered.
Benefits2009
31
Choice Plus Benefits Summary
TypesofCoverageNetworkBenefits/CopaymentAmountsNon-NetworkBenefits/CopaymentAmounts
This Benefit Summary is intended only to highlight your
Benefitsandshouldnotbereliedupontofullydetermine
coverage.Thisbenefitplanmaynotcoverallofyour
healthcareexpenses. More complete descriptions of
Benefits and the terms under which they are provided
are contained in the Summary Plan Description that
you will receive upon enrolling in the Plan.
IfthisBenefitSummaryconflictsinanywaywiththe
SummaryPlanDescriptionissuedtoyouremployer,the
SummaryPlanDescriptionshallprevail.
TermsthatarecapitalizedintheBenefitSummaryare
definedintheSummaryPlanDescription.
WhereBenefitsaresubjecttoday,visitand/ordollar
limits,suchlimitsapplytothecombineduseofBenefits
whetherin-Networkorout-of-Network,exceptwhere
mandatedbystatelaw.
NetworkBenefitsarepayableforCoveredHealth
Servicesprovidedbyorunderthedirectionofyour
Networkphysician.
*PriorNotificationisrequiredforcertainservices.
Annual Deductible: $250 per Covered Person per
calendar year, not to exceed $500 for all Covered
Personsinafamily.
Annual Deductible:$500perCoveredPersonper
calendaryear,nottoexceed$1,000forallCovered
Personsinafamily.
Out-of-Pocket Maximum:$1,500perCoveredPerson,
percalendaryear,nottoexceed$3,000forallCovered
Personsinafamily.TheOut-of-PocketMaximumdoes
notincludetheAnnualDeductible.Copaymentsforsome
CoveredHealthServiceswillneverapplytotheOut-ofPocketMaximumasspecifiedinSection1oftheCOC.
Out-of-Pocket Maximum:$3,000perCoveredPerson,
percalendaryear,nottoexceed$6,000forallCovered
Personsinafamily.TheOut-of-PocketMaximumdoes
notincludetheAnnualDeductible.Copaymentsfor
someCoveredHealthServiceswillneverapplytothe
Out-of-PocketMaximumasspecifiedinSection1ofthe
COC.
1. Ambulance Services - Emergency only
GroundTransportation:10%ofEligibleExpenses
AirTransportation:10%ofEligibleExpenses
SameasNetworkBenefit
2. Dental Services - Accident only
*10%ofEligibleExpenses
*Priornotificationisrequiredbeforefollow-up
treatmentbegins.
*SameasNetworkBenefit
*Priornotificationisrequiredbeforefollow-up
treatmentbegins.
3. Durable Medical Equipment
NetworkandNon-NetworkBenefitsforDurable
MedicalEquipmentarelimitedto$1,500per
calendaryear.
10%ofEligibleExpenses*30%ofEligibleExpenses
*Priornotificationisrequiredwhenthecostismore
than$500.
4. Emergency Health Services
$75pervisit SameasNetworkBenefit
*NotificationisrequiredifresultsinanInpatientStay.
Maximum Policy Benefit:NoMaximumPolicy
Benefit.
Maximum Policy Benefit:$1,000,000perCovered
Person.
5. Eye Examinations
$15pervisit 30%ofEligibleExpenses
Refractiveeyeexaminationsarelimitedtooneevery
EyeExaminationsforrefractiveerrorsarenotcovered.
othercalendaryearfromaNetworkProvider.
6. Home Health Care
NetworkandNon-NetworkBenefitsarelimitedto
60visitsforskilledcareservicespercalendaryear.
10%ofEligibleExpenses*30%ofEligibleExpenses
7. Hospice Care
NetworkandNon-NetworkBenefitsarelimitedto
360daysduringtheentireperiodoftimeaCovered
PersoniscoveredunderthePlan.
10%ofEligibleExpenses*30%ofEligibleExpenses
8. Hospital - Inpatient Stay
10%ofEligibleExpenses*30%ofEligibleExpenses
9. Injections Received in a Physician's Office
$15pervisit 30%perinjection
10. Maternity Services
Same as 8, 11, 12 and 13
NoCopaymentappliestoPhysicianofficevisitsfor
prenatalcareafterthefirstvisit.
Same as 8, 11, 12 and 13
*Notification is required if Inpatient Stay exceeds 48
hoursfollowinganormalvaginaldeliveryor96hours
followingacesareansectiondelivery.
11. Outpatient Surgery, Diagnostic and Therapeutic
Services
OutpatientSurgery 10%ofEligibleExpenses30%ofEligibleExpenses
OutpatientDiagnosticServicesForlabandradiology/Xray:NoCopayment
Formammographytesting:NoCopayment
OutpatientDiagnostic/TherapeuticServices-CT
Scans,PetScans,MRIandNuclearMedicine
30%ofEligibleExpenses
10%ofEligibleExpenses30%ofEligibleExpenses
OutpatientTherapeuticTreatments10%ofEligibleExpenses30%ofEligibleExpenses
12. Physician's Office Services
32
13. Professional Fees for Surgical and Medical
Services
PreventiveMedicalCare-NoCopayment
SicknessorInjury-$15pervisit,exceptthatthe
CopaymentforaSpecialistPhysicianOfficevisitis$25
pervisit.
NoCopayment.
30%ofEligibleExpenses
10%ofEligibleExpenses30%ofEligibleExpenses
YOUR BENEFITS
TypesofCoverageNetworkBenefits/CopaymentAmountsNon-NetworkBenefits/CopaymentAmounts
14. Prosthetic Devices
NetworkandNon-NetworkBenefitsforprosthetic
devicesarelimitedto$2,500percalendaryear.
10%ofEligibleExpenses30%ofEligibleExpenses
15. Reconstructive Procedures
Same as 8, 11, 12, 13 and 14
16. Rehabilitation Services - Outpatient Therapy
NetworkandNon-NetworkBenefitsarelimitedas
follows:20visitsofphysicaltherapy;20visitsof
occupationaltherapy;20visitsofspeechtherapy;20
visitsofpulmonaryrehabilitation;and36visitsof
cardiacrehabilitationpercalendaryear.
$15pervisit 30%ofEligibleExpenses
17. Skilled Nursing Facility/Inpatient Rehabilitation
Facility Services
NetworkandNon-NetworkBenefitsarelimitedto
60dayspercalendaryear.
10%ofEligibleExpenses*30%ofEligibleExpenses
18. Transplantation Services
*10%ofEligibleExpenses*30%ofEligibleExpenses
Benefitsarelimitedto$30,000pertransplant.
19. Urgent Care Center Services
$35pervisit 30%ofEligibleExpenses
Additional Benefits
*Same as 8, 11, 12, 13 and 14
Mental Health and Substance Abuse Services Outpatient
MustreceivepriorauthorizationthroughtheMental
Health/SubstanceAbuseDesignee.NetworkandNon-
NetworkBenefitsarelimitedto20visitspercalendar
year.
$25perindividualvisit;$15pergroupvisit30%ofEligibleExpenses
Mental Health and Substance Abuse Services Inpatient and Intermediate
MustreceivepriorauthorizationthroughtheMental
Health/SubstanceAbuseDesignee.NetworkandNon-
NetworkBenefitsarelimitedto30dayspercalendar
year.
10%ofEligibleExpenses30%ofEligibleExpenses
Spinal Treatment
Benefits include diagnosis and related services and are
limitedtoonevisitandtreatmentperday.Networkand
Non-NetworkBenefitsarelimitedto24visitsper
calendaryear.
$25pervisit
Audiometric Testing
Maximum$40PerExamMaximum$40PerExam
Hearing Aid
Maximum$400Benefit
30%ofEligibleExpenses
Maximum$400Benefit
Benefits2009
33
Exclusions
United HealthCare Insurance Company
Exceptas maybespecificallyprovidedinSection1oftheSummaryPlan Description(SPD)or
throughaRidertothePlan,thefollowingarenotcovered:
followedmastectomy.)Physicalconditioningprogramssuchasathletictraining,bodybuilding,
exercise,fitness,flexibility,anddiversionorgeneralmotivation.Weightlossprogramsformedical
andnon-medicalreasons.Wigs,regardlessofthereason forthehairloss.
