Benefit highlights guide plan year

Transcription

1 Benefit highlights guide 2014 plan year

2 Oregon Health & Science University knows how important it is to have good, affordable health and welfare benefits. That s why we offer competitive benefits that can provide protection, peace of mind and savings. Whether it s health care, income protection, or other benefits, we ve got you covered. This guide provides a general overview of your benefit choices and enrollment information to help you select the coverage that is right for you. Know enrollment When can I enroll? New employees As a new employee, you must enroll in benefits within 60 days of your date of hire. Our benefits plan year runs from Jan. 1 through Dec. 31. Open enrollment As a benefits-eligible employee, you have an opportunity once a year to enroll in or make changes to your benefit plans during the open enrollment period, unless you experience a qualified family status change. Open enrollment is typically held in October. Open enrollment for your 2014 benefits is Oct. 1 through Oct. 31, 2013 with elections effective Jan. 1, Note: With the exception of flexible spending accounts, your current benefit selections will remain unchanged in 2014 unless you go online and make a change. However, if you did not complete the plan requirements for 2013, you will be moved to the OHSU PPO Standard or 250 PPO Standard medical plan for the 2014 plan year (see page 6). How do I enroll? Log on to Oracle Employee Self Service at to enroll in or make changes to your benefits. Before logging on, have a list of your benefit selections/changes, as well as the names, Social Security Numbers, birthdates and addresses of those you wish to designate as beneficiaries or enroll as dependents. If you plan to opt out of OHSU medical or OHSU dental coverage, you must provide the other employer s name, group name and group plan number under which you are covered. Go to and click Click Here to begin. Login using your regular OHSU network username and password. In the Main Menu under Employee Self Service, choose Benefits to enroll or make changes. Contents Know enrollment...2 When can I enroll?...2 How do I enroll?...2 Know who is eligible...3 Who can I cover?...3 What if things change?...3 Know the cost of your benefits...4 Medical and dental costs for How it works...4 Know your medical and prescription drug benefits...5 Medical benefits summary...5 Eligibility for the lowest cost OHSU benefits...6 Know your wellness benefits...7 Healthy TEAM Healthy U...7 HealthySteps...7 Weight Watchers...7 Smoking Cessation...7 Know your dental benefits...8 Know your vision benefits...8 Know your income protection benefits...9 Life and AD&D coverage...9 Disability...9 Know your additional benefits...10 Flexible Spending Accounts (FSAs)...10 Employee Assistance Program (EAP)...10 Travel assistance...10 Did you know?...11 Click Add Dependents or Beneficiaries to update before selecting benefits. Know your rights...11 Click Next and follow the onscreen instructions to select your benefits. Know how to get information...12 Once you have successfully submitted your selections and completed enrollment, print the confirmation page for your records. 2

3 Know who is eligible Who can I cover? You can enroll in the benefits listed in this guide if you are a 0.5 FTE or greater and working in a benefits-eligible position. For more detailed information on employee and dependent eligibility, visit the Benefits O2 website at: If you participate in OHSU benefits, you also may enroll: Your spouse (opposite or same sex) or domestic partner (opposite or same sex; registered or unregistered); Your child(ren) (including child(ren) of a domestic partner or spouse) up to age 26 who does not have access to their own employer coverage. This applies regardless of marital or student status; Your child(ren) of any age who is incapable of supporting themselves due to a mental or physical disability and who is totally dependent on you; and Your child(ren) by adoption or court-ordered judgment who otherwise meet the dependent eligibility. Please refer to the plan summaries or contact OHSU Benefits for additional information. Verification of dependents In 2013, OHSU began the practice of verifying dependents enrolled in medical coverage a practice very common at other employers. An audit of all dependents was conducted during the summer of OHSU Benefits is working on an ongoing audit process for newly added dependents not verified as part of that audit. Stay tuned for updates from Benefits about the new ongoing verification process for new dependents. What if things change? The benefits you choose will be effective through the end of the calendar year. You cannot make changes to your coverage during the year, unless you have a qualified family status change including: Marriage, establishment of a domestic partnership, legal separation, divorce or termination of a domestic partnership; Birth, legal adoption of a child, or placement of a child with you for legal adoption; Death of your spouse/domestic partner or dependent child; or Change in residence (only if your current coverage isn t available in the new location or if you are offered an option that you were not previously offered). To make a change due to a qualified family status change, you must notify and submit any applicable forms and/or documentation to OHSU Benefits within 31 days* of the event. OHSU Benefits will review your request and determine whether the change you are requesting is allowed. Only benefit changes which are consistent with the qualified family status change are permitted. *60 days if you, your spouse/domestic partner, or eligible dependent child loses coverage under Medicaid or a state Children s Health Insurance Program (CHIP) or becomes eligible for state-provided premium assistance. Know how to choose When you think about your health care costs, the first thing that comes to mind is probably your premium the amount that comes out of every paycheck for coverage. But to see the total picture, you also have to consider what you re likely to pay out of your pocket, such as when you go to the doctor or get a prescription. Keep this in mind as you review the following health care options. 3

