1 The MetroHealth System Employee Benefits Employee Benefit Summaries These Summaries do not need to be printed. It is for your information only. To begin, either click on a form title below or click on the NEXT button to go to the next page. Summaries Benefits Summary MH Employee Plan Benefits MH Plus Plan Benefits MH Urgent / Express Care Facilities HealthSpan Plan Voluntary LTD Life Insurance Coverage Options Cigna Dental MetroHealth Dental Plan Option Vision Plan Hearing Aid Benefit Prescription Drug Benefits Flexible Spending Accounts (FSA) Summary Important Phone Numbers and Websites Questions? Please call Employee Benefits Department at , or The following documents are to serve as an overview of benefits only. In the event of any discrepancies between the summary and the plan document, the plan document will prevail.
2 The MetroHealth System Benefits Summary Non-Union & OPBA Employees Full-time = Budgeted to work at least 60 hours Bi-weekly Part-time = Budgeted to work at least 35 hours Bi-weekly Benefits are effective the first day of the month following employment. Benefits begin immediately if your first day of employment is the first working day of the month. Benefit Eligibility Highlights Bi-weekly Cost MetroHealth Employee Plan Full-time Part-time You exclusively select MetroHealth providers for all covered procedures except life-threatening emergencies, urgent care or services not provided by MetroHealth. Full-time Part-time Calendar year deductible: $100 individual/$200 family Out-of-pocket maximum: $500 individual/$1000 family Primary care office visit: $15 co-payment Specialty care office visit: $30 co-payment Urgent care visit: 90% after a $50 co-payment Co-Insurance 90% Deductions Single - $ Party - $75.00 Family - $80.00 Deductions Single - $ Party - $ Family - $ The MetroHealth Plus Plan Full-time Part-time The plan is a 2-Tier plan. If you enroll in this plan, you have access to The MetroHealth System (Tier-1) as well as providers in the (MMO) Medical Mutual of Ohio provider network (Tier-2). Benefits are paid the highest level if you select MetroHealth providers. When you select providers from the (MMO) Network, you will be responsible for a larger portion of the cost. There are no benefits payable for providers other than the preferred networks. Tier-2 out of pocket amounts intergrate to Tier-1. Tier-1 amounts do not integrate to Tier-2. Full-time Part-time Tier 1 - MetroHealth Primary care office visit: $15 co-payment Specialty care office visit: $30 co-payment Calendar year deductible: $100 individual/$200 family Out-of-pocket maximum: $500 individual/$1000 family Urgent care visit: 90% after a $50 co-payment Co-Insurance 90% Tier 2 - MMO Provider Network Primary care office visit: $40 co-payment Specialty care office visit: $50 co-payment Calendar year deductible: $400 individual/$800 family Out-of-pocket maximum: $2000 individual/$4000 family, 70% co-insurance after deductible Deductions Single - $105 2-Party - $145 Family - $155 Deductions Single - $ Party - $ Family - $ HealthSpan (formerly known as Kaiser) This plan may encourage you to use participating providers by charging you lower deductibles, co-payments and co-insurance amounts. Refer to detailed summary for specific itemized details. Full-time Part-time Calendar year deductible: $0 Out-of-pocket maximum: $2000 individual/$6000 family Primary Care office visit & Urgent care visit: $10 participating provider, No coverage when using a non-participating provider. Deductions Single - $ Party - $ Family - $ Deductions Single - $ Party - $ Family - $ Dental Full-time Part-time Cigna PPO Plan Dental PPO plan allows you and your family to visit the provider of your choice. If you choose a Cigna PPO provider for dental care, participating PPO Cigna dentists have agreed to accept negotiated fees, resulting in lower out-of-pocket cost. The complete Cigna dental provider listing can be accessed at Full-time Part-time Dental Preventive Services - UCR, 2x per calendar year, not subject to deductible Basic Services - 80% UCR, subject to deductible Major Services - 60% UCR, subject to deductible Deductible $25 individual/$75 family (applies to basic and major services) $1,500 per person per year Deductions Dental/Vision Single - $ Party - $10.30 Family - $19.14 Note: This rate includes vision. Deductions Dental/Vision Single - $ Party - $17.16 Family - $31.90 Note: This rate includes vision. MetroHealth Dental Plan The MetroHealth plan allows you to only use MetroHealth dentists to mange your overall dental care. For services not available at MetroHealth you must access Cigna Network providers. Full-time Part-time No deductible $1,750 annual dollar maximum Preventative Services Other covered services 90% Orthondotia 90%/$1,500 lifetime maximum Single - $ Party - $5.15 Family - $9.57 Note: This rate includes vision. Single - $ Party - $8.58 Family - $15.95 Note: This rate includes vision.
