Welcome to Open Enrollment Mercy Medical ... - Trinity Healthmybenefits.trinity-health.org/documents/Clinton Final.pdf · and platinum. The graphic shows where each of the choices

Welcome to Open Enrollment Mercy Medical CenterClinton!Trinity Health and Mercy Medical CenterClinton are pleased to provide you with the information you will need to enroll in benefitsfor next year. Throughout the rest of this communication, you will see Trinity Health and Mercy Medical CenterClinton referred toas simply Trinity Health. If you have more questions after reviewing this guide, refer to the For More Information section to learnwhere you can get answers.

Whats Inside

Whats New for 2017 2

Who is Eligible 3

About the Medical Plans 4

Medical Coverage 5

Medical Plan Highlights 6

More About the Health 8Savings PPO

Live Your Whole Life 9

More About the Medical 10Plans

Dental Coverage 11

Vision Care Coverage 12

Flexible Spending 13Accounts

Life Insurance 14

Time Away from Work 15

Voluntary Benefits 16

How to Enroll 17

For More Information 18

Important Reminders 19

Additional Notices

Your Top Three Tasks for Open Enrollment

1 Review and make changes to your benefit elections byNov. 2, 2016.

2 Review and update your beneficiaries.

3 Submit your Personal Health Application for life insurance toThe Hartford by Jan. 9, 2017, if applicable.

Its also a good time of year to:

Update your personal information through Self-Service (ESS).

Check the eligibility rules if you, your spouse/eligible adult and/or dependent childboth work at Trinity Health at http://mybenefits.trinity-health.org.

Review the Live Your Whole Life section of this Guide to learn about resourcesthat will help you maintain your health and incentives on your medicalcontributions throughout the year.

Print copies of your benefit elections for proof of enrollment.

If you want to contribute to the Health Savings Account, the Health Care orDependent Care Flexible Spending Accounts or elect PTO cash-out, you mustmake an election. Last years election will not carry forward.

If you want to participate in the Essential PPO Assist Plan for 2017, you mustapply each year and meet specific income and eligibility guidelines. For moreinformation on the Essential PPO Assist Plan, refer to page 7.

Mercy Medical CenterClinton 1

Whats New for 2017

We have a new health insurance provider - BlueCrossBlueShield. As a result, you will receive new insurancecards.

You will have the opportunity to contribute $50 moreper year to your HSA, up to a maximum of $3,400 in2017, if you have colleague only coverage. The IRScontribution limit for all other coverage levels remains$6,750. Trinity Healths contribution amount to yourHSA will remain the same as in 2016.

If you apply and qualify for the Essential PPO Assistplan for 2017, the total amount Trinity Healthcontributes to your employer sponsored HealthReimbursement Account (HRA) increases from $750 to$850 for colleague only coverage and increases from$1,500 to $1,700 for all other coverage levels.

Beginning January 1, 2017, your dental coverage willcover ceramic and porcelain fillings for posterior teethand fluoride treatment up to age 19 (previously age 14).

Beginning January 1, 2017, we will be offering animproved well-being program to help you maintain alower contribution per pay period for your medical costs.Updates to the Live Your Whole Life website allow foreasier navigation and a more user-friendly experience.

If you have family coverage or have a spouse on yourplan, please note that there are now separate incentiveamounts for colleagues and spouses/eligible adults inthe Live Your Whole Life program with Traditional,Health Savings or Essential PPO Plans. If both youand your spouse/eligible adult complete the activities ineach period, you will maintain the Full Incentiveamounts. If only one of you completes the activities ineach period, you will start earning the 1-PersonIncentive amounts.

Your Enrollment RequirementsIf you dont make benefit elections on or before Nov. 2, 2016, you will automatically receive a default package ofbenefits, which includes the same elections you had last year for medical, dental, vision, life insurance, AD&D anddisability. Keep in mind:

If you want to contribute to the Health Savings Account, the Health Care or Dependent Care Flexible SpendingAccounts or elect PTO cash-out you must make an election. Last years election will not carry forward.

If you want to participate in the Essential PPO Assist Plan for 2017, you must apply each year and meet specificincome and eligibility guidelines. For more information on the Essential PPO Assist Plan, refer to page 7.

If you wish to participate in these programs next year you must complete your enrollment by Nov. 2, 2016 at 11:59p.m. EST.

2 Mercy Medical CenterClinton

Adding FamilyMembersIf youre adding family members toyour benefit plan during this yearsopen enrollment, youre required toprovide written documentation (forexample, marriage certificate orbirth certificate) verifying theirdependent status to HumanResources no later than Nov. 4,2016. If you dont submit therequired documentation by thedeadline, your dependents willnot be enrolled for coverage for2017, and youll be required towait until next years openenrollment period to add them tothe plan provided they remaineligible, and you provide writtendocumentation verifying theirdependent status at that time.

You are required to provide a SocialSecurity number for each of yourdependents over the age of one inorder for them to be covered.Please provide any missingdependent Social Security numbersto Human Resources.

Please note, you have the option topurchase coverage for yourspouse/eligible adult anddependents. If you and yourspouse/eligible adult ordependent(s) both work for TrinityHealth, and are benefits eligible, youcannot elect dual coverage (enrolledas a colleague and a dependent). Inaddition, only one of you will be ableto elect coverage for your child(ren).

Who Is Eligible

Eligible Individual Definition

Colleague Regularly scheduled full- or part-time colleague with 32 ormore budgeted hours per pay period (32 or more

budgeted hours per pay period for short-term disability

and 32 or more budgeted hours per pay period for

long-term disability.)

Spouse/Eligible Adult You may cover your spouse or Eligible Adult. An EligibleAdult is an adult who resides and has financial

interdependence with the colleague, and is not a tax

qualified dependent or related by blood, adoption or

marriage to the colleague.

Dependent Children Dependent children are eligible for coverage through theend of the Plan Year in which they turn age 26, regardless

of marital status, student status, residency, financial

dependency or other requirements provided they meet all

of the following criteria:

They are:

Your or your spouse/eligible adults natural children;

Your or your spouse/eligible adults legally adopted

children or children placed with you or your eligible adult

for adoption; or

Children for whom you or your spouse/eligible adult are

the court-appointed legal guardian.

Not otherwise covered under the Plan or any other

group health plan offered by the Employer.

Note: Children of eligible adults may be covered only if

their eligible adult is covered.

New HiresNew hires are eligible for benefits on the first day of the month following 30days of employment.

To view the complete eligibility rulesand documentation requirements foryou and your family visithttp://mybenefits.trinity-health.org.


More about the Clinically-Integrated NetworkA Clinically-Integrated Network (CIN) joins local physicians and health care providers that have made a decision to partner witha Regional Health Ministry (RHM) to deliver services focused on high quality and cost-efficient care designed to improve thehealth of those we serve.

Seeking care within the CIN can help you and your physician make health care decisions that ensure that you are accessing theright care, at the right time, in the right setting. In addition, by utilizing our CIN you will pay less out-of-pocket for the care youreceive, because all of the CIN providers are in our Tier 1 network.

Choose your Primary Care Physician (PCP)Maintaining a relationship with your PCP is important because they are trained to recognize any health problems you may have.A PCP is the doctor you see for most services, including annual check-ups. Your PCP can also help you identify and meet yourhealth goals and help you prevent serious, long-term health conditions. And, by following their preventive recommendations,they can help keep your health care costs low. Trinity Health encourages you to select a PCP and develop a relationship withthem. To find an in-network physician or provider, visit http://mybenefits.trinity-health.org.