4 Know the cost of your benefits OHSU provides benefit-eligible employees benefit dollars to apply toward the cost of benefits. OHSU provides you a set amount of monthly funds depending on your employee representation and the coverage level you select. The funds are applied to the cost of the medical and dental benefit options you choose to enroll in. If your benefit dollars don t cover the complete cost of the benefits you choose, the difference will be deducted from your paycheck 24 times a year. Below are the benefit dollars that OHSU is contributing to your benefit selections for OHSU s monthly benefit contribution Full-time ( ) Unclassified ONA represented* AFSCME represented Part-time (.50.74) Full-time ( ) Part-time (.50.69) Full-time ( ) Part-time (.50.74) Medical opt out** $100 $50 $50 $50 $50 $0 Employee only $ $ $ $ $ $ Employee & spouse/domestic partner $ $ $ $ $ $ Employee & child(ren) $ $ $ $ $ $ Employee & family $ $ $ $ $ $ *As of the time of Open Enrollment, the ONA contract with the 2014 benefit dollars had not been finalized. ONA benefit dollars are calculated here based on the current contract but may change when the ONA contract is ratified. **The medical opt out rate reflects the contribution amount employees will receive and can use for dental, life and optional coverage. Medical and dental costs for 2014 The rates listed below are the monthly costs for the medical and dental plans by coverage level (number of dependents) you choose. Your benefit dollars paid to you by OHSU (shown above) help you pay for these premiums, along with FSA benefits you select. (See pages 5 and 8 for medical and dental benefit summaries) Monthly medical premiums Employee only Employee & spouse/ domestic partner Employee & child(ren) Employee & family OHSU PPO $ $ $ $ OHSU PPO Standard $ $ $ $1, PPO $ $1, $ $1, PPO Standard $ $1, $ $1, Kaiser Permanente $ $1, $1, $1, Monthly dental premiums Employee only Employee & spouse/ domestic partner Employee & child(ren) Employee & family Moda Health $43.10 $93.80 $ $ Kaiser Permanente $87.08 $ $ $ Williamette Dental Group $45.40 $88.50 $80.30 $ How it works Here are two examples of how to apply benefit dollars to your benefit selections and understand your paycheck deduction. Example 1 Mya: Meet Mya. She is a single, full-time employee classified as an unclassified employee. She s selected the OHSU PPO medical plan and Moda Health dental plan for Since she s completed the requirements listed on page 6, she s eligible for lower medical plan premiums in 2014 and to participate in the OHSU PPO, instead of the OHSU PPO Standard. Example 2 John: Meet John. He is a married, full-time employee classified as an AFSCME represented employee. He wants to cover his wife and three children under the 250 PPO medical plan and Moda Health dental plan for Since he s not completed the requirements listed on page 6, he s not eligible for lower medical plan premiums in 2014 so cannot participate in the 250 PPO, only the 250 PPO Standard. Employee only benefit premiums (monthly) OHSU PPO Medical: $ Moda Health Dental: $43.10 OHSU Benefit Contribution: $ Mya s cost: Nothing, Mya will receive back $1.36 monthly [($ $43.10) - $ = $1.36] Employee & family benefit premiums (monthly) 250 PPO Standard Medical: $1, Moda Health Dental: $ OHSU benefit contribution: $ John s cost: $ monthly [($1, $151.84) - $ = $464.64] 4