3 Benefit Eligibility Highlights Bi-weekly Cost Vision Full-time Part-time Vision The Eyemed vision care plan allows you to choose Eyemed network providers and out-of-network providers. Visit eyemedvisioncare.com for participating network providers. Services reimbursed are based on network used. Coverage is based on calendar year schedule. Full-time Part-time In Network Eye exam - $0 (Unless contact exam) Frames -$0 co-pay, plus 80% of balance over $120 Contact lenses $0 co-pay, plus 85% of balance over $120 Disposable contacts $0 co-pay, plus of balance over $120 (contacts in lieu of lenses/frames). Lenses per pair 0% co-pay (single, bifocal, trifocal and lenticular). Out of Network Eye exam - $40 Frames - $50 Contact lenses $100 (in lieu of lenses/frames). Lenses - Single $50 Bifocal $70 Trifocal $90 Lenticular $90 Deductions Vision/Dental Refer to Dental for Vision Rate Deductions Vision/Dental Refer to Dental for Vision Rate Prescription Drug Plan Full-time Part-time The plan allows you to purchase prescriptions at a MetroHealth pharmacy, participating retail pharmacies or through Caremark s mail-service program. Employees who elect a health care plan Caremark Retail & Mail Order Program Short-term medications - 30 day supply Long-term maintenance medications - 90 day supply dispensed through mail-order program. Co-payment schedule is available in the Benefits Office. MetroHealth Outpatient Pharmacies & Mail Order Program Prescriptions filled when written by a MetroHealth physician only. 30 day short-term medications and 90 day long-term maintenance medications dispensed at reduced co-payments. Co-payment schedule is available in the Benefits Office. Fully paid by the hospital Fully paid by the hospital Life Insurance Full-time Part-time Full-time Basic Term Life & Accidental Death & Dismemberment Coverage is equal to 12 times base annual salary - maximum of $300,000. Automatically enrolled. Fully paid by the hospital Not available Participation is voluntary for Supplemental and Dependent Life. Supplemental Life You can elect to purchase one or two times your base salary Matching amount of Accidental Death & Dismemberment (Coverage over $100,000 requires Evidence of Insurability (EOI) Application). Rates based on age & salary Not available Dependent Life There are four dependent life options for your spouse and unmarried children at least 14 days of age to age 26. Participation is voluntary for Supplemental and Dependent Life. Option 1: Option 2: Option 3: Option 4: $5,000 spouse $2,000 children $10,000 spouse $4,000 children $20,000 spouse $8,000 children $50,000 spouse $20,000 children Option 1: $0.44 $0.10 Option 2: $0.88 $0.20 Option 3: $1.76 $0.40 Option 4: $3.00 $1.15 Not available Long-Term Disability (LTD) Full-time Part-time Protection against loss of income if you become disabled and are unable to work. Participation is voluntary. Full-time Benefits begin after you have been continuously disabled for 90 days Benefit equal to 60% of your pre-disability income up to maximum of $10,000 a month. $.58/$100 salary Not available
4 Benefit Eligibility Highlights Bi-weekly Cost Tuition Assistance Full-time Part-time Tuition Assistance is available after you complete three months of employment. Full-time Part-time $6,000 for graduate work and $4,000 for undergraduate work per calendar year. The amount of tuition assistance will be prorated for part-time employees. Refer to hospital policy for additional requirements. Fully paid by the hospital Fully paid by the hospital Vacation Full-time Part-time Budgeted 40 hours or more bi-weekly Eligible upon completion of one year of service. Vacation allowance is determined by type of position. Part-time employees earn vacation on a pro-rated basis. Fully paid by the hospital Fully paid by the hospital Sick Hours Full-time Part-time All Employees Sick hours are accrued at the rate of 4.6 hours for each 80 hours of active service up to a maximum of 15 days per calendar year. Fully paid by the hospital Fully paid by the hospital Holidays Full-time Part-time The MetroHealth System recognizes ten holidays. Full-time Part-time Recognized holidays are New Year s Day, Memorial Day, Labor Day, Thanksgiving Day, Christmas Day and Independence Day. Fully paid by the hospital Fully paid by the hospital Martin Luther King Day, President s Day, Columbus Day and Veteran s Day are deemed personal floating holidays. Holiday pay is prorated for employees who work 20 hours or more per week. Health Care Account Full-time Part-time Allows you to use pre-tax dollars to pay for unpaid healthcare expenses. Full-time Part-time Annual Maximum: $2,500 Participation is voluntary Employee Contributions Employee Contributions Dependent Care Account Full-time Part-time A Dependent Care Account allows you to use pre-tax dollars to pay for dependent care expenses to permit you and your spouse to work or look for employment. Full-time Part-time Annual Maximum: $5,000 Annual Maximum: $2,500 (if married and filing separately) Participation is voluntary. Employee Contributions Employee Contributions Ohio Public Employees Retirement System (OPERS) Full-time Part-time Retirement plan in place of Social Security All employees who are paid by the state of Ohio, a county, municipality or any other political subdivision of state or local government in Ohio are enrolled in OPERS Annual Contribution Limits Participation in OPERS 1/1/1994 and after $260,000 Participation in OPERS prior to 1/1/1994 $385,000 Participation is mandatory. All Employees OPERS offers three retirement plans to choose from: The Traditional Plan is a defined benefit plan which the member s benefit is based on a formula determined by years of service credit and average of five highest years of salary. The Member Direct Plan is a defined contribution plan under which the employee and the employer s contributions are invested as directed by the member. The retirement benefit is based on gains and losses on those contributions. The Combined Plan is both a defined benefit and a defined contribution plan. The retirement benefit is determined by a formula (similar to Traditional Plan) and gains and losses on contributions. Employee Contributions 10% of salary Employer 14% of salary Employee Contributions 10% of salary Employer 14% of salary
5 457 Deferred Compensation Full-time Part-time Program that allows you to set aside part of your income for retirement with pre-tax dollars, reducing your taxable income. You may also rollover funds from pre-tax programs such as IRA, 401 (k), or 403 (b). Participation is voluntary. No eligibility waiting period, immediate participation Maximum amount you can defer in 2014 is $17,500 Over age 50 - $23,000 Employee Contributions Employee Contributions RTA Commuter Program Full-time Part-time Purchase RTA monthly express or local pass with pre-tax dollars. Participation is voluntary. All Employees Employee Contributions Employee Contributions Employee Services Metrocize Exercise facility located on the 7 th floor of the Hamann Building at the Medical Center. Open 24 hours a day, seven days a week. $60 annual enrollment fee. Discount Tickets For information on employee discounts visit the Employee Services website available on The MetroHealth Information Village (MIV). From the home page click on department / click on Human Resources / click on Employee Services. Travel Services information available on the MIV Credit Union Mandatory Direct Deposit Your check is automatically deposited in a bank or credit union of your choice. Paydays are every other Tuesday. Parking $15.72 bi-weekly payroll deduction applies to the MetroHealth Medical Center, The Elisabeth Severance Prentiss Center and MH Senior Wellness Center. Our Vision MetroHealth will be the most admired public health system in the nation, renowned for our innovation, outcomes, service and financial strength. Vision Our Mission Leading the way to a healthier you and a healthier community through service, teaching, discovery and teamwork. Dedicated Employees and Volunteers Patient Experience and Engagement Clinical Excellence Operational and Financial Effectiveness Community Impact Education and Research Mission
6 Health Care Option: MetroHealth Employee Plan Schedule of Benefits MetroHealth Employee Plan Benefits Effective 1/1/2014 Benefit Period Benefit Maximum Benefit Period Deductible Coinsurance Out-of-Pocket Maximum (including copayments and coinsurance) Office Visit (Illness/Injury) 1 4 Specialist Office Visit 1 4 Preventive Services, in accordance with state and federal law 2 Routine Physical Exam 2 (One exam per benefit period, ages 21 and over) Well Child Care Services Exam 2 /Up to age 9: no limit /Age 9-21:one exam per benefit period Well Child Care Laboratory Tests and Immunizations 2 To age 21 All Immunizations 2 Routine Mammogram Routine Pap Test One per benefit period Routine Endoscopic Services Routine Laboratory, X-ray, Medical Tests Diagnostic Laboratory, X-ray, Medical Tests Medically Necessary Surgical Services Oral Surgery When participant covered under both medical and dental plan, paid under medical Dental Limited to removal of impacted teeth, an accidental injury, except for chewing, to sound, natural teeth and treatment is received within one year of an accident Prosthetics excludes dentures Physical Therapy Facility and Professional 25 visits then medical review Occupational Therapy Facility and Professional 25 visits then medical review Chiropractic Therapy 1 4 Professional Only 12 visits per benefit period Prior authorization not required to access Medical Mutual providers. Medically necessary, maintenance service not included Speech Therapy Professional Only 25 visits then medical review (For speech loss or impairment due to an illness or injury) Cardiac Rehabilitation Podiatry 1 4 Routine foot care not covered Nutritional Counseling For Cardiovascular Disease/Eating Disorders/ Gastrointestinal Disorders/Hypertension/Kidney Disease/Seizure Semi-Private Room and Board Maternity Skilled Nursing Facility 100 days per benefit period Organ Transplants (MMO will coordinate care using a SuperMed Network provider) Acupuncture Allergy Testing Allergy Treatments Air & Ground Ambulance Subject to medical review Home Healthcare 30 visits per benefit period Hospice 180 days per benefit period Private Duty Nursing Durable Medical Equipment / Prosthetics / Orthotics / Home Infusion Services Prior authorization not required to access SuperMed providers. TMJ Coverage limited to Office Visit and X-Ray Fertility Limited to services to diagnose only Emergency Room/Urgent Care MetroHealth Express Care CVS Caremark Minute Clinics Urgent Care Office Visit 1 4 Non-life threatening emergency that occurs outside of MetroHealth Service area or normal business hours. Prior authorization not required to access Medical Mutual urgent care facility/providers. Emergency use of an Emergency Room Non-Emergency use of an Emergency Room 3 4 Mental Health and Substance Abuse Residential Treatment Facility Covered only if approved by Case Management Inpatient Mental Health and Substance Abuse Services / Prior authorization not required to access Medical Mutual providers for Chemical Dependency and Adolescent Mental Health. Outpatient Mental Health and Substance Abuse Services 1 4 / Prior authorization not required to access Medical Mutual providers for eating disorders, family counseling or chemical dependency. MetroHealth Facility and Professional Providers January 1 through December 31 Unlimited $100 Individual / $200 2-Party/Family 90% / 10% $500 Individual / $1,000 2-Party/Family $15 copay $30 copay $30 copay $30 copay 2 visits per benefit period covered at, additional services covered at Not covered $15 copay $15 copay $50 copay, then 90% $100 copay, then 90% $15 copay
7 How the MetroHealth Employee Plan Works You must use MetroHealth providers and facilities for all services except for those noted on the Schedule of Benefits. Expenses for non-covered services are entirely your responsibility. In the event of a life threatening or accidental emergency, please use the closest emergency facility. Medical Emergency A sudden and acute onset of illness with severe symptoms, which requires medical treatment within 24 hours of onset of symptoms associated with potential life-threatening illness. How to Find Providers in the Medical Mutual of Ohio (MMO) Network To confirm your provider is in-network, please visit MedMutual.com and register for My Health Plan on Medical Mutual s secure member information site: Go to MedMutual.com Click on Register Here under the My Health Plan login. You will need to have the identification number and group number listed on your identification (ID) card available to register. You will also need to enter your name and personal identification information exactly as it appears on your ID card. Once you are registered for My Health Plan, please use the Find a Provider tool to see if your doctor is in the network. Log into My Health Plan and locate the Find a Provider tool. Choose the type of provider you are looking for. To find a specific doctor, enter the doctor s last name. To find providers located near you, enter your address and Zip Code. You can also search for doctors by specialty, gender, language spoken and hospital affiliation. Call Medical Mutual for Assistance If you need help registering for My Health Plan or using the Find a Provider Tool, or if you would like personal assistance finding a provider, please call Medical Mutual s Customer Service Department toll-free at Covered Services not available at MetroHealth If you require Inpatient, Outpatient, or Professional Services that are not available at MetroHealth, your provider must contact Medical Mutual s Care Management Department at for determination prior to seeking services. When eligible procedures or services are performed outside of MetroHealth, they will be covered at the Tier 1 level of benefits only if the following conditions have been satisfied: The procedure/service must be medically necessary, Your physician must prescribe the procedure/service, and MetroHealth does not perform the procedure/service. Covered Services outside of MetroHealth service area If you or your dependents are traveling outside of the MetroHealth service area, services will only be covered when an emergency occurs. To locate a provider outside of the service area in Ohio, please call and select option 3. If you require services outside the state of Ohio, please call FirstHealth at This document is only a partial listing of benefits. This is not a contract of insurance. The contract or certificate will contain the complete listing of covered services. 1 The office visit copay applies to the cost of the office visit only. 2 Preventive services include evidence-based services that have a rating of A or B in the United States Preventive Services Task Force, routine immunizations and other screenings, as provided for in the Patient Protection and Affordable Care Act. 3 Copay waived if admitted. The copay applies to room charges only. All other covered charges are subject to coinsurance. 4 Copays and coinsurance apply to the out-of-pocket maximum. Copays continue once out-of-pocket maximum is met.