Acupressure;hypnotism;rolfing;massagetherapy;aromatherapy;acupuncture;andotherformsof
alternativetreatment.
K. Providers
A. Alternative Treatments
B. Comfort or Convenience
Personalcomfortorconvenienceitemsorservicessuchastelevision;telephone;barberorbeauty
service;guestservice;supplies,equipmentandsimilarincidentalservicesand suppliesforpersonal
comfort includingairconditioners,airpurifiersandfilters,batteriesandbatterychargers,
dehumidifiersandhumidifiers;devicesor computerstoassistincommunicationandspeech.
C. Dental
Exceptas specificallydescribedascoveredinSection1oftheSPDforservicestorepair a sound
naturaltooththathasdocumentedaccident-relateddamage,dentalservicesareexcluded.Thereisno
coverageforservicesprovidedfortheprevention,diagnosis,andtreatmentoftheteeth,jawbonesor
gums(includingextraction,restoration, andreplacementofteeth,medicalorsurgicaltreatmentsof
dentalconditions,andservicestoimprovedentalclinicaloutcomes).Dental implantsanddentalbraces
areexcluded.Dentalx-rays,suppliesandappliancesandallassociatedexpensesarisingoutofsuch
dentalservices(includinghospitalizationsandanesthesia)areexcluded,exceptasmightotherwisebe
requiredfortransplantpreparation,initiationofimmunosuppressives,orthedirecttreatmentofacute
traumaticInjury,cancer,orcleftpalate.Treatmentforcongenitallymissing,malpositioned,orsuper
numeraryteethisexcluded,evenifpartofaCongenital Anomaly.
D. Drugs
Servicesperformedbyaproviderwithyoursamelegalresidenceorwhoisafamilymemberbybirth
or marriage,includingspouse,brother,sister,parentorchild. Thisincludesanyservicetheprovider
mayperformonhimselforherself.Servicesprovidedatafree-standingorHospital-baseddiagnostic
facilitywithoutanorderwrittenby aPhysicianorotherproviderasfurther described in Section 2 of
theSPD(thisexclusiondoesnotapplytomammographytesting).
L. Reproduction
Health services and associatedexpenses for infertility treatments.Surrogateparenting. The reversal of
voluntarysterilization.
M. Services Provided under Another Plan
Healthservicesforwhichothercoverageisrequiredbyfederal,stateorlocallawtobepurchasedor
providedthroughotherarrangements,includingbutnotlimited tocoveragerequiredbyworkers’
compensation,no-faultautomobileinsurance,orsimilarlegislation.Ifcoverageunderworkers’
compensationorsimilarlegislationisoptionalbecauseyoucouldelectit,orcouldhaveitelectedfor
you, Benefitswillnotbe paidforany Injury, Mental Illness or Sicknessthatwouldhave been covered
under workers’compensationorsimilarlegislationhad that coveragebeenelected. Health services for
treatmentofmilitaryservice-relateddisabilities,whenyouarelegallyentitledtoothercoverageand
facilitiesarereasonablyavailabletoyou.Healthserviceswhileonactivemilitaryduty.
N. Transplants
Prescriptiondrugproductsforoutpatientusethatarefilledbyaprescriptionorderorrefill.Self-
Healthservicesfororganortissuetransplantsareexcluded,exceptthosespecified as covered in
injectablemedications. Non-injectable medications given in aPhysician’sofficeexcept as required in an Section1oftheSPD.Anysolidorgantransplantthatisperformedasatreatmentforcancer.Health
Emergency.Over-the-counterdrugsandtreatments.
servicesconnectedwiththeremovalofanorganortissuefromyouforpurposesofatransplantto
anotherperson.Healthservicesfortransplantsinvolvingmechanicaloranimalorgans.Anymultiple
E. Experimental, Investigational or Unproven Services
organtransplantnotlistedasaCoveredHealthServiceinSection1oftheSPD.
Experimental,InvestigationalorUnproven Servicesareexcluded.ThefactthatanExperimental,
InvestigationalorUnprovenService,treatment,deviceorpharmacologicalregimenistheonly
O. Travel
availabletreatmentforaparticularconditionwillnotresultinBenefitsiftheprocedureisconsideredto Healthservicesprovidedinaforeigncountry,unlessrequiredasEmergencyHealthServices.
beExperimental,InvestigationalorUnproveninthetreatmentofthatparticularcondition.
Travelortransportationexpenses,eventhoughprescribedbyaPhysician.Sometravelexpenses
relatedtocoveredtransplantationservicesmaybereimbursedatourdiscretion.
F. Foot Care
Routinefootcare(including thecutting orremoval of corns and calluses); nail trimming, cutting, or P. Vision and Hearing
debriding;hygienicandpreventivemaintenancefootcare;treatmentofflatfeetorsubluxationofthe Purchase cost of eye glasses, contactlenses,orhearingaids.Fittingcharge for hearing aids, eye
foot;shoeorthotics.
glassesorcontactlenses.Eyeexercisetherapy.Surgerythatisintendedtoallowyoutoseebetter
withoutglassesorothervisioncorrectionincludingradialkeratotomy,laser,andotherrefractiveeye
G. Medical Supplies and Appliances
surgery.
Devices usedspecificallyassafety items or to affect performanceprimarily insports-related activities.
Prescribedornon-prescribedmedicalsuppliesanddisposablesuppliesincludingbutnotlimitedto
Q. Other Exclusions
elastic stockings, acebandages,gauzeanddressings,ostomysupplies,syringesanddiabetictest strips.
Healthservicesandsuppliesthatdo not meet the definition of a Covered Health Service - see
Orthoticappliancesthatstraightenorre-shapeabodypart(includingcranialbandingandsometypesof definition in Section 10 of the SPD.
braces).Tubingsand masks are not coveredexceptwhenused withDurableMedicalEquipmentas
Physical,psychiatricorpsychologicalexaminations,testing,vaccinations,immunizationsor
describedinSection1oftheSPD.
treatmentsotherwisecoveredunderthePlan,whensuchservicesare:(1)requiredsolelyforpurposes
H. Mental Health/Substance Abuse
of career, education, sportsor camp,travel,employment,insurance, marriage or adoption; (2)relating
to judicial or administrativeproceedingsororders;(3)conductedforpurposesofmedicalresearch;or
Servicesperformedinconnectionwithconditionsnotclassifiedinthecurrenteditionofthe
(4) to obtain or maintain a license of anytype.
Diagnostic and Statistical Manual of theAmericanPsychiatricAssociation.Servicesthatextend
beyond theperiodnecessaryforshort-termevaluation,diagnosis,treatment,orcrisisintervention.
Health services received as aresultofwar or any act ofwar, whetherdeclaredor undeclared or caused
Mental Healthtreatmentofinsomniaandothersleepdisorders,neurologicaldisorders,andother
duringserviceinthearmedforcesofanycountry.
disorderswithaknownphysicalbasis.
Health services received after the date your coverage under the Plan ends, including health services for
Treatmentofconductandimpulsecontroldisorders,personalitydisorders,paraphiliasandotherMental medicalconditionsarisingpriortothedateyourcoverageunderthePlan ends.
Illnesses thatwill notsubstantiallyimprove beyond the current level of functioning, or that are not
Healthservicesforwhichyouhavenolegalresponsibilitytopay,orforwhichachargewouldnot
subjecttofavorablemodificationormanagementaccordingtoprevailingnationalstandardsofclinical
ordinarilybemadeintheabsenceofcoverageunderthePlan.IntheeventthataNon-Network
practice,asreasonablydeterminedbytheMentalHealth/SubstanceAbuseDesignee.
providerwaivesCopaymentsand/ortheAnnualDeductibleforaparticularhealth service, no Benefits
Servicesutilizingmethadonetreatmentas maintenance,L.A.A.M.(1-Alpha-Acetyl-Methadol),
areprovidedforthehealthserviceforwhichCopaymentsand/ortheAnnualDeductiblearewaived.
