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2020
A Guide to Your Benefits
Sinai Union
2
Welcome to your benefits
At LifeBridge Health, we CARE BRAVELY not only for our patients and their families, but also for our dedicated team members who help our patients and families every day.
Please use this benefits guide as a resource for the plans offered by LifeBridge Health for the 2020 calendar year. We want to ensure you understand the benefits and the packages we offer, so you can get the most out of them.
Please take the time to review the options outlined in this booklet and select coverage that works best for you and your family. Typically, unless you have a change in your family status, the selections that you make will stay in place for the entire 2020 calendar year.
If you have any questions, please do not hesitate to reach out to Employee Services by calling 410-601-8000 or emailing [email protected].
As a LifeBridge Health team member, your health and well-being are important to us. We are excited to CARE BRAVELY for you, so you can care for others, and we’re proud of the benefits that we have to offer to you and your loved ones.
Best,
Neil M. Meltzer President & Chief Executive Officer
Table of Contents3 Benefit Basics
5 Medical Plans
6 Prescription Drug Coverage
8 Health Savings Account
9 Flexible Spending Accounts
10 Dental Plan
11 Life Insurance & Disability
12 Additional Benefits
15 403(b) Retirement Savings Plan
16 Dependent Verification Process
17 Glossary of Terms
19 Contact Information
Enrolling in Your Benefits
Collect any dependent/spouse
documentation required and
submit to Employee Services
Review this guide and the information on
BridgeNet
New Hires You have 30 days to enroll in your benefits. If you do not enroll during this time, you will not be eligible to enroll until the next annual enrollment period unless you experience a qualified life event.
Pay close attention to your first paycheck
with your new payroll deductions
Make your benefit elections and enroll
in GHR
Review and print your benefits confirmation
statement
3
Benefit Basics
Your 2020 Benefits Are Effective January 1 Through December 31
You and the Affordable Care ActIf you work full-time, as defined by the Affordable Care Act (ACA) requires that LifeBridge Health offer you affordable medical coverage. If you are a part-time (.6 FTE or under) or variable hour associate, the number of hours you work may flex between full-and part-time employment which may impact your medical coverage eligibility each year. Full-time, as defined under the ACA, is working on average 30 hours per week during the applicable review period.
Making Changes During the Plan YearYou may only change your benefit elections during the year if you experience a qualified life event such as:
• Marriage, divorce or legal separation • Birth or adoption of a child • Death of your spouse or dependent child• Change in employment status of team member, spouse
or dependent child
To make changes, contact Employee Services within 30 days of a qualifying life event. You may need to provide proof of the event, such as a marriage license. If you don’t take action, you’ll have to wait until the next enrollment period to make changes unless you experience another qualifying life event.
Covering Yourself and Your FamilyMedical, prescription, dental and Spending Account benefits are effective 60 days after the day of hire (effective 61st day). All other benefits are effective the first of the month following 60 days of employment.
The following dependents are eligible:
• Your legal spouse
• Children up to age 26 (regardless of their student status or if they are claimed as a dependent for income tax purposes), or your disabled children if disabled before age 26*
*Note: Voluntary benefits may have different age requirements so please review the materials carefully.
Are You Providing Coverage to a New Dependent?If you enroll a new dependent for benefits, you will be required to provide documentation to confirm their eligibility. All documentation should be submitted to Employee Services at [email protected] or via fax at 410-601-8001. If you do not provide the required documents within 30 days, your dependents will not have coverage. View page 18 for detailed requirements.
4
Benefit Basics
LifeBridge Health pays the full cost of many of your benefits. For others, LifeBridge Health and you share the cost or you pay the full cost. Pretax means the cost comes out of your pay before taxes are deducted. After-tax means your cost comes out of your pay after taxes are deducted. The chart shows who pays for each benefit and the related tax treatment.