5 Know your medical and prescription drug benefits Providing comprehensive and quality medical coverage at a reasonable cost is a challenge for all employers. OHSU meets that challenge by providing employees with two medical plan options (three for certain long-term employees eligible for the Kaiser medical plan, described below). If you enroll in the OHSU PPO or 250 plans, you automatically receive pharmacy and vision coverage. See page 8 for vision benefit information. The information below is a summary of medical coverage only. Please visit or (depending on the medical plan you are enrolled in) or for plan summaries detailing coverage information, limitations and exclusions. Any coinsurance or copays shown in the chart below are amounts for which you are responsible. Medical benefits summary Requirements Key features OHSU PPO/OHSU PPO Standard 250 PPO/250 PPO Standard Kaiser Permanente Non-OHSU OHSU provider provider Must select Primary Care Physician (PCP) and complete two of six requirements (see page 6). Employees who didn t participate in wellness programs in 2013 can only select the Standard option in Non-network Network provider provider Must select Primary Care Physician (PCP) and complete two of six requirements (see page 6). Employees who didn t participate in wellness programs in 2013 can only select the Standard option in Network provider only Available only to AFSCME represented employees hired before 10/1/1998 and ONA represented and unclassified employees hired before 1/1/1998. All care must be received by a participating Kaiser Permanente facility, except for true emergencies. Annual calendar year deductible $250/person or $750/family $500/person or $1,500/ family None Medical out-of-pocket (OOP) max (includes deductible) $1,600/person or $3,250/family $4,250/person or $8,750/family $3,500/person or $7,000/family $4,250/person or $8,750/family $1,000/person or $2,000 family Lifetime maximum Unlimited Unlimited Unlimited Home and doctor s office visits $25 copay $25 copay $15 copay Preventive care Lab and X-ray services Hospital services Inpatient (per admission) Outpatient No charge, not subject to deductible; frequency limitations apply 20% 20% 20% ; subject to deductible; frequency limitations apply No charge, not subject to deductible; frequency limitations apply 20% 20% 20% ; subject to deductible; frequency limitations apply No charge No charge $200 copay per visit for hospital/facility charge Emergency care (waived if admitted) $150 copay, then 20% of allowable $150 copay, then 20% of allowable $75 copay (waived if admitted) Prescription OOP max $1,500/person or $2,500/family $1,500/person or $2,500/family Included in medical OOP max Retail prescription drug (30-day supply) Value Generic Preferred Non-preferred Mail-order prescription drug (90-day supply) Value Generic Preferred Non-preferred (See page 4 for medical premiums) $2 20%, $100 max 30%, $100 max 50%, $100 max $6 10%, $100 max 20%, $100 max 33%, $100 max $4 25%, $10 min & $100 max 35%, $10 min & $100 max 50%, $10 min & $100 max Not covered $2 20%, $100 max 30%, $100 max 50%, $100 max $6 10%, $100 max 20%, $100 max 33%, $100 max $4 25%, $10 min & $100 max 35%, $10 min & $100 max 50%, $10 min & $100 max Not covered $15 copay per formulary prescription 5