Cyclazocine,ortheirequivalents.Treatmentprovidedinconnectionwithortocomplywithinvoluntary
ChargesinexcessofEligibleExpensesorinexcessofanyspecifiedlimitation.
commitments,policedetentionsandothersimilararrangements,unlessauthorizedbytheMental
Services for the evaluation and treatment oftemporomandibularjointsyndrome(TMJ),whetherthe
Health/Substance Abuse Designee.Residential treatmentservices. Services or suppliesthat in the
servicesareconsideredtobemedicalordentalinnature.
reasonable judgment of the Mental Health/Substance Abuse Designee are not, for example,consistent
withcertain national standards orprofessional research further described in Section 2oftheSPD.
Upper andlowerjawbonesurgeryexceptasrequiredfordirecttreatmentofacutetraumaticInjuryor
cancer.Orthognathicsurgery, jaw alignment, and treatment for thetemporomandibularjoint,except as
I. Nutrition
atreatmentofobstructivesleepapnea.
Megavitaminandnutritionbasedtherapy;nutritionalcounselingforeitherindividualsorgroups.
Surgicaltreatmentandnon-surgicaltreatmentofobesity(includingmorbidobesity).
Enteral feedings and other nutritional and electrolytesupplements,includinginfantformulaanddonor
Growth hormone therapy;sextransformationoperations;treatmentofbenigngynecomastia(abnormal
breastmilk.
breastenlargementinmales);medical andsurgicaltreatmentofexcessivesweating(hyperhidrosis);
J. Physical Appearance
medical and surgical treatment for snoring, exceptwhenprovidedaspartoftreatmentfordocumented
Cosmetic Procedures including, but not limited to, pharmacologicalregimens;nutritionalproceduresor obstructivesleepapnea.Oralappliancesforsnoring.Custodialcare;domiciliarycare;privateduty
treatments;salabrasion,chemosurgeryandothersuchskinabrasionproceduresassociatedwiththe
nursing;respitecare;restcures.
removal ofscars,tattoos,and/orwhichareperformedasatreatmentforacne.Replacementofan
Psychosurgery.Speechtherapyexceptasrequiredfortreatmentofaspeechimpedimentorspeech
existingbreastimplantisexcludediftheearlierbreastimplantwasaCosmeticProcedure.
dysfunctionthatresultsfromInjury,strokeorCongenitalAnomaly.
(Replacementofanexistingbreastimplantisconsideredreconstructiveiftheinitialbreastimplant
This summary of Benefits is intended only to highlight your Benefits and should notbereliedupontofullydeterminecoverage.Thisplanmaynotcover allyourhealthcareexpenses.Pleaserefertothe
Summary Plan Description for a completelistingof services,limitations,exclusionsand adescription of all the terms and conditions of coverage.If this descriptionconflictsin anyway withtheSummary Plan
Description,theSummaryPlanDescriptionprevails.Termsthatarecapitalizedin theBenefitSummaryaredefinedintheSummaryPlanDescription.
04I_BS_ChcPlsASXGMXXX04
34
Benefits2009
XXX-XXXXX_1004
United HealthCare Insurance Company
ASO HSA Choice Plus $1,250 Plan Non-AFSCME
With this HSA Choice Plus high-deductible health plan coverage, you have the
optiontoopenaHealthSavingsAccount(HSA).AnHSAisafinancialaccount
that you can use to accumulate tax-free funds to pay for qualified health care
expenses, as defined by the Internal Revenue Service. The account acts like a
regularcheckingaccountwithadebitcardandaccruesinterest.Allmoneyinthe
accountisownedbyyouandisfullyvestedassoonasitisdeposited.Fundscan
accumulate over time and theaccountisportableamongemployers.Ifyouuse
the funds for qualifiedhealthcareexpenses,youwillpay notaxes.Ifyouusethe
moneyforotherexpenses,youwillpayataxandapenaltyfee.
HSAChoicePlusplangives you the freedom to see any Physician or other health
careprofessionalfromtheNetwork,includingspecialists,withoutareferral.With
thisplan,youwillreceivethe highest level of benefits whenyouseekcarefroma
networkphysician,facilityorotherhealthcareprofessional.Inaddition,youdo
nothavetoworryabout anyclaimformsorbills.
You also may choose to seek care outside the Network, without a referral.
However, you should know that care received from a non-network physician,
facility or other health care professional means a higher deductible and
Copayment. In addition, if you choose to seek care outside the Network, your
planonlypaysaportionof those charges and it is yourresponsibilitytopaythe
remainder.Thisamountyouarerequiredtopay,whichcould be significant, does
notapplytotheOut-of-PocketMaximum.Werecommendthatyouaskthenon-
network physician or health care professional about their billed charges before
you receive care.
Some of the Important Benefits of Your Plan:
Youhaveaccessto a Networkof physicians,
facilities and other health care professionals,
includingspecialists, withoutdesignatinga
Primary Physician or obtainingareferral.
Benefits are available for office visitsandhospital
care,aswellasinpatientandoutpatientsurgery.
Care CoordinationSM services are available to
helpidentifyandpreventdelaysincarefor
thosewhomightneedspecializedhelp.
ASXGFXXX04
Emergencies are covered anywhereinthe
world.
Papsmearsare covered.
Prenatalcareiscovered.Routine
check-upsarecovered.
Childhood immunizationsarecovered.
Mammogramsarecovered.
Vision and hearing screenings arecovered.
Benefits2009
35
HSA Choice Plus Benefits Summary
TypesofCoverage
NetworkBenefits/CopaymentAmounts
Non-NetworkBenefits/CopaymentAmounts
This Benefit Summary is intended only to highlight your
Benefitsandshouldnotbereliedupontofullydetermine
coverage.Thisbenefitplanmaynotcoverallofyour
healthcareexpenses. More complete descriptions of
Benefits and the terms under which they are provided
are contained in the Summary Plan Description that
you will receive upon enrolling in the Plan.
IfthisBenefitSummaryconflictsinanywaywiththe
SummaryPlanDescriptionissuedtoyouremployer,the
SummaryPlanDescriptionshallprevail.
TermsthatarecapitalizedintheBenefitSummaryare
definedintheSummaryPlanDescription.
WhereBenefitsaresubjecttoday,visitand/ordollar
limits,suchlimitsapplytothecombineduseofBenefits
whetherin-Networkorout-of-Network,exceptwhere
mandatedbystatelaw.
NetworkBenefitsarepayableforCoveredHealth
Servicesprovidedbyorunderthedirectionofyour
Networkphysician.
*PriorNotificationisrequiredforcertainservices.
Combined Medical and Drug Annual Deductible: For
singlecoverage,theAnnualDeductibleis$1,250per
CoveredPersonpercalendaryear.Forfamilycoverage,
theAnnualDeductibleis$2,500percalendaryearforall
CoveredPersonsinafamily.Nooneinthefamilyis
eligibleforbenefitsuntilthefamilydeductibleissatisfied.
Combined Medical and Drug Annual Deductible: For
singlecoverage,theAnnualDeductibleis$2,500per
CoveredPersonpercalendaryear.Forfamilycoverage,
theAnnualDeductibleis$3,000percalendaryearforall
CoveredPersonsinafamily.Nooneinthefamilyis
eligible for benefits until the family deductible is
satisfied.
1. Ambulance Services - Emergency only
GroundTransportation:10%ofEligibleExpenses
AirTransportation:10%ofEligibleExpenses
SameasNetworkBenefit
2. Dental Services - Accident only
*10%ofEligibleExpenses
*Priornotificationisrequiredbeforefollow-up
treatmentbegins.