Trinity Health Offers Choice in Medical BenefitsYou may be wondering how your benefits at Trinity Health compare with those offered through the Marketplace. On thehealth insurance Marketplace, the value of each medical plan is categorized into a Metal rating bronze, silver, goldand platinum. The graphic shows where each of the choices at Trinity Health falls on the continuum of coverageavailable on the Marketplace. Our plans range from covering benefits higher than the Silver Marketplace plan to justbelow the Platinum plan.

TraditonalPPO


Watch this Videoto Learn More

Scan the tag with yoursmartphone to downloadand view a video aboutyour 2017 medical planchoices. Get the freemobile application athttp://www.scanlife.com/get-the-app. If you dont have asmartphone, visit yourbenefits website to view thevideo.

Medical CoverageTrinity Health is offering you three medical plan choices for 2017 which support ourefforts to provide a common experience for all colleagues and provide meaningfulchoices. All three plans are administered by BlueCross BlueShield of Michigan andsupport our clinically-integrated network structure.

The three medical plan options are the Traditional PPO, the Health Savings PPO,and the Essential PPO. Each plan offers these three tiers so you can pay less byreceiving care from network providers.

Tier 1, or the Mercy ACO network providers, are facilities or physicians alignedwith our organization that provide you with the most cost-effective care. Forservices unavailable through Mercy ACO network providers, select BlueCrossBlueShield providers will be available at the Tier 2 benefit level.

Tier 2 includes select BlueCross BlueShield Providers (facilities andphysicians) not listed under Tier 1. Using Tier 2 providers can save youmoney, but not as much as using our Tier 1 network.

Tier 3 providers are out-of-network providers (for example, Mayo Rochester)and this Tier provides the lowest level of coverage. You can use these facilitiesand physicians for care, but you will pay the most out of your pocket when youdo. Out-of-network referrals are required for all three medical plans.

How the medical plan works

Traditional PPOIf you elect coverage under the Traditional PPO, you pay for a portion of the medical services you receiveuntil you meet the annual deductible. Then, coinsurance begins up to the annual out-of-pocket maximum.

Health Savings PPOWith the Health Savings PPO, you pay less per pay period for coverage leaving more money in yourpaycheck and you have access to a Health Savings Account (HSA) to help pay for current and futuremedical expenses. Heres how it works:

First You pay the full cost of medical and prescriptionexpenses until you reach the annual deductible (Note:preventive care services and certain preventive 90-daygeneric prescriptions do not require you to meet thedeductible).

Second Once you meet the deductible, you pay coinsurance untilyou reach the out-of-pocket maximum.

Third Once you reach the out-of-pocket maximum, TrinityHealth pays 100% of all remaining eligible expensesduring the year.

To learn more about the Health Savings PPO, see page 8 of thisenrollment guide.

If you enroll in the Health SavingsPPO, you will automatically havean HSA. Trinity Health and MercyMedical CenterClintoncontribute to your HSA to helpyou pay for expenses toward yourannual deductible andout-of-pocket maximum. You canalso contribute to this account tobuild savings for current andfuture medical expenses. Weencourage you to consult with atax advisor for IRS rules and taximplications related to HSAs.

Essential PPOThe Essential PPO works the same as the Traditional PPO where you pay for a portion of the medicalservices you receive until you meet the annual deductible. Then, coinsurance begins. If you elect theEssential PPO, you pay less in premium contributions than in the Traditional PPO, however, yourout-of-pocket costs are higher.


Medical Plan HighlightsFor more information about your medical plan options or to find a provider, visit http://mybenefits.trinity-health.org.

Medical Plan Network Tier Traditional PPO Health Savings PPO1 Essential PPO1

Highlights

Trinity Health-funded account All Tiers N/A HSA: $650 / $1,300 HRA: $850 / $1,700(Individual / Family) if you qualify

Tier 1 $250 / $500 $1,300 / $2,600 $1,000 / $2,000

Annual deductible Tier 2 $750 / $1,500 $2,500 / $5,000 $2,500 / $5,000(Individual / Family)

Tier 3 $1,500 / $3,000 $3,500 / $7,000 $4,000 / $8,000

Tier 1 10%* 10%* 20%*

Coinsurance Tier 2 20%* 20%* 30%*

Tier 3 40% R&C* 40% R&C* 40% R&C*

Tier 1 0% no deductible 0% no deductible 0% no deductible

Preventive care Tier 2 0% no deductible 0% no deductible 0% no deductible

Tier 3 40% R&C* 40% R&C* 40% R&C*

Tier 1 $20 / $30 10%* 20%*

Office visit Tier 2 $30 / $40 20%* 30%*(PCP / Specialist)

Tier 3 40% R&C* 40% R&C* 40% R&C*

Urgent care visit All Tiers 0% after $35 copay 10%* 20%*

Emergency room All Tiers 0% after $100 copay 10%* 0% after $100 copay

Tier 1 None** None ** None**

Inpatient Tier 2 $500** $500** $750**admission

Tier 3 $1,000** $1,000** $1,000**

Tier 1 $50** None** $50**

Outpatient Tier 2 $100** $100** $100**surgical services

Tier 3 $200** $200** $200**

Tier 1 $2,500 / $5,000 $2,600 / $5,200 $3,500 / $7,000Out-of-pocketmaximum Tier 2 $4,750 / $9,500 $5,000 / $10,000 $5,500 / $11,000(Individual / Family)

Tier 3 $9,500 / $19,000 $7,000 / $14,000 $9,000 / $18,000Trinity-Health Retail Trinity-Health Retail Trinity-Health Retail

Owned Pharmacy Pharmacy Owned Pharmacy Pharmacy Owned Pharmacy Pharmacy

Generic $8 $10 $8 $10Prescription drug Brand formulary 16% ($24 min, 20% ($30 min, 16% after 20% after 20% ($24 min, 25% ($30 min,34 day supply $64 max) $80 max) deductible, 0% deductible, 0% $64 max) $80 max)

after out-of-pocket after out-of-pocketBrand 32% ($48 min, 40% ($60 min, max max 40% ($48 min, 50% ($60 min,non-formulary $80 max) $100 max) $96 max) $120 max)

Trinity-Health Mail Trinity-Health Mail Trinity-Health MailOwned Pharmacy Order Owned Pharmacy Order Owned Pharmacy Order

Generic $24 $25 $24 $2590 day supply Brand formulary 16% ($72 min, 20% ($75 min, 16% after 20% after 20% ($72 min, 25% ($75 min,

$192 max) $200 max) deductible, 0% deductible, 0% $192 max) $200 max)after out-of-pocket after out-of-pocket

Brand 32% ($144 min, 40% ($150 min, max max 40% ($144 min, 50% ($150 min,non-formulary $240 max) $250 max) $288 max) $300 max)

Out-of-pocket maximum based on Deductible and out-of-pocket Out-of-pocket maximum based onTier 2 based on Tier 1 Tier 2

1The individual deductible only applies to those enrolled in colleague-only coverage for the Health Savings PPO and Essential PPO Assist Plans. For allother coverage levels, the full family deductible must be met even if only one person in the family is receiving care.

*Subject to deductible.**Subject to deductible and coinsurance.Select, generic preventive drugs are covered at 100% and are not subject to the annual deductible. See the MyBenefits website for thecomplete list of eligible drugs.


Paying for medical coverageContribution levels for the medical plans are based on the Social Security taxable wage base ($118,500 for 2016, indexedannually) to ensure our benefit plan cost-sharing model is appropriately aligned with our colleagues income levels. The amountyou pay for medical coverage is based on your annual base salary (your base rate of pay times your budgeted hours) and yourparticipation in the Well-Being programs. If at any time during the 2017 plan year, you earn $118,500 or more, you will pay ahigher premium contribution per pay period for your medical insurance.