8 Health Care Option: MetroHealth Plus Plan Schedule of Benefits MetroHealth Plus Plan Benefit Period Benefit Maximum Benefit Period Deductible Effective 1/1/2014 Coinsurance Out-of-Pocket Maximum including copays and coinsurance 4 5 Tier 2 out-of-pocket amounts apply to Tier 1. Tier 1 out-of-pocket amounts do not apply to Tier 2 Office Visit (Illness/Injury) 1 4 Specialist Office Visit 1 4 Preventive Services, in accordance with state and federal law 2 Routine Physical Exam 2 (One exam per benefit period, ages 21 and over) Well Child Care Services Exam 2 /Up to age 9: no limit / Age 9-21: one exam per benefit period Well Child Care Laboratory Tests and Immunizations 2 To age 21 All Immunizations 2 Routine Mammogram Routine Pap Test One per benefit period Routine Endoscopic Services Routine Laboratory, X-ray, Medical Tests Diagnostic Laboratory, X-ray, Medical Tests Medically Necessary Surgical Services Oral Surgery When participant covered under both medical and dental plan, paid under medical Dental Limited to removal of impacted teeth, an accidental injury, except for chewing, to sound, natural teeth and treatment is received within one year of an accident Prosthetics excludes dentures Physical Therapy Facility and Professional 25 visits then medical review Occupational Therapy Facility and Professional 25 visits then medical review Chiropractic Therapy Professional Only 12 visits per benefit period Speech Therapy Professional Only 25 visits then medical review (For speech loss or impairment due to an illness or injury) Cardiac Rehabilitation Podiatry 1 4 Routine foot care not covered Nutritional Counseling For Cardiovascular Disease/Eating Disorders/Gastrointestinal Disorders/Hypertension/Kidney Disease/Seizure Semi-Private Room and Board Maternity Skilled Nursing Facility 100 days per benefit period Organ Transplants (MMO will coordinate care using a SuperMed Network provider) Acupuncture Allergy Testing Allergy Treatments Air & Ground Ambulance Subject to medical review Home Healthcare 30 visits per benefit period Hospice 180 days per benefit period Private Duty Nursing Durable Medical Equipment / Prosthetics / Orthotics / Home Infusion Services TMJ Coverage limited to Office Visit and X-Ray Fertility Limited to services to diagnose only Emergency Room/Urgent Care MetroHealth Express Care CVS Caremark Minute Clinics Urgent Care Office Visit 1 4 Non-life threatening emergency that occurs outside of MetroHealth Service area or normal business hours. Emergency use of an Emergency Room Non-Emergency use of an Emergency Room 3 4 Mental Health and Substance Abuse Residential Treatment Facility Covered only if approved by Case Management Inpatient Mental Health and Substance Abuse Services Outpatient Mental Health and Substance Abuse Services TIER 1 TIER 2 MetroHealth January 1 through December 31 Unlimited $100 Individual / $200 2-Party/Family 90% / 10% $500 Individual $1,000 2-Party/Family $15 copay $30 copay $30 copay $30 copay 2 visits/benefit period covered at, additional services covered at 90% after deductible Not covered $15 copay $15 copay $50 copay, then 90% $100 copay, then 90% $15 copay MMO PPO $400 Individual / $800 2-Party/Family 70% / 30% $2,000 Individual $4,000 2-Party/Family $40 copay $50 copay 70% 70% 70% 70% 70% 70% 70% 70% 70% Not covered Not available $15 copay $50 copay, then 70% $100 copay, then 70%
9 The MetroHealth Plus Plan allows you to use providers or facilities in The MetroHealth System (Tier1) or Medical Mutual of Ohio (MMO) network (Tier 2). Benefits are paid at the highest level if you use MetroHealth providers/facilities. When you use providers/facilities in the MMO network (Tier 2) you will be responsible for a larger portion of the cost as indicated on the Schedule of Benefits. Expenses for covered services from Tier 2 providers are always reimbursed at 70%. There is no provision in the MetroHealth Plus Plan for services from a Tier 2 network provider to be covered at Tier 1 even if it is your only alternative. Medical Emergency How the MetroHealth Plus Plan Works A sudden and acute onset of illness with severe symptoms, which requires medical treatment within 24 hours of onset of symptoms associated with potential life-threatening illness. How to Find Providers in the Medical Mutual of Ohio (MMO) Network To confirm your provider is in-network, please visit MedMutual.com and register for My Health Plan on Medical Mutual s secure member information site: Go to MedMutual.com Click on Register Here under the My Health Plan login. You will need to have the identification number and group number listed on your identification (ID) card available to register. You will also need to enter your name and personal identification information exactly as it appears on your ID card. Once you are registered for My Health Plan, please use the Find a Provider tool to see if your doctor is in the network. Log into My Health Plan and locate the Find a Provider tool. Choose the type of provider you are looking for. To find a specific doctor, enter the doctor s last name. To find providers located near you, enter your address and Zip Code. You can also search for doctors by specialty, gender, language spoken and hospital affiliation. Call Medical Mutual for Assistance If you need help registering for My Health Plan or using the Find a Provider Tool, or if you would like personal assistance finding a provider, please call Medical Mutual s Customer Service Department toll-free at Covered Services outside of MetroHealth service area To locate a provider outside of the service area in Ohio, please call and select option 3. If you require services outside the state of Ohio, please call FirstHealth at This document is only a partial listing of benefits. This is not a contract of insurance. The contract or certificate will contain the complete listing of covered services. 1 The office visit copay applies to the cost of the office visit only. 2 Preventive services include evidence-based services that have a rating of A or B in the United States Preventive Services Task Force, routine immunizations and other screenings, as provided for in the Patient Protection and Affordable Care Act. 3 Copay waived if admitted. The copay applies to room charges only. All other covered charges are subject to deductible and coinsurance. 4 Under Tier 1 copays and coinsurance apply to out-of-pocket max. Copay continues once out-of-pocket maximum is met. 5 Under Tier 2 coinsurance applies to out-of-pocket max.
10 Metro ExpressCare Four Convenient Locations You can use MetroHealth s ExpressCare facilities if you are in the MetroHealth Employee or Plus Plans. Co-payment will be the same as an office visit ($15). Providers are available to treat adults and children for conditions that require attention sooner than a normal appointment with your doctor but are not life-threatening. Cold and Flu symptoms Ear, throat and sinus infections Sprains and strains Minor cuts and bumps Skin rashes Walk-ins welcome.* Call for more information. *Go straight to nearest Emergency Room for life-threatening medical conditions that require immediate attention. MetroHealth Beachwood Health Center 3609 Park East Dr., Ste. 300 North Building Beachwood, OH Monday - Friday: 7:30 a.m. - 7:30 p.m. Sunday: 10 a.m. - 2 p.m. MetroHealth Broadway Health Center 6835 Broadway Avenue Cleveland, OH Monday - Friday: 7:30 a.m. - 7:30 p.m. Saturday: 8 a.m. - 4 p.m. Sunday: 10 a.m. - 2 p.m. MetroHealth Middleburg Heights Health Center 7800 Pearl Road Middleburg Heights, OH Monday Friday: 7:30 a.m. 7:30 p.m. Saturday 8 a.m. - 4 p.m. MetroHealth West Park Health Center 3838 West 150th Street Cleveland, OH Monday - Friday: 7:30 a.m. - 7:30 p.m. Saturday 8 a.m. - 4 p.m.