*SameasNetworkBenefit
*Priornotificationisrequiredbeforefollow-up
treatmentbegins.
3. Durable Medical Equipment
NetworkandNon-NetworkBenefitsforDurable
MedicalEquipmentarelimitedto$2,500per
calendaryear.
10%ofEligibleExpenses
*30%ofEligibleExpenses
*Priornotificationisrequiredwhenthecostismore
than$1,000.
4. Emergency Health Services
10%ofEligibleExpenses
SameasNetworkBenefit
*NotificationisrequiredifresultsinanInpatientStay.
5. Eye Examinations
10%ofEligibleExpenses
Refractiveeyeexaminationsarelimitedtooneevery
othercalendaryearfromaNetworkProvider.
30%ofEligibleExpenses
EyeExaminationsforrefractiveerrorsarenotcovered.
6. Home Health Care
NetworkandNon-NetworkBenefitsarelimitedto
60visitsforskilledcareservicespercalendaryear.
10%ofEligibleExpenses
*30%ofEligibleExpenses
7. Hospice Care
NetworkandNon-NetworkBenefitsarelimitedto
360daysduringtheentireperiodoftimeaCovered
PersoniscoveredunderthePlan.
10%ofEligibleExpenses
*30%ofEligibleExpenses
8. Hospital - Inpatient Stay
10%ofEligibleExpenses
*30%ofEligibleExpenses
9. Injections Received in a Physician's Office
10%perinjection
30%perinjection
10. Maternity Services
Same as 8, 11, 12 and 13
Same as 8, 11, 12 and 13
*Notification is required if Inpatient Stay exceeds 48
hoursfollowinganormalvaginaldeliveryor96hours
followingacesareansectiondelivery.
Combined Medical and Drug Out-of-Pocket
Maximum: For single coverage, the Out-of-Pocket
Maximumis$2,500perCoveredPersonpercalendar
year.Forfamilycoverage,theOut-of-PocketMaximumis
$5,000percalendaryearforallCoveredPersonsina
family.TheOut-of-PocketMaximumdoesincludethe
AnnualDeductible.
Maximum Policy Benefit: NoMaximumPolicy
Benefit.
Combined Medical and Drug Out-of-Pocket
Maximum: For single coverage, the Out-of-Pocket
Maximumis$5,000perCoveredPersonpercalendar
year.Forfamilycoverage,theOut-of-PocketMaximum
is$10,000percalendaryearforallCoveredPersonsina
family.TheOut-of-PocketMaximumdoesincludethe
AnnualDeductible.
Maximum Policy Benefit: $1,000,000perCovered
Person.
11. Outpatient Surgery, Diagnostic and Therapeutic
Services
36
OutpatientSurgery
10%ofEligibleExpenses
30%ofEligibleExpenses
OutpatientDiagnosticServices
Forpreventivediagnosticservices:
NoCopayment
Forpreventivemammographytesting:
NoCopayment
For sickness and injury related diagnostic services:
10%ofEligibleExpenses
30%ofEligibleExpenses
.
30%ofEligibleExpenses
30%ofEligibleExpenses
OutpatientDiagnostic/TherapeuticServices-CT
Scans,PetScans,MRIandNuclearMedicine
10%ofEligibleExpenses
30%ofEligibleExpenses
OutpatientTherapeuticTreatments
10%ofEligibleExpenses
30%ofEligibleExpenses
12. Physician's Office Services
Preventive medical care:
NoCopayment
Sickness&Injury:10%ofEligibleExpenses
NoCopayment.
30%ofEligibleExpenses
13. Professional Fees for Surgical and Medical
Services
10%ofEligibleExpenses
30%ofEligibleExpenses
14. Prosthetic Devices
NetworkandNon-NetworkBenefitsforprosthetic
devicesarelimitedto$2,500percalendaryear.
10%ofEligibleExpenses
30%ofEligibleExpenses
Benefits2009
YOUR BENEFITS
TypesofCoverage
NetworkBenefits/CopaymentAmounts
Non-NetworkBenefits/CopaymentAmounts
15. Reconstructive Procedures
Same as 8, 11, 12, 13 and 14
*Same as 8, 11, 12, 13 and 14
16. Rehabilitation Services - Outpatient Therapy
NetworkandNon-NetworkBenefitsarelimitedas
follows:20visitsofphysicaltherapy;20visitsof
occupationaltherapy;20visitsofspeechtherapy;20
visitsofpulmonaryrehabilitation;and36visitsof
cardiacrehabilitationpercalendaryear.
10%ofEligibleExpenses
30%ofEligibleExpenses
17. Skilled Nursing Facility/Inpatient Rehabilitation
Facility Services
NetworkandNon-NetworkBenefitsarelimitedto
60dayspercalendaryear.
10%ofEligibleExpenses
*30%ofEligibleExpenses
18. Transplantation Services
*10%ofEligibleExpenses
*30%ofEligibleExpenses
Benefitsarelimitedto$30,000pertransplant.
19. Urgent Care Center Services
10%ofEligibleExpenses
30%ofEligibleExpenses
Mental Health and Substance Abuse Services Outpatient
MustreceivepriorauthorizationthroughtheMental
Health/SubstanceAbuseDesignee.NetworkandNon-
NetworkBenefitsarelimitedto20visitspercalendar
year.
10%ofEligibleExpenses
30%ofEligibleExpenses
Mental Health and Substance Abuse Services Inpatient and Intermediate
MustreceivepriorauthorizationthroughtheMental
Health/SubstanceAbuseDesignee.NetworkandNon-
NetworkBenefitsarelimitedto30dayspercalendar
year.
10%ofEligibleExpenses
30%ofEligibleExpenses
Spinal Treatment
Benefits include diagnosis and related services and are
limitedtoonevisitandtreatmentperday.Networkand
Non-NetworkBenefitsarelimitedto24visitsper
calendaryear.
10%ofEligibleExpenses
30%ofEligibleExpenses
Audiometric Testing
Maximum$40PerExam
Maximum$40PerExam
Hearing Aid
Maximum$400Benefit
Maximum$400Benefit
Additional Benefits
Benefits2009
37
Exclusions
ASO
Exceptas maybespecificallyprovidedinSection1oftheSummaryPlan Description(SPD)or
throughaRidertothePlan,thefollowingarenotcovered:
A. Alternative Treatments
Acupressure;hypnotism;rolfing;massagetherapy;aromatherapy;acupuncture;andotherformsof
alternativetreatment.
B. Comfort or Convenience
Personalcomfortorconvenienceitemsorservicessuchastelevision;telephone;barberorbeauty
service;guestservice;supplies,equipmentandsimilarincidentalservicesand suppliesforpersonal
comfort includingairconditioners,airpurifiersandfilters,batteriesandbatterychargers,
dehumidifiersandhumidifiers;devicesor computerstoassistincommunicationandspeech.
C. Dental
Exceptas specificallydescribedascoveredinSection1oftheSPDforservicestorepair a sound
naturaltooththathasdocumentedaccident-relateddamage,dentalservicesareexcluded.Thereisno
coverageforservicesprovidedfortheprevention,diagnosis,andtreatmentoftheteeth,jawbonesor
gums(includingextraction,restoration, andreplacementofteeth,medicalorsurgicaltreatmentsof
dentalconditions,andservicestoimprovedentalclinicaloutcomes).Dental implantsanddentalbraces
areexcluded.Dentalx-rays,suppliesandappliancesandallassociatedexpensesarisingoutofsuch
dentalservices(includinghospitalizationsandanesthesia)areexcluded,exceptasmightotherwisebe
requiredfortransplantpreparation,initiationofimmunosuppressives,orthedirecttreatmentofacute
traumaticInjury,cancer,orcleftpalate.Treatmentforcongenitallymissing,malpositioned,orsuper
numeraryteethisexcluded,evenifpartofaCongenital Anomaly.
