2017 benefits guide - good samaritan hospital, los...
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2017 Benefits Guide
Los Angeles, CA
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Good Samaritan Hospital A Tradition of Caring
November 2016
This benefit guide provides essential information about the benefit plans available to eligible employees and their families.
The plans are designed to cover healthcare, prescription drugs, dental and vision treatments, loss of income through disability insurance and family financial protection. These are issues we all must address to have a sense of personal and family security. This guide provides a summary of each of these benefits.
As we look ahead to 2017, we’d like to share with you a new coverage option so you can make the best decisions about your benefits for the upcoming year.
WHAT’S NEW• New Medical Plan. In addition to the Good Samaritan Hospital Plan, you will have a NEW Medical Plan
option to choose from. We are excited to offer the NEW Anthem Vivity Health Maintenance Organization (HMO). To learn more about this new offering access the educational video at: https://www.vivityhealth.com/join. (Scroll down under the welcome and Select See Vivity in Action.)
WHATS CHANGING• Prescription Drugs. All Good Samaritan Hospital Plan participants will be receiving a new CVS/Caremark
ID card. You must use this new card starting January 1, 2017. The old cards will no longer be active after December 31, 2016. Your current active prescriptions and pre-certifications will all be transitioned.
• FSA Plans. We are changing Flexible Spending Account (FSA) providers from Zenith-American Solutions to Discovery Benefits. Employees enrolled in the FSA plans will have a benefits debit card to use for reimbursements as well as access to the mobile site for faster, easier claims processing. To learn about the advantages and savings of using a FSA, watch the FSA 101 video at https://www.discoverybenefits.com/about/videos/employees.
• Medical Opt-Out Credits. Due to new health care reform regulations going into effect in January 2017, the cash back for those who waive medical coverage will no longer be available. This change applies to all employees.
WHAT’S NOT CHANGING• There have been no changes to the Good Samaritan Hospital Plan design this year. • Dental, Vision, Life Insurance, Disability Insurance, Pet Insurance and Identity Theft are all remaining the
same.For more information, please review your medical plan options on pages 6-12 of this guide carefully so that you may select the plan that is best for you and your family’s needs.
The choices you make can help you lead a healthier and happier life, both at home and at work.
If you have any questions about the 2017 benefits program, contact Human Resources at 213-977-2378.
Wishing you a healthy 2017!
Sincerely,
Human Resources
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Table of Contents
Eligibility.................................................................................................................................. 4
Making Changes to Your Benefits............................................................................................ 5
Good Samaritan Hospital Medical Plan................................................................................. 6
How the Plan Works................................................................................................................ 8
How the HMO Plan Works...................................................................................................... 9
HMO Medical Plan.................................................................................................................. 10
Dental....................................................................................................................................... 11
Vision Plan............................................................................................................................... 12
Life Insurance.......................................................................................................................... 13
Basic.................................................................................................................................. 13
Supplemental (Employee, Spouse and Child(ren))......................................................... 14
Voluntary Personal Accident................................................................................................... 15
Disability.................................................................................................................................. 16
Short-Term Disability....................................................................................................... 16
Long-Term Disability....................................................................................................... 17
Flexible Spending Accounts..................................................................................................... 18
Employee Assistance Plan........................................................................................................ 20
Child Care Center.................................................................................................................... 21
Other Benefits.......................................................................................................................... 22
Employee Health.............................................................................................................. 22
Wellness............................................................................................................................ 22
Fitness Center................................................................................................................... 22
Voluntary Pet Insurance......................................................................................................... 23
Identity Theft........................................................................................................................... 24
Disclaimers.............................................................................................................................. 25
Contacts................................................................................................................................... 26
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Benefit Program Overview
This benefit guide briefly describes the 2017 benefits offered to eligible employees and their dependents and provides access to information and resources to help you make informed plan and coverage decisions. While going through this guide, be sure to review each benefit, think about your personal needs and decide what’s best for your particular lifestyle.
Eligibility SummaryYou may enroll in our benefit plans if you are full-time or part-time meeting the hours requirements listed below:
Shifts Hours Per Week
8,1040 Full-time32 Part-time24 Part-time
12 36 Full-time24 Part-time
Your coverage will start at the beginning of the pay period following 30 days of employment.
Eligible DependentsAs you become eligible for benefits, so do your dependents. In general, eligible dependents include:
• Your spouse
• Registered domestic partner (Documentation must be provided)
• Your children under the age of 26 living in the United States
— Children are defined as natural, adopted or foster children and stepchildren.
— Children can remain covered until the end of the month in which they turn 26.
— If your child is mentally or physically disabled, coverage may continue beyond the age of 26 once documentation ofthe ongoing disability is provided.
When does Coverage Begin?Coverage begins on the first day of the pay period following 30 days from date of hire or status change, such as transfer to a benefit eligible position.
When does Coverage End?If you leave employment or lose coverage, coverage will continue until the last day of that month.
A certified copy of a marriage certificate or birth certificate is needed to add dependents to coverage.
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Benefit Program Overview
2017 Open Enrollment You can only change your benefits during the annual Open Enrollment period for them to be effective for the next year. Open Enrollment is your one opportunity to add or delete coverage and/or dependents, increase or decrease your supplemental life or personal accident insurance coverage and/or the amount of money allocated to a dependent care or healthcare reimbursement account.
If you do not enroll for coverage during Open Enrollment, you will automatically be enrolled in all of your current coverage with the exception of the Flexible Spending Accounts (FSAs). You must actively re-enroll for the FSA plans each year. Once enrolled, no changes can be made to coverage without a qualifying life event during the year.
Making Changes to Your BenefitsYou can make some limited changes during the Plan Year due to qualified life event changes. These changes include:• Marriage or divorce• Birth or adoption of a child• Death of a spouse or dependent• Beginning or end of spouse’s employment • Change in benefit status for you or your spouse/registered domestic partner• Gain or loss of other coverage
If you have a life event change, you must provide documentation to Human Resources within 30 days of the status change in order to qualify for a change in coverage. Failure to notify Human Resources within 30 days will require you to wait until the next annual Open Enrollment.
2017 Open Enrollment PeriodOpen Enrollment is from November 7 - 18, 2016. All employees must enroll online using the iPortal at Good Samaritan. You will need your Account ID and Password to make your choices.
Any changes you make to your benefit choices will be effective January 1, 2017.
Enrollment is Simple!All employees will be required to make their Open Enrollment choices online via the iPortal at a Good Samaritan kiosk. Kiosks are located at your workstation, the Nursing Training Room (Lucas Building, 1st Floor, across the hall from Audio Visual Room) and within HR. You’ll need:
User ID: your assigned Account IDPassword: assigned to you
If you do not know your Account ID, contact the Help Desk at extension 4029.
Our online benefits enrollment tool will allow you to:
• Access important plan material and required notices
• Add, update or change dependent information
• Make your enrollment selections
• View your elections and cost data• New hires will be provided with an enrollment kit to make initial elections.
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Good Samaritan Hospital Medical Plan
Key FeaturesTier 1:
Good SamaritanHospital Providers₁
Tier 2:Anthem Blue Cross (PPO)
In-Network
Tier 3:Anthem Blue Cross PPO
Out-of-Network
Deductible None $1,000 Individual$2,000 Family
$1,750 Individual$3,000 Family
Preventive Care Services (Adult) 100% 100% (no deductible) Not coveredWell Baby/Well Child Care and Immunizations (birth through age 6)
100% (no deductible) 100% (no deductible) Not Covered
Physician Office Visit Copay $30 80% after deductible 50% after deductiblePediatrician Office Visit Copay $30 $35 50% after deductibleLiveHealth Online(24/7 video access to a doctor) $49 $49 NA
Hospitalization100%
80% after deductible if service is not available at GSH
60% if service is available at GSH
50% after deductible plus $500 in-patient deductible**
Hospital Emergency Room $200 copay per incident (waived if admitted)
$200 copay per incident(waived if admitted)
$250 copay per incident(waived if admitted)
Hospital Emergency Room Ser-vices: Non-emergency care 60% 60% after deductible 50% after deductible
Diagnostic Tests (X-rays / Labs) 100% (at GSH only)₂ 80% after deductible 50% after deductible
Outpatient Surgery (Facility charges) $200 copay
80% after deductible, if service is not available at GSH
60% after deductible, if service is available at GSH
50% after deductible**
Chiropractic $30 Plan pays 80% after deductible up to $2,500 annual maximum Not covered
Mental Health / Substance AbuseInpatient & Outpatient Not available 80% after deductible 50% after deductible
Annual Out-of-Pocket Maximum (including deductibles and copays)
$2,000 Individual$4,000 Family
$3,000 Individual$5,000 Family
$5,000 Individual$10,000 Family
Lifetime Maximum Unlimited
1. Refer to GSH Participating Provider Listing in Human Resources
2. Laboratory and Radiology tests referred outside of Good Samaritan Hospital (Tier 1) are subject to the calendar year deductible and coinsurance of 80% (Anthem PPO provider) or 60% if labs aren’t contracted with Anthem.
** You must obtain a utilization review or be subject to an additional $400 deductible for non-participating hospitals/providers.
3. Case Management: You can contact customer service at 800-759-3030 to initiate a case manager and find out more about your health issue and your treatment options.
4. Home Health Services require a prior authorization and has to be medically necessary. Your provider needs to contact 800-274-7767 to request a prior authorization.
Medical Plan Costs• Refer to your rate sheet• Medical coverage is deducted on a pre-tax basis
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Good Samaritan Hospital Medical Plan
Network Pharmacies OnlyGeneric $10Preferred Brand $40Non-Preferred Brand $60Specialty $100 (per 30-day supply)Mail Order or CVS/Caremark Retail Pharmacy - Up to 90 Days
• Generic• Preferred Brand• Non-Preferred Brand
$20$80
$120
Annual Out-of-Pocket Maximum $1,500 Individual$4,500 Family
Your Prescription Drug Plan is offered through CVS/Caremark and is summarized below.
Generic: Generic drugs are classified as Generic medications by the U.S. Food and Drug Administration (FDA). Preferred Brand: Preferred Brand drugs are classified as Preferred medications by CVS/Caremark. Non-Preferred Brand: Non-Preferred drugs are classified as Non-Preferred medications by CVS/Caremark. Speciality: Specialty medications must be ordered through Caremark Specialty Pharmacy and are limited to a 30-day supply.
Log on to www.caremark.com to check coverage and copay information for a specific medicine.
Mail Order Your Maintenance Medications If you are taking a maintenance medication, you will save time and money by having it delivered through the mail order. You can get up to a 90-day supply sent to you automatically. Simply complete the mail order form and attach your physician’s prescription. You can also choose to utilize the voluntary maintenance choice program, allowing you to to obtain your 90-day supply at a CVS retail pharmacy.
Dispense As Written RulesIf either you or your doctor request a brand-name medicine when a generic equivalent is available, you will pay the generic copay, plus the difference in cost between the brand-name and the generic medicine.
ID CardsYou will receive separate ID cards for the Medical Plan and Prescription Drug Plan. Medical: Anthem ID cardPrescription Drug: CVS/Caremark ID card
NOTE: All Good Samaritan Hospital Plan participants will be receiving a new CVS/Caremark ID card. You must use this new card starting January 1, 2017. The old cards will no longer be active after December 31, 2016. Your current active prescriptions and pre-authorizations will all be transitioned.
Prescription Drug Customer Service1-800-707-5587www.caremark.com
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Tier 1: GSHProviders & Lab
Tier 2: Anthem Blue CrossIn-Network Providers & Lab Tier 3: Out-of-Network
Deductible: $0Office Visit Copay: $30
Lab Work & Diagnostic Tests (at GSH): Covered at 100%
Deductible: $1,000
Office Visit: plan covers 80% after deductible is met
Lab Work & Diagnostic Tests: plan covers 80% after deductible is met
Deductible: $1,500
Office Visit: plan covers 50% after deductible is met
Lab Work & Diagnostic Tests: plan covers 50% after deductible is met
Total Cost to You:$30
Total Cost to You:$1,000 + 20% Coinsurance
Total Cost To You:$1,500 + 50% Coinsurance
How The Plan Works
The choices you make in regards to where you receive care directly impacts the cost you pay for those services.
Not Feeling Well?
Best Value!
Good Samaritan’s Plan allows you the freedom to choose where you receive your care. Costs are determined by where you go for services. Members benefit from discounted in-network provider rates. And, as a Good Samaritan Hospital employee you can receive significant cost savings by using Good Samaritan Hospital’s participating providers as your first choice for care. If you need services Good Samaritan is unable to provide or you prefer to access a different provider, you can receive care through Anthem Blue Cross PPO network and non-network providers.
Good Samaritan Hospital participating providers will continue to offer you the best value and keep your out-of-pocket expenses to a minimum, especially if you require hospital care. If you choose to seek care from a provider not on the Good Samaritan Hospital participating provider list, your out-of-pocket expense will be higher.
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How The HMO Plan Works
Introducing Anthem Vivity HMOIn addition to the Good Samaritan Hospital Plan, you will have a NEW medical plan option for you to choose from. We are introducing a Health Maintenance Organization (HMO) plan through Anthem Vivity.
What is a HMO? HMO means “Health Maintenance Organization.” HMO plans offer a wide range of healthcare services through a network of providers who agree to supply services to members. With a HMO plan, you must remain within the network for all services, and there is no coverage out of the network except for emergencies.
How it WorksAs a member of Vivity, you’ll be required to choose a primary care physician (PCP) to oversee all of your healthcare needs. If you do not select a PCP, one will be automatically provided for you that is based on your address you have listed in Anthem’s system. Before you can see a specialist, you’ll need to obtain a referral from your PCP. Members do not need a referral to see an allergist, dermatologist, ENT specialist or OB/GYN.
The Vivity Network provides you more flexibility and choice than a traditional HMO plan, and with that provides you with excellent care with many of the partnering hospitals in Southern California as long as you have a referral from your PCP.
• Good Samaritan Hospital• Cedars-Sinai• Huntington Memorial Hospital• MemorialCare Health System
• PIH Health• Torrance Memorial Medical Center• UCLA Health
Additionally, your Vivity plan ID card gives you access to many of Anthem’s tools and resources, such as • 24/7 Nurseline – If you are not quite certain if you should go to the ER in the middle of the night, this free, 24-hour phone
service can help. Simply call the toll-free number - day or night - to speak to a registered nurse who can answer your basic health questions and address concerns.
• LiveHealth Online – You have access to a Virtual Provider visit in case you are unable to make it to Urgent Care. For example: if you have a cold or flu bug and you just can’t quite make it to the doctor, the LiveHealth Online Physician can diagnose and treat common illness such as cold and flu right from your home
To learn more about this new offering and access the educational video at: https://www.vivityhealth.com/join. (Scroll down under the welcome and Select See Vivity in Action.)
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With Anthem Vivity HMO health care costs are predictable with no deductibles, low co-pays, and no claims to file. Keep in mind that you’ll likely have no coverage for services rendered by out-of-network providers or for services rendered without a proper referral from your PCP.
HMO Medical Plan
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Anthem Vivity HMO
Medical Benefits Key Features In-Network OnlyAnnual Deductible None
Preventive Care (adult) 100% Well Baby/Well Child Care and Immunizations (birth through age 6) 100%
Physician Office Copay $30 (Must use a PCP)*
Specialist Office Copay $40 (Must have a referral from your PCP)
LiveHealth Online (24/7 video access to a doctor)
$20
Hospitalization Inpatient
Outpatient$500 per day ( up to a max of $1,500)
$250 per procedure
Hospital Emergency Room $150 copay; waived if admitted
Diagnostic Tests (X-rays / Labs) No charge;$100 for CT, MRI, PET Scans
Outpatient Surgery (Facility Charges) $250 per procedure
Chiropractic 60 day limit per benefit period
$30 copay per visit
Mental Health / Substance AbuseInpatient
Outpatient
$500 per day ( up to a max of $1,500)
$30Annual Out of Pocket Maximum (EE/ Family)
$2,500 /$5,000
Prescription Drug Benefits Summary Vivity Rx Plan
Generic $15 copay Sample Anthem Participating pharmacies include:
CVS Walgreens
CostcoTarget
A full list of in-network pharmacies can be found at www.vivityhealth.com.
Brand Formulary (Preferred) $40 copay
Non-Formulary (Non-preferred) $75 copay
Specialty 30% Coinsurance up to $250 max per prescrip-tion
*Employees must access their Anthem Vivity primary care physician for all services. Your PCP will refer for all other services such as specialty visits, diagnostics tests and hospitalizations. You can go directly (self-refer) to dermatologists; ear, nose and throat (ENT) doctors, OB/GYNs and allergists in your medical group, without a referral from your doctor.
Home Health Services require a prior authorization and has to be medically necessary. Your PCP will handle the process on your behalf.
Anthem Vivity HMO Customer Service• Vivity Concierge for help with transferring your care and medicines• Call the Vivity Concierge at 1-844-VIVITY (1-844-484-8489) to answer your questions
ID CardsYou will receive one ID card for Anthem Vivity medical and prescription drug benefits.
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Dental Plan
You have the choice of two dental plans – a Pre-paid comprehensive plan from United Concordia or a Preferred Provider Organization (PPO) plan from Cigna. Your plan choices offer flexibility in choosing where you receive your care. Please review the information below to choose the best option for you and your family.
United Concordia Pre-paid Plan The United Concordia Pre-paid plan offers you lower costs by limiting your choice to network providers only. After enrolling, you’ll be assigned a network service provider which you can change at any time. You’ll simply pay a set copay amount based on the type of service you need and copay schedules can be found in the dental brochure available in Human Resources. Please note, with this plan there is no coverage for services received out of network.
Cigna PPO The Cigna PPO plan allows you the freedom to choose your dentist but selecting an in-network dentist will keep your costs lower, as Cigna dentists have agreed to provide care at discounted rates. You don’t receive an ID card for the Cigna PPO dental plan. Your dentist may verify your coverage by contacting Cigna Member Services at 800-244-6224.
United Concordia Cigna PPO
Dental Services Pre-Paid Dental PPO Advantage PPO/Out-of-Network*
Annual Deductible Individual
FamilyNone
Participant Pays:$50
$150
Participant Pays:$100$300
Maximum Benefit Unlimited Plan pays a maximum of $1,200
Diagnostic Services Exams and X-rays Refer to copay schedule 100% (deductible waived) 80% of covered expenses
Preventive ServicesCleanings and fluoride applications Refer to copay schedule 100% (deductible waived) 80% of covered expenses
Endodontic Services Filings Refer to copay schedule 80% 80% of covered expenses
Basic Restorative Services Refer to copay schedule 80% 80% of covered expenses
Root Canals Refer to copay schedule 80% 80% of covered expenses
Oral SurgeryExtractions and impactions Refer to copay schedule 80% 80% of covered expenses
Periodontic Services Refer to copay schedule 80% 80% of covered expenses
Prosthodontic ServicesCrowns, bridges and dentures Refer to copay schedule
50% (some crowns and bridgework are limited to 25%
if replaced within first 24 months of coverage)
50% of covered expenses (some crowns and bridgework are
limited to 25% if replaced within first 24 months of coverage
Orthodontia ServicesAdult and child Refer to copay schedule Not Available
Insurance Carrier United Concordia Cigna
*Claims payment may differ between in and out-of-network coverage.
Dental Plan Costs• Refer to your rate sheet• Dental coverage is deducted on a pre-tax basis
Vision Plan
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Vision coverage is available through VSP to encourage you and your eligible dependents to maintain healthy eyesight. Vision coverage provides benefits for eye exams, prescription eyeglasses and contact lenses. Under this plan, you can see any doctor of your choice but you’ll receive substantial savings if you use a provider who is a VSP member. You don’t receive an ID card for the VSP vision plan. Your provider may verify your eligibility for coverage by contacting VSP Member Services at 800-877-7195. Below is a quick summary of the key features and costs:
Services VSP Member Doctor Non-member DoctorOffice Visit $25 copay $25 copay
AllowanceExamination (12 month interval) Paid in full $45Lenses (24 month interval)
SingleBi-focalTrifocal
Lenticular
Paid in full$45 per pair$65 per pair$85 per pair
$125 per pairFrames (24 months interval) $130 allowance $47Contact Lenses (24 month interval)
NecessaryElective
Paid in full$130*
$210 allowance$105* allowance
*Allowance is provided toward the cost of contact lenses and related services in lieu of spectacle lenses and frames.
Contact lenses are paid in full when they’re determined to be “medically necessary” for the patient. When selecting contact lenses from a member doctor, the standard examination will be covered in full.
Extra charges may apply for any cosmetic features, such as oversize lens blanks or a frame exceeding the allowable maximum. Tinted or photochromic lenses are not covered under this plan.
Vision Plan Costs• Refer to your rate sheet• Vision coverage is deducted on a pre-tax basis
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Life Insurance
Your benefits program plays an important role in assuring your family will be financially secure if you or a dependent should pass away. Good Samaritan offers you a variety of choices so you can select the plans that best meet the needs of you and your family.
Basic Employee Life InsuranceGood Samaritan provides eligible employees with coverage equal to 1 x your annual base salary (coverage will have a minimum of $15,000 and a maximum of $50,000). For employees over the age of 70, the benefit amount reduces by 50%.
Basic Employee Life Insurance costs are covered by Good Samaritan Hospital.
Supplemental Life InsuranceFor employees who wish to have additional financial security, Good Samaritan offers additional voluntary life insurance for you and your dependents. This plan is offered through Unum and deductions are taken on an after-tax basis.
When you are offered this plan for the first time, you can enroll in coverage up to the Guarantee Issue Limits. Guarantee Issue means you do not need to answer health questions when you enroll.
Coverage Options Guarantee Issue Limits
Employee 1 – 5 x salaryUp to $500,000 maximum coverage
New Hire- noneAnnual enrollment- can increase
coverage by 1 level.
Spouse/Domestic PartnerIncrements of $5,000 to a maximum of 50% of employee coverage (up to
$100,000)$25,000
Child(ren) $5,000 for children (between ages 6 months and 26) $5,000
If you are approved for supplemental life insurance for yourself, you may elect coverage for your spouse and eligible children. You will only be allowed to increase your life insurance amounts by 1 level each year.
If you elect supplemental life insurance in excess of the guarantee issue limits, satisfactory evidence of insurability (EOI) is required:• If you initially decline spouse coverage and want to enroll at a later date, you’ll be required to submit EOI each
time you apply for coverage.
Life Insurance
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Supplemental Life Insurance Rates
Employee or Spouse Age
Bi-weekly Employee rates
per $1,000 of coverage
Bi-weekly Spouse/ Domestic Partner Rates per $1,000
Bi-weekly Child(ren) Rate
$5,000*
Less than 30 $.015 $.015
$.61**You pay $.61 per pay
period for supplemental life coverage for one or
more children.
Age 30 to 39 $.026 $.026
Age 40 to 44 $.041 $.041
Age 45 to 49 $.063 $.063
Age 50 to 54 $.106 $.106
Age 55 to 59 $.175 $.175
Age 60 to 64 $.264 $.264
Age 65+ $.426 $.426
Other Plan Features:
Conversion Privilege (Basic and Supplemental Life)When coverage ends under the plan, you and your dependents can convert your coverage to Individual Whole Life Policies without EOI. You can convert the amount you or your dependents are insured for or a lower amount. You and your dependents must apply for individual life insurance under this conversion privilege and pay the first premium within 31 days after the date your employment terminates or when you or your dependents are no longer eligible to participate in the group plan.
Portability Feature (Basic and Supplemental Life)If you leave the hospital for any reason other than sickness or injury, you can keep your basic life coverage and a portion of your supplemental term life insurance coverage (up to a combined 5 x earnings). Portability coverage rates are based on the insurance carrier’s rate schedule. You must apply for coverage and pay the first monthly premium within 31 days after the date your coverage ends or the date you are no longer eligible.
Accelerated BenefitIf a doctor certifies that an insured individual is terminally ill and not expected to live more than 12 months, the insured may request payment of up to 50% of their life insurance amount to a maximum of $500,000.
Conversion & Portability forms are available online along with additional plan details in the Summary Plan Description.
Life Plan Costs• Basic Life: provided by Good Samaritan • Supplemental Life: refer to the chart above• Supplemental Life coverage is deducted on an after-tax basis
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Voluntary Personal Accident
Voluntary Personal Accident insurance provided through Zurich offers a benefit to your named beneficiary in the event of your death by accident. You may choose benefits in the following amounts:
Voluntary Personal Accident Benefit Amounts$25,000 $400,000$50,000 $500,000*
$100,000 $600,000*$200,000 $700,000*$300,000 $750,000*
* Amounts of $500,000 or more may not exceed ten times your base annual salary.
The family plan provides coverage for spouses/domestic partners and eligible children based on a percentage of the employee’s elected sum depending on family composition. If an accidental injury results in the loss of your life, a hand (at or above the wrist), a foot (at or above the ankle) or eye (involving irrevocable and complete loss of sight) within 365 days of the accident, a benefit is payable. Your full principal sum is payable for loss of life. Half of your principal sum is payable for loss of hand, foot or eye. However, no more than 100% of the principal sum is payable for all losses resulting from one accident.
Coverage Bi-weekly Employee Cost Bi-weekly Family Cost
$25,000 $.29 $.47$50,000 $.58 $.92
$100,000 $1.16 $1.85$200,000 $2.31 $3.69$300,000 $3.46 $5.54$400,000 $4.62 $7.38$500,000 $5.77 $9.23$600,000 $6.92 $11.08$700,000 $8.08 $12.92$750,000 $8.66 $13.84
Voluntary Personal Accident coverage is deducted on an after-tax basis.
Short-Term Disability
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Short-Term DisabilityCoverage Tax Status Cost
Base Plan: covers 60% of income up to a weekly maximum of
$1,000
Base Plan: taxable when you receive the benefits
Provided by Good Samaritan Hospital
Buy-up Plan: covers 60% of income up to a weekly maximum
of $1,500
Buy-up Plan: non-taxable when you receive the benefits
$.081 per $100 of covered payrollDeducted on an after-tax basis
Benefits are integrated with the California State disability plan. If your bi-weekly base pay is $3,334 or less ($86,684 annually), the Base Plan provides the maximum benefit to you.
Short-Term DisabilityIf you can’t work because of a non-occupational illness or injury, it’s important that you have a source of income to meet your needs. Good Samaritan helps to provide this income by offering a Short-Term Disability (STD) plan through Unum. Benefits are paid after you’ve been disabled for 30 days for any non-occupational illness or injury that causes disability (including pregnancy). The amount of your benefit depends on your plan selection and is calculated from your base pay as of your last day of full-time work (to a weekly maximum benefit of $1,500 under the buy-up plan). If qualified, benefits will begin on your 31st day after your disability and continue for up to 22 weeks.
Exclusion The Base Plan is paid by Good Samaritan Hospital. Should you become disabled, the benefit would be taxable. When you pay the premium for the Buy-up Plan, the benefit you receive is tax-free. The STD Buy-up Plan doesn’t cover any disability that occurs in the first 12 months of coverage if the disability is caused by, contributed to or resulting from a pre-existing condition.
Pre-existing Condition If you received medical treatment, consultation, care or services (including diagnostic measures) or took prescribed drugs or medicines in the three months just prior to your effective date of coverage. If in subsequent enrollment periods you buy-up coverage, the difference in benefit between the basic coverage and buy-up coverage will be subject to the pre-existing condition limitations.
The Buy-up STD coverage is deducted on an after-tax basis.
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Long-Term Disability
Long-Term DisabilityGood Samaritan offers a Long-Term Disability (LTD) plan through Unum that helps replace your income if you become disabled and can’t work for an extended period of time. The Base LTD Plan is provided by Good Samaritan Hospital. If you’re disabled according to the policy’s definition of disability, after 180 days you may be eligible to receive a monthly benefit based on your monthly earnings. Benefits are paid for any illness or injury (occupational or non-occupational) that causes disability. If qualified, benefits will begin on your 181st day after your disability and may continue up until age 65. Because Good Samaritan pays for the base plan, the benefits are taxable if you become disabled and receive benefits. However, should you purchase the buy-up option and fund this plan with after-tax deductions, your benefit will be non-taxable.
Exclusions: The LTD Buy-up Plan doesn’t cover any disability that occurs in the first 12 months of coverage if the disability is caused by, contributed to or resulting from a pre-existing condition. Pre-existing condition: If you received medical treatment, consultation, care or services (including diagnostic measures) or took prescribed drugs or medicines in the three months just prior to your effective date of coverage.
Disability Plus Benefit:
Should you experience a severe disability and are unable to perform at least two activities of daily living, or if you have a cognitive impairment, Unum will provide an additional 20% of income (base plan will then have a monthly maximum of $4,000 and the Buy-up Plan will have a $10,000 monthly maximum.
Long-Term DisabilityBenefit Tax Status Disability Plus Cost
Base Plan: covers 60% of income up to a monthly
maximum of $2,000
Base Plan: benefits are taxable when you receive them
Base Plan: additional 20%, $4,000 maximum
Provided by Good Samaritan Hospital
Buy-up Plan: covers 60% of income up to a monthly
maximum of $8,000
Buy-up Plan: benefits are non-taxable
Buy-up Plan: additional 20%, $10,000 maximum
$0.52 per $100 of covered payroll
Deducted on an after-tax basis
Benefits are integrated with the California State disability plan. If your bi-weekly base pay is less than $1,538.46 ($40,000 annually), the Base Plan provides the maximum benefits to you.
The Buy-up LTD coverage is deducted on an after-tax basis.
If you have regular, planned or predictable healthcare or dependent care expenses, a Flexible Spending Account (FSA) might be a good fit for you. With an FSA, your eligible out-of-pocket medical, dental or vision expenses and/or dependent care expenses may be paid with pre-tax dollars. The FSA is administered by Discovery Benefits.
The FSA is simple to use! Money is deducted from your paycheck before it’s taxed and deposited into your FSA fund. When you have eligible healthcare expenses not covered under the medical, dental or vision plans, you simply submit them for reimbursement. You save in taxes what you would have otherwise paid. To learn about the advantages and savings of using a FSA, watch the FSA 101 video at https://www.discoverybenefits.com/about/videos/employees.
Health Care Flexible Spending AccountWhat you can pay for: • Deductibles and copays under your medical, dental and vision plans• Charges in excess of the allowable amount for medical, dental or vision benefits• Eligible charges not covered by your medical, dental and vision plans• Healthcare expenses that exceed coverage maximums, such as charges for private room hospitalization or chiropractic
care
• Refer to the IRS publication 502 for a complete list of qualified expenses
How Much You Can Contribute You can contribute up to a maximum of $2,600 in a Plan Year. If you terminate from the company before the end of the Plan Year, your election(s) will cease. However, if you have a positive account balance, you may still reimburse yourself for any eligible expenses in the Plan Year until your balance is zero if the charges were incurred while you were an active participant in the plan or if you continue coverage under COBRA.
How You Use It Each pay period you will contribute to your FSA through payroll deductions. That amount will get applied to a Benefits Debit Card. Use a Discovery Benefits Debit Card to pay for eligible services and products. Payments are automatically withdrawn from your reimbursement account, so there are no out-of-pocket costs. Be sure to keep your receipt for tax purposes.
Tools and Resources:Access www.DiscoveryBenefits.com for a listing of eligible expenses and to manage your account online. You can also download the Discovery Benefits mobile app. • Check account balances• Upload photos of receipts• File claims• View account activity• Contact customer service
Flexible Spending Accounts
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USE IT OR LOSE IT The money you set aside during 2017 must be used to pay expenses incurred in 2017. The IRS requires you forfeit any money that you have not used by the end of the Plan Year. You can file claims incurred and paid in 2017, no later than March 31, 2018.
Contributions to the Flexible Spending Accounts are taken on a pre-tax basis.
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Flexible Spending Accounts
Dependent Care Flexible Spending AccountThis account provides a way for you to accumulate pre-tax funds to reimburse yourself for childcare or daycare expenses for a disabled dependent while you and your spouse are employed. After you pay for eligible daycare expenses during the year, you can submit them to be reimbursed. After you elect the amount you’ll put into this account, you can’t change your decision during the Plan Year unless you have a qualified status change. You must use your amount for eligible expenses within the Plan Year or forfeit any money left in the account. These accounts may not be stopped mid-year unless you’re no longer in a benefit eligible status.
You may use the Dependent Care Reimbursement Account if:• You work full-time or part-time• You are married and your spouse also works full-time or part-time or is a full-time student or disabled
Eligible dependent care expenses include, but aren’t limited to: • Licensed day care• Schooling for children below the kindergarten level
• Housekeepers whose main responsibility is caring for a dependent
How Much You Can Contribute The maximum amount you may direct to this account is $5,000 per Plan Year. If you’re married, the amount you set aside may not exceed your spouse’s income (if your spouse is a full-time student or disabled, they will be considered to have an income of $200-$400 per month for this purpose, depending on how many dependents you have). If your spouse also has a Dependent Care Reimbursement Account, the combined amount you and your spouse may set aside can’t exceed $5,000. If you’re married and file separate tax returns, the maximum contribution amount is $2,500 per spouse. In most cases, a family with a combined income for more than $24,000 a year will benefit from using one of these accounts instead of taking the dependent credit on their taxes. Generally, both options can’t be used, so you’ll need to decide which is best for you. Should you terminate from Good Samaritan Hospital before the end of the Plan Year, your elections will cease. However, if you have a positive account balance, you may still reimburse yourself for any eligible expenses throughout the Plan Year until the balance is zero.
A dependent child is defined as a child under the age of 13. An eligible disabled dependent is someone who lives with you more than six months of the year and for whom you’re responsible for more than one half of their own support. Dependent care services provided on or after the dependent’s 13th birthday aren’t eligible for reimbursement.
Employee Assistance Plan
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Contact:1-800-227-1060www.members.mhn.com Company Code: goodsam
Good Samaritan Hospital provides all employees with 24/7 access to an Employee Assistance Plan (EAP). You can access a number of services through MHN.Our EAP is available 24 hours a day, 7 days a week. This is a no-cost benefit that is available to you and your dependents. The EAP offers confidential support and resources to assist you through life’s challenges.
Clinical AccessThe EAP will help members identify and resolve issues related to family conflict, relationships, domestic violence, stress, changes in mood and more. Face-to-face clinical counseling, telephonic consultations and web-video consultations are available. In addition, members can visit the EAP member website for emotional health tools and information or to search for a provider and generate a referral. Your coverage includes up to 5 face-to-face visits or phone calls, free of charge.
Work & Life Services You can get assistance with financial and legal matters, identity theft recovery, receive childcare and eldercare advice and more. Our member website includes easy to use financial and legal tools, childcare and eldercare directories and several work-life articles.
Health & Wellness ServicesMHN’s member website features powerful health and wellness tools, content and self-help programs that add real value for members. Services include an online health assessment, help with weight management, smoking cessation, nutrition, stress and a complete Wellness Center.
Financial ServicesYou can speak with an advisor over the phone about budgeting, credit and financial questions (excluding investment advice and loans) and retirement planning.
Legal ServicesTalk to a lawyer over the phone or face to face about:
• Personal and family law, including adoption, divorce and custody issues• Civil, consumer and criminal law• Financial and tax matters• Real estate• Estate planning
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We provide a Child Care Center located at 1350 Shatto Street, just one block from the main hospital. The hours of operation are 6:15 am to 5:30 pm, Monday through Friday.Children may attend two, three, four or five days per week. Our programs care for children between the ages of 3 months and 5 years.
Infant Program: Provides a warm, safe, clean and welcoming environment for your baby. Infants may join this group at 3 months of age.
Toddler Program:This program integrates a variety of specially designed activities for busy and growing toddlers.
Preschool Program: Our staff provides activities including art, music, physician education, language and math in a safe, warm and loving environment helping children grow intellectually, socially, emotionally and physically
Child Care Center
Contact the Director of the Child Care Center at 213.977.2355
Employee HealthThe Employee Health Department is located in the 637 Lucas building on the ground floor. The department opens at 7:30am. Employees can stop by on-site to receive:• Immunizations• Workplace injury assessments • Flu shots
• Annual health screenings
Employee Wellness ProgramGood Samaritan Hospital believes in the value of healthy employees and takes their well-being very seriously. That’s why we provide an employee wellness program, called Project Wellness, to promote and support our employees. Project Wellness includes:• Biometric Screenings: we provide employees and staff with easy and convenient access to health screenings such as
cholesterol, glucose, blood pressure, body composition, and bone density • Employee Health Fair: Annual health fair provides information and resources on your personal health needs. Topics
include: nutrition, diabetes, sleep disorders, stroke awareness, cancer data and mammogram scheduling. Other participants include: Leverage Concierge, LAH Federal Credit Union, and the Good Company Employee Donation Program. Good Sam health providers (Anthem, Cigna, United Concordia) are on hand to answer questions. An “Ask the Doctor” table provides dental and/or medical information.
• Health Risk Assessments: Determine your overall health status by completing the MyHealth Assessment. Identify your health risks and see how your health compares to other members. Then learn what steps you can take to make the biggest improvements in your lifestyle and your health. www.anthem.com/ca
• Health Topics: Access a variety of health topics to assist you in managing your diabetes, cancer, quit smoking, lose weight or manage your pregnancy. www.anthem.com/ca
Fitness CenterGood Samaritan Hospital provides employees with convenient access to an on-site fitness center. The fitness center is located in the 637 Lucas building on the ground floor. The center is open from 4:30 a.m. to 9:00 p.m. You can apply for membership within the Employee Health Department, directly next door to the fitness center. Membership is for a full month at a time and can be canceled by submitting a cancellation form to Employee Health. Refunds are not permitted.
Costs:
Leverage Concierge ServicesLeverage Concierge is located in the lobby of the 637 Lucas building and is open Wednesday, Thursday, and Friday from 7:30am to 4pm. The service center provides discount movie tickets, discount tickets to local and national attractions, quality GSH-branded jackets, polo shirts, blankets, gym bags, pens, umbrellas and other items that can be bought with cash or Hospitality Bucks. Leverage Concierge also provides dry cleaning/laundry services, express shipping, package receiving, stamp purchase, In-and-Out gift cards, Ralph’s gift cards, and vouchers for the cafeteria and car washing. Discounted shopping and travel, promotions, special discounts, and more can be viewed at www.myleverageonline.com. Use company code GSNH850 to register and access your account.
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Other Benefits
Payroll Deductions $5.00 per pay period (after-tax)Non-payroll deductions $12 per month (3-month minimum)
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Voluntary Pet Insurance
Voluntary Pet Insurance Voluntary Pet Insurance coverage is offered through Nationwide Pet Insurance. With coverage from Nationwide, you can focus on giving your pet the best care possible instead of focusing on the cost of treatment. Plans are designed by veterinarians to provide the best reimbursement for your premium dollar. This plan is discounted for Good Samaritan Hospital employees. All plans cover chronic and recurring conditions that are not pre-existing at enrollment. This coverage is at no extra charge.
Major Medical Plan Comprehensive• Includes benefits for some hereditary conditions after the first year of coverage• Chronic condition coverage included at no extra cost• Flexible Deductible• Maximum annual benefit of $14,000
Medical Plans Economical• Chronic condition coverage included at no extra cost• Flexible deductible• Maximum annual benefit of $7,000
Feline Select Plans (just for cats)• Coverage for the 15 most common cat conditions• No deductible• Maximum annual benefit of $9,000For Avian & Exotic pet plan information, please call VPI.
EnrollmentOnline at www.petinsurance.com or call 1-877-738-7874
Filing a claim in three easy steps:
1. Pay your veterinarian directly
2. Send your claim form and receipts
3. Get reimbursed
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Identity Theft
Identity TheftStarting in January 2017, you will be offered the opportunity to enroll in Identity Theft protection services provided by Identity Force. This coverage recovers out-of-pocket expenses and lost wages in the event your identity is stolen. Services include:• Identity monitoring• Credit protection
• Restoration • Child watch
This coverage is portable and available on an after-tax basis.
Monitor & AlertUltraSecure UltraSecure + Credit
Change of Address Monitoring l l
Credit Report Monitoring l
Court Record Monitoring l l
Fraud Alert Reminders l l
Identity Monitoring l l
Identity Threat Alerts l l
Pay Day Loan Monitoring l l
Proactive Credit Monitoring l l
Sex Offender Monitoring l l
ControlUltraSecure UltraSecure + Credit
Delete Now l l
Credit Reports (Three Bureau) Quarterly
Credit Scores (Three Bureau) Quarterly
Credit Score Tracker l
Identity Health Score l l
Junk Mail Opt-Out l l
Medical Insurance Form l l
Online Protection Tools l l
RelaxUltraSecure UltraSecure + Credit
Identity Restoration Specialist l l
Identity Theft Insurance ($1 Million) l l
Lost Wallet Assistance l l
Monthly CostUltraSecure UltraSecure + Credit
Employee Only $9.95 $16.95Employee + Spouse/Domestic Partner $19.90 $33.90Employee + Child(ren) $14.95 $21.95Employee + Family $24.90 $38.90
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Notices & Disclaimers
Required NoticesPlease refer to the Good Samaritan Intranet site to access the required health notices.
Affordable Care ActGood Samaritan’s employee benefits plan meets the minimum essential coverage provision as well as the affordable provision of the Affordable Care Act. If you choose to receive benefit coverage through a State or Federal health care exchange you may not be eligible for a subsidy.
Summary Benefits Coverage (SBC) This guide serves as a summary of the plans offered by Good Samaritan Hospital. For all specific plan details, please refer to the SBC on each plan located in Good Samaritan Intranet site.
Contacts
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Employee SupportHuman Resources 213-977-2378 www.goodsam.org
Enrollment or Changes Access the iPortalUser ID = Account IDPassword = AssignedContact IT for Account ID set up and password resets.
Carrier Contacts Phone Number Website AddressGood Samaritan Hospital Plan Policy # 276140
800-759-3030Anthem Blue Cross Medical Plan www.anthem.com/ca PO Box 60007
Los Angeles, CA 90060Good Samaritan Hospital Plan Prescription DrugsPolicy # 2163GS01Group: 216301A
CVS/Caremark1-800-707-5587 www.caremark.com PO Box 52116
Phoenix, AZ 85072-2116
Anthem Vivity HMO Policy # 276140V001 1-844-4-VIVITY www.vivityhealth.com
Dental
Cigna PPO Dental PlanPolicy #3333899
800-244-6224www.mycigna.com PO Box 188037
Chattanooga, TN 37422-8037
United Concordia Pre-Paid Dental Plan
Policy # 740095866-357-3304
www.ucci.com
United Concordia Claims Office
PO Box 10194Van Nuys, CA 91410
VisionPolicy #12081621
Vision Service Plan (VSP) 800-877-7195 www.vsp.com PO Box 997105
Sacramento, CA 95899-7105
Employee AssistanceMHN Employee
Assistance Program800-227-1060
www.members.mhn.com (company code: goodsam)
7755 Center Avenue, Ste 700Huntington Beach, CA 92647
Flexible Spending Accounts
Discovