Employee Benefits Guide 2018 - Let's deal with it together - Valley Behavioral Health
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Employee
Benefits Guide
2018
What’s inside:
Contact Information
How to Enroll
Benefits Information
Disclosure
Let’s deal with it together.
Contact Information
Enrollment Notice
Table of Contents
Contact Information 3 I understand that, in order to enroll in
Medical Plan Information 5 benefits, I must login to Ultipro in order to
Health Savings Account Information 7 enroll or decline coverage. I understand
that if I fail to enroll (within 15 days of hire
Flexible Spending Account Information 8
date), I am waiving coverage and will not
Dental Plan Information 9 have coverage. I understand that my next
Vision Plan Information 10 opportunity to enroll will not be until the
Life Plan Information 11 next open enrollment in 2019, unless I have a
STD Plan Information 12 qualified change in status event.
LTD Plan Information 12
401(k) 13
Have an Issue?
First
»» Call the insurance company or benefit
provider using the contact numbers listed
below.
Second
»» If your issues are still not resolved, please
contact Karyne Anderson in Human
Resources.
Contact Information
Benefit Plan Telephone Internet
Medical - Group # G1010990
SelectHealth 800-538-5038 selecthealth.org
Dental - Group #5983963
MetLife 800-275-4638 metlife.com/mybenefits
Vision - Group #5983963
MetLife 800-275-4638 metlife.com/mybenefits
Life and Disability
800-275-4638 metlife.com/mybenefits
MetLife
Health Savings Account
866-382-3510 healthequity.com
Health Equity
Flexible Spending Account
855-399-3035 nbsbenefits.com
NBS
Human Resources
Karyne Anderson 801-263-7214 karynea@valleycares.com
3
This information is designed to help you choose a benefit plan for 2018. Please refer to the Plan Documents provided by the carrier for information regarding
coverage, limitations, and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.
General Information
Who is Eligible Important Notices
»» Fully benefitted employee that works 40+ hours per week. The following benefit summaries are for ease of comparison.
»» ACA eligible (medical benefits) employee that works 30-40 This brief highlight brochure provides a summary only of
hours per week benefits available to eligible employees and their eligible
»» Your legal spouse and/or domestic partners. dependents. Valley Behavioral Health reserves the right to
»» Your children up to age 26 regardless of marital or audit the dependency status of individuals enrolled by an
student status. employee. This process may include a complete eligibility
»» Your unmarried children of any age, if they depend on verification of all enrolled dependents and/or verifying
you for support due to a physical or mental disability relationship and status of new dependents registered during
(documentation required). open enrollment, by new-hires, and qualifying events. Ensure
that you are covering only eligible dependents when you enroll
in the plan offerings.
When does coverage begin for new hires?
The information in this booklet supersedes all prior summaries.
Coverage begins the first of the month following 30 days of However, since this booklet is only a summary, it does not
employment. You must be full time and actively at work for describe every detail of the benefit programs outlined. If there
your coverage to become effective. are any inconsistencies or discrepancies between this booklet
and the governing plan documents and benefit contracts, the
Choose Wisely governing plan documents and benefit contracts will prevail.
The governing plan documents and benefit contracts are
The choices you make will remain in effect during the 2018 available for your review in your Human Resource Department.
plan year unless you have an IRS approved qualifying change
of status Refer to the carrier’s literature for specific details. No rights
shall accrue to you and/or your dependents because of any
statement, error, or omission in this comparison. Reasonable
Financial hardship is not a qualifying event efforts are made to keep employees informed of any changes
for benefit changes in benefit plans. Please note that these benefits are subject to
change.
A Qualifying Change of Status Occurs for
the Following: When Coverage Ends
»» You get married, legally separated, or divorced.
»» You add a dependent child through birth, adoption, or Most coverages terminate on the last day of the month your
change in custody. employment with Valley Behavioral Health ends. Your life
»» Your spouse or child dies. and disability coverages will always end on the last day of
»» Your work schedule changes, i.e. reduction or increase in your employment. Refer to carrier literature, summary plan
hours which affects eligibility. descriptions, and master plan documents for specific plan
»» Your spouse begins or terminates employment, which provisions, limitations, and exclusions.
affects benefit coverage.
»» You or your spouse loses health coverage through his/her
employer.