D. Drugs
exercise,fitness,flexibility,anddiversionorgeneralmotivation.Weightlossprogramsformedical
andnon-medicalreasons.Wigs,regardlessofthereason forthehairloss.
K. Providers
Servicesperformedbyaproviderwithyoursamelegalresidenceorwhoisafamilymemberbybirth
or marriage,includingspouse,brother,sister,parentorchild. Thisincludesanyservicetheprovider
mayperformonhimselforherself.Servicesprovidedatafree-standingorHospital-baseddiagnostic
facilitywithoutanorderwrittenby aPhysicianorotherproviderasfurther described in Section 2 of
theSPD(thisexclusiondoesnotapplytomammographytesting).
L. Reproduction
Health services and associatedexpenses for infertility treatments.Surrogateparenting. The reversal of
voluntarysterilization.
M. Services Provided under Another Plan
Healthservicesforwhichothercoverageisrequiredbyfederal,stateorlocallawtobepurchasedor
providedthroughotherarrangements,includingbutnotlimited tocoveragerequiredbyworkers’
compensation,no-faultautomobileinsurance,orsimilarlegislation.Ifcoverageunderworkers’
compensationorsimilarlegislationisoptionalbecauseyoucouldelectit,orcouldhaveitelectedfor
you, Benefitswillnotbe paidforany Injury, Mental Illness or Sicknessthatwouldhave been covered
under workers’compensationorsimilarlegislationhad that coveragebeenelected. Health services for
treatmentofmilitaryservice-relateddisabilities,whenyouarelegallyentitledtoothercoverageand
facilitiesarereasonablyavailabletoyou.Healthserviceswhileonactivemilitaryduty.
N. Transplants
Healthservicesfororganortissuetransplantsareexcluded,exceptthosespecified as covered in
Prescriptiondrugproductsforoutpatientusethatarefilledbyaprescriptionorderorrefill.Self-
Section1oftheSPD.Anysolidorgantransplantthatisperformedasatreatmentforcancer.Health
injectablemedications. Non-injectable medications given in aPhysician’sofficeexcept as required in an
servicesconnectedwiththeremovalofanorganortissuefromyouforpurposesofatransplantto
Emergency.Over-the-counterdrugsandtreatments.
anotherperson.Healthservicesfortransplantsinvolvingmechanicaloranimalorgans.Transplant
servicesthatarenotperformedataDesignatedFacility.Anymultipleorgantransplantnotlistedasa
E. Experimental, Investigational or Unproven Services
Covered Health Service in Section 1 oftheSPD.
Experimental,InvestigationalorUnproven Servicesareexcluded.ThefactthatanExperimental,
InvestigationalorUnprovenService,treatment,deviceorpharmacologicalregimenistheonly
O. Travel
availabletreatmentforaparticularconditionwillnotresultinBenefitsiftheprocedureisconsideredto
Healthservicesprovidedinaforeigncountry,unlessrequiredasEmergencyHealthServices.
beExperimental,InvestigationalorUnproveninthetreatmentofthatparticularcondition.
Travelortransportationexpenses,eventhoughprescribedbyaPhysician.Sometravelexpenses
relatedtocoveredtransplantationservicesmaybereimbursedatourdiscretion.
F. Foot Care
Routine foot care (including the cutting or removal of corns and calluses); nail trimming, cutting, or P. Vision and Hearing
debriding; hygienicand preventive maintenancefootcare; treatment of flat feet or subluxation of the
Purchase cost of eye glasses, contactlenses,orhearingaids.Fittingcharge for hearing aids, eye
foot;shoeorthotics.
glassesorcontactlenses.Eyeexercisetherapy.Surgerythatisintendedtoallowyoutoseebetter
withoutglassesorothervisioncorrectionincludingradialkeratotomy,laser,andotherrefractiveeye
G. Medical Supplies and Appliances
surgery.
Devices usedspecificallyassafety items or to affect performanceprimarily insports-related activities.
Prescribedornon-prescribedmedicalsuppliesanddisposablesuppliesincludingbutnotlimitedto
Q. Other Exclusions
elastic stockings, acebandages,gauzeanddressings,ostomysupplies,syringesanddiabetictest strips.
Healthservicesandsuppliesthatdo not meet the definition of a Covered Health Service - see
Orthoticappliancesthatstraightenorre-shapeabodypart(includingcranialbandingandsometypesof
definition in Section 10 of the SPD.
braces).Tubingsand masks are not coveredexceptwhenused withDurableMedicalEquipmentas
describedinSection1oftheSPD.
Physical,psychiatricorpsychologicalexaminations,testing,vaccinations,immunizationsor
treatmentsotherwisecoveredunderthePlan,whensuchservicesare:(1)requiredsolelyforpurposes
H. Mental Health/Substance Abuse
of career, education, sportsor camp,travel,employment,insurance, marriage or adoption; (2)relating
Servicesperformedinconnectionwithconditionsnotclassifiedinthecurrenteditionofthe
to judicial or administrativeproceedingsororders;(3)conductedforpurposesofmedicalresearch;or
Diagnostic and Statistical Manual of theAmericanPsychiatricAssociation.Servicesthatextend
(4) to obtain or maintain a license of anytype.
beyond theperiodnecessaryforshort-termevaluation,diagnosis,treatment,orcrisisintervention.
Health services received as aresultofwar or any act ofwar, whetherdeclaredor undeclared or caused
Mental Healthtreatmentofinsomniaandothersleepdisorders,neurologicaldisorders,andother
duringserviceinthearmedforcesofanycountry.
disorderswithaknownphysicalbasis.
Treatmentofconductandimpulsecontroldisorders,personalitydisorders,paraphiliasandotherMental
Illnesses thatwill notsubstantiallyimprove beyond the current level of functioning, or that are not
subjecttofavorablemodificationormanagementaccordingtoprevailingnationalstandardsofclinical
practice,asreasonablydeterminedbytheMentalHealth/SubstanceAbuseDesignee.
Health services received after the date your coverage under the Plan ends, including health services for
medicalconditionsarisingpriortothedateyourcoverageunderthePlan ends.
Healthservicesforwhichyouhavenolegalresponsibilitytopay,orforwhichachargewouldnot
ordinarilybemadeintheabsenceofcoverageunderthePlan.IntheeventthataNon-Network
providerwaivesCopaymentsand/ortheAnnualDeductibleforaparticularhealth service, no Benefits
Servicesutilizingmethadonetreatmentas maintenance,L.A.A.M.(1-Alpha-Acetyl-Methadol),
Cyclazocine,ortheirequivalents.Treatmentprovidedinconnectionwithortocomplywithinvoluntary areprovidedforthehealthserviceforwhichCopaymentsand/ortheAnnualDeductiblearewaived.
ChargesinexcessofEligibleExpensesorinexcessofanyspecifiedlimitation.
commitments,policedetentionsandothersimilararrangements,unlessauthorizedbytheMental
Health/Substance Abuse Designee.Residential treatmentservices. Services or suppliesthat in the
Services for the evaluation and treatment oftemporomandibularjointsyndrome(TMJ),whetherthe
reasonable judgment of the Mental Health/Substance Abuse Designee are not, for example,consistent
servicesareconsideredtobemedicalordentalinnature.
withcertain national standards orprofessional research further described in Section 2oftheSPD.
Upper andlowerjawbonesurgeryexceptasrequiredfordirecttreatmentofacutetraumaticInjuryor
I. Nutrition
cancer.Orthognathicsurgery, jaw alignment, and treatment for thetemporomandibularjoint,except as a
Megavitaminandnutritionbasedtherapy;nutritionalcounselingforeitherindividualsorgroups.Enteral treatmentofobstructivesleepapnea.
feedings and other nutritional and electrolytesupplements,includinginfantformulaanddonorbreast
Surgicaltreatmentandnon-surgicaltreatmentofobesity(includingmorbidobesity).
milk.