Benefit Who Pays Tax Treatment
Medical LifeBridge Health/You Pretax
Dental LifeBridge Health/You Pretax
Basic Life and Accidental Death & Dismemberment (AD&D) Insurance
LifeBridge HealthN/A, except on
Life Insurance greater than $50,000
Short-Term Disability Coverage
LifeBridge Health N/A
Buy-up Short-Term Disability Coverage
You After-tax
Employee Assistance Plan LifeBridge Health N/A
403(b) Retirement Savings Plan
LifeBridge Health/You Pretax
5
LifeBridge Health offers two medical plan options - administered by CareFirst BlueCross BlueShield (CareFirst). Each plan offers comprehensive health care benefits, including free preventive care services and coverage for prescription drugs. Here’s how the plans compare.
Health Saver Plan (with HSA) Premium Health Plan
Plan Provision LBH Network
CareFirst In-Network
Out-of-Network
LBH Network
CareFirst In-Network
Out-of-Network
Company Contribution to HSA 1 Individual Family
$7001 $1,4001 N/A
Calendar Year Deductible Individual Family
$2,800 $5,200
$3,000 $6,000
$3,000 $6,000
$100 $300
$600 $1000
$600 $1000
Annual Out-of-Pocket Maximum (Includes deductible, copays and coinsurances)Individual Family
$4,000 $8,000
$5,000 $10,000
$6,600 $13,200
$1,000 $3,000
$2,000 $6,000
$5,600 $11,200
You Pay You Pay
Primary Physician Office Visit 20%* 40%* 50%* $25 30%* 40%*
Specialist Office Visit 20%* 40%* 50%*$35 for first6 visits then
100%30%* 40%*
Preventive Care – one per calendar year (includes annual physicals, immunizations, routine cancer screenings and well child visits)
$0Plan pays 100%
$0Plan pays 100%
50%* $0Plan pays 100%
$0Plan pays 100%
40%*
Diagnostic Service (includes Advanced imaging (PET, MRI, CT), other imaging (X-ray, sonogram), Lab and other services)
20%* 40%* 50%* $02
Plan pays 100%30%* 40%*
Emergency Care3 20%* 20%* 20%* $100 copay per visit
$100 copay per visit
$100 copay per visit
Urgent Care 20%* 40%* 50%* $25 copay $35 copay 40%
Outpatient Facility and AmbulatorySurgical Facility 20%* 40%* 50%* $0* 30%* 40%*
Inpatient Hospitalization4 20%* 40%* 50%* $0* $500 copay + 30%*
$500 copay + 40%*
* After Deductible 1 If enrolling in the Health Saver Plan; the first half of funding is provided in January and the second half is provided in July as long as you are still enrolled in the plan.
2 Must be performed by LifeBridge Health Provider, designated LifeBridge health Lab or Facility.3 Emergency Room copay waived only if admitted; Emergency services available out-of-network.4 Pre-authorization required.
Important Considerations• You may use in- or out-of-network providers. You will always pay the least if you use the LifeBridge Provider Network.
Using a provider in the CareFirst network, instead of an out-of-network provider, will also help you save.
• You must meet an annual deductible before the medical plan begins to cover a portion of the cost for most care.
• Deductibles and Out-of-Pocket Maximums cross apply. Anything spent in either the LifeBridge Health Network, CareFirst In-Network or Out-of-Network levels will accumulate toward all deductibles and out-of-pocket maximums for the year.
• Out-of-pocket maximums apply to both plans. This is the maximum amount you will pay for health care costs in a calendar year. Your bi-weekly contribution rates will continue.
• You may be required to obtain pre-authorization from the plan prior to receiving certain services. If either you or your provider does not pre-authorize care when necessary, you may not have coverage for that service.