11 Health Care Option: HealthSpan Plan Summary Medial Services provided or arranged by HealthSpan physician Effective 1/1/ /31/2014 Out of Pocket Maximum (Calendar Year Single / Family) Outpatient Care Office Visits Primary Care Physician Office Visits Specialist Vision Exams available through affiliated providers Allergy treatment Prenatal Care Outpatient surgery Occupational Therapy: 30 visits per calendar year Physical Therapy: 30 visits per calendar year Speech Therapy: 30 visits per calendar year Preventive services Preventive Adult Physical primary care exam Preventive Well Child Care primary care exam as defined by Patient Protection and Affordable Care Act (PPACA) Preventive Mammogram and cervical cancer screening as defined by Patient Protection and Affordable Care Act (PPACA) Preventive Lab and X-ray screenings as defined by Patient Protection and Affordable Care Act (PPACA) Preventive Immunizations as defined by Patient Protection and Affordable Care Act (PPACA) diagnostic services Laboratory and diagnostic testing, X-rays hospital inpatient care Inpatient Services URGENT CARE SERVICES Urgent Care Visits EMERGENCY SERVICES (Fee waived if admitted) Emergency Services provided at a Plan Facility AMBULANCE SERVICES Only when transportation in any other vehicle would endanger your health BIOLOGICALLY BASED MENTAL ILLNESSES Inpatient Services (does not include residential services) Outpatient Services MENTAL HEALTH SERVICES Inpatient Services (does not include residential services) Outpatient Services CHEMICAL DEPENDENCY SERVICES Inpatient Services (does not include residential services) Outpatient Services ALTERNATE CARE Home Health Services Hospice Home Care / Respite Care Skilled care in a Skilled Nursing Facility Up to 100 days per calendar year INFERTILITY SERVICES Inpatient Outpatient DURABLE MEDICAL EQUIPMENT, EXTERNAL PROSTHETICS AND ORTHOTICS DME Rider providers coverage for Medicare approved durable medical equipment EXTENDED DEPENDENT COVERAGE Dependents 5 are covered up to age 26 at the end of the month Full-Time Students are covered up to age 26 at the end of the month Member Pays $2,000 / $6,000 Unlimited $10 per visit $10 per visit $10 per visit 3 No Charge No Charge $10 per visit $10 per visit 3 $10 per visit 3 $10 per visit 3 No Charge No Charge No Charge No Charge No Charge No Charge 1 No Charge 1 $10 per visit $30 per visit No Charge 1 No Charge 1 $10 per visit No Charge 1 $10 per visit No Charge 1 $10 per visit No Charge 1 No Charge No Charge 1 1 When a plan deductible is indicated, services are subject to deductible. 2 Services received at non-plan Emergency facilities that do not meet the definition of Emergency Services may not be eligible for coverage. 3 Amount is not subject to, nor does it contribute toward the satisfaction of the Out-of-Pocket Maximum. Effective January 1, 2014, upon renewal, contracts for employers with 51 or more employees will automatically accumulate deductibles and covered Essential Health Benefits to the Outof-Pocket Maximum. HealthSpan will apply transitional relief to delay the accumulation of prescription drugs, pediatric dental, pediatric vision and chiropractic services. 4 Plan Deductibles are Embedded. The Individual Deductible counts toward the Family Deductible. Each family member is responsible for meeting the specified Individual Deductible amount, enabling that family member to receive benefits before meeting the Family Deductible. Once the Family Deductible is met, coverage begins for all covered family members. 5 Group contracts starting on or after 7/1/2010 may provide additional Dependent coverage up to age 28, when certain criteria are met. Contact your employer for more details. 30% 1 30% 20% 3
12 HealthSpan Plan Summary This summary of benefits contains highlights only. This is not a contract. Specific benefits, exclusions and limitations are contained in the Group Agreement we have with your employer and the Evidence of Coverage you will receive when you become a member. For specific questions about coverage, existing Members may call our Customer Relations Department at (216) or toll-free at New Members may call a HealthSpan Representative at (216) or toll-free at Our TTY line is (216) for the hearing impaired. For additional HealthSpan Services, visit our website, healthspan.org. Through healthspan.org, members can access comprehensive, physician-reviewed information on a variety of health topics, search for specific topics in our health and drug encyclopedias, complete a total health assessment, and more. Members who receive care at HealthSpan medical centers can also use our website to check most lab test results, schedule non-urgent primary care appointments, refill most prescriptions, order ID cards, and questions to their HealthSpan practitioner or a member services representative. In addition, members can call our 24-Hour Care Line to receive advice and assistance. Basic Coverage Information: Any person may cancel coverage within 72 hours after having signed the agreement or offer to enroll in the plan. Cancellation occurs when written notice of cancellation is given to HealthSpan or its agents or representatives. The notice of cancellation shall be considered given when the prospective subscriber mails a letter to HealthSpan. Out-of-Pocket Maximum: The Plan s Deductible, any benefit specific deductible, and the following benefits do not apply towards the satisfaction of the Out-of- Pocket Maximum: Copayments and Coinsurance on services that are not Basic Health Care Services, such as but not limited to: Skilled Nursing, Durable Medical Equipment/Prosthetics and Orthotics, and Prescription Drug Benefits. General Limitations and Exclusions including but not limited to: Services that are not medically necessary; services and supplies not provided, arranged, or authorized by a HealthSpan or affiliated physician; services that are the financial responsibility of an employer or services a government agency is required by law to provide; services provided under any Workers Compensation or employer s liability law; certain physical examinations, cardiac rehabilitation exercise program; custodial or intermediate care; long term rehabilitative services including physical, speech, and occupational therapy; services other than artificial insemination for conception by artificial means, including but not limited to, in vitro fertilization, ovum transplants, gamete intrafallopian transfer, zygote intrafallopian transfer; conception by artificial means; services related to the procurement and storage of donor semen; services related to sexual reassignment; services to reverse voluntary, surgically induced infertility; experimental or investigational services; non-human and artificial organs and their implantation; specialized behavioral modification programs for chronic conditions; alternative medical services including acupuncture, naturopathy, and massage therapy; hypnotherapy and hypnotic anesthesia; cosmetic surgery or services.