Growth hormone therapy;sextransformationoperations;treatmentofbenigngynecomastia(abnormal
J. Physical Appearance
breastenlargementinmales);medical andsurgicaltreatmentofexcessivesweating(hyperhidrosis);
Cosmetic Procedures including, but not limited to, pharmacologicalregimens;nutritionalproceduresor medical and surgical treatment for snoring, exceptwhenprovidedaspartoftreatmentfordocumented
treatments;salabrasion,chemosurgeryandothersuchskinabrasionproceduresassociatedwiththe
obstructivesleepapnea.Oralappliancesforsnoring.Custodialcare;domiciliarycare;privateduty
removal ofscars,tattoos,and/orwhichareperformedasatreatmentforacne.Replacementofan
nursing;respitecare;restcures.
existingbreastimplantisexcludediftheearlierbreastimplantwasaCosmeticProcedure.
Psychosurgery.Speechtherapyexceptasrequiredfortreatmentofaspeechimpedimentorspeech
(Replacementofanexistingbreastimplantisconsideredreconstructiveiftheinitialbreastimplant
dysfunctionthatresultsfromInjury,strokeorCongenitalAnomaly.
followedmastectomy.)Physicalconditioningprogramssuchasathletictraining,bodybuilding,
This summary of Benefits is intended only to highlight your Benefits and should notbereliedupontofullydeterminecoverage.Thisplanmaynotcover allyourhealthcareexpenses.Pleaserefertothe
Summary Plan Description for a completelistingof services,limitations,exclusionsand adescription of all the terms and conditions of coverage.If this descriptionconflictsin anyway withtheSummary Plan
Description,theSummaryPlanDescriptionprevails.Termsthatarecapitalizedin theBenefitSummaryaredefinedintheSummaryPlanDescription.
04I_BS_HSAChcPls
38
Benefits2009
ASXGFXXX04
XXX-XXXX
Notes
Benefits2009
39
Kaiser Permanente HMO
Rate Listing
forBDOFCUYAHOGACNTYCOMMISSIONERS-0200
Classic
RatesEffective1/1/2009-12/31/2009
OUTPATIENT CARE
Physician Office Visits including Annual Gynecological Exam
Allergy treatment
•Specialty care
•Vision Exams available through affiliated providers
Prenatal Care
Outpatient surgery
Urgent Care-At Kaiser Permanente facilities or outside the service area
Physical, Speech, and Occupational Therapy
•Up to 30 visits per calendar year per medical condition
PREVENTIVE SERVICES
Routine adult physical primary care exam
Routine Well Child Care primary care exam
Routine Mammogram and PAP Test
Routine Lab and X-rays associated with routine physical exam
DIAGNOSTIC SERVICES
•Laboratory and diagnostic testing, X-rays
HOSPITAL INPATIENT CARE
No annual or lifetime limit on covered days, including:
•Physician and surgeon services; Room and board, anesthesia, operating
and recovery rooms; Laboratory and diagnostic testing, x-rays
EMERGENCY SERVICES (Fee waived if admitted)
Emergency Services provided at a Plan Facility
Emergency Services provided at a non-Plan Facility
(must be authorized by Kaiser Permanente)
AMBULANCE SERVICES
Only when transportation in any other vehicle would endanger your health
BIOLOGICALLY BASED MENTAL HEALTH SERVICES
Inpatient Services
Outpatient Services
MENTAL HEALTH SERVICES
Inpatient - 30 days of hospital care per calendar year
Outpatient - 20 visit maximum
•Individual (each visit counts as one visit against maximum)
•Group (each visit counts as one-half of a visit against maximum)
CHEMICAL DEPENDENCY SERVICES
Inpatient
•Detoxification in a general hospital
•Detoxification in a specialized facility--1 admit per year
Outpatient
•Detoxification
•Individual Therapy
1.1.08Classic1441656.doc
40
Benefits2009
$15 per visit
No Charge
$15 per visit
$15 per visit
No Charge
$15 per visit
$15 per visit
$15 per visit
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
$25 per visit
$25 per visit
No Charge
No Charge
$15 per visit
No Charge
$15 per visit
$7 per visit
No Charge
No Charge
$15 per visit
$15 per visit
ALTERNATE CARE
Home Health Services
Hospice Home Care/Respite Care
Skilled care in a Skilled Nursing Facility
•Up to 100 days per calendar year
INFERTILITY SERVICES
•Inpatient
•Outpatient
PRESCRIPTION DRUGS
•Covered Formulary Drugs and Accessories up to a 31 day supply at
Kaiser Permanente and affiliated network facilities
•Up to 62 day supply of maintenance drugs by mail order from the Kaiser
Permanente Mail Order Pharmacy
DURABLE MEDICAL EQUIPMENT
Medicare approved durable medical equipment
HEARING AID RIDER
1 hearing aid every 36 months
No Charge
No Charge
No Charge
30%*
30%
$5 copay
No Charge
Covered up to $1,000
per aid per ear
*Whenaplandeductibleisindicated,inpatientinfertilityservicesaresubjecttodeductible.
Monthly Premium
x
x
x
x
x
Sub
Family
$377.68
$1,009.65
NotesandRestrictions
Ratesaremonthlyandbaseduponcensussubmitted.Finalrateswillbebasedonactualenrollment.
Do not cancel your current medical coverage until youhavereceivedapprovalfromKaiserPermanente.
Medicareeligibleemployeesworkingforgroupswithlessthan20employeesareNOTELIGIBLEforAddedChoicecoverage.
Finalriskcategorydeterminedbymedicalevaluation.
The benefits listed above are only a summary.Detailedbenefitinformationandexclusionsareavailableonrequest.
1.1.08Classic1441656.doc
Benefits2009
41
Kaiser Permanente HMO
Rate Listing
forBDOFCUYAHOGACNTYCOMMISSIONERS(AFSCME)-0202
Classic
RatesEffective1/1/2009-12/31/2009
OUTPATIENT CARE
Physician Office Visits including Annual Gynecological Exam
Allergy treatment
•Specialty care
•Vision Exams available through affiliated providers
Prenatal Care
Outpatient surgery
Urgent Care-At Kaiser Permanente facilities or outside the service area
Physical, Speech, and Occupational Therapy
•Up to 30 visits per calendar year per medical condition
PREVENTIVE SERVICES
Routine adult physical primary care exam
Routine Well Child Care primary care exam
Routine Mammogram and PAP Test
Routine Lab and X-rays associated with routine physical exam
DIAGNOSTIC SERVICES
•Laboratory and diagnostic testing, X-rays
HOSPITAL INPATIENT CARE
No annual or lifetime limit on covered days, including:
•Physician and surgeon services; Room and board, anesthesia, operating
and recovery rooms; Laboratory and diagnostic testing, x-rays
EMERGENCY SERVICES (Fee waived if admitted)
Emergency Services provided at a Plan Facility
Emergency Services provided at a non-Plan Facility
(must be authorized by Kaiser Permanente)
AMBULANCE SERVICES
Only when transportation in any other vehicle would endanger your health
BIOLOGICALLY BASED MENTAL HEALTH SERVICES
Inpatient Services
Outpatient Services
MENTAL HEALTH SERVICES
Inpatient - 30 days of hospital care per calendar year
Outpatient - 20 visit maximum
•Individual (each visit counts as one visit against maximum)
•Group (each visit counts as one-half of a visit against maximum)
CHEMICAL DEPENDENCY SERVICES
Inpatient
•Detoxification in a general hospital
•Detoxification in a specialized facility--1 admit per year
Outpatient
•Detoxification
•Individual Therapy
1.1.08ClassicAFSCME1441658.doc
42
Benefits2009
$15 per visit
No Charge
$15 per visit
$15 per visit
No Charge
$15 per visit
$15 per visit
$15 per visit
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
$25 per visit
$25 per visit
No Charge
No Charge
$15 per visit
No Charge
$15 per visit
$7 per visit
No Charge
No Charge
$15 per visit
$15 per visit
ALTERNATE CARE
Home Health Services
Hospice Home Care/Respite Care
Skilled care in a Skilled Nursing Facility
•Up to 100 days per calendar year
INFERTILITY SERVICES
•Inpatient
•Outpatient
PRESCRIPTION DRUGS
•Covered Formulary Drugs and Accessories up to a 31 day supply at
Kaiser Permanente and affiliated network facilities
•Up to 62 day supply of maintenance drugs by mail order from the Kaiser
Permanente Mail Order Pharmacy
DURABLE MEDICAL EQUIPMENT
Medicare approved durable medical equipment
No Charge
No Charge
No Charge
30%*
30%
$5 copay
No Charge
*Whenaplandeductibleisindicated,inpatientinfertilityservicesaresubjecttodeductible.
x
x
x
x
x
NotesandRestrictions
Ratesaremonthlyandbaseduponcensussubmitted.Finalrateswillbebasedonactualenrollment.