Medical Plans
6
Health Saver Plan (With HSA) Premium Health Plan
Plan Provision Retail and Mail Order LBH Pharmacy1CVS/Other Retail
Pharmacies
Annual Deductible
Individual Family
Included in Medical (see page 5)
$75 per person$225 per family
Annual Out-of-Pocket Maximum
Individual Family
Included in Medical (see page 5)
$1,000 per person$2,000 per family
Retail Prescription Drugs (30-day supply)
• Generic• Formulary• Non-formulary• Specialty
20%* 30%*40%*
50%* (LifeBridge Health Pharmacy only)
$10*2 $30*$50* $0*
$10*$40*$70*
Not Covered
Mail Order Prescription Drugs (90-day Supply)3
• Generic • Formulary• Non-formulary• Specialty
20%* 30%*40%*
50%* (LifeBridge Health Pharmacy only)
$20*2
$60*$100*$0*
$20*$80*$140*
Not Covered
*After deductible 1 LifeBridge Health Pharmacies: Sinai, Northwest, and Anchor Pharmacy (at Carroll Hospital Location only).2 $0 copay for generics to treat high blood pressure, cholesterol, depression and diabetes, if the prescription is filled at LifeBridge Health Pharmacy.3 Long Term Medications (Maintenance) must be filled at a LifeBridge Health Pharmacy or through CVS Mail Order.
Prescription Drug CoverageThis chart provides information about your prescription drug coverage. You can save on your prescriptions by using a LifeBridge Health Pharmacy (Sinai Pharmacy, Northwest Outpatient Pharmacy or Anchor Pharmacy, the on-site location at Carroll Hospital) or Mail Order.
Save With a LifeBridge Health PharmacyNo Cost Preventive Medications: There is no copay ($0) for generics used to treat high blood pressure, cholesterol, depression and diabetes if the prescription is filled at a LifeBridge Health Pharmacy.
Long-term Medications: You have two options to receive a 90-day supply if you are taking a long-term medication. Long-term medications are those taken regularly for chronic conditions such as high blood pressure, asthma, diabetes or high cholesterol, and must be filled using one of these options:
• Option 1: A LifeBridge Health Pharmacy, including Sinai Outpatient Pharmacy, Northwest Outpatient Pharmacy or Anchor Pharmacy, the on-site location at Carroll Hospital.
• Option 2: Mail Order through a LifeBridge Health Pharmacy or CVS Caremark. For LifeBridge Health, please call 410-601-7100 or visit lifebridgehealth.org/outpatientpharmacy. For CVS Caremark, call 866-294-2110 or visit www.caremark.com.
DefinitionsGeneric – A drug that offers equivalent uses, doses, strength, quality and performance as a brand-name drug, but is not trademarked.
Formulary – A drug with a patent and trademark name that is considered “preferred” by the drug plan administrator because it is appropriate to use for medical purposes and is usually less expensive than other brand-name drugs.
Non-formulary – This type of drug is “not preferred” and is usually more expensive than generic and formulary brand drugs.
Specialty – These drugs are typically the most expensive options, may require special handling, can be difficult to administer and often require additional clinical monitoring.
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Medical & Prescription Drug RatesBi-Weekly Rates Health Saver Plan (With HSA) Premium Health Plan
Full-Time Part-Time Full-Time Part-Time
Individual $36.92 $49.85 $72.00 $147.69
Associate/Spouse $81.23 $109.85 $158.77 $324.46
Associate/Child $59.08 $79.85 $115.38 $235.85
Associate/Family $103.38 $139.85 $201.69 $413.08
SurchargesIf applicable, there are two surcharges:
• Smoker Surcharge – $30 per pay period• Spousal Surcharge – $30 per pay period, if your spouse has access to other health coverage through their
employer and that employer is not LifeBridge Health.
Note: Surcharges are applicable only to enrollments in the Medical Plans
8
Health Savings Account A Health Savings Account (HSA) provides additional options for paying medical expenses with tax-free savings. LifeBridge contributes to your account to help offset some of your eligible expenses.