»» You receive a qualified medical child support order
(QMCSO). »» Your employment with Valley
»» Your spouse’s open enrollment; may be considered a Behavioral Health ends
qualifying status change. »» The group policy ends
»» You are no longer eligible under the
OR Whichever plan
is earliest »» Your death
You have a 60 day special election period »» You retire
for the following: »» You enter the armed forces of any
country on a full-time basis
»» You and/or your spouse
and dependents gain or lose
Medicare or Medicaid coverage.
»» You qualify for a state
sponsored premium assistance
program.
Don’t forget to add
newborn babies to your
plan within 30 days of
their birth!
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This information is designed to help you choose a benefit plan for 2018. Please refer to the Plan Documents provided by the carrier for information regarding
coverage, limitations, and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.
Medical
SelectHealth HDHP
High Deductible Health Plan (HSA)
In-Network Out-of-Network
Network SelectMed Plus
Annual Deductible $3,000 per Individual $6,000 per Individual
$6,000 per Family $12,000 per Family
Out-of-Pocket Max $5,000 per Individual $10,000 per Individual
No Lifetime Max $10,000 per Family $20,000 per Family
Preventive Services Covered 100% Not Covered
Primary Care: $15 AD^
Office Visits Copay You Pay: 40% AD
Specialist: $25 AD
Urgent and Emergency Urgent Care: $35 AD Urgent Care: 40% AD
Care Emergency Room: $75 AD Emergency Room: $75 AD
Mental Health Services
Inpatient You Pay: 20% AD
You Pay: 20% AD You Pay: 40% AD
Outpatient
Office Visits You Pay: $15 AD
Preventive medications available prior to deductible*
Tier 1: $7 Copay AD
Prescription Drugs
Tier 2: $21 AD
30 Day Supply
Tier 3: $42 AD
Tier 4: $100 AD
Tier 1 $7 Copay AD
Prescription Drugs Tier 2: $42 AD
90 Day Supply
Tier 3: $126 AD
For Inpatient and Outpatient services you pay the full negotiated rate until the annual deductible is met,
then you pay coinsurance.
Coinsurance AD You Pay: 20% AD You Pay: 40% AD
Please refer to the Summary Plan Document for full plan description
^AD = After Deductible
*See Carrier Preventive Drug List for specifics
Employee Rates per Month
With ValleyFit Without ValleyFit
Participation Participation
Employee $72.04 $93.64
Two-Party $142.84 $185.74
Family $221.98 $288.58
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This information is designed to help you choose a benefit plan for 2018. Please refer to the Plan Documents provided by the carrier for information regarding
coverage, limitations, and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.Medical
SelectHealth HDHP
High Deductible Health Plan (HSA)
In-Network Out-of-Network
Network SelectCare Plus
Annual Deductible $1,750 per Individual $3,500 per Individual
$3,500 per Family $7,000 per Family
Out-of-Pocket Max $5,000 per Individual $10,000 per Individual
No Lifetime Max $10,000 per Family $20,000 per Family
Preventive Services Covered 100% Not Covered
Primary Care: $15 AD^
Office Visits Copay You Pay: 40% AD
Specialist: $25 AD
Urgent and Emergency Urgent Care: $35 AD Urgent Care: 40% AD
Care Emergency Room: $75 AD Emergency Room: $75 AD
Mental Health Services
Inpatient You Pay: 20% AD
You Pay: 20% AD You Pay: 40% AD
Outpatient
Office Visits You Pay: $15 AD
Preventive medications available prior to deductible*
Tier 1: $7 Copay AD
Prescription Drugs
Tier 2: $21 AD
30 Day Supply
Tier 3: $42 AD
Tier 4: $100 AD
Tier 1 $7 Copay AD
Prescription Drugs Tier 2: $42 AD
90 Day Supply
Tier 3: $126 AD
For Inpatient and Outpatient services you pay the full negotiated rate until the annual deductible is met,
then you pay coinsurance.