Do not cancel your current medical coverage until youhavereceivedapprovalfromKaiserPermanente.
Medicareeligibleemployeesworkingforgroupswithlessthan20employeesareNOTELIGIBLEforAddedChoicecoverage.
Finalriskcategorydeterminedbymedicalevaluation.
The benefits listed above are only a summary.Detailedbenefitinformationandexclusionsareavailableonrequest.
1.1.08ClassicAFSCME1441658.doc
Benefits2009
43
Kaiser Permanente HMO
Rate Listing
forBDOFCUYAHOGACNTYCOMMISSIONERS-0200
MetroHealth Advantage
RatesEffective1/1/2009-12/31/2009
OUTPATIENT CARE
Office Visits-Primary Care Physician
Allergy treatment
Office Visits-Specialist
•Vision Exams available through affiliated providers
Prenatal Care
Outpatient surgery
Urgent Care-At Kaiser Permanente facilities or outside the service area
Physical, Speech, and Occupational Therapy
•Up to 30 visits per calendar year
PREVENTIVE SERVICES
Routine adult physical primary care exam
Routine Well Child Care primary care exam
Routine Mammogram and PAP Test
Routine Lab and X-rays associated with routine physical exam
DIAGNOSTIC SERVICES
•Laboratory and diagnostic testing, X-rays
HOSPITAL INPATIENT CARE
No annual or lifetime limit on covered days, including:
•Physician and surgeon services; Room and board, anesthesia, operating
and recovery rooms; Laboratory and diagnostic testing, x-rays
EMERGENCY SERVICES (Fee waived if admitted)
Emergency Services provided at a Plan Facility
Emergency Services provided at a non-Plan Facility
(must be authorized by Kaiser Permanente)
AMBULANCE SERVICES
Only when transportation in any other vehicle would endanger your health
BIOLOGICALLY BASED MENTAL HEALTH SERVICES
Inpatient Services
Outpatient Services
MENTAL HEALTH SERVICES
Inpatient - 30 days of hospital care per calendar year
Outpatient - 20 visit maximum
•Individual Therapy
•Group Therapy (each visit counts as one-half visit against maximum)
CHEMICAL DEPENDENCY SERVICES
Inpatient
•Detoxification in a general hospital
•Detoxification in a specialized facility--1 admit per year
Outpatient
•Detoxification
•Individual Therapy
1.1.08MetroHMO1441655.doc
44
Benefits2009
$5 per visit
No Charge
$5 per visit
$5 per visit
No Charge
$5 per visit
$5 per visit
$5 per visit
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
$25 per visit
$25 per visit
No Charge
No Charge
$5 per visit
No Charge
$5 per visit
$2 per visit
No Charge
No Charge
$5 per visit
$5 per visit
ALTERNATE CARE
Home Health Services
Hospice Home Care/Respite Care
Skilled care in a Skilled Nursing Facility
•Up to 100 days per calendar year
INFERTILITY SERVICES
•Inpatient
•Outpatient
PRESCRIPTION DRUGS
•Covered Formulary Drugs and Accessories up to a 31 day supply at
Kaiser Permanente and affiliated network facilities
•Up to 90 day supply of maintenance drugs by mail order from the Kaiser
Permanente Mail Order Pharmacy
DURABLE MEDICAL EQUIPMENT
Medicare approved durable medical equipment
HEARING AID RIDER
1 hearing aid every 36 months
No Charge
No Charge
No Charge
30%*
30%
$5 generic
$10 no generic available
$15 brand
$10 generic
$20 no generic available
$30 brand
No Charge
Covered up to $500 per
aid per ear
*Whenaplandeductibleisindicated,inpatientinfertilityservicesaresubjecttodeductible.
x
x
x
x
x
NotesandRestrictions
Ratesaremonthlyandbaseduponcensussubmitted.Finalrateswillbebasedonactualenrollment.
Do not cancel your current medical coverage until youhavereceivedapprovalfromKaiserPermanente.
Medicareeligibleemployeesworkingforgroupswithlessthan20employeesareNOTELIGIBLEforAddedChoicecoverage.
Finalriskcategorydeterminedbymedicalevaluation.
The benefits listed above are only a summary.Detailedbenefitinformationandexclusionsareavailableonrequest.
1.1.08MetroHMO1441655.doc
Benefits2009
45
EPO Option
SuperMed Plus
Effective 01/01/09
Cuyahoga County Employees
Benefits
Benefit Period
Dependent Age Limit
Pre-Existing Condition Waiting Period
Blood Pint Deductible
Lifetime Maximum
Gatekeeper
Benefit Period Deductible – Single/Family
Coinsurance
Coinsurance Out-of-Pocket Maximum
(Excluding Deductible) – Single/Family
Physician/Office Services
Office Visit (Illness/Injury)1
Surgical Services in a physician’s office1
OB/GYN Visit1
Urgent Care Office Visit1
All Immunizations
Allergy Testing
Allergy Treatments
Preventative Services
Routine Physical Exams (Age 18 and over)1
Well Child Care (Birth to age 18)1
Routine Vision Exam (One exam per benefit
period) 1
Routine Hearing Exams
Routine Mammogram (One per benefit period)
Routine Pap Test
Endoscopic Services
Colon Cancer Screening
All Routine Lab, X-rays and Medical Test
Outpatient Services
Surgical Services (other than a physician’s
office)
Diagnostic Services
Physical, Chiropractic and Occupational
Therapies (20 visits per benefit period)
Cardiac Rehabilitation
Speech Therapy (10 visits per benefit period)
Emergency use of an Emergency Room2
Non-Emergency use of an Emergency Room2
46 Cuyahoga
Benefits2009
County 2 tier EPO SMP 111505.doc
Network
Non-Network
st
January 1 through December 31st
23: Removal end of month
Does Not Apply
0 Pints
Unlimited
Not Required
None
Not Covered
100%
Not Covered
None
Not Covered
$15 copay, then 100%
$15 copay, then 100%
$15 copay, then 100%
$15 copay, then 100%
100%
$25 copay, then 100%
$15 copay, then 100%
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
100%
100%
100%
Not Covered
Not Covered
Not Covered
100%
100%
100%
100%
100%
100%
100%
$15 copay, then 100%
Not Covered
Not Covered
100%
Not Covered
100%
Not Covered
$15 copay, then 100%
Not Covered
$75 copay, then 100%
$75 copay, then 100%
Not Covered
Benefits
Inpatient Facility
Semi-Private Room and Board
Maternity
Skilled Nursing Facility (100 days per benefit
period)
Additional Services
Ambulance
Durable Medical Equipment
Education & Training
Home Healthcare
Hospice
Organ Transplants
Private Duty Nursing
Mental Health and Substance Abuse
Inpatient Mental Health & Substance Abuse
Services (30 days per benefit period; limited
to one admit per benefit period; Substance
Abuse limited to three admissions per lifetime)
Outpatient Mental Health & Substance Abuse
Services (20 visits per benefit period) 2
Network
Non-Network
100%
100%
100%
Not Covered
Not Covered
Not Covered
100%
100%
100%
100%
100%
100%
$50 copay, then 100%
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
100%
$250 deductible per admit
($500 Single / $1,250 Family)
Not Covered
$15 copay, then 100%
Not Covered
Note:
Benefits will be determined based on Medical Mutual’s medical and administrative policies and procedures.