Account Type Health Savings Account (HSA)
Eligibility You must be enrolled in the Health Saver Plan with HSA and meet these requirements:
• Not be claimed as a dependent on another person’s tax return.• Not be covered under another medical plan that is not HSA-eligible • Not be enrolled in Medicare Part A or B, or be in receipt of VA medical or prescription benefits
within the previous three months.
Your contributions You contribute on a pretax basis and you can change how much you contribute from each paycheck. The IRS maximum annual contribution is $3,500 for individual coverage and $7,000 for family coverage. If you are age 55 or older, you may make a “catch-up” contribution of $1,000.
Company’s contributions LifeBridge Health contributes to your account (the first half is paid in January and the second half is paid in July as long as you are still enrolled in the plan).
• $700 for individual coverage• $1,400 for family coverageThe combination of your contribution and the company contribution cannot exceed the IRS maximum for 2020 of $3,550 for individual coverage and $7,100 for family coverage.
Eligible expenses Medical, dental, vision and prescription drug expenses incurred by you and your covered family members.
If you also wish to enroll in a Health Care FSA, you will only be eligible for a Limited-Purpose Health Care Flexible Spending Account (FSA).
Using your account Use the debit card linked to your HSA or submit a claim form to cover the expenses, or pay the expenses out of pocket and save your HSA money for future health care expenses.
Remaining Funds Any money left in your HSA at the end of the year will roll over to the next year — you’ll never lose your HSA dollars.
If you leave LifeBridge Health or retire, you can take your HSA with you so you can continue to pay and save for eligible health care expenses.
Fees There is a monthly fee of $2 for the HSA. As long as you are enrolled in the Health Saver Plan, at the end of the year, LifeBridge Health reimburses the fee for you.
Setting Up Your HSA
To set up your HSA, you must complete the Customer Identification Program (CIP) process within 90 days of enrolling. BNY Mellon will verify the information you provide, which is similar to the information you must provide when setting up any bank account. If additional information is needed, BNY Mellon will contact you via U.S. mail, and you will have up to 90 days to respond.
Once you pass the CIP process, you will receive a debit card from WageWorks in the mail. To view your balance, submit claims and more, set up a WageWorks account at www.wageworks.com.
Remember to set up your beneficiary directly with WageWorks.
9
Flexible Spending Accounts
A Flexible Spending Account (FSA) helps you pay for eligible health care costs using tax-free dollars. You decide how much money you would like to contribute to the account on a pretax basis.
Provision Limited Purpose (FSA)
BenefitsSpecifically for associates enrolled in the Health Saver Plan. Saves on eligible expenses not covered by insurance; reduces your taxable income
Your contributions* Maximum contribution is $2,700
Eligible expenses Eligible expenses are limited to qualifying dental and vision expenses.
Using your accountWhen you incur expenses, you can access account funds in your account to pay for eligible expenses.
Use the debit card linked to your HSA to cover the expenses, or pay the expenses out of pocket and submit a claim to be reimbursed by your FSA.
Use It or Lose It Reimbursable expenses must be incurred between January 1 and December 31. Claims for reimbursement must be submitted by March 31, of the following year. Please plan your contributions carefully. FSA elections do not automatically contribute from year to year, you must actively enroll each year.
*You are not able to make changes to your annual contribution unless you experience a qualified life event.
10
Dental Plan
Regular dental care is an important part of caring for your overall health. Your dental plan is the United Concordia Dental Plan.
Provision Silver Plan Gold Plan
In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible N/A N/A N/A N/A
Annual Maximum N/A N/A N/A $1,000 combined
Periodic Oral Evaluation $5 copay N/A $5 copay $12 allowance
Dental Bi-weekly Rates Silver Plan Gold Plan
Individual $0.00 $8.80
Employee/Child(ren) $0.00 $15.45
Employee/Spouse $0.00 $17.59
Family $0.00 $24.16
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Life Insurance & Disability
What would your family do if your income was lost due to death or disability? Life and disability insurance are important for you and your family’s financial security.