Coinsurance AD You Pay: 20% AD You Pay: 40% AD
Please refer to the Summary Plan Document for full plan description
^AD = After Deductible
*See Carrier Preventive Drug List for specifics
Employee Rates per Month
With ValleyFit Without ValleyFit
Participation Participation
Employee $173.90 $226.10
Two-Party $346.90 $451.00
Family $537.70 $699.00
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This information is designed to help you choose a benefit plan for 2018. Please refer to the Plan Documents provided by the carrier for information regarding
coverage, limitations, and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.Health Savings Account
What is an HSA? HSA Funding
»» A tax-advantaged savings account that belongs to you. In 2018, the maximum amount the IRS allows you to contribute
»» Works in conjunction with your medical plan to provide to your HSA is $3,450 for single and $6,900 for family coverage,
a tax free way to pay for medical costs both before and but you don’t have to contribute it as a lump sum. If you are
after the deductible. over age 55, you are eligible to contribute an additional $1,000
»» You are only eligible to contribute to an HSA if you are per year. You may contribute to your HSA through pre-tax
covered by a qualified high-deductible health plan payroll deductions. The more you contribute, the more you
(HDHP). have available to pay for medical, dental, and vision expenses
»» If you have secondary coverage that is not also a HDHP, on a tax favored basis. Your contribution combined with the
you are not eligible to contribute to an HSA. This may contribution from Valley Behavioral Health cannot exceed
include coverage with a spouse, Medicare, TriCare, etc. the IRS maximums without incurring penalties. Please plan
»» Funds in the HSA can be used for Medical, Dental, or your contributions with the maximum limits in mind. Valley
Vision expenses. Behavioral Health will match your contribution dollar for
»» Funds deposited are not taxed as income and the dollar up to a maximum of $750 for an individual and $1,500
account can grow income tax free. for 2 or more parties enrolled.
»» Can be used for yourself, your spouse, and tax dependent
children. Why HSAs?
How to use an HSA Traditional health plans have high premiums. At the end of the
year, all of the money that you and your employer have spent
on premiums is gone. On the other hand, with a health savings
»» Until you meet your deductible, you are responsible to
account (HSA)-qualified high-deductible health plan (HDHP),
pay the provider the negotiated rate. This rate is typically
the premium is lower, and some of the money you would have
lower than any price you could negotiate on your own.
spent on premiums can go into your HSA instead.
»» Always show your Insurance Card as expenses won’t go
towards the deductible unless you show your Medical
Additionally, you save money on taxes and are given more
card
flexibility and control over your health care costs
»» Some doctors may require that you pay the full amount
or a portion of the bill upfront, but most will simply bill
your insurance, and then bill you for the balance once the You Can Grow Your Account Through
claim has been processed. Saving or Investing
»» The insurance plan will apply all discounts that apply and
credit your deductible. All of the money in the HSA remains yours, even if you leave
»» Once the claim is processed you will receive an your job, leave your qualifying health plan, or retire. In other
explanation of benefits (EOB) showing the amount you words, an HSA is not a “use-it-or-lose-it” type of account.
are responsible for. You decide how to use the HSA money, including whether to
»» When picking up a prescription from the pharmacy, save it or spend it for health care expenses. As your balance
present your insurance card. The pharmacy will apply the rolls over from year to year, it may earn interest. When your
carrier discount and then you pay the pharmacy using balance is large enough, you can invest it—tax-free—the same
your HSA debit card. The amount you pay will then be way you can invest dollars from other retirement accounts.
applied to your deductible.
»» Once your single or family deductible has been satisfied, You Gain Triple-Tax Savings
your physician visits, hospital claims, and pharmacy
charges will be processed by your health insurance plan »» Contributions to the HSA are tax-free for you—whether
and you will pay copays or coinsurance. they come from you, your employer, or as gifts from
»» You can pay these charges using your HSA debit card as friends or relatives.
long as you have a balance in your HSA. »» Your account and investment earnings are tax-free.
»» You can withdraw your money tax-free at any time, as
long as you use it for qualified medical expenses.
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This information is designed to help you choose a benefit plan for 2018. Please refer to the Plan Documents provided by the carrier for information regarding
coverage, limitations, and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.Flexible Spending Account
What is a Flexible Spending Account? How it Works
A tax-advantaged plan that allows you to put money aside for During annual enrollment or your initial enrollment, you decide
your plan year. how much you want to deposit into your reimbursement
»» Monies elected are not taxed, saving you from 10%-30% account(s). That amount is deducted evenly during the year
or more on the money deposited, depending on your tax from your paycheck before taxes are taken out. When you have
rate. an expense that qualifies, you may use your FSA Card or you
»» All money elected is available from the 1st day of the plan may pay the bill, submit a claim, and receive a reimbursement
year. with tax-free dollars from your account. It is important
»» PICK APPROPRIATE to retain receipts whether you’re using your debit card or
»» {Full} – You can elect up to the IRS allowed amount submitting claims for reimbursement in case of IRS audit or in
annually, deducted on a per paycheck basis. case substantiation is requested by National Benefit Services,
»» Amounts can be used for Medical, Dental, and Vision LLC (NBS).
expenses. You can check your balance and view detailed claims history
»» Generally, over the counter items are not eligible. by logging into your account at www.NBSbenefits.com.
»» Receipts may be required for reimbursement.
»» {Limited Purpose} – You can elect up to the IRS allowed What is a Dependent Care Reimbursement
amount annually, deducted on a per paycheck basis.
»» If you have a Qualified High Deductible Medical Plan
Account?
coupled with an HSA, mounts can be used for Dental or
The Dependent Care Reimbursement Account lets you set aside
Vision expenses.
up to $5,000 in pre-tax dollars to pay for eligible dependent
»» You cannot use the FSA for medical expenses until you
care expenses so you and your spouse, if married, can work.
have met your plan deductible.
»» Generally, over the counter items are not eligible.
With the Dependent Care Account, you can set aside tax-
»» Receipts may be required for reimbursement.
free income to pay for qualified dependent care expenses,
»» Applies to both Full & Limited Purpose
such as day care, that you normally pay with after-tax
»» Eligible expenses need to have been incurred during the
dollars. Qualified dependents include children under 13 and/
plan year.
or dependents who are physically or mentally handicapped.
»» {Rollover} – The plan will roll over up to $500 a year.
If your spouse is unemployed or doing volunteer work, you
»» You have until March 1st to submit for reimbursement
cannot set up a reimbursement account.
from the prior plan year.
»» Any amount over $500 is forfeited.
»» You must meet the following criteria in order to set up
»» {Grace} – You have until March 15th to incur eligible
this account:
services from the prior plan year.
»» Your child is under the age of 13 or is mentally/
»» Requests for reimbursement must be submitted by March
physically handicapped;
30th.
»» You and your spouse both work;
»» Any funds left in the account is forfeited.
»» You are a single head of household; or
»» Your spouse is disabled or a full-time student.
»» Each calendar year the IRS allows you to contribute the
following amounts, depending on your family status:
»» If you are single, the lesser of your earned income or
$5,000.
»» If you are married, you can contribute the lowest of:
»» Your (or your spouse’s) earned income.
»» $5,000 if filing jointly, or $2,550 if filing
separately.
8
This information is designed to help you choose a benefit plan for 2018. Please refer to the Plan Documents provided by the carrier for information regarding
coverage, limitations, and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.Dental
MetLife
In-Network Out-of-Network
Network MetLife - PDP Plus
$50 per Individual, $150 per Family
Annual Deductible The deductible is waived for preventive/diagnostic care and applies to basic
and major expenses.
Calendar Year
$2,000 per Individual
Maximum
Plan pays 100% of covered services Covers up to 80% of MAC
Preventive »» Limited to one routine visits per six months
services »» Intra-oral complete series of x-rays or panoramic film x rays: once every 60 months
Exams, Cleanings »» Topical fluoride treatment: once every 12 months to age 14
»» Sealants: application provided to dependents to age 14 no more than once per tooth every 60
months
Basic Services You pay 20% Covers up to 60% of MAC
Major Services You pay 50% Covers up to 40% of MAC
Orthodontic Care Not covered
Orthodontic
N/A
Lifetime Max
»» Please refer to the Summary Plan Document for full plan description
»» The Maximum Allowed Charge (MAC) means the lesser of the amount charged by the dentist or the maximum amount
which the In-Network dentist has agreed to accept as payment in full for the dental service.
Employee Rates per Month
Employee $7.70
Two-Party $15.40
Family $24.50
9
This information is designed to help you choose a benefit plan for 2018. Please refer to the Plan Documents provided by the carrier for information regarding
coverage, limitations, and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.Vision
MetLife
In-Network Out-of-Network
Network Vision PPO
Exams - Every Plan Year You pay $10 $45 Allowance
Lenses - Every Plan Year
Single Vision $30 Allowance
Lined Bifocal You pay $10 $50 Allowance
Lined Trifocals $65 Allowance
Lenticular $100 Allowance
Frames - Every Plan Year $150 Retail Allowance $70 Allowance
Contacts - Every Plan Year
Elective (Instead of $150 Retail Allowance $150 Allowance
Glasses) Covered in full with maximum Applied to the contact lens
Contact Lense Fitting copay of $60 allowance
Standard
Please refer to the Summary Plan Document for full plan description.
Employee Rates per Month
Employee $10.28
Two-Party $19.32
Family $27.51
10
This information is designed to help you choose a benefit plan for 2018. Please refer to the Plan Documents provided by the carrier for information regarding
coverage, limitations, and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.Life Insurance
Being a responsible adult means making sure loved ones filling out a MetLife Evidence of Insurability (EOI) form,
who depend on you are financially safeguarded if you which may include taking a physical examination, and
unexpectedly leave them behind. The way you provide that you may be declined coverage. Future exams will be at
protection is with life insurance. your cost.
Basic Life and Accidental Death and Employee
Dismemberment
You may purchase coverage in $25,000 increments up to
Valley Behavioral Health is pleased to provide each full time $500,000, not to exceed 5 times your basic annual earnings.
active benefits eligible employee with basic life insurance There is a Life Coverage Amount of $100,000 without
and accidental death and dismemberment (AD&D) through providing proof of good health during the initial enrollment
MetLife. This coverage is completely free to you as the period only.
employee
Spouse
Basic Employee Life 1x salary up to $300,000
You may purchase Voluntary Life Insurance for your spouse.
Basic AD&D 1x salary up to $300,000 Coverage is in increments of $5,000, up to $150,000, not to
Basic Spouse Life $10,000 exceed 50% of the employee’s supplemental life insurance
amount. Anything up to $25,000 is available to your spouse
Basic Child Life $5,000 (Benefit for children without proof of good health during the initial enrollment
age 15 days to less than 6 period.
months is $100)
Children
Voluntary Life Children’s insurance coverage is for unmarried dependent
children from 15 days of age to age 26, subject to eligibility
Voluntary Life is additional protection you can purchase to requirements. Coverage for children age 15 days to less than
provide more coverage for you and your family. This policy 6 months is $100. From age 6 months to age 26, coverage can
gives you the advantage of purchasing life insurance at be elected for $1,000, $2,000, $4,000, $5000, or $10,000 and
group rates with the convenience of being payroll deducted. is inclusive for all children. This means that if you have one
This benefit is not a pre-tax benefit option. child or many, you pay one flat amount; however, each child
is covered individually for the selected coverage amount.
Enrollment
Age Reductions
»» When you first become eligible for our benefit program(s),
you must either enroll or waive coverage for Voluntary The coverage you have or select as additional coverage will
Life Insurance. If you do not enroll yourself and your reduce by 35% beginning at age 65, an additional 15% at age
dependents for coverage the first time you are eligible 70, and another 15% at age 75. Benefits will terminate at
and you wish to enroll during a subsequent enrollment retirement.
period, you will have to provide proof of good health by
Life Coverage Increments Maximum
Amount Amount
Voluntary Employee Life $100,000 $25,000 $500,000
Voluntary Spouse Life $25,000 $5,000 $150,000
Voluntary Child Life $10,000 $1,000 $10,000
Voluntary AD&D
Voluntary AD&D maximum amounts are equal to your Benefits resulting from the accidental death are paid to the
supplemental life insurance. No Evidence of Insurability is named beneficiary. Benefits resulting from a dismembering
required to elect Voluntary AD&D. AD&D is a policy that pays injury are paid to the insured. The loss must occur 365 days
benefits to your beneficiary if the cause of your death is due of the accident.
to an accident. Fractional amounts of the policy will be paid
out if you lose a bodily appendage or sight because of an Maximum Amount Rate per $1,000
accident. Additionally, AD&D generally pays benefits for the
Employee $500,000 Included
loss of limbs, fingers, toes, sight, and permanent paralysis.
Spouse $150,000 with
In the event of an accidental death, this insurance will pay
Life rate
benefits in addition to any life insurance. Child(ren) $10,000
11
This information is designed to help you choose a benefit plan for 2018. Please refer to the Plan Documents provided by the carrier for information regarding
coverage, limitations, and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.Short & Long Term Disability
Short & Long Term Disability Short Term Disability Benefits
How long would your savings last if you could not work for
several weeks or even months? After a benefit waiting period, Weekly Benefit 60% of your weekly salary
Short Term Disability replaces a portion of your income by Maximum Weekly Benefit $1,000
paying monthly benefits if you experience a covered Short-
Elimination Period - Injury 14 days
term illness or accident.
Maximum Benefit Period - 11 weeks
Short Term Disability insurance is designed to pay a monthly Injury
benefits to you in the event you cannot work because of a Elimination Period - Sickness 14 days
covered illness or injury. This benefit replaces a portion of your
Maximum Benefit Period - 11 weeks
income, thus helping you to meet your commitments in a time
Sickness
of need.
Chances are you already purchase home, auto and life
insurance to protect yourself against the threat of loss. And
you probably have health insurance to guard against costly Long Term Disability Benefits
medical bills. So, what steps have you taken to help shield
yourself, your lifestyle and those who count on you from an
unexpected loss of income? Would you be able to meet your Weekly Benefit 50% of the first $20,000 of
financial obligations if you became disabled and unable to predisability earnings
work? Group Short Term Disability insurance is designed to Maximum Monthly Benefit $10,000
pay a monthly benefit to you in the event you cannot work
Elimination Period - Injury 90 days
because of a covered illness or injury. This benefit replaces a
portion of your income, thus helping you to meet your financial Maximum Benefit Period - SSNRA
commitments in a time of need. By sponsoring group Short- Injury
Term disability insurance through MetLife, your employer offers Elimination Period - Sickness 90 days
you an excellent opportunity to help protect yourself and your
Maximum Benefit Period - SSNRA
lifestyle. The advantages to you include: Convenience – with
Sickness
premiums deducted directly from your paycheck, you do not
have to worry about mailing monthly payments; and Peace of
Mind – you can take comfort and satisfaction in knowing that
you have taken a step toward securing your income during a
period of a covered disability.
12
This information is designed to help you choose a benefit plan for 2018. Please refer to the Plan Documents provided by the carrier for information regarding
coverage, limitations, and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.401(k)
401(k) Retirement Savings Plan
Eligibility
There is no age requirement to participate in the 401(k). Employees are eligible to participate following one year of employment,
and must have completed 1000 hours of service.
Employer Match
Valley Behavioral Health will make a safe harbor matching contribution equal to 100% of your elective deferrals that do not
exceed 5% of your compensation.
Vesting
Your “vested percentage” in your account attributable to qualified safe harbor contributions is determined under the following
schedule. You will always, however, be 100% vested in your qualified safe harbor contributions if you are employed on or after
your normal retirement age or if you terminate employment on account of your death, or if you terminate employment as a
result of becoming disabled.
Vesting Schedule
Qualified Safe Harbor Contributions
Years of Service Percentage
Less than 2 0%
2 years 100%
Automatic Enrollment
If you do not take action to enroll or opt out of participation then you will be auto-enrolled for a 3% pre-tax contribution. Your
contribution rate will increase 1% annually until you reach 6%.
Get More Information
Visit the web site at www.empower-retirement.com/participant, or call the Voice Response System, toll free, at 1-800-338-
4015 for more information. The web site provides information regarding your plan, as well as financial education information,
financial calculators, and other tools to help you manage your account.
Investment Options and Allocation Changes
A wide array of core investment options are available through your plan. Once you have enrolled, investment option information
is available through the web site or Voice Response System.
Use your Personal Identification Number (PIN) and username to access the web site, or you can use your Social Security Number
and PIN to access the Voice Response System. You can move all or a portion of your existing balances between investment
options (subject to plan rules) and change how your payroll contributions are invested.
Withdrawals
Qualifying distribution events are as follows:
»» Retirement
»» Permanent disability
»» Financial hardship (as defined by the Internal Revenue Code and your Plan’s provisions)
»» Severance of employment (as defined by the Internal Revenue Code provisions)
»» Attainment of age 59 1/2
»» Death (your beneficiary receives your benefits)
13
This information is designed to help you choose a benefit plan for 2018. Please refer to the Plan Documents provided by the carrier for information regarding
coverage, limitations, and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.Disclosure Notices
Privacy Policy »» All stages of reconstruction on the breast on which the
mastectomy was performed
»» Surgery and reconstruction of the other breast to
Summary of Privacy Practices produce a symmetrical appearance
»» Prostheses and treatment of physical complications of
This Summary of Privacy Practices summarizes how medical the mastectomy including lymphedema
information about you may be used and disclosed in the
administration of your claims, and of certain rights you have. Under WHCRA, coverage of mastectomies and breast
reconstruction benefits are subject to deductibles, co-
payments, and coinsurance limitations consistent with those
Our Pledge Regarding Medical Information established for other benefits under your plan. Following the
initial reconstruction, any additional modification or revision
We are committed to protecting your personal health is covered only to the extent that it is not otherwise limited
information. We are required by law to (1) make sure that any or excluded from coverage by your plan. Revisions requested
medical information that identifies you is kept private; (2) as the result of the normal aging process will not be covered.
provide you rights with respect to your medical information;
(3) give you a notice of our legal duties and privacy practices; Michelle’s Law
and (4) follow all privacy practices and procedures currently
in effect. A new federal law allows continued coverage for seriously ill
college students. A college student will be able to maintain
health care eligibility for up to one year after full-time student
How We May Use and Disclose Medical status is lost due to a medically necessary leave of absence
Information About You from school.
We must obtain your written authorization for any use and Genetic Information Nondiscrimination Act
disclosure of your medical information. We may use and (GINA)
disclose your personal health information without your
permission to facilitate your medical treatment, of payment Under this Federal law, group health plans are prohibited
for any medical treatments, and for any other health care from adjusting premiums or contribution amounts for a group
operation. We may also use and disclose your personal health based on genetic information. A health plan is also prohibited
information without your permission as allowed or required from requiring an individual or his/her family member to
by law. We cannot retaliate against you if you refuse to sign an undergo a genetic test, although the plan may require that a
authorization or revoke an authorization you had previously voluntary test be taken for research purposes.
given.
Mandatory Insurer Reporting Law
Your Rights Regarding Your Medical This law took effect 01/01/2009 and is part of the Medicare,
Information Medicaid, and SCHIP Extension Act of 2007 (MMSEA). Under
this Federal law, providers of group health plans are required
You have the right to inspect and copy your medical to report certain information to the Secretary of Health and
information, request corrections of your medical information Human Services to determine Medicare entitlement. As such,
and to obtain an accounting of your medical information. employees are required to provide social security numbers for
You also have the right to request that additional restrictions all dependents enrolled in the medical plan. You will be asked
or limitations be placed on the use or disclosure of your to enter social security numbers for all dependents you cover
medical information, or that communication about your on your medical plan.
medical information be made in different ways or at different
locations. Waiving Coverage
Women’s Health and Cancer Rights Act If you decide that you and/or your dependents have
appropriate benefits from an alternate source, you may
In accordance with the Women’s Health and Cancer Rights choose to waive your existing coverage. If you are declining
Act (WHCRA), we will cover the following for the treatment of enrollment for yourself and/or your dependents (including
breast cancer: your spouse) because of other health insurance coverage,
you may in the future be able to enroll yourself and/or your
dependents in this plan, providing that you request enrollment
Mastectomies within 30 days after your other coverage ends. If you have a
Reconstructive Surgery new dependent as a result of your marriage, birth, adoption,
or placement for adoption, you may be able to enroll yourself
If you are receiving benefits in connection with a mastectomy, and your dependents provided that you request enrollment
coverage will be provided according to the carrier Utilization within 30 days after the event.
Management criteria and in a manner determined in
consultation with the attending physician and the patient for
the following:
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This information is designed to help you choose a benefit plan for 2018. Please refer to the Plan Documents provided by the carrier for information regarding
coverage, limitations, and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.Disclosure Notices
Premium Assistance Under Medicaid and Medicare Part D Creditable Coverage
the Children’s Health Insurance Program Notice
(CHIP)
Please read this notice carefully and keep it where you
If you or your children are eligible for Medicaid or CHIP and can find it. This notice has information about your current
you’re eligible for health coverage from your employer, your prescription drug coverage with Valley Behavioral Health
state may have a premium assistance program that can help and about your options under Medicare’s prescription drug
pay for coverage, using funds from their Medicaid or CHIP coverage. This information can help you decide whether
programs. If you or your children aren’t eligible for Medicaid or not you want to join a Medicare drug plan. If you are
or CHIP, you won’t be eligible for these premium assistance considering joining, you should compare your current
programs but you may be able to buy individual insurance coverage, including which drugs are covered at what cost,
coverage through the Health Insurance Marketplace. with the coverage and costs of the plans offering Medicare
For more information, visit www.healthcare.gov prescription drug coverage in your area. Information about
where you can get help to make decisions about your
If you or your dependents are already enrolled in Medicaid or prescription drug coverage is at the end of this notice.
CHIP and you live in a State listed below, contact your State
Medicaid or CHIP office to find out if premium assistance is There are two important things you need to know about
available. your current coverage and Medicare’s prescription drug
coverage:
If you or your dependents are NOT currently enrolled in
Medicaid or CHIP, and you think you or any of your dependents 1. Medicare prescription drug coverage became available
might be eligible for either of these programs, contact your in 2006 to everyone with Medicare. You can get this
State Medicaid or CHIP office or dial 1-877-KIDS NOW or coverage if you join a Medicare Prescription Drug Plan
www.insurekidsnow.gov to find out how to apply. If you or join a Medicare Advantage Plan (like an HMO or PPO)
qualify, ask your state if it has a program that might help you that offers prescription drug coverage. All Medicare
pay the premiums for an employer-sponsored plan. drug plans provide at least a standard level of coverage
set by Medicare. Some plans may also offer more
If you or your dependents are eligible for premium assistance coverage for a higher monthly premium.
under Medicaid or CHIP, as well as eligible under your employer
plan, your employer must allow you to enroll in your employer 2. Valley Behavioral Health has determined that the
plan if you aren’t already enrolled. This is called a “special prescription drug coverage offered by the Benefit Plan
enrollment” opportunity, and you must request coverage is, on average for all plan participants, expected to pay
within 60 days of being determined eligible for premium out as much as standard Medicare prescription drug
assistance. If you have questions about enrolling in your coverage pays and is therefore considered Creditable
employer plan, contact the Department of Labor Coverage. Because your existing coverage is Creditable
Coverage, you can keep this coverage and not pay a
Utah Medicaid and Chip information: higher premium (a penalty) if you later decide to join a
Website: http://health.utah.gov/upp Medicare drug plan.
Phone: 1-866-435-7414
When Can You Join A Medicare Drug Plan?
Newborns and Mothers Health Protection
Act You can join a Medicare drug plan when you first become
eligible for Medicare and each year from October 15th to
The Newborns’ and Mothers’ Health Protection Act of 1996 December 7th.
(NMHPA) affects the amount of time you and your newborn
child are covered for a hospital stay following childbirth. However, if you lose your current creditable prescription
In general, health insurers and Health Maintenance drug coverage, through no fault of your own, you will also
Organizations (HMOs) may not restrict benefits for a hospital be eligible for a two (2) month Special Enrollment Period
stay in connection with childbirth to less than 48 hours (SEP) to join a Medicare drug plan.
following a vaginal delivery or 96 hours following a delivery
by cesarean section. These are only summaries. Full statements
are available from Human Resources.
If you deliver in the hospital, the 48-hour (or 96-hour) period
ACA
starts at the time of delivery. If you deliver somewhere other
than the hospital and you are later admitted to the hospital in Pursuant to the Affordable Care Act, Valley Behavioral Health
connection with the childbirth, the period begins at the time has adopted a 12-month lookback measurement period in
of admission. order to determine the full-time status of new and ongoing
part-time, variable hour, or seasonal employees. According
Also, a health insurer or HMO cannot require you or your to the ACA, any employee who is employed for, on average,
attending provider to obtain prior authorization for your at least 130 hours of service a month during that lookback
delivery or show that the 48-hour (or 96-hour) stay is period must be considered full time and offered health
medically necessary. However, a health insurer or HMO may insurance benefits during a subsequent stability period. The
require you to get prior authorization for any portion of stay applicable stability period for Valley Behavioral Health is 12
after the 48 hours (or 96 hours) months. This offer of coverage is being made because you met
this definition of a full-time employee during your applicable
lookback period.
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This information is designed to help you choose a benefit plan for 2018. Please refer to the Plan Documents provided by the carrier for information regarding
coverage, limitations, and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.You can also read