13 Voluntary Long-Term Disability (LTD) LTD replaces your income if you are sick or injured and cannot work, and begins after you have been disabled for 90 days. These plans provide income protection to replace up to 60% of salary, tax free, as described below. The chart below shows your eligibility requirements and cost for each coverage. Detailed information regarding each plan is available on the MIV/Department/Benefits/LTD and Life to review summaries. This is a summary of benefits only. A complete description of benefits and limitation will be provided in the certificate of coverage. All coverage is subject to the terms and conditions of the group policy. Employees budgeted to work at least 60 hours bi-weekly are eligible to enroll in LTD. The pre-existing provision of the LTD plan applies. Option Eligibility Participants Benefit Rate Option 1 Employee budgeted to work at least 60 hours bi-weekly with 5 or more years of service 60% of base annual salary, maximum $10,000 per month - your benefit is based on Own Occupation for 12 months $.33/$100 of salary up to $200,000 Option 2 Employee budgeted to work at least 60 hours bi-weekly with less than 5 years of service or with more than 5 years of service 60% of base annual salary, maximum $10,000 per month - your benefit is based on Own Occupation for 24 months $.585/$100 of salary up to $200,000 Option 3 Physician budgeted to work at least 60 hours bi-weekly All Source Integration is based on total W-2 earnings, the lesser of $15,000 or 60% of your average monthly earnings with no offsets, or 70% of your average monthly earnings less all other income benefits (Sick Pay, OPERS, Social Security etc.) Your benefits is based on Own Occupation. $.98/$100 of salary up to $300,000 Option 4 Executive budgeted to work at least 60 hours bi-weekly All Source Integration is based on total W-2 earnings, the lesser of $15,000 or 60% of your average monthly earnings with no offsets, or 70% of your average monthly earnings less all other income benefits (Sick Pay, OPERS, Social Security etc.) Your benefits is based on Own Occupation. $.82/$100 of salary up to $300,000 LTD Plan Benefit Sample Paid through payroll deduction on an after-tax basis, therefore if you receive a LTD benefit that income is tax free and offset by other income. Example: W2 Earnings of $200,000 Monthly Benefit: $200,000 divided by 12 = $16,555 x 60% = $10,000 Bi-weekly Contribution Samples: Employee in.58 LTD Plan > or < less 5 years of service $40,000 divided by 100=$400 x.585 =$234 divided by 26 pay periods = $9.00 Employee in.33 LTD Plan with >5 years of service $40,000 divided by 100=$400 x.33=$132 divided by 26 pay periods = $5.08 Physician $200,000 divided by 100=$2,000 x.98=1960 divided by 26 pay periods = $75.38 Executive $200,000 divided by 100=$2,000 x.82=1640 divided by 26 pay periods = $63.08
14 Life Insurance Enrollment Life Insurance Coverage Options Basic Life and Basic Accidental Death & Dismemberment (AD&D) Non-Bargaining Employees, Employees of the Ohio Patrolmen s Benevolent Association (OPBA), budgeted to work at least 60 hours Bi-weekly (excludes Executives & Physicians). The Metro- Health System provides, at no cost to you, Basic Life Insurance in an amount equal to 1.5 times base annual earnings, to a maximum of $300,000, Basic AD&D insurance in an amount equal to 1.5 times your basic annual earnings, to a maximum of $300,000. Supplemental Life Insurance Coverage Eligible Class for Supplemental Life: Non-Bargaining Employees, Employees of the Ohio Patrolmen s Benevolent Association (OPBA), Employees of the AFSCME Bargaining Unit, budgeted to work at least 60 hours Bi-Weekly. Employees are eligible to purchase Supplemental Life Insurance in the amount of one or two times annual base salary with a matching amount of Accidental Death & Dismemberment (AD&D). Coverage amount will be reduced to 67% at age 70 and will further be reduced to 50% of the original amount at age 75. Guarantee Issue Amount for Optional Life You can purchase 1 or 2 times your basic annual earnings up to $500,000. Amounts available with no evidence of insurability required ($800,000 max basic and optional combined): Employees earning $100,000 or less can elect 1x or 2x salary Optional Life without submitting Evidence of Insurability Form (EOI) proof of insurability. Employees earning greater than $100,000 can elect 1x salary Optional Life without submitting Evidence of Insurability Form (EOI). If you would like to apply for 2x salary Optional Life you can request Evidence of Insurability Form (EOI) from Benefits Department. If the EOI is approved your Supplemental Life will be effective the first day of the month following your approval. Bi-weekly Rates per $1,000 of coverage Age Rate Age Rate Age Rate <30 $ $ $ $ $ $ $ $ $ $ $.356 Bi-weekly Calculation Age Annual Salary (1x)... $40,000 Divide by 1, Bi-weekly Rate Bi-weekly Contribution... $2.68 Imputed Income The IRS requires you to be taxed on the value of employer-provided group term life insurance over $50,000. The taxable value of this life insurance coverage is called imputed income. Even though you don t receive cash, you are taxed as if you received cash in an amount equal to the value of this coverage. Physicians & Executives As an employee at the executive or physician level budgeted to work at least 60 hours bi-weekly, MetroHealth provides you with Basic Group Variable Universal Life (GVUL) with a matching amount of Accidental Death & Dismemberment coverage at no charge. Amount of coverage is based on your level of employment. You are eligible to elect voluntary supplemental coverage other than your initial eligibility period with Metlife. Voluntary supplemental coverage is available from 1 to 4 times your annual salary, to a maximum amount of $2M (employer paid Basic Life and Supplemental combined). Coverage above guaranteed issue requires the completion of a Health Questionnaire and Authorization Form and underwriting approval. If the coverage exceeds $500,000 a blood test is also required. For more information go to the Metlife website mybenefits.metlife.com (please register for a first time user) or call a MetLife customer service representative at Tax-Deferred Investment Opportunity You also have the ability to make after-tax deductions into variable investment portfolios, which have the potential to grow on a tax-deferred basis and build cash value. Extra premium for investment can be invested in your choice of one or more of the 22 investment portfolios. For more information log on to the MetLife website mybenefits.metlife.com (register for first time users) or call MetLife customer service at Dependent Life Insurance Eligible Class for Dependent Life: All employees budgeted to work at least 60 hours bi-weekly. There are four dependent life options for your spouse and unmarried children at least 14 days of age to age 26. Dependent Life Options Option 1 $5,000 Spouse $.44 $2,000 Children $.10 $5,000 Spouse & $2,000 Children $.54 Option 2 $10,000 Spouse $.88 $4,000 Children $.20 $10,000 Spouse & $4,000 Children $1.08 Option 3 $20,000 Spouse $1.76 $8,000 Children $.40 $20,000 Spouse & $8,000 Children $2.16 Option 4 $50,000 Spouse $3.00 $20,000 Children $1.15 $50,000 Spouse & $20,000 Children $4.15 * The amount of Dependent Optional Life Insurance for a child under 14 days is None. The amount of Dependent Optional Life for a child age 14 days but under 6 months is $500.