Company-Provided InsuranceLifeBridge Health automatically provides the following insurance benefits at no cost to you.1 You do not need to enroll.
Account Type Benefit
Basic Life Insurance
• 1x your base annual earnings, up to a maximum benefit of $50,000
Basic Accidental Death and Dismemberment (AD&D) Insurance
• 1x your base annual earnings, up to a maximum benefit of $50,000
Short-Term Disability for you
• 66.7% of your weekly earnings, up to $350 per week
• 14 calendar day elimination period • Benefits begin on the 15th day of
disability due to a non-work related injury and illness, and are payable up to the 26 weeks, if approved
Account Type Benefit
Buy-up Short- Term Disability for you
• Ability to purchase buy up to a maximum of $700 per week.
• Benefits begin on the 15th day of disability due to injury or illness, and are payable up to 26 weeks.
Reminder regarding Life Insurance: Keep your beneficiary information up-to-date in GHR.
Employee Paid Insurance
Important Considerations For Your Disability Plans• If approved by the carrier, your disability payments
begin after an elimination period. The elimination period is the length of time you must be continuously disabled and unable to perform your primary position (due to a non-work related injury or illness) and under the appropriate care of a physician before the disability benefits become payable.
• Benefits may be reduced by other income, such as Social Security.
• In your first 12 months of coverage, any disability that arises from a condition for which you received treatment or took medications to treat in the three months prior to your effective date will be excluded.
• To place a disability claim please contact Cigna directly.
12
Additional Benefits
Employee Assistance Program – CareBridge If you find yourself in need of professional support to deal with personal, work, financial or family issues, the Employee Assistance Program (EAP) can help. You and your immediate family (spouse, dependent children) can use the EAP for help with:
• Marriage and family problems• Job-related issues• Stress, anxiety and depression• Parent and child relationships• Legal and financial counseling• Identity theft counseling• Financial planning• Various other issues
The program is available 24/7, is completely confidential and offered at no cost. If you need help or guidance, call a CareBridge counselor at 800-437-0911 or visit www.myliferesource.com, access code: KKNH3.
Hyatt LegalAttorney fees can be expensive. With this plan, attorney fees for the legal services listed below are fully paid for when you use a network attorney. There is no limit on the number of times you may use the plan.
Covered services include, but are not limited to:
• Wills, trusts, powers of attorney, guardianship• Mortgages, home equity loans, deeds, property
tax assessments• Small claims assistance• Elder law• Identity theft• Immigration assistance• Debt collection defense/consumer protection• Bankruptcy issues• Adoption• Traffic ticket defense, restoration of driving privileges
Bi-weekly Rate
Hyatt Legal $8.54
Group Voluntary Critical Illness CoverageGroup Voluntary Critical Illness coverage through MetLife pays benefits for non-medical, critical illness-related expenses that your medical plan might not cover. Benefits are in the form of a lump sum payment, which is paid after a diagnosis is made.
Critical Illness Insurance
Eligible Individual Initial Benefit
Employee $10,000 or $20,000
Spouse 100% of the employees Initial Benefit
Dependent Children 50% of the employee's Initial Benefit
Your initial benefit provides a lump-sum payment upon the first diagnosis of a covered condition. Your plan also pays a recurrence benefit for the certain covered conditions. The maximum amount that you can receive through your Critical Illness Insurance is three times the amount of your initial benefit.
MetLife will provide an annual benefit of $50 per calendar year for taking one of the eligible screening/prevention measures. MetLife will pay only one health screening benefit per covered person per calendar year. More details can be found on BridgeNet.
13
Group Voluntary Accident CoverageGroup Voluntary Accident coverage through MetLife can pay benefits for off-the-job accidents, plus some benefits that correspond with medical care. The coverage can be used on its own or to fill a gap left by other coverage. It pays a benefit up to a specified amount for dislocation/fracture, initial hospitalization confinement, hospitalization confinement, intensive care, ambulance service, medical expenses, outpatient physician’s treatment and more.