6 Eligibility for the lowest cost OHSU benefits For the past several years, OHSU has offered wellness programs that employees can participate in to receive lower premiums on the OHSU PPO and 250 plans. Employees who haven t participated in the wellness programs have paid 5% higher in premium rates (termed the Standard plan option). Employees who participate in the OHSU wellness program offerings will continue to see savings in their medical costs next plan year. Note: New employees automatically are given the lower premium option for their first year but must participate in the OHSU wellness program to continue to see savings in their medical costs. To qualify for savings on your 2015 medical costs, you must complete the following requirements by Sept. 30, 2014: Requirement #1 Designate a primary care provider (PCP) in Oracle. (There s no need to repeat if you have previously completed and there are no changes.) Requirement #2 This requirement only applies if your OHSU PCP has identified you to participate. Employees or their covered dependents receiving an invitation from their OHSU PCP to participate in the OHSU Care Coordination Plus program must enroll and complete the program. If eligible, you will receive a personalized invitation from your PCP. The OHSU Care Coordination Plus program is for select patients with chronic conditions that require a range of services. Additional benefits include: a designated Nurse Care Manager, better coordination of information and a single point of access to your care team at OHSU. Requirement #3 Additionally, each employee must complete two of the following actions by Sept. 30, While only two of these six actions are required to quality for the 2015 medical cost savings, employees are welcome to participate in more than one at no cost. 1. Complete the OHSU Benefits Quiz/Survey. 2. Get your flu shot by Oct. 31, 2013 at: One of the employee flu shot clinics; or A location of your choice. You will need to complete and return the OHSU influenza declination form and fax the form to Forms are available from Occupational Health Services. 3. Earn 1,000 points in the HealthySteps program. Opting out of medical coverage 4. Complete the Healthy TEAM Healthy U program. 5. Complete the OHSU-sponsored smoking cessation program; start by calling QUIT4 LIFE or visit 6. Complete the OHSU-sponsored weight management program with Weight Watchers; start by calling AT WORK and talk to a local Weight Watchers At Work manager about setting up a meeting at your worksite. Note: Employees not meeting these requirements will not be eligible for medical cost savings for You must enroll in medical insurance unless you have coverage under another group medical plan. To opt out, you must provide proof of coverage (name of group medical plan and policy number) to OHSU. If you choose to opt out, you will receive reduced benefit dollars, shown on page 4. If you lose coverage under another group plan, you must enroll in the OHSU medical coverage within 31 days after losing coverage. Know your terms Coinsurance A percentage of costs you pay out of pocket for covered expenses after you meet the deductible. Copay (copayment) A fee you have to pay out of pocket for certain services, such as a doctor s office visit or prescription drug. Deductible The amount you pay out of your pocket before the health plan will start to pay its share of covered expenses. Network Doctors, pharmacists and other health care providers who make up the plan s preferred providers. When you use network providers, you pay less because they have agreed to negotiated pricing. Out-of-pocket maximum (OOP max) The most you pay each year out of your pocket for covered expenses. Once you ve reached the out-of-pocket maximum, the health plan pays 100% for covered expenses. Preventive care Services you receive when you are not sick or injured so that you will stay healthy. Preventive care services include annual physicals, wellness screenings and well-baby care. 6

7 Know more about your benefits What about acupuncture and chiropractic benefits? Acupuncture and chiropractor visits are a drug-free way to minimize pain. Since people often develop a tolerance to drugs or need higher dosages to achieve the same effect, these forms of treatment are a great alternative. Also, they allow your doctor to examine your response immediately and adjust treatment as needed. For employees enrolled in the OHSU PPO or 250 plan, OHSU pays for 70% of the allowable for acupuncture and chiropractic visits, with a maximum of 60 visits per calendar year. You can save money by using the in crowd No matter which health care options you choose, it s critical to make sure your providers are in the insurance carrier s network before you enroll. It could have a large impact on your out-of-pocket expenses if your providers are not innetwork. To see if your providers are in the network, refer to the Know how to get information section on page 12. Know your wellness benefits Healthy Team Healthy U (HTHU) is a health promotion program designed by OHSU faculty and staff and refined by our own employees. It is a behavior-based program to help employees achieve and maintain a healthy lifestyle and capture the power of employees working together. Numerous benefits have been documented, including reduced blood pressure, lower body weight among those who are overweight, improved diet and exercise behaviors and feeling healthier. Furthermore, employees felt less depressed, missed less work, and reported being happier after participating in HTHU. For more information on HTHU, including how to register, visit HealthySteps HealthySteps is an individual-initiated employee wellness program offered by OHSU Benefits and managed by The Division of Health Promotion and Sports Medicine. HealthySteps is an OHSU website that allows you to track and record your wellness activities. Being physically active, controlling your body weight, attending health-related seminars, giving blood and others, can all be tracked on the website. For more information on HealthySteps, including how to register, visit Weight Watchers Benefit-eligible OHSU employees can participate in Weight Watchers at no cost. Employees can choose to attend a community Weight Watchers meeting or coordinate a meeting at their worksite with their colleagues. Employees can also participate independently in the Weight Watchers online program. For more information on the Weight Watchers benefit, including how to register, visit Smoking Cessation If you use tobacco and would like to quit, OHSU Benefits wants to provide support and resources to assist you. OHSU has partnered with the American Cancer Society to provide free resources to employees wanting to quit using tobacco. Resources include unlimited toll-free access to Quit Coaches, free nicotine replacement therapy (patch or gum) mailed directly to your home, and other tools to assist you in your goal to quit using tobacco. For more information on cessation resources available, please call the American Cancer Society - Quit For Life Program at QUIT-4-LIFE ( ) or enroll online at Know how to stay well Did you know all the plans cover preventive care? It s true! Network preventive care like annual physicals, wellness screenings, immunizations, and well-baby care is 100% covered without having to pay your deductible. So, be sure to schedule your annual preventive screening. 7