15 CIGNA Dental PPO The CIGNA Dental PPO plan is administered by CIGNA. The plan offers both network and non-network coverage. You will be able to take advantage of discounted prices for dental care through an extensive network of providers. You do not need to be enrolled in a medical plan to enroll in the Dental/Vision plans. MetroHealth Dentists MetroHealth dentists are also in-network providers under the CIGNA Dental PPO. In-Network Dentists Looking for an in-network dentist or specialist? Visit and click on Provider Directory at the top of the page. Click dentist and enter your Zip Code to find a dentist near you. The easiest way is through MyCIGNA automatically knows which CIGNA dental plan and network you belong to. If you see an in-network dentist, the dentist will have the information in order to submit the claim to CIGNA. CIGNA can also provide the account number of the MetroHealth Plan if they call CIGNA s Member Service phone number at Out-of-Network Dentists If you see an Out-of-Network dentist, you may ask the dentist to submit the dental claim for you and provide them with the customer service number in order to obtain the remittance information. You can also print the ID card on that will contain all the information necessary to submit a claim. Claim forms are also available on the MIV/Departments/Benefits/Dental/Vision. COVERED SERVICES Annual Deductible Preventive Services Basic Services (rebasing, realigning, endodontic, fillings, root canals, extractions, periodontics) Major services (crowns, bridges, inlays, partials, dentures) Orthodontia: Includes children up to age 19 PLAN BENEFIT $25 Individual/$75 Family Plan pays not subject to deductible Plan pays 80% subject to deductible Plan pays 60% subject to deductible Plan Pays 80% not subject to deductible ($1,500 lifetime maximum) Three or more family members pay a combined total of $75 deductible per calendar year. $1,500 calendar year maximum for preventive, basic and major services combined. Charges are subject to usual, customary and reasonable rates or contractual discount. Oral surgical procedures will be considered under the medical plan.
16 MetroHealth Dental Plan Option How the MetroHealth Dental Plan Works The MetroHealth Dental Plan option is just like the MetroHealth Employee Medical Plan, you must use MetroHealth dentists for all your dental care except for services which are not available at MetroHealth. The MetroHealth Dental Plan will be administered by CIGNA. MetroHealth Dental Department There are seven full-time Dentists and six part-time Dentists that treat adults and children. General Dentist are the primary care provider for patients in all age groups who take responsibility for the diagnosis, treatment, management and overall coordination of services to meet patients oral health needs. These oral health care needs include: fillings, root canals, crowns, veneers, bridges, implants, gum care as well as preventive education. Veneers and implants are not a covered benefit under the plan. People aiding in oral health service include dental assistants, dental hygienists, dental technicians, dental residents, and extended function dental assistants. Periodontist There is one part-time Periodontist diagnosing, preventing and treating gum disease. Our Periodontist can also place dental implants as well as perform cosmetic periodontal treatments. Endodontists No Endodontist on staff. All of our general Dentists are trained in endodontic procedures and refer only the most difficult cases. Oral Surgeons There are two full-time and one part-time Board Certified Oral Surgeons on staff. Our Oral Surgeons are trained in providing conscious and general sedation procedures. Pedodontists There is one Board Certified Pedodontist. Orthodontists No Orthodontist on staff. Three full-time dentists are credentialed to provide clear braces for patients. (Pedodontists perform limited orthodontia/ braces.) Hygienists There are four full-time Hygienists. Covered Services Not Available at MetroHealth For specialty services not available at MetroHealth go to or call to locate a network provider. If you enroll in the MetroHealth Dental Plan and seek services from other than a MetroHealth provider and the service is available at MetroHealth, no benefits will be paid. When eligible specialty services are provided by a network provider, they will be covered COVERED SERVICES PLAN BENEFIT at 90% of UCR. The highlights of the plan include: No Individual or Family Deductible Higher Annual Maximum Preventive 90% reimbursement for all covered services Bi-weekly Employee Contribution 50% less than the Cigna Dental PPO Annual Deductible None Preventive Services Plan pays Basic Services (rebasing, realigning, endodontic, Plan pays 90% fillings, root canals, extractions, periodontics) Major services (crowns, bridges, Plan pays 90% inlays, partials, dentures) Orthodontia: Includes children up to age 19 Plan Pays 90% (Not available at MetroHealth, go to ($1,500 lifetime mycigna.com for a list network providers) maximum) $1,750 calendar year maximum for preventive, basic and major services combined Charges are subject to usual, customary and reasonable rates or contractual discount. Oral surgical procedures will be coordinated under medical
17 Vision Plan Non-Bargaining & Ohio Patrolmen s Benevolent Association (OPBA) bargaining unit employees budgeted to work at least 35 hours bi-weekly are eligible to enroll in the vision plan. You do not need to be enrolled in a medical plan to enroll in a Dental and Vision Plan. Plan Information MetroHealth has selected EyeMed Vision Care as your vision wellness program. The plan allows you to improve your health through a routine eye exam, while saving you money on your eye care purchases. The plan is available through thousands of provider locations participating in the EyeMed Select Network. The EyeMed Network EyeMed Vision Cares network of providers includes private practitioners, as well as the nation s premier retailers, LensCrafters, Sears Optical, Target Optical, and JC Penney Optical, and most Pearle Vision locations. To locate EyeMed Vision Care providers near you, visit and choose the Select Network. You may also call EyeMed s Customer Care Center at EyeMed s Customer Care Center can be reached Monday through Saturday 8 a.m. to 11 p.m. EST and Sunday 11 a.m. to 8 p.m. EST. Using In-Network