This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an
officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or
certificate will contain the complete listing of covered services.
In certain instances, Medical Mutual’s payment may not equal the percentage listed above. However, the
covered person’s coinsurance will always be based on the lesser of the provider’s billed charges or Medical
Mutual’s negotiated rate with the provider.
1
2
The office visit copay applies to the cost of the office visit only.
Copay waived if admitted.
Cuyahoga County 2 tier EPO SMP 111505.doc
Benefits2009
47
County of Cuyahoga
Metrohealth Select1
Effective 1/1/09
Benefits
Benefit Period
Dependent Age Limit
Lifetime Maximum
Benefit Period Deductible
Coinsurance
Coinsurance Out-of-Pocket Maximum
(Excluding Deductible)
Physician/Office Services
Office Visit (Illness/Injury) 2
Urgent Care Office Visit2
Ambulatory Surgery (in office)
Immunizations
Allergy Treatments
Allergy Testing
Routine Services
Office Visit/Routine Physical Exam2
Well Child Care2
Hearing Exams
Routine Vision Exam
Routine Mammogram
Routine Pap Test
Routine Laboratory, X-ray and Diagnostic
Medical Tests
Outpatient Services
Surgical Services
Diagnostic Services
Physical Therapy (30 visits per benefit
period)
Occupational Therapy (30 visits per benefit
period
Speech Therapy (30 visits per benefit
period)
Cardiac Rehabilitation
Emergency Room3
Inpatient Facility
Semi-Private Room and Board
Maternity
Skilled Nursing Facility (100 days per
benefit period)
Organ Transplants
48
Benefits2009
January 1st through December 31st
23; Removal upon End of Month
Unlimited
None
None
None
$5 copay, then 100%
$5 copay, then 100%
$5 copay, then 100%
100%
100%
100%
100%
100%
100%
$5 copay, then 100%
100%
100%
100%
$5 copay, then 100%
100%
$5 copay, then 100%
$5 copay, then 100%
$5 copay, then 100%
100%
$25 copay, then 100%
100%
100%
100%
100%
Benefits
Additional Services
Ambulance
Durable Medical Equipment
Home Healthcare
Hospice
Mental Health and Substance Abuse
Inpatient Mental Health Services (30 days
per benefit period)
Outpatient Mental Health Services
(30 visits per benefit period)
Inpatient Substance Abuse Services (one
admit per year for Detox in a specialized
facility)
Outpatient Substance Abuse
Note:
100%
100%
100%
100%
100%
$10 copay, then 100% -Individual therapy
$5 copay, then 100% -Group therapy (each visit counts as
half a visit towards maximum)
100%
$10 copay, then 100%
Copayments on any single covered basic health care service will not exceed 40% of the average cost to
Medical Health Insuring Corporation of Ohio of providing the service.
Benefits will be determined based on Medical Mutual’s medical and administrative policies and procedures.
This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an
officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or
certificate will contain the complete listing of covered services.
1
Elective Services which are not authorized and not performed at Metrohealth Medical Center will not be covered.
Emergency services will be treated as authorized services and eligible for benefit coverage.
2
The office visit copay applies to the cost of the office visit only.
3
Copay waived if admitted.
Benefits2009
49
Cuyahoga County Employees – Benefits for
Non-AFSCME members only1
Hearing Option for Metrohealth Select
Benefit Description
Benefit Period
Dependent Age Limit
Coinsurance
Audiometric Exam
Hearing Aid Evaluation, Conformity Evaluation &
Hearing Aid
Note:
Dollar Maximum
Frequency
st
January 1 through December 31st
Same as Medical
100%
Covered under the Medical Benefits
$500 per hearing aid,
1 every rolling 36 months
per ear
Benefits will be determined based on Medical Mutual’s medical and administrative policies and procedures.
This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an
officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or
certificate will contain the complete listing of covered services.
In certain instances, Medical Mutual’s payment may not equal the percentage listed above. However, the
covered person’s coinsurance will always be based on the lesser of the provider’s billed charges or Medical
Mutual’s negotiated rate with the provider.
1
AFCSME Locals 1746, 2927, and 3366 will receive Hearing benefits through the AFSCME Care Plan
Cuyahoga County Hearing 092508..doc
50
Benefits2009
Your Anthem Benefits
Cuyahoga County - Anthem Dental PPO - Summary of Benefits
Thisisnotacontract;itisapartiallistingofbenefitsandservices.Allcoveredservices are subject to the conditions, exclusions,
qualifications,limitations,termsandprovisionsoftheDentalCertificate.
BENEFITS
Annual Deductible (Single/Family)
Annual Maximum
DIAGNOSTIC/PREVENTIVE
Diagnostic and Preventive Services (no deductible)
x oral evaluations
x X-rays
x cleanings
x space maintainers
x other selected diagnostic and preventive services
GENERAL/RESTORATIVE
General (Adjunctive) Services (deductible applied)
x emergency palliative treatment
x consultations
x general anesthesia (surgical procedures)
x I.V. sedation (surgical procedures)
x office visits for observation
x other selected general services
Restorative Services (deductible applied)
x amalgam and composite restorations
x pin retention procedures
SPECIALTY
Endodontic Services (deductible applied)
x root canal therapy
x apexification
x therapeutic pulpotomy
x other selected endodontic services
Oral Surgery Services (deductible applied)
x simple and surgical tooth extractions
x other selected oral surgery services
Periodontal Services (deductible applied)
x gingivectomy
x crown lengthening
x osseous surgery
x soft tissue grafts
x other selected periodontal services
PROSTHODONTIC
Prosthodontic Services (deductible applied)
x crowns/onlays
x partial and full dentures
x other selected prosthodontic services
Missing Tooth Benefit
Services for the replacement of teeth (tooth) lost prior to the
member's effective date of coverage under this plan.
x removable prosthodontics (partials or dentures)
x fixed prosthodontics (bridges) for the replacement of teeth
(or tooth)
ORTHODONTIC
Orthodontic Services (no deductible)
x non-surgical dental services related to the supervision,
guidance and correction of growing or mature teeth
x examination
x records
x tooth guidance
x repositioning (straightening) of the teeth
NETWORK/NON-NETWORK (MEMBER’S RESPONSIBILITY)
$0 Network and $50/$150 Non-network
None
Covered in full* Network and Non-network
BENEFITS
Separate Orthodontic Lifetime Maximum
NETWORK/NON-NETWORK (MEMBER’S RESPONSIBILITY)
$1,000 Network and Non-network combined
20% Network/20% Non-network
20% Network/20% Non-network
50% Network/50% Non-network
Not Covered
Child only to age 19: 50% Network/50% Non-network
Note: A waiting period may apply. Please refer to your Dental Certificate for additional information.
* When choosing a Non-network provider, the member is responsible for any balance due after the plan payment, including but not limited to, benefits that are covered in f
See back for additional important information
In Indiana: Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc.
In Kentucky: Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc.
In Ohio: Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company.
Independent licensees of the Blue Cross and Blue Shield Association.
51
2009
Open Enrollment
for
Employee Flex Benefits
October 14, 2008
through
NOVEMBER 10, 2008
COMMISSIONERS
Jimmy Dimora
Timothy F. Hagan
Peter Lawson Jones
Board of Cuyahoga County Commissioners
Office of Human Resources / Benefits Division
1255 Euclid Avenue, Room 310
Cleveland, OH 44115
Phone: 216-443-3539
Fax: 216-443-5600
Ohio Relay Service 711
www.hr.cuyahogacounty.us