Page 2 - 2015 Advia CU Benefits & Notices
P. 2
Advia CU - MI 2015
Table of Contents
Introduction .............................................................................................................................................. 4
Changing Your Benefits ........................................................................................................................... 4
Newborns’ & Mothers’ Health Protection.................................................................................................. 5
Women’s Health & Cancer Rights Act (WHCRA) ..................................................................................... 5
Protecting Your Privacy............................................................................................................................ 5
Michelle’s Law ......................................................................................................................................... 5
New Health Insurance Marketplace Coverage Options and Your Health Coverage ................................. 6
Medical Coverage .................................................................................................................................... 9
Patient Protection Notice........................................................................................................................ 10
Waiver of Medical Coverage – Opt Out Option ...................................................................................... 10
Summary of Benefits & Coverage (SBC) ............................................................................................... 10
Dental Coverage .................................................................................................................................... 17
Vision Coverage (Employer Paid) 12/24/24............................................................................................ 18
Vision Coverage (Buy Up Option - VOLUNTARY) 12/12/12................................................................... 19
Health Reimbursement Arrangement (HRA) .......................................................................................... 20
Health Savings Account (HSA) .............................................................................................................. 20
Flexible Spending Accounts (FSA)......................................................................................................... 21
Employee Assistance Program (EAP).................................................................................................... 23
Basic Life/AD&D and Optional Life/AD&D Coverage.............................................................................. 24
Short Term Disability (STD) Coverage ................................................................................................... 25
Long Term Disability (LTD) Coverage .................................................................................................... 25
Employee Contributions - 2015 .............................................................................................................. 27
For More Information About Our Coverage ............................................................................................ 27
General Notice of COBRA Continuation Coverage Rights ..................................................................... 28
About Your Prescription Drug Coverage and Medicare – Notice of Creditable Coverage....................... 31
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) ................. 33
Summary of Benefits & Coverage (SBC) – Active/Retired EEs – PPO 250 ............................................ 36
Summary of Benefits & Coverage (SBC) – Active EEs – HRA PPO 1500.............................................. 44
Summary of Benefits & Coverage (SBC) – Active EEs – HRA HMO 1000 ............................................. 52
Summary of Benefits & Coverage (SBC) – Active EEs – HSA HMO 1300 ............................................. 60
Notes ..................................................................................................................................................... 68
INFORMATION ABOUT MEDICARE
IF YOU HAVE MEDICARE OR WILL BECOME ELIGIBLE FOR MEDICARE WITHIN THE NEXT 12 MONTHS, A NEW FEDERAL LAW
GIVES YOU MORE CHOICES ABOUT YOUR PRESCRIPTION DRUG COVERAGE. PLEASE SEE PAGES 31-12 FOR DETAILS.
Salus Group© Copyright 2014 Page | 2
Table of Contents
Introduction .............................................................................................................................................. 4
Changing Your Benefits ........................................................................................................................... 4
Newborns’ & Mothers’ Health Protection.................................................................................................. 5
Women’s Health & Cancer Rights Act (WHCRA) ..................................................................................... 5
Protecting Your Privacy............................................................................................................................ 5
Michelle’s Law ......................................................................................................................................... 5
New Health Insurance Marketplace Coverage Options and Your Health Coverage ................................. 6
Medical Coverage .................................................................................................................................... 9
Patient Protection Notice........................................................................................................................ 10
Waiver of Medical Coverage – Opt Out Option ...................................................................................... 10
Summary of Benefits & Coverage (SBC) ............................................................................................... 10
Dental Coverage .................................................................................................................................... 17
Vision Coverage (Employer Paid) 12/24/24............................................................................................ 18
Vision Coverage (Buy Up Option - VOLUNTARY) 12/12/12................................................................... 19
Health Reimbursement Arrangement (HRA) .......................................................................................... 20
Health Savings Account (HSA) .............................................................................................................. 20
Flexible Spending Accounts (FSA)......................................................................................................... 21
Employee Assistance Program (EAP).................................................................................................... 23
Basic Life/AD&D and Optional Life/AD&D Coverage.............................................................................. 24
Short Term Disability (STD) Coverage ................................................................................................... 25
Long Term Disability (LTD) Coverage .................................................................................................... 25
Employee Contributions - 2015 .............................................................................................................. 27
For More Information About Our Coverage ............................................................................................ 27
General Notice of COBRA Continuation Coverage Rights ..................................................................... 28
About Your Prescription Drug Coverage and Medicare – Notice of Creditable Coverage....................... 31
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) ................. 33
Summary of Benefits & Coverage (SBC) – Active/Retired EEs – PPO 250 ............................................ 36
Summary of Benefits & Coverage (SBC) – Active EEs – HRA PPO 1500.............................................. 44
Summary of Benefits & Coverage (SBC) – Active EEs – HRA HMO 1000 ............................................. 52
Summary of Benefits & Coverage (SBC) – Active EEs – HSA HMO 1300 ............................................. 60
Notes ..................................................................................................................................................... 68
INFORMATION ABOUT MEDICARE
IF YOU HAVE MEDICARE OR WILL BECOME ELIGIBLE FOR MEDICARE WITHIN THE NEXT 12 MONTHS, A NEW FEDERAL LAW
GIVES YOU MORE CHOICES ABOUT YOUR PRESCRIPTION DRUG COVERAGE. PLEASE SEE PAGES 31-12 FOR DETAILS.
Salus Group© Copyright 2014 Page | 2