8 Know your dental benefits Dental coverage is key to your overall health and wellness. You can enroll in dental benefits through Moda Health, Kaiser Permanente or Willamette Dental Group for yourself and your family. If you use network providers, you ll pay less. You can still get care from any providers out of the network, but you ll pay more. Any coinsurance shown in the chart below are amounts for which you are responsible. Dental benefits summary Key features Moda (ODS) Kaiser Permanente Willamette Dental Group Annual deductible $50 per person or $150 per family None None Preventive and diagnostic services No charge, not subject to deductible No charge No charge Annual maximum benefit $1,500 None None Routine fillings 20% after deductible is met No charge No charge Root canals 20% after deductible is met No charge No charge Prosthodontic care (crowns, bridges and dentures) 50% after deductible is met $75 copay per procedure/unit; $25 copayment for relines and rebases $75 copay per procedure/unit Orthodontia services 50% ($1,500 lifetime maximum) Not covered $150 copay for pre-orthodontia; $1,200 copay for comprehensive orthodontia (no lifetime maximum) (See page 4 for dental premiums) Know your vision benefits At no additional cost, you automatically are enrolled for Vision Service Provider (VSP) benefits if you participate in the OHSU or 250 Plan. If you participate in the Kaiser medical plan, you are also automatically enrolled for vision benefits through the Kaiser vision plan at no additional cost. This information is a summary of vision coverage only, visit or for more information on your vision benefits. Key features OHSU PPO/OHSU PPO Standard 250 PPO/250 PPO Standard Kaiser Permanente VSP provider Non-VSP provider VSP provider Non-VSP provider Kaiser provider only Exam No charge Plan reimburses up to $50 No charge Plan reimburses up to $50 $15 copay Lenses and frames Contacts Single vision, lined bifocals and lined trifocals: $25 copay Up to $150 allowance for frames Up to $140 allowance for elective contacts in lieu of glasses Single vision lenses: $50 copay Bifocal lenses: $75 copay Trifocal lenses: $100 copay Frames: $70 copay Up to $140 allowance for elective contacts in lieu of glasses Single vision, lined bifocals and lined trifocals: $25 copay Up to $150 allowance for frames Up to $140 allowance for elective contacts in lieu of glasses Single vision lenses: $50 copay Bifocal lenses: $75 copay Trifocal lenses: $100 copay Frames: $70 copay Up to $140 allowance for elective contacts in lieu of glasses Up to $150 allowance for lenses and frames Up to $150 allowance for elective contacts in lieu of glasses Exam every 12 months; lenses and frames or contacts every 24 months Frequency Exam allowed every 12 months; lenses and frames or contacts every 24 months Exam allowed every 12 months; lenses and frames or contacts every 24 months 8

9 Know your income protection benefits OHSU provides eligible employees with a variety of plans to provide replacement income to you or your beneficiaries in the event of disability, accident or death. This information is a summary of coverage only. Refer to your certificates of coverage for more detail. Basic life coverage OHSU provides you with basic life insurance in the amount of $25,000 at no cost to you. Voluntary life and accidental death and dismemberment (AD&D) coverage You can also purchase additional life and AD&D insurance for yourself, your spouse/domestic partner and child(ren). Remember, life insurance isn t just about paying for memorial services. It s also about making sure your family can maintain its standard of living over the long run. How much your family would need depends on your situation (debts, expenses, etc.). You can elect additional coverage for: Yourself: In increments of $25,000, from $25,000 up to a maximum of $1,000,000. Your Spouse/Domestic Partner: In increments of $25,000, up to a maximum of $500,000. Optional Dependent Life: For any dependent, available in the amount of $4,000. This is separate from and/or in addition to spouse/domestic partner life insurance. Optional AD&D: Employee coverage is available in increments of $50,000, up to $500,000. Family AD&D coverage is set at a fixed percentage of the employee coverage you select. Note: Life insurance premiums are based upon the dollar coverage amount you select and your age or the age of the dependent you are covering. AD&D premiums are based upon the dollar coverage amount you select. For more detail on premium costs, visit the OHSU Benefits O2 page at For new hires and newly benefit-eligible employees, medical certification for yourself or your spouse/domestic partner is required for life insurance policies above $50,000. For current benefit-eligible employees making changes to their life insurance coverage during open enrollment, medical certification for yourself or your spouse/domestic partner is required for life insurance policies above $25,000. All increases or changes to life insurance amounts must be approved by The Standard before they can go into effect. Disability According to the National Safety Council, 490 Americans became disabled in the last 10 minutes. Without disability insurance, those Americans could have no income for as long as they can t work. You have the option to buy short-term disability (STD) and long-term disability (LTD) insurance through The Standard. Short-Term Disability: Benefit pays 65% of your weekly pay for up to 180 days from the date of disability (some limitations apply). You may choose an 8-day, 30-day, or 90-day waiting period. Long-Term Disability: Benefit pays 65% of your monthly earnings, coordinated with other income and benefits, after you have been disabled for 180 days (some limitations apply). STD and LTD insurance premiums are a percentage of your biweekly earnings based upon the waiting period you select. For more detail on premium costs, visit the OHSU Benefits O2 page at 9

10 Know your additional benefits Be ready for the unexpected Will you need dental services such as a filling, root canal, or crown in the next year? Do you wear glasses or contact lenses? If you answered yes to either of these questions, consider the Health Care Flexible Spending Account. This account can help soften the impact of unexpected dental and vision expenses even if you don t enroll in medical or dental coverage. Flexible Spending Accounts (FSAs) OHSU offers two types of FSAs no matter which medical option you choose that can help you save for out-of-pocket expenses: You can use the Health Care FSA (HFSA) for eligible health care expenses such as deductibles, copays, coinsurance, prescription drugs, dental and vision expenses. You can use the Dependent Care FSA (DFSA) for eligible child and elder care expenses so you (and your spouse, if married) can work or go to school. Each year, you can contribute up to $2,500 to the HFSA and up to $5,000 to the DFSA. The amount you choose to contribute will be deducted from your paycheck 24 times a year. There are tax savings, too, because contributions go from your paycheck into your FSA pre-tax. This lowers your taxable income, so you pay less in taxes. Plus, when you have eligible expenses, you pay for them with tax-free money. Visit for a current list of eligible expenses, claims filing deadlines and other information about your accounts. Employee Assistance Program (EAP) OHSU s EAP services are provided by Moda Health. The EAP provides you and eligible members of your household 24/7 access to confidential counseling to help you address issues such as relationships, drug and alcohol abuse, financial hardship and general stress or depression. Many issues can be addressed directly with your EAP professional; in some cases, you may be referred to other resources. The EAP is available 24 hours, 7 days a week by visiting or by calling Travel assistance OHSU provides benefit-eligible employees access to travel assistance through FrontierMEDEX. Resources include help with travel, medical or security problems, anywhere in the world. For more information, call FrontierMEDEX at

11 Did you know? You have urgent care options OHSU Family Medicine clinics at Richmond, Scappoose and the South Waterfront offer evening and Saturday hours. Richmond and Scappoose are open Monday through Friday 8 a.m. to 8 p.m. and Saturday 9 a.m. to 1 p.m. South Waterfront is open Monday through Friday 7 a.m. to 8 p.m. and Saturday 9 a.m. to 1 p.m. Employees enrolled in the OHSU PPO or 250 plan also can use urgent care services at a ZoomCare clinic. With locations throughout the Portland area, ZoomCare can be a convenient option when an employee or family member is faced with an urgent need. For more information on ZoomCare locations and appointments, visit You have a voice - the Employee Benefits Council The EBC is a unique and valuable group that functions on the idea of by the people, for the people. The Council is made up of your fellow employees to discuss the important topics - like what medical plans you are offered - and make decisions on how to move forward with your needs in mind. OHSU believes you know yourself best and you should have a voice in the benefits available to you. It s important you have good, affordable health and welfare benefits to keep you and your family healthy. Much like our tree, which is a symbol of life, growth,and renewal, the EBC represents you to make sure you have an array of health, wellness and financial components available for your total compensation and rewards at OHSU. For more information about the EBC, visit Know your rights Women s Health and Cancer Rights Act Federal law requires a group health plan to provide coverage for the following services to an individual receiving plan benefits in connection with a mastectomy: Reconstruction of the breast on which the mastectomy has been performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; and Prostheses and physical complications for all stages of a mastectomy, including lymphedema (swelling associated with the removal of lymph nodes). The group health plan must determine the manner of coverage in consultation with the attending physician and patient. Coverage for breast reconstruction and related services will be subject to deductibles and coinsurance amounts that are consistent with those that apply to other benefits under the plan. Medicaid and the Children s Health Insurance Program (CHIP) Medicaid and CHIP offer free or low-cost health coverage to children and families. If you are eligible for health coverage from your employer, but are unable to afford the premiums, some states have premium assistance programs that can help pay for coverage. Some states use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums. 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, you can contact your state Medicaid or CHIP office by calling KIDS- NOW or visiting to find out how to apply. You must request coverage within 60 days of being determined eligible for premium assistance. Health Care Reform Notice OHSU believes our Kaiser Permanente medical plan is a grandfathered health plan under U.S. Health Care Reform legislation (Patient Protection and Affordable Care Act, or the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at You may also contact the U.S. Department of Health and Human Services at Additional notices Please contact OHSU Benefits for additional information and full notices on: Medicaid and the Children s Health Insurance Program (CHIP) Health Insurance Portability and Accountability Act (HIPAA) of 1996; Family and Medical Leave Act of 1993; Continuation of Coverage Rights under COBRA; Medicare Part D Creditable Coverage Notice; and Other additional important notices about your rights. 11

12 Know how to get information Refer to the charts below for additional contact information about your OHSU benefit options. For individual benefits Contact... Call... Visit... Medical: Moda Health Group # OHSU PPO or OHSU PPO Standard 250 PPO or 250 PPO Standard Kaiser Permanente HMO (medical, prescription and vision) Dental options Life and disability options Flexible Spending Accounts (HFSA and/or DFSA) Prescription: Moda Health Group # Vision: VSP Group # Kaiser Permanente Group #8553 Moda Health Group # Kaiser Permanente Group #8553 Willamette Dental Group Group #OR102 The Standard Group # Benefit Help Solutions In Portland: Outside Portland: In Portland: Outside Portland: In Portland: Outside Portland: In Portland: Outside Portland: EAP Moda Health Travel assistance FrontierMEDEX N/A For all benefits Contact... Call... /Visit... General benefit questions OHSU Benefits In and outside Portland: benefits About this guide This guide highlights your benefits. Official plan and insurance documents govern your rights and benefits under each plan. For more details about your benefits, including covered expenses, exclusions and limitations, please refer to the individual summary plan descriptions (SPDs), plan document, or certificate of coverage for each plan. If any discrepancy exists between this guide and the official documents, the official documents will prevail. OHSU reserves the right to make changes at any time to the benefits, costs and other provisions relative to benefits. OHSU Benefits Mail code: HR 3181 S.W. Sam Jackson Park Road Portland, OR tel fax