Traditional PPO Health Savings PPO Essential PPOFull TimeFull 1 - Person No Full 1 - Person No Full 1 - Person No

Your per pay period cost Incentive Incentive Incentive Incentive Incentive Incentive Incentive Incentive Incentive

For colleagues earning less than the 2016 SSTWB - Level 1

Colleague only $85.88 N/A $100.88 $60.03 N/A $75.03 $35.53 N/A $50.53

Colleague plus spouse/ $207.83 $222.83 $237.83 $176.08 $191.08 $206.08 $117.23 $132.23 $147.23eligible adult

Colleague plus child(ren) $146.43 N/A $161.43 $124.05 N/A $139.05 $82.60 N/A $97.60

Colleague plus family $259.79 $274.79 $289.79 $220.09 $235.09 $250.09 $146.54 $161.54 $176.54

For colleagues earning the 2016 SSTWB or more - Level 2





Traditional PPO Health Savings PPO Essential PPOPart TimeFull 1 - Person No Full 1 - Person No Full 1 - Person No

Your per pay period cost Incentive Incentive Incentive Incentive Incentive Incentive Incentive Incentive Incentive

For colleagues earning less than the 2016 SSTWB - Level 1





For colleagues earning the 2016 SSTWB or more - Level 2





The 2016 Social Security taxable wage base (SSTWB) is $118,500.

Need help with your health care costs?You may be eligible for the Essential PPO Assist plan (Assist Plan) if you meet certainincome requirements. It is the same as the Essential PPO, but includes a TrinityHealth-funded Health Reimbursement Account (HRA) to help you pay for your health carecosts at the time of service. To participate in the Assist Plan, you must apply and meetspecific income and eligibility guidelines. To learn more, see the application form on theMyBenefits website. Apply by submitting a completed application form with a copy of yourmost recent Federal Income Tax Form 1040 or 1040EZ to Human Resources by Nov. 4,2016.

NOTE: If you think you qualify for the Assist Plan, you should elect the medical plan youthink will be best for you which could be the Traditional PPO, the Health Savings PPO, orthe Essential PPO. If you qualify for the Assist Plan, you will be moved to the Assist Plan.Otherwise, you will remain in the plan you elected during open enrollment.

How do theIncentives work?For more informationon how to achieve Fulland 1-Personincentives, see the LiveYour Whole Life sectionon page 9.


More about theHealth SavingsPPOThe Health Savings PPOis a consumer-drivenhealth plan which givesyou the opportunity toparticipate in a plan whereyour health care costs aremore closely determinedby your decisions. Hereare some reasons toconsider choosing theHealth Savings PPO in2017:

I liked that I savedmoney in premiumcontributions spending moneyonly when I usedmedical care.

I can really savefor my health careexpenses when Iuse the HSA.

Its great that TrinityHealth makes its fullcontribution to my HSAin January.

For certain genericpreventive drugs anddiabetes and asthmadrug classes, I didnthave to pay mydeductible before theplan started payingthose expenses.

How thedeductible worksThe Health SavingsPPO Plan includes acombined deductible.A combineddeductible means thefull family deductiblemust be met even ifonly one person inthe family is receivingcare. Coinsurancebegins once thecombined deductiblehas been met.

How the Health Savings Account (HSA) worksWhen you enroll in the Health Savings PPO plan, you automatically have a Health SavingsAccount (HSA) through Health Equity to help you pay for current or future health care costs.Trinity Health will make a full contribution to your account in January based on the coveragelevel you elect. In addition, you can also contribute to this account up to IRS limits:

Coverage Level Trinity Health Your Voluntary Total IRS AllowedContributions Contributions* HSA Contributions

Colleague only $650 $2,750 $3,400All other coverage levels $1,300 $5,450 $6,750

*If you are 55 or older, you can contribute an additional $1,000 in catch-up contributions to your HSA.May be subject to state taxation.

Questions about the HSA

How do I get an HSA? To be eligible for the HSA, you must enroll in the Health SavingsPPO. In addition, you cannot have coverage under any other medical plan, such as Medicare,TRICARE, or coverage through a spouses health plan.

Who can use funds in my HSA? You and your dependents can pay for medical, dental andvision expenses with funds in your HSA. Dependents must be claimed on your tax return.

Why would I contribute to my HSA? Contributions to the HSA are a great way to save ontaxes. With the HSA, you do not pay taxes on the amount you contribute through payrolldeductions, the amount you withdraw for medical expenses, and the interest you earn in theaccount (up to amounts set by federal law). Keep in mind that you can change the amountyou contribute to your HSA at any time during the plan year.

How can I use the money in my HSA? You may use the HSA to pay for qualified medicalexpenses now and during retirement for you and your qualified dependents.

How do I pay for medical expenses with my HSA? When you receive eligible health careservices, you can pay for those services with your HSA debit card, or through several onlineand smartphone app options. Youll receive more information about your payment options ifyou enroll in the Health Savings PPO with the HSA.

What happens if I dont use all the money in my HSA each year? Any money you donot use during the year is carried over, without any limits. Remember, you own the money inyour HSA and it is yours to keep even when you change jobs or retire.

Can I enroll in the Health Care Flexible Spending Account (HCFSA) if I have anHSA? When you enroll in the Health Savings PPO which includes the HSA, you will not haveaccess to the health care flexible spending account (HCFSA). However, the HSA may be seenas having more advantages over the HCFSA including:

The opportunity to carry over savings from year to year you do not forfeit any amount inyour HSA at the end of the plan year (if you are currently enrolled in the HCFSA for 2016and you elect the HSA for 2017, you must utilize your account funds by Dec. 31, 2016);

Contributions of up to $6,750 in tax-free HSA dollars each year (the HCFSA maximum is$2,550);

Your HSA dollars are saved in a bank account that may earn interest.How do I know if the Health Savings PPO, including an HSA, may be right for me?Your medical plan choice depends on your personal situation. If you answer yes to some ofthese questions, the Health Savings PPO plan may be right for you:

Would you like to have lower per pay period contributions deducted from your paycheck? Do you want to save on taxes by contributing to the

HSA for your health care costs?

Do you need a way to pay for future health care costs? Can you see your HSA balance growing as you keep

making contributions each year?

We encourage you to consult with a tax advisor for IRSrules and tax implications related to an HSA.

May be subject to state taxation.

For more information about the HealthSavings PPO, including the HealthSavings Account (HSA), visitwww.healthequity.com/ed/trinityhealthor http://mybenefits.trinity-health.org.


Live Your Whole LifeStaying healthy all the way around - in body, mind, and spirit - makes us happier and more productive at home and on the job. AtTrinity Health, we believe that an annual Health Assessment, a Health Screening and healthy activities are essential steps inunderstanding your well-being. Its so important that we provide an incentive when you and your covered spouse or eligible adultcomplete these steps.

To continue complying with the legal requirements for wellnessprograms, Trinity Health made some changes to the incentives for2017. Heres how this years program will work:

1 All colleagues start with the Full Incentive amounts.Note: See the box to the right to understand the new optionsfor Full and 1-Person Incentives.

2 There are two Periods where you can earn LifePoints tomaintain your Full Incentive amounts.

3 To maintain these incentives throughout the year, youneed to earn 100 LifePoints in each Period by completingthe required activities.

New Incentive StructureThere are now separate incentive amounts forcolleagues and spouses/eligible adults. If both youand your spouse/eligible adult complete the activitiesin each period, you will maintain the Full Incentiveamounts. If only one of you completes the activitiesin each period, you will only maintain a 1-PersonIncentive amount. (See the section Paying forMedical Coverage for contribution rates with Fulland 1-Person Incentives.)

Period 1 Earn 100 LifePoints by March 31, 2017

Complete your Health Assessment

The Health Assessment is an online questionnaire about your health habits. Your answers are kept secure and confidential;summary data is used to identify areas for future well-being and prevention programs.

