Benefits Guide 2021-2022 - Health Financial Work-Life
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2021–2022 Benefits Guide • Health • Financial • Work-Life
WELCOME Look Inside
We are committed to providing you with a competitive, Medical Coverage
comprehensive benefits program that provides the care
you and your family need to lead healthy, productive Dental Coverage
lives. Please review this guide carefully for highlights of Vision Coverage
our benefits and discuss your options with your family.
Benefits Contact Directory
Eligibility Important Notices
• Full-time employees working 25 hours or more per week
• Benefits are effective on the first day of employment
Qualified Life Events
Elections you make at this time will remain in effect until our next Open Enrollment
period. In addition, if you decline coverage for yourself and/or your dependent(s)
when first becoming eligible, you must wait until the next Open Enrollment period
to enroll. However, if you experience a qualified life event during the year, you may
make changes to your elections at that time.
Qualified life events include: How To Enroll
• Change in status: Marriage, divorce, legal separation, annulment or death
• Change in number of dependents: Birth, death, adoption/placement for
adoption or dependent reaching limiting age
• Change in employment status of employee, dependent or spouse that affects Step 1: Contact HR no later
that individual’s eligibility
than May 28, 2021 to make
• Change in employee, spouse or dependent coverage on spouse’s plan
during spouse’s Open Enrollment period any plan changes (e.g. switch
• Changes in entitlement to Medicare, Medicaid or State Children’s Health plans, add dependents).
Insurance Program (CHIP)* for employee, dependent or spouse
• Change in eligibility for group health plan premium assistance under
Medicaid or CHIP* for employee, dependent or spouse
Step 2: Bring any and all
It is your responsibility to notify Human Resources (HR) within 31 days of the event. necessary information to your
If you fail to do so, you will not be able to enroll or make changes until the next Open appointment (e.g., dependent
Enrollment period. When you, your dependent(s) or your spouse become enrolled
as a result of a qualified life event, coverage will be made effective retroactive to the
date of birth, Social Security
date of the event. For more information, please contact HR. number)
*In such cases you have 60 days to notify HR of the event instead of 31.
Step 3: All paperwork must
be completed and submitted
by May 28, 2021 to be
effective July 1, 2021.
2
BENEFITS
Medical Coverage: Blue Cross® Blue Shield® of Illinois (BCBSIL)
We’re proud to offer employees medical coverage that not only provides coverage for illness and injury, but also enables you and
your family to focus on staying well. Following is a high-level overview of the coverage available. For complete coverage details,
please refer to the Summary Plan Description (SPD).
HMO Illinois and
PPO Blue Choice Select PPO Blue Advantage
Plan Feature HMO
In-Network Out-of-Network In-Network Out-of-Network In-Network Only
Annual Deductible
Employee only $1,000 $400 $0
Family $2,000 $800 $0
Annual Out-of-Pocket Maximum
Employee only $2,500 $5,400 $1,500 $4,400 $1,500
Family $6,250 $10,800 $3,750 $8,800 $3,000
Office Visit
Plan pays 80% after Plan pays 80% after
Primary Care Physician $20 copay $20 copay $20 copay
deductible is met deductible is met
Plan pays 80% after Plan pays 80% after
Specialist $40 copay $20 copay $20 copay
deductible is met deductible is met
Plan pays 100%, Plan pays 80% after Plan pays 100%, Plan pays 80% after
Preventive Care Plan pays 100%
no deductible deductible is met no deductible deductible is met
Emergency Room Visit
$200 copay $200 copay $200 copay
(copay waived if admitted)
$300 copay, then $300 copay, then
Plan pays 90% after Plan pays 90% after
Inpatient Hospital Stay plan pays 80% after plan pays 80% after $250 copay
deductible is met deductible is met
deductible is met deductible is met
Prescription Drugs (Tier 1/Tier 2/Tier 3)
Retail
$10/$40/$60 copay $10/$20/$40 copay $10/$20/$40 copay
(up to a 30-day supply)
Mail Order $20/$80/$120
N/A $20/$40/$80 copay N/A $20/$40/$80 copay
(up to a 90-day supply) copay
3Dental Coverage: Blue Cross® Blue Shield® of Illinois (BCBSIL)
Following is a high-level overview of your dental coverage. For complete coverage details, please refer to the Summary Plan
Description (SPD).