Providers When making an appointment with the provider of your choice, identify yourself as an EyeMed member; provide your name and the name of your organization or plan number, located on the front of your ID card. Confirm the provider is an in-network provider for the Select Network. MetroHealth Ophthalmologists are In-Network providers. When you receive services at a participating EyeMed provider, the provider will file your claim. You will have to pay the cost of any services or eyewear that exceeds any allowances, and any applicable copayments. You will also owe state tax, if applicable and the cost of non-covered expenses (for example, vision perception training). Using Out-of-Network Providers If you receive services from an out-of-network provider, you will pay for the full cost of the service at the point of service. You will be reimbursed up to the maximums as outlined in the Summary of Covered Vision Care Services. To receive your out-of-network reimbursement, complete and sign an out-of-network claim form, attach your itemized receipts and send to: EyeMed Vision Care Attn: OON Claims P.O. Box 8504 Mason,OH For your convenience, an EyeMed out-of-network claim form is available at or by calling EyeMed s Customer Care Center at
18 Covered Services Summary of Vision Care Services Your In-Network Cost Out-of-Network Reimbursement* Exam Dilation as necessary $0 Up to $40 Refraction $0 Exam Options Contact Lenses Standard Fit and Follow-Up Up to $40 N/A Premium Fit and Follow-Up 90% of retail price N/A Frames 80% of balance Up to $50 over $120 Standard Plastic Lenses Single Vision $0 Up to $50 Bifocal $0 Up to $70 Trifocal $0 Up to $90 Lenticular $0 Up to $90 Standard Progressive $65 Up to $70 Premium Progressive $65 plus 80% of charge Up to $70 less $120 allowance Standard Lens Options UV coating $15 N/A Tint (solid and gradient) $15 N/A Standard scratch resistance $0 $8 Standard polycarbonate $40 N/A Standard anti-reflective coating $45 N/A Other add-ons and services 80% of retail price N/A Contact Lenses** Conventional 85% of balance Up to $100 over $120 Disposable of balance Up to $100 over $120 Medically necessary $0 (paid in full by plan) Up to $160 Lasik or PRK from US Laser Network 85% of retail price / N/A 95% of promotional price Frequency - based on date of service Exam Lenses or Contact Lenses Frames Once every calendar year Once every calendar year Once every calendar year This summary is not the Summary Plan Description document. * You are responsible to pay the out-of-network provider in full at time of service and then submit an out-ofnetwork claim form for reimbursement. You will be reimbursed up to the amount shown on the chart. ** For prescription contact lenses for only one eye, the Vision Care plan will pay one-half of the amount payable for contact lenses for both eyes.
19 Who is covered? All non-union and OPBA members and dependents enrolled in the MetroHealth Employee or MetroHealth Plus plans are eligible for hearing aid benefits. AFSCME employees should contact the AFSCME Care Plan at for benefits. What is the benefit? One (1) hearing aid for each ear every rolling twenty-four (24) months. The plan will pay up to a maximum allowable benefit of $800 for each hearing aid. If the hearing aid(s) are more costly than the maximum allowable benefit under the plan, it is the member s responsibility to pay the provider the difference The benefit includes a comprehensive audiological evaluation, ear impression and required visits necessary for the proper fitting/use of the hearing aid. Hearing aids must be prescribed, fitted, serviced and dispensed by a licensed audiologist or other provider who is a hearing instrument dispenser or other hearing care professional; otherwise, no benefits are available How do I get reimbursed? Attach an original, paid, itemized receipt to a Medical Mutual of Ohio claim form, which is available on the MIV/Departments/Benefits. What is not covered under the Hearing Aid Program? Charges associated with the return of a hearing aid. Charges associated with repairs. Charges for amplification devices. Hearing Aid Benefits RTA Commuter Advantage Program RTA monthly passes can be purchased at discounted prices through payroll deduction. You can purchase local/ express passes for $42.50 bi-weekly ($85.00 monthly) using pre-tax dollars. Passes can be picked up at the Human Resources Department Main Campus or Old Brooklyn Campus each month.
20 Caremark Prescription Drug Plan The plan allows you to purchase prescription drugs at MetroHealth outpatient pharmacies (provided a MetroHealth physician has written your prescription) or MetroHealth s new mail service option, a Caremark participating retail pharmacy or through Caremark s mail order program. Generic Copayments Incentive If you are taking a brand-name medicine that does not have an exact generic equivalent, but an alternative is available, you may receive a letter from CVS Caremark. The letter will provide the name of the brand-name medicine, as well as the alternative to discuss with your doctor. If your doctor agrees, MetroHealth will pay for the first fill of the alternative drug. There is no cost to you. This is only applicable to the specific alternative outlined in the letter. Exclusive Specialty Specialty medications are high cost drugs that are prescribed to members with rare and chronic conditions such as cancer, hemophilia, hepatitis C, HIV, multiple sclerosis and rheumatoid arthritis. If you take a specialty medication, you will be required to fill it through either the MetroHealth outpatient pharmacies, if available, or CVS Caremark s specialty pharmacy. Impacted members will be contacted via letter as well as phone for assistance in the transition. Pharmacy Advisor Members with diabetes will have help from a CVS Caremark Pharmacy Advisor. The advisor will provide guidance to help individuals stay on track with their medication and offer one-on-one advice. Over-the-Counter (OTC) Equivalents MetroHealth will not cover prescriptions for Non-Sedating Antihistamines (NSAs) because there are several NSAs available over-the counter (OTC) without a prescription. Talk to your doctor about using an OTC alternative. NSA medications used for allergies and nasal congestion such as Allegra and Clarinex have OTC equivalent medications available.
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