Completing your Health Screening

Knowing your numbers like blood pressure, cholesterol, glucose and more - will provide a more complete picture of yourhealth. There are several ways to submit your numbers:

Get a health screening at scheduled on-site events, Visit your healthcare provider and submit the completed Health Screening Form (you may use results from

August 1, 2016 - March 31, 2017); or

Visit a Live Your Whole Life community access lab location.Note: To maintain your Full Incentive amount, the health assessment and health screening must be completed by you andyour covered spouse or eligible adult in Period 1 (Oct. 1, 2016 - March 31, 2017.) If you (and your spouse/eligible adult, ifapplicable) do not complete your health assessment and health screening by March 31, 2017, you will not maintain theincentive of a lower per pay period cost for medical coverage as of May 1, 2017.

Period 2 Earn 100 LifePoints by June 30, 2017

To continue receiving the incentive throughout the year, you and your covered spouse or eligible adult need to earn 100LifePoints by participating in a Meaningful Choice activity that interests you within Period 2. You can choose from a variety ofMeaningful Choice Activities that fit your lifestyle. Some examples include talking with a health coach, completing a stage ofan online journey module, tracking well-being items such as hours of sleep or time spent volunteering.

If you (and your spouse/eligible adult, if applicable) do not earn 100 LifePoints by June 30, 2017, you will not maintain theincentive of a lower per pay period cost for medical coverage as of August 1, 2017.

Need another chance to earn your Full Incentives?If you did not complete the required activities by the Period 1 deadline, you still have one morechance to regain your Full Incentive amounts. If you complete both the Period 1 and Period 2activities by June 30, 2017, you will regain the Incentive (Full or 1-Person, depending on if yourspouse/eligible adult completes the activities) starting August 1, 2017.

If you feel that you are unable to complete the Live Your Whole Life incentive activities by thedeadline due to extenuating circumstances (e.g. medical hardship, military deployment), youmay request an exception. For your exception request to be reviewed, the form must becompleted and returned prior to the end of each Period. Exception forms can be found atwww.mybenefits.trinity-health/lywl or by calling 1.855.491.8781.

For more informationon dates and activities,please visit the LiveYour Whole Lifewebsite at mybenefits.trinity-health.org/lywlor call 1-855-491-8781.


Be a smart health care consumerAs you know, the cost of high-quality health care continues to increase each year. Being a smart consumer meansgetting the best price on something you need, whether its a new car or health care.

Being a smart health care consumer doesnt mean you should avoid trips to the doctor it means making the bestdecisions about when to go to the doctor. Regular checkups can improve your health and extend your life. By gettingthe recommended exams and tests, you increase your chances of discovering problems before an illness significantlyaffects your health. Plus, preventive care is beneficial not only to your physical well-being, it also makes sense for yourfinancial health because generally, its covered by your medical plan. For more information on preventive care benefits,visit http://mybenefits.trinity-health.org.

An easy way to be a smart health care consumer is to choose a Trinity Health Tier 1 provider when you or a familymember needs medical care. Besides receiving excellent care at our own facilities, you receive the highest level ofbenefits while paying the lowest available copayment and coinsurance amounts.

Prescriptions available at your Mercy Medical pharmacyRemember, purchasing your medications at your Mercy Medical pharmacy may save you money. Also, you can fillprescriptions for up to a 90-day supply of your medications at our own pharmacy.

Maintenance Choice program for your maintenance medicationsOur prescription drug plan requires that you receive your maintenance medications* in 90-day supplies through yourTrinity Health owned pharmacy or through the CVS Caremark Mail Service Pharmacy. Once you reach your plan limit(initial fill and 2 refills) for filling 30-day supplies at a retail pharmacy, you will pay the full cost of your medications if youdo not move your prescription to one of the long-term options listed here.

*A maintenance medication is a long-term medication taken regularly for chronic conditions or long-term therapy.


Dental CoverageYou have a choice between two Delta Dental of Michigan plan options: the High plan and the Standard plan. Our plans utilizethe Delta Premier and PPO networks. Visit www.deltadentalmi.com for providers in your area.

Dental Plan Highlights High Plan Standard Plan

Participating Dentist Nonparticipating Dentist Participating Dentist Nonparticipating Dentist

Annual deductible

Individual/Family $25/$50 $50/$100 $50/$100 $100/$150

Class I - Preventive services 100% covered 100% covered 100% covered 100% covered

($0 colleague cost) (Usual and Customary ($0 colleague cost) (Usual and Customary

rates apply) rates apply)

Class II - Basic services 20% after deductible 20% after deductible 40% after deductible 40% after deductible

Class III - Major restorative services 40% after deductible 40% after deductible 50% after deductible 50% after deductible

Class IV - Orthodontics 50% after deductible 50% after deductible Not covered

Maximums

Per person annual (non-orthodontics) $1,750 $1,250 $1,500 $1,000

Per person lifetime (orthodontics) $1,500 $1,500 Not applicable Not applicable

Your per pay period cost Full-time Part-time Full-time Part-time

Colleague only $2.91 $11.65 $2.52 $8.40

Colleague plus spouse/eligible adult $6.99 $23.30 $4.20 $16.80

Colleague plus child(ren) $7.86 $26.21 $4.73 $18.90

Colleague plus family $11.36 $37.86 $6.83 $27.31

NOTES: When you receive services from a non-participating dentist, you will be responsible for the difference between whatyour dentist charges and the Delta Dental non-participating dentist fee. Fluoride treatments are covered once every 12 monthsup to age 19. Bitewing x-rays are covered once every 12 months.

For more information about yourdental plan options or aboutDelta Dental, visithttp://mybenefits.trinity-health.org.


Vision Care CoverageYou have a choice between two United Health Care vision plan options: the High plan and the Standard plan. Visitwww.myuhcvision.com for providers in your area.

UHC Vision Plan Highlights High Plan Standard Plan

In-network Out-of-network In-network Out-of-network(reimbursement schedule) (reimbursement schedule)

Benefit frequency Calendar year Calendar year Calendar year Calendar year

Vision exam Covered in full Up to $40 $10 copayment Up to $40

Pair of lenses

Single vision Up to $40 Up to $40

Bifocal $0 copayment Up to $60 $0 copayment Up to $60

Trifocal Up to $80 Up to $80

Lenticular Up to $80 Up to $80

Frames $150 retail allowance Up to $45 $150 retail allowance Up to $45

Covered frame at retail locations at retail locations

Non-covered frame

Contact lenses

(in lieu of eyeglasses)

Elective Contact lens coverage is provided under the plan and may vary dependent on the type of contact lensesNecessary prescribed. Please see the benefit summary on My Benefits for additional information.

Additional pair of eyeglasses

or contact lenses20% discount 20% discount 20% discount 20% discount

Additional lens options The following lens

options are covered in

full: standard scratch-

resistant coating, standard

basic and high-end

progressive lenses,

standard polycarbonate

lenses, standard anti-

reflective coating, UV,

tints, photochromic,

Transitions, edge coating

The following lens options

are covered in full:

standard scratch-resistant

coating, standard

polycarbonate lenses

Your per pay period cost

Colleague only $5.29 $3.17

Colleague plus $10.98 $5.81

spouse/eligible adult

Colleague plus child(ren) $11.52 $6.11

Colleague plus family $16.22 $8.43

For more information about yourvision care plan options, visithttp://mybenefits.trinity-health.org.


Health Care and Dependent Care Flexible Spending AccountsYou have the opportunity to set aside before-tax money to offset eligible health care or dependent care expenses. There aretwo different types of Flexible Spending Accounts a Health Care Flexible Spending Account (HCFSA) and a Dependent CareFlexible Spending Account (DCFSA).