The below chart shows a range of potential payment amounts for a given category of covered conditions. Actual payments are determined by the benefit type.
Covered Benefits Low Plan High Plan
MetLife Accident Insurance Pays You MetLife Accident Insurance Pays You
Injuries – 12 covered injury types
Ranging from $25 – $5,000 per injury Ranging from $50 – $10,000 per injury
Medical Services & Treatment – 15 covered types
Ranging from $15 – $1,000 per medical service/treatment type
Ranging from $25 – $2,000 per medical service/treatment type
Hospital Coverage (Accident) $500 (non-ICU) or $1,000 (ICU) per accident $1,000 (non-ICU) or $2,000 (ICU) per accident
Admissions $100 per day (non-ICU), up to 31 days $200 per day (non-ICU), up to 31 days
Confinement $200 per day (ICU), up to 31 days $400 per day (ICU), up to 31 days
Inpatient Rehab$100 per day, up to 15 days per accident and 30 days per calendar year
$200 per day, up to 15 days per accident and 30 days per calendar year
Accidental Death$25,000 $75,000 is passenger in common carrier
$50,000 $150,000 is passenger in common carrier
Dismemberment, Loss & Paralysis $250 - $10,000 per injury $500 – $50,000 per injury
Lodging$100 per night, up to 31 nights; up to $3,100 in total lodging benefits available per calendar year
$200 per night, up to 31 nights; up to $6,200 in total lodging benefits available per calendar year
Health Screening (Wellness)$50 payable 1x per covered insured per calendar year, if covered insured takes a covered test
$50 payable 1x per covered insured per calendar year, if covered insured takes a covered test
Bi-Weekly Group Voluntary Accident Rates Low Plan High Plan
Employee Only $3.30 $5.46
Employee Plus Spouse $6.94 $11.63
Employee Plus Child $6.92 $11.40
Family $8.34 $14.34
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Identity Theft ProtectionThis service through InfoArmor is designed to protect your identity and assets through identity, credit and social media monitoring. InfoArmor also extends dependent coverage to any dependent who lives in the same household as the employee or who is financially dependent on them, with no age limit.
PrivacyArmor is available in two comprehensive plans to fit your needs with PrivacyArmor Essential and PrivacyArmor Plus. Both products include:
• Identity and credit monitoring• Annual credit report and monthly credit score tracking• Threshold monitoring• Social media reputation monitoring• Digital wallet storage and monitoring• Full-service identity restoration• $1,000,000 identity theft insurance policy• A digital exposure report
Note: If you are newly enrolling, you need to set up an account with InfoArmor. You will receive a home mailer and an email to your work email address.
Learn more at MyPrivacyArmor.com Questions? Contact InfoArmor
PrivacyArmor Essential PrivacyArmor Plus
$3.66 per Individual per Paycheck
$4.59 per Individual per Paycheck
$6.43 per Family per Paycheck
$8.28 per Family per Paycheck
Feature PrivacyArmor Essential
PrivacyArmor Plus
Credit Monitoring Tri-Bureau Credit Monitoring
Annual Credit Report Monthly Credit Score Tracking Social Media Reputation Monitoring Digital Wallet Storage & Monitoring Full-Service Identity Restoration Privacy Advocate Assistance $1,000,000 Identity Theft Insurance Policy Expanded Data Sources for Transactions on Financial Accounts
Additional Proactive Alerts on Financial Account Transactions
Threshold Monitoring on all Financial Accounts
Pet InsurancePet Insurance through PetFirst helps offset the cost of caring for your dog or cat, and covers everything from preventive care to accidents and illness, as well as the costs of X-rays, office visits, medications, surgeries and hospital stays.
Home and Auto Discount ProgramYou can receive special group discounts on auto, home, and renter’s insurance through Liberty Mutual. The policies are tailored to suit your needs. Please contact Liberty Mutual to inquire and/or enroll.