PPO DHMO
Plan Feature
In-Network Out-of-Network In-Network Only
Annual Deductible (Individual / Family) $75 / $225 $100 / $300 $0 / $0
Annual Maximum Benefit $2,000 Unlimited
Preventive 100%
Basic 80%
Scheduled copays
Major 50%
Orthodontia (Child Only) 50%
Vision Coverage: EyeMed Basic Life: Blue Cross® Blue Shield®
Following is a high-level overview of your vision coverage. of Illinois (BCBSIL)
For complete coverage details, please refer to the Summary Provides your named beneficiary(ies) with a benefit in
Plan Description (SPD). the event of your death. This benefit is provided at no cost
to you.
Plan Out-of-
Frequency In-Network
Feature Network
Examination Every 12 $10 copay Up to $40
Voluntary Short-Term Disability:
months Blue Cross® Blue Shield® of Illinois
Basic Lenses
(single/bifocal/
Every 12
months
$10 copay Up to
$30/$50/$70
(BCBSIL)
trifocal)
Disability insurance provides benefits that replace part of
Frames Every 24 $100 Up to $70 your lost income when you become unable to work due to a
months allowance, covered injury or illness.
20% off
balance Voluntary Long-Term Disability
Contact Every 12 $100 Up to $70
Provided at an affordable group rate through Blue Cross®
Lenses months allowance,
Blue Shield® of Illinois (BCBSIL).
(in lieu of 15% off
glasses) balance Benefit Percentage 60%
Monthly
$1,500
Benefit Maximum
When Benefits Begin 8th day
Maximum
12 weeks
Benefit Duration
4BENEFITS CONTACT DIRECTORY
Topic Contact Phone Number Website & Network
General Benefits and/or Enrollment Human Resources 708-484-6200
Medical Coverage BCBSIL 800-458-6024 www.bcbsil.com
Dental Coverage BCBSIL 800-458-6024 www.bcbsil.com
Vision Coverage EyeMed 844-225-3107 www.eyemed.com
Life and Disability BCBSIL 800-458-6024 www.bcbsil.com
5IMPORTANT NOTICES
Mental Health Parity Act Summary of Benefits and
Per the Mental Health Parity Act, benefits for mental health Coverage (SBC)
and substance-use disorder must be treated like benefits
As an employee, the health benefits available to you
for regular medical and surgical care. For example, if there
represent a significant component of your compensation
is no limitation on the number of days for inpatient and
package. They also provide important protection for you
number of visits for outpatient medical care, then there
and your family in the case of illness or injury. To help you
can be no limitation for mental health and substance-
make an informed choice, the company makes available
use disorder treatments. As always, treatments must be
a Summary of Benefits and Coverage (SBC), which
medically necessary to qualify for coverage. Plan participants
summarizes important information about our health coverage
should review their plan’s certificate of coverage or benefit
in a standard format, to help you compare across options.
document for specific information about coverage, limitations
The SBC also includes a Glossary of Health Coverage and
and exclusions for mental health care and substance-use
Medical Terms to help you better understand health care
disorder treatments.
terms used in the SBC. You can obtain a copy of the SBC at
no cost to you by contacting your local HR representative.
Women’s Health and Cancer
Please note: This guide is intended to provide you with highlights of our
Rights Act benefits program. It is not intended to address all details. Actual benefit
coverage is specified in the Summary Plan Descriptions (SPDs). In the event
of any differences between this guide and the SPDs, the SPDs will govern.
On January 1, 1999, a federal law, the Women’s Health and
Cancer Rights Act of 1998, became effective, which affects
our company plan options. This law requires group health
plans that provide coverage for mastectomies (ours does)
and to also provide coverage for reconstructive surgery and
prostheses following mastectomies. As required under the
law, we have included this notice to inform you about it.
The law mandates that a participant or eligible beneficiary
who is receiving benefits, on or after the law’s effective date
(January 1, 1999, for our Plan), for a covered mastectomy
and who elects breast reconstruction in connection with the
mastectomy, will also receive coverage for:
• All stages of 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 treatment of physical complications of all
stages of mastectomy, including lymphedemas.
This coverage will be provided in consultation with the patient
and the patient’s attending physician and will be subject to
the same annual deductible, coinsurance and/or copayment
provisions otherwise applicable under the Plan.
If you have any questions about coverage for mastectomies
and post-operative reconstructive surgery, please contact
your local HR representative.
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