Health Care Flexible Spending Account (HCFSA) Dependent Care Flexible Spending Account (DCFSA)

How much can I contribute? Before-tax dollars in any amount between $130 and

$2,550

Before-tax dollars in any amount between $130 and

$5,000

What expenses will it cover? Eligible health care products and services used by you

and/or your eligible dependents. Examples include:

Vision care, including eyeglasses, contact lenses andsaline solution

Dental care, both preventive and restorative Orthodontia Physical therapy, counseling, or psychological

services

Chiropractic care and acupuncture Copayments, coinsurance and deductibles Prescribed Over-the-Counter (OTC) medicationsFor a list of expenses that are eligible for HCFSA reim-

bursement, visit http://mybenefits.trinity-health.org.

Expenses for the care of your eligible dependents (child

under age 13 or qualifying adult incapable of self-care)

while you work:

Babysitting or au pair services Before and after-school programs Day care and nursery school Pre-school programs Elder care services

When do I have to spend the

money?

Contributions made to the HCFSA during the 2017

calendar year can be used for claims with dates of

service between Jan. 1, 2017 and Mar. 15, 2018.

Contributions made to the DCFSA during the 2017

calendar year can be used for claims with dates of

services between Jan. 1 and Dec. 31, 2017.

How do I access my FSA

savings?

You can use a variety of payment options to access your

FSA savings. These include the WageWorks Health

Card, Pay my Provider, Pay me Back, or by using the

Mobile application.

You can use a variety of payment options to access your

FSA savings. These include the Pay my Provider, Pay

me Back, or by using the Mobile application.

Reminders: If you choose to enroll in the Health Savings PPO medical plan option, you cannot enroll in the HCFSA. The Health

Savings Account works just like the HCFSA but offers additional benefits, such as the opportunity to carry over unusedfunds, contribute up to $2,750/individual ($5,450/family), plus an additional $1,000 in catch-up contributions if you are age 55or over, and earn interest on your savings.

You must make HCFSA and/or DCFSA elections for 2017 during open enrollment. Yourprior year elections will NOT carry forward.

HCFSA and DCFSA claims for the 2017 plan year must be postmarked on or before Mar.31, 2018.

If you choose to contribute to the HCFSA for the first time in 2017, a new WageWorksHealth Card will be mailed to your home. Otherwise, you will only receive a newWageWorks Health Card when your current card expires.

For more information about yourFSA benefits and to obtain a listof eligible expenses, visithttp://mybenefits.trinity-health.org.

Take advantage of WageWorks mobile siteAs the nations largest independent provider of consumer-directed benefit solutions, WageWorks offersFSA participants the latest technology to make it easier to manage your savings. Their mobile site andnew EZ Receipts app offer the following features:

Check your current HCFSA and DCFSA account balances Submit HCFSA and DCFSA claims Submit WageWorks Health Care card receiptsLearn more at www.wageworks.com or contact your Human Resources representative.


Life InsuranceColleague life insurance optionsIf eligible, you receive employer-provided basic life/AD&D insurance at one times yourannual base salary.

In addition, you have the option to purchase supplemental coverage for yourself in theincrements shown in the table below. If you purchase colleague supplemental lifeinsurance and youre approved, the premium contributions will be deducted from yourpaycheck on an after-tax basis.

You will be eligible for will preparation services through The Hartfords EstateGuidanceWill Services at no charge. To get started, access The Hartfords EstateGuidance WillServices online at www.estateguidance.com/wills and enter the Trinity Health Web IDWILLHLF in the Promotional Code box.

Colleague Life InsurancePlan Highlights (full- and part-time)

Basic life/AD&D One times annual base salary(employer-paid)

Supplemental life One to eight times annual base salary

Supplemental AD&D One to eight times annual base salary

Maximum amounts Basic life: $1.5 million

Supplemental life: $1.5 million

(Combined: $3 million)

Personal HealthApplications

Any increase in colleague Supplemental life coverage will require you tocomplete a Personal Health Application form. For more information aboutyour life insurance benefits or to obtain a Personal Health Application form,visit http://mybenefits.trinity-health.org. NOTE: Personal Health Applicationforms should be sent to The Hartford by Jan. 9, 2017.

Costs for colleague supplemental life insurance coverage are based on your age as of Jan. 1, 2017, and will

be available when you enroll online.

Dependent life insurance optionsYou have the option to purchase coverage for your dependents (including your spouse,eligible adult or eligible children). You may elect coverage for your dependents withoutelecting coverage for yourself. If you and your spouse or eligible adult both work forTrinity Health and are benefit eligible, you cannot elect Spouse/Eligible Adultcoverage for that individual. Also, only one of you will be able to elect coverage foryour child(ren). If your dependent child also works at Trinity Health and is benefiteligible, you cannot elect child life coverage for that individual.

Dependent Life InsurancePlan Highlights (full- and part-time)

Spouse/Eligible Adult life1 Child(ren) life2

Coverage amount Coverage amount*

$10,000

$20,000

$50,000

$80,000

$100,000

$5,000

$10,000

$20,000

PersonalHealthApplication

Any increase in spouse/eligible adult supplemental life coverage will require you tocomplete a Personal Health Application form. NOTE: Personal Health Applicationforms should be sent to The Hartford by Jan. 9, 2017.

1 Costs for spouse/eligible adult life insurance coverage arebased on your age as of Jan. 1, 2017, and will be availablewhen you enroll online.

2 Child(ren) life insurance costs cover all of your eligiblechildren, and will be available when you enroll online. For more information about your life

insurance benefits or to obtain aPersonal HealthApplication form, visithttp://mybenefits.trinity-health.org

Are yourbeneficiariesup-to-date?You may want to take amoment to review thebeneficiary(ies) you haveon file for your lifecoverage. If you haventyet designatedbeneficiary(ies), your lifeinsurance benefits willbe paid according to theplan provisions asoutlined in the SummaryPlan Description.

You may change yourbeneficiary(ies) duringthe Open Enrollmentprocess or anytimethroughout the year.

Beneficiary(ies)designated for Basic LifeInsurance apply to anyEmployee SupplementalLife Insurance elections.


Time Away From WorkAt Trinity Health, we are working to harmonize time offbenefits across our Ministry. Our goal is to help strengthenand enhance our people-centered health system and provideour colleagues with meaningful benefits that are competitiveand sustainable. Here are some of the benefits you receive asyou need time away from work.

Short-term disabilityShort-term disability (STD) pays a benefit if you are unable towork because of a qualified injury or illness. NOTE: this is anemployer provided benefit. No election is required to receivethis benefit.

Amount of benefit For non-management colleagues: 60% of base pay

For management colleagues: 100% of base pay

When benefits

begin

For non-management colleagues: After a 7

calendar day elimination period following an injury

or illness

For management colleagues: First day of injury or

illness

How long benefits

continue

Up to 180 days

Use of PTO time Non-management colleagues are required

to use PTO for days scheduled to work

during the first 7 calendar days.

Long-term disabilityLong-term disability (LTD) pays a benefit if you are unable towork for a long period of time because of a qualified injury orillness. You have the option to elect more LTD coveragethrough a buy-up election during open enrollment.

Amount of

employer-provided

benefit

For non-management colleagues: 60% of base pay,

not to exceed $10,000 per month

For management colleagues: 70% of base pay

Amount of

available buy-up

coverage

For non-management colleagues: 66 2/3% of base

pay

For management colleagues: This option is not

available

Cost for buy-up

coverage

For non-management colleagues:

Based on your income level Available when you enroll online

When benefits

may begin

For non-management colleagues: After 180 days of

disability

For management colleagues: After your STD

benefits are exhausted

How long benefits

continue

Benefits continue until you are able to return

to work, are deemed no longer disabled, or

until age 65 or older, depending on when the

disability begins.

For more information about your disability benefits, visithttp://mybenefits.trinity-health.org.

For more information about yourdisability benefits, visithttp://mybenefits.trinity-health.org.

PTO cash-outUnder the PTO program, hourly colleagues earn PTO basedon your hours worked. You are able to cash out a certainamount of your unused PTO each year.

How much time can

you cash out

You can cash out between 8 and 40 hours,

provided you maintain a minimum PTO bank

of 40 hours.

Electing to cash out Election for 2017 may only be made during

open enrollment to avoid taxation on the value

of your PTO bank. Your election is irrevocable

and cannot be changed.

Payment date for

cash-out

You will receive your cash-out with the first

pay in Dec. 2017.

You may cash out only hours you will accrue during thecalendar year in which you plan to receive payment.Consequently, you may not cash out PTO hours carried overfrom previous years. For example, Jane has a PTO balanceof 100 hours as of Dec. 31, 2016. During open enrollment,she elects to cash out 40 hours in 2017. Jane cannot cashout any of the 100 hours she earned in 2016 or earlier. Shemust plan her 2017 cash-out amount on only the hours shewill accrue in 2017.

REMINDER: If you want to cash out PTO in 2017, you mustmake a new PTO cash-out election. Your prior year electionwill NOT carry forward.

For more information aboutthe program, visithttp://mybenefits.trinity-health.org.


Voluntary BenefitsIn addition to your group benefits, Trinity Health has partnered with The Farmington Company to provide eligible colleagues theopportunity to elect personal insurance plans. Individual policy options include :

Life insurance Accidental Death and Dismemberment (AD&D) Insurance Cancer insurance Critical illness insurance Auto/home insurance Pet insurance Identity theft insurance Hospital Indemnity Accident insuranceFor more information, call 1-866-251-9529. Be sure to tell the representative that you are a member of Trinity Health and MercyMedical CenterClinton.


How to EnrollAnnual enrollment is conductedusing our web-based tool whichyou access through your benefitswebsite. It takes only about 10minutes to make your benefitelections online, and you may notneed to fill out any forms. If youdont have a computer withInternet access in your workplaceor your home, you can enroll atcomputer stations provided byyour Human Resourcesdepartment or at your local publiclibrary. You can enroll any timethats convenient to you duringthe open enrollment period 24hours a day, seven days a week.

During the two-week openenrollment period, you can makeas many changes to your benefitelections as you wish. The lastday to modify your choices isNov. 2, 2016.

Be sure that your personalinformation is secure on theenrollment website. Trinity Healthhas taken extra precautions toensure the integrity of allconfidential records.

When you enroll onlineThe Employee SelfService webpages arecompatible with webbrowser Internet Explorer(IE). Page layout can bedistorted with browserssuch as Safari, Chrome orFirefox.

Step-by-step instructions

1. Access the MyBenefits website through the Internet athttp://mybenefits.trinity-health.org.

2. Click on the section titled My Health & Welfare.

3. Click on the State and Name/Location of your Trinity Health RegionalHealth Ministry.

4. Select 2017 Open Enrollment.

5. Click on Enroll Now.

6. Enter your user ID, password and the unique code shown on the screen:

User ID: Your employee ID (if you dont remember your employee IDnumber, refer to your pay advice).

Password: Enter your existing password. If you forgot your passwordand have set up your two security questions, click the Forgot Passwordlink for a new password to be generated. If this is your first time loggingin, your password will be your first initial of both your first and last nameas it appears on your pay statement in capital letters, followed by youremployee ID. For example: Jane Doe, employee ID#123456 = User ID of123456 and password of JD123456.

Unique Code: Enter the combination of random letters and numbersshown on the screen.

Click on Sign In. You may be prompted to change your password.

For problems logging in, contact Trinity Resolution Center at TrinityResolution Center 1.888.667.3003 and select option 2.

7. Under Benefits, click Benefits Home TH. The e-benefits home page is thestarting point for enrolling in your benefits. You may choose from thefollowing options/links:

Benefits Summary: Review your current coverage. Benefits Enrollment: Review detailed information on coverage and

dependents and make any open enrollment changes for 2017 by Nov. 2,2016 at 11:59 p.m. EST. Remember, if you enroll in the Health SavingsPPO, you cannot enroll in the Health Care Spending Account (HCFSA).

8. Follow the instructions on the online enrollment system.

9. Be sure to print the enrollment page for your records by clicking on theprinter icon located at the top of the screen.

Review your confirmation statement.

If you do not change or correct your benefit elections by Nov. 2, 2016 at 11:59p.m. EST, IRS regulations require you to remain in your elections throughout2017 or until you experience a qualified status change. For more information onqualified status changes, visit http://mybenefits.trinity-health.org.

Review your confirmation statementIf the confirmation statement that you receive in your home mail does notmatch the benefits that you elected, contact your Human Resourcesrepresentative immediately to make the necessary corrections to yourbenefit enrollment record.


For More InformationWe hope this enrollment guide has provided you and your family with all of the information you need to make your benefitelections for 2017. In addition to Open Enrollment, please remember to review and update your personal information, such asyour address, phone number, and emergency contacts as necessary. You may update your personal information at any timethroughout the year. If you still have questions about your options or the open enrollment process, you can:

Attend a benefits fair, where youll receive additional information and have an opportunity to ask questions regarding yourbenefit options.

Benefits fair

Day Time(s) Campus Room

Wednesday, Oct. 19 11:00 a.m. 3:00 p.m. South AuditoriumThursday, Oct. 20 11:00 a.m. 3:00 p.m. North Conference Room A

Contact or stop by your Human Resources department.

Get assistance completing the Health Assessment by contacting Andrea Barnett, Wellness Coordinator at 1-563-244-5801.

Get assistance with computer enrollment.

Day Time(s) Campus Room

Wednesday, Oct. 19 1:30 p.m. 3:30 p.m. North Training Room 1Wednesday, Nov. 2Friday, Oct. 21 9:00 a.m. 11:30 a.m. South CafeteriaFriday, Oct. 21 11:30 a.m. 12:30 p.m. MLC-North Nurses StationMonday, Oct. 24 3:00 p.m. 5:00 p.m. South CafeteriaTuesday, Oct. 25 2:30 p.m. 4:30 p.m. MLC-North Nurses StationThursday, Oct. 27 7:00 a.m. 9:30 a.m. South CafeteriaMonday, Oct. 31 8:30 a.m. 10:30 a.m. MLC-North Nurses StationWednesday, Nov. 2 11:00 a.m. 1:00 p.m. South Cafeteria

Visit http://mybenefits.trinity-health.org.


Important Reminders

Benefit elections are final for 2017Remember, the benefits you elect during open enrollment will be in effect fromJan. 1 through Dec. 31, 2017. The choices you make now are final for 2017,because open enrollment is your only opportunity during the year to switchmedical, dental or vision plan coverage.

For more information on qualifiedfamily status changes, visithttp://mybenefits.trinity-health.org.

If you experience a qualified familystatus change or certain employ-ment status changes and provideany required documentation to yourHuman Resources representative within 30 days of the event, you will be allowedto make certain benefit changes that are consistent with the status change. Forexample, if you get married during the plan year, youll be able to add yourspouse to your coverage within 30 days of the marriage. For more informationon qualified family status changes, visit http://mybenefits.trinity-health.org.

HIPAA privacy notice is available onlineTrinity Health takes the security of its colleagues and family members PersonalHealth Information (PHI) very seriously. To access a copy of the HealthInformation Portability and Accountability Act (HIPAA) Privacy Notification, visithttp://mybenefits.trinity-health.org. If you are unable to access the HIPAA noticeonline, contact your Human Resources representative to request a paper copyby mail.

Medical plan election notificationWhen you enroll in a Trinity Health medical plan, the medical plan coverageprovides benefits through a clinically integrated network (CIN) of hospitals,physicians, and other health care providers and professionals, including carecoordinators and case managers that monitor and coordinate all aspects of yourmedical care. Trinity Health and Mercy Medical CenterClinton participate in theCIN. When you and your covered dependents receive health care services atfacilities or by the colleagues of your employer or a health care provider orprofessional affiliated with your employer, colleagues of your employer or ahealth care provider or professional affiliated with your employer will have accessto and may use and disclose your and your covered dependents personal healthinformation to manage and coordinate your care. Any access to and use anddisclosure of protected health information will comply with the privacy andsecurity regulations under HIPAA and any applicable state privacy and securitylaws.

Plan documents and Summary of Benefits andCoverage (SBC) are available onlineHealth Care Reform legislation requires all employers to provide an easy-to-readsummary of their medical plan options called the Summary of Benefits andCoverage (SBC). The SBC provides basic information about your medical planoptions, comparison examples, and a glossary of terms. To access a copy of theSBC, visit http://mybenefits.trinity-health.org. If you are unable to access theSBC online, contact your Human Resources representative to request a papercopy by mail.

Notice: Womens Health andCancer Rights Act of 1998The Womens Health and Cancer RightsAct of 1998 requires all employers whoprovide a medical benefit plan to itsemployees to communicate the coverageprovisions established under the Act.Trinity Healths medical benefit planprovisions are as follows:

The Trinity Health medical benefit planwill not restrict benefits if you or youreligible dependent receives benefitsfor a mastectomy and elects breastreconstruction in connection with themastectomy.

Benefits will not be restricted providedthat the breast reconstruction isperformed in a manner determined inconsultation with your (or your eligibledependents) physician, and mayinclude: Reconstruction of the breast on

which the mastectomy wasperformed;

Surgery and reconstruction of theother breast to produce asymmetrical appearance; and

Prostheses and treatment ofphysical complications of all stagesof mastectomy, includinglymphedemas.

Benefits for breast reconstruction may besubject to appropriate plan coverageprovisions and limitations, includingannual deductible, copayment andcoinsurance provisions that areconsistent with those established forother benefits under the plan.

If you have any questions about yourmedical plan provisions relating to theWomens Health and Cancer Rights Actof 1998, contact your Human Resourcesrepresentative.


Premium Assistance Under Medicaid and the Childrens Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and youre eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children arent eligible for Medicaid or CHIP, you wont be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has aprogram that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you arent already enrolled. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2016. Contact your State for more information on eligibility

ALABAMA Medicaid FLORIDA MedicaidWebsite: http://myalhipp.com/ Phone: 1-855-692-5447

Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268

ALASKA Medicaid GEORGIA MedicaidThe AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: - on Payment (HIPP) Phone:

ARKANSAS Medicaid INDIANA Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.hip.in.gov Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1-800-403-0864

COLORADO Medicaid IOWA MedicaidMedicaid Website: http://www.colorado.gov/hcpf Medicaid Customer Contact Center: 1-800-221-3943

Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562

http://www.healthcare.gov/http://www.insurekidsnow.gov/http://www.askebsa.dol.gov/http://myalhipp.com/http://flmedicaidtplrecovery.com/hipp/http://myakhipp.com/mailto:[email protected]://dhss.alaska.gov/dpa/Pages/medicaid/default.aspxhttp://dch.georgia.gov/medicaidhttp://myarhipp.com/http://www.hip.in.gov/http://www.indianamedicaid.com/http://www.colorado.gov/hcpfhttp://www.dhs.state.ia.us/hipp/

Medicaid MedicaidWebsite: Phone: 1-

Website:

Medicaid Medicaid dWebsite: Phone: 1-

Medicaid Website: /

/

Medicaid Phone: 609 -631-2392 Website:

Medicaid MedicaidWebsite:

Phone: 1-

Website: /Phone: 1-800-541-2831


Phone: 1-800-442-6003 Maine

Website: a Phone: 919-855-4100

Medicaid d MedicaidWebsite: Phone: 1-800-462-1120

Website:http://www.nd.gov/dhs/services/medicalserv/medicaid

Phone: 1-844-854-4825 OTA Medicaid Medicaid d

Website: Phone: 1-

Website:

Medicaid MedicaidWebsite: Website:

-Phone: 1-

MONTANA Medicaid MedicaidWebsite:

Phone: 1-800-694-3084

Website: http://www.dhs.pa.gov/hipp Phone: 1-


ska/Pages/accessnebraska_index.as px

Phone: 1-855-632-7633

Website: http://www.eohhs.ri.gov/ Phone: 401-462-5300

Medicaid MedicaidMedicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1 -800-992-0900

Website: http://www.scdhhs.gov Phone: 1-888-549-0820

http://www.kdheks.gov/hcf/http://www.dhhs.nh.gov/oii/documents/hippapp.pdfhttp://chfs.ky.gov/dms/default.htmhttp://www.state.nj.us/humanservices/dmahs/clients/medicaid/http://www.state.nj.us/humanservices/dmahs/clients/medicaid/http://www.njfamilycare.org/index.htmlhttp://dhh.louisiana.gov/index.cfm/subhome/1/n/331http://www.nyhealth.gov/health_care/medicaid/http://www.maine.gov/dhhs/ofi/public-assistance/index.htmlhttp://www.maine.gov/dhhs/ofi/public-assistance/index.htmlhttp://www.ncdhhs.gov/dmahttp://www.mass.gov/MassHealthhttp://www.nd.gov/dhs/services/medicalserv/medicaid/http://mn.gov/dhs/ma/http://www.insureoklahoma.org/http://www.dss.mo.gov/mhd/participants/pages/hipp.htmhttp://healthcare.oregon.gov/Pages/index.aspxhttp://www.oregonhealthcare.gov/index-es.htmlhttp://dphhs.mt.gov/MontanaHealthcarePrograms/HIPPhttp://www.dhs.pa.gov/hipphttp://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/accessnebraska_index.aspxhttp://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/accessnebraska_index.aspxhttp://www.eohhs.ri.gov/http://dwss.nv.gov/http://www.scdhhs.gov/

Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: http://www.hca.wa.gov/free-or

Phone: 1-800-5

Website: Phone: 1-800-440-0493

Website: e

Phone: 1-8 -598

Website: Medicaid:

CHIP:

Website:

Phone: 1-800 002

Website: http://www.greenmountaincare.org/ Phone: 1-800-250-84

Website: Phone: 531

icaid Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282

see if other states have added a 31

www.dol.gov/ebsa 1-8 -444

Centers for Medicare Medicaid www.cms.hhs.gov

1-8 -2 Menu 15 5

Paperwork Reduction Act Statement

the of 1995 104-1 no persons are to respond to a of information such a of Management and number. notes that a cannot conduct or sponsor a of information it is approved under the and a and the is not to respond to a of information u it a

number. 44 . notwithstanding other provisions of no person be to for to with a of information if the of information does not a

number. 44 3512.

reporting burden for this of information is estimated to average seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or other aspect of this of

suggestions for reducing this to the of of and 200 Constitution

20210 or and reference the 1210-0 .

Phone: 1-877-543-7669

http://dss.sd.gov/http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-programhttp://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-programhttp://gethipptexas.com/http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspxhttp://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspxhttp://health.utah.gov/medicaidhttp://health.utah.gov/chiphttps://www.dhs.wisconsin.gov/publications/p1/p10095.pdfhttp://www.greenmountaincare.org/https://wyequalitycare.acs-inc.com/http://www.coverva.org/programs_premium_assistance.cfmhttp://www.coverva.org/programs_premium_assistance.cfmhttp://www.dol.gov/ebsahttp://www.cms.hhs.gov/mailto:[email protected]

NOTICE REGARDING WELLNESS PROGRAM

The Live Your Whole Life Colleague Health Plan Well-Being Incentive Program (the Well-Being Program) is a voluntary

wellness program available to all colleagues and their spouses/eligible adult dependents, if applicable, who are enrolled in a

participating medical and prescription drug program (a group health plan) offered by the colleagues Trinity Health employer.

The Live Your Whole Life Well-Being Program is administered according to federal rules permitting employer-sponsored wellness

programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the

Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable,

among others. If you choose to participate in the Live Your Whole Life Well-Being Program you will be asked to complete a

voluntary health risk assessment or HRA that asks a series of questions about your health-related activities and behaviors and

whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You will also be asked to complete

a biometric screening, which will include measuring blood pressure, measuring Body Mass Index (BMI) through height and weight

measurements, a waist circumference measurement and a blood test for total cholesterol, high density lipoproteins (HDL), low

density lipoproteins (LDL), triglycerides, and blood glucose. In addition, certain other activities that are intended to help

colleagues improve their health or prevent disease (referred to as meaningful choice activities) are offered under the Live Your

Whole Life Well-Being Program. You are not required to complete the HRA, biometric screening or participate in any of

meaningful choice activities.

However, colleagues who are enrolled in a group health plan offered by their Trinity Health employer and who choose to

complete a voluntary HRA, biometric screening and meaningful choice activities will receive an incentive of a lower per pay cost

for the group health plan coverage. If a colleagues spouse/eligible adult dependent, is also enrolled in the Trinity Health group

health plan, the colleague will receive an additional incentive of lower per pay cost for the coverage if the spouse/eligible adult

completes an HRA, biometric screening and meaningful choice activities. Although you are not required to complete the HRA,

biometric screening or the meaningful choice activities, only colleagues (and their spouses/eligible adult dependents, if

applicable) who do so will receive the incentive of a lower per pay cost for group health plan coverage throughout the plan year.

Additional incentives of up to $500 may be available for colleagues and their spouses/eligible adult dependents, if applicable, who

submit a claim for non-surgical weight loss reimbursement.

If you (or your spouse/eligible adult dependent, if applicable) are unable to participate in any of the health-related activities

required to earn an incentive, you (or your spouse/eligible adult dependent, if applicable) may be entitled to a reasonable

accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by

contacting the Live Your Whole Life consumer support line (powered by RedBrick Health) at 855-491-8781.

The information from your HRA and the results from your biometric screening will be used to provide you with information to help

you understand your current health and potential risks, and may also be used to offer you services through the Live Your Whole

Life Well-Being Program, such as condition management, medical management, case management and health and well-being

coaching. You also are encouraged to share your results or concerns with your own doctor.

Protections from Disclosure of Medical Information

We are required by law to maintain the privacy and security of your personally identifiable health information. Although the Well-

Being Program and Trinity Health may use aggregate information they collect to design a wellness program based on identified

health risks in the workplace, the Live Your Whole Life program will never disclose any of your personal information either

publicly or to your employer, except as described in the paragraph below, as necessary to respond to a request from you for a

reasonable accommodation needed to participate in the Well-Being Program, or as expressly permitted by law. Medical

LYWL 2

information that personally identifies you that is provided in connection with the Well-Being Program will not be provided to your

supervisors or managers and may never be used to make decisions regarding your employment.

All Trinity Health group health plans provide care coordination, care management, utilization review and referral services to help

manage the healthcare provided to covered members. By enrolling in a Trinity Health group health plan you understand that the

plan will provide services to manage each covered members care. These services may be provided through independent third-

party administrators, a clinically integrated network of hospital, physicians and other health care providers and professionals

(CIN) and other healthcare providers. Your participation in a Trinity Health group health plan means that the persons contracted

to provide these services will have access to your personal health information, including health information you disclose through

an HRA, biometric screening or other Well-Being Program activities. Trinity Health facilities and healthcare providers and

professionals affiliated with Trinity Health facilities participate in certain CINs. Information about your medical treatment at any

facility and from any healthcare provider or professional may be accessed and used by individuals who work at a Trinity Health

facility or provider (including your employer) participating in a CIN or the group health plan not only for treatment but also to

manage and coordinate your healthcare.

Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to

carry out specific activities related to the Well-Being Program, and you will not be asked or required to waive the confidentiality of

your health information as a condition of participating in the Well-Being Program or receiving an incentive. Anyone who receives

your information for purposes of providing you services as part of the Well-Being Program will abide by the same confidentiality

requirements. The only individual(s) who will receive your personally identifiable health information is (are) third-party

administrators, members of a CIN and other healthcare providers and professionals such as registered nurses, doctors, case

managers, medical managers, health coaches, condition managers and the Well-Being Program administrator in order to provide

you with services under the Well-Being Program.

In addition, all medical information obtained through the Well-Being Program will be maintained separate from your personnel

records, information stored electronically will be encrypted, and no information you provide as part of the Well-Being Program will

be used in making any employment decision. Any access to, use or disclosure of your medical information obtained through the

Well-Being Program will comply with the privacy and security regulations under the Health Insurance Portability and

Accountability Act and any applicable state privacy and security laws. Appropriate precautions will be taken to avoid any data

breach, and in the event a data breach occurs involving information you provide in connection with the Well-Being Program, we

will notify you as soon as possible.

You may not be discriminated against in employment because of the medical information you provide as part of participating in

the Well-Being Program, nor may you be subjected to retaliation if you choose not to participate.

If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact

the Live Your Whole Life consumer support line (powered by RedBrick Health) at 855-491-8781.

LYWL 2

ACA

Notice Informing Individuals About Nondiscrimination and Accessibility Requirements and Sample Nondiscrimination Statement: Discrimination is Against the Law

The Trinity Health Corporation Welfare Benefit Plan (Plan) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

The Plan, through Trinity Health Corporation and the other participating employers in the Plan:

Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages

If you need these services, contact Jodi Weiner. If you believe that the Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Jodi Weiner, Trinity Health Corporation Vice President, Benefits & Well-Being, 20555 Victor Parkway, Livonia, MI 48152, 855-812-1297 (telephone), (248) 347-5437 (fax), [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Jodi Weiner is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATENCIN: si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Llame al 855-812-1297.

855-812-1297

CH : Nu bn ni Ting Vit, c cc dch v h tr ngn ng min ph dnh cho bn. Gi s 855-812-1297.

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PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag

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ATTENTION : Si vous parlez franais, des services d'aide linguistique vous sont proposs gratuitement. Appelez le 855-812-1297.

UWAGA: Jeeli mwisz po polsku, moesz skorzysta z bezpatnej pomocy jzykowej. Zadzwo pod numer 855-812-1297.

ATENO: Se fala portugus, encontram-se disponveis servios lingusticos, grtis. Ligue para 855-812-1297.

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero

855-812-1297.

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfgung. Rufnummer:

855-812-1297.

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OBAVJETENJE: Ako govorite srpsko-hrvatski, usluge jezike pomoi dostupne su vam besplatno. Nazovite 855-812-1297.

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AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel 855-812-1297.

ATENIE: Dac vorbii limba romn, v stau la dispoziie servicii de asisten lingvistic, gratuit. Sunai la 855-812-1297.

KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu 855-812-1297.

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Ige nti: O buru na asu Ibo asusu, enyemaka diri gi site na call 855-812-1297.

AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi 855-812-1297.

Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 855-812-1297.

PI KENE: Na ye jam n Thuja, ke kuny yen kc waar thook at kuka lu yk abac ke cn wnh cuat piny. Yup 855-812-1297

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LYWL 2.pdfNOTICE REGARDING WELLNESS PROGRAMProtections from Disclosure of Medical Information

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