Please note: Liberty Mutual will bill you directly. No payroll deduction is offered.
15
403(b) Retirement Savings Plan
LifeBridge Health offers 403(b) Retirement Savings Plan giving you an easy way to save for your future through payroll deductions.
EligibilityYou are eligible to participate in the plan on your date of hire.
Your ContributionsContributions from your pay are made on a pretax basis up to the IRS annual limit of $19,500 for 2020. If you are 50 years of age or older, (or if you will reach age 50 by the end of the year), you may make an additional catch-up contribution of $6,500, in addition to the IRS annual limit.
Vesting Vesting refers to your right of ownership to the money in your account. You are immediately vested in all of your contributions and earnings on your contributions.
For More InformationFor additional details about the 403(b) Retirement Savings Plan or to enroll or change your contribution rates or investment elections, please refer to Transamerica Retirement Solutions at 800-755-5801, or www.lbh.trsretire.com.
Remember: you can make changes to your 403(b) plan at anytime during the plan year.
16
You are required to complete the Dependent Verification Process for any dependent or spouse that will be newly covered with LifeBridge Health Benefits. If you are not sure if you have the required dependent verification on file, please contact Employee Services. Your dependent(s) will not have coverage until you complete this process.
As part of our commitment to control health care costs, LifeBridge Health (LBH) is taking steps to ensure that only eligible dependents are covered under our medical, dental and/or vision plans. To accomplish this, LBH has implemented a dependent verification program. This process is intended to ensure that each dependent enrolled in the LBH medical, dental and/or vision plans is accurately listed and eligible for coverage.
There are three (3) steps to the verification program clearly detailed below. Please complete all 3 steps for the dependents you enrolled in benefits, if applicable.
1. Make sure that you provide legible copies of all required documentation.
2. Write your name and employee ID number on each piece of documentation.
3. Write “Not For Official Use” on each document and cross out the first five digits of any social security number.
Required Documentation:Spouse:
• A copy of your marriage certificate AND• One form of documentation establishing current marital
status such as a joint household bill, joint bank/credit account, joint mortgage or lease, or front page of your jointly filed federal tax return.
Child:
• A copy of the child’s birth certificate, naming you or your legally married spouse as the child’s parent, or appropriate court order / adoption decree naming you or your legally married spouse as the child’s legal guardian.
Disabled Dependent:
• A copy of the child’s birth certificate, naming you or your legally married spouse as the child’s parent, or appropriate court order / adoption decree naming you or your legally married spouse as the child’s legal guardian AND
• A copy of a physician certification confirming the child’s disability status.
All required documentation must be received by Employee Services as soon as possible. You can submit documentation via fax at 410-601-8001 or email at [email protected]
Your dependent(s) will not have coverage until we receive the documentation. If documentation is not received within 30 days of your start date, your dependent will not be eligible for coverage until the next open enrollment period unless they experience a qualifying life event.
If you have any questions regarding this process please contact Employee Services at 410-601-8000 or [email protected]
Dependent Verification Process
17
Glossary of Terms
After-tax – The contributions you make for benefits such as Life and AD&D insurance and Disability insurance are subject to Social Security tax, federal income tax and, in most cases, state and local income taxes.
Calendar Year Maximum – The benefit amount paid each year for each family member enrolled in the dental plan.
Coinsurance – The sharing of cost between you and the plan. For example, 80 percent coinsurance means the plan covers 80 percent of the cost of service after a deductible is met, and you will be responsible for the remaining 20 percent of the cost.
Copay – A fixed amount (for example $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
Deductible – The amount you have to pay for covered health care services before your health plan begins to pay.
Elimination Period – The time period between the beginning of an injury or illness and receiving benefit payments from the insurer.
Health Savings Account (HSA) – An HSA is a personal health care account for those enrolled in an HDHP. You may use your HSA to pay for qualified medical expenses such as doctor’s office visits, hospital care, prescription drugs, dental care, and vision care. You can use the money in your HSA to pay for qualified medical expenses now, or in the future. Your HSA can be used for your expenses and those of your spouse and dependents, even if they are not covered by the HDHP.
High Deductible Health Plan (HDHP) – A qualified High Deductible Health Plan (HDHP) is defined by the Internal Revenue Service (IRS) as a plan with a minimum annual deductible and a maximum out-of-pocket limit. These minimums and maximums are determined annually and are subject to change.
In-network – A designated list of health care providers (doctors, dentists, etc.) with whom the health insurance provider has negotiated special rates. Using in-network providers lowers the cost of services for you and the Company.
LifeBridge Health (LBH) Network – LifeBridge Health Provider Network
Out-of-network – Health care providers that are not in the Plan’s network and who have not negotiated discounted rates. The cost of services provided by out-of-network providers is much higher for you and the Company. Additional deductibles and higher coinsurance will apply.
Out-of-pocket maximum – The most you will pay of your own money before services are 100 percent covered by the medical plan. Your annual deductible is included in your out-of-pocket maximum.
Pretax – The contributions you make for medical, dental, vision, HSA, FSA health care spending and FSA dependent care spending are not subject to Social Security tax, federal income tax or, in most cases, state and local income taxes.
Reasonable & Customary Charges (R&C) – Prevailing market rates for services provided by health care professionals within a certain area for certain procedures. Reasonable and Customary rates apply to out-of-network charges.
18
Notes
19
Contact InformationPlan Provider Phone Number Website
Medical CareFirst 866-595-6245 www.carefirst.com
Prescription Drugs CVS 866-294-2110 http://caremark.com/wps/portal
Dental UCCI 866-357-3304 www.unitedconcordia.com
Flexible Spending Accounts WageWorks 877-924-3967 www.wageworks.com
FMLA/LOA Requests FMLA Source 877-462-3652 www.fmlasource.com
Credit Union First Financial Federal
Credit Union410-321-6060 www.firstfinancial.org
Health Savings Account (HSA) WageWorks 877-924-3967 www.wageworks.com
Life Insurance and AD&D MetLife 800-438-6388 www.mybenefits.metlife.com
Disability Cigna 800-781-2006 www.cigna.com
Employee Assistance Program Carebridge800-437-0911
Company Access Code: KKNH3
www.myliferesource.com
Critical Illness/Accident Insurance
MetLife 800-438-6388 www.mybenefits.metlife.com
Legal Assistance Hyatt Legal 800-438-6388
Company Access Code: 571687
www.mybenefits.metlife.com
Identity Theft Protection InfoArmor 800-789-2720 www.InfoArmor.com
Home and Auto Insurance Liberty Mutual 800-295-3549 www.libertymutual.com
Pet Insurance PetFirst 866-937-7387 www.petfirst.com/lifebridge
403(b) Retirement Savings PlanTransamerica
Retirement Solutions800-755-5801 www.lbh.trsretire.com
Additional Resources Service Phone Number Website
Employee ServicesFor HR/Benefit/Payroll
inquires410-601-8000 [email protected]
Mobile Wallet Card
Provides you access to plan contact
information, group numbers and benefit
guides anywhere from your computer or
mobile phone
— mymobilewalletcard.com/lifebridge
Enrollment Counselors
Additional support in understanding your
benefits and/or to make enrollment elections
855-736-1446 —
About this Guide: This benefit summary provides selected highlights of the LifeBridge Health employee benefits program. It is not a legal document and shall not be construed as a guarantee of benefits nor of continued employment at the company. All benefit plans are governed by master policies, contracts and plan documents. Any discrepancies between any information provided through this summary and the actual terms of such policies, contracts and plan documents shall be governed by the terms of such policies, contracts and plan documents. LifeBridge Health reserves the right to amend, suspend or terminate any benefit plan, in whole or in part, at any time. The authority to make such changes rests with the Plan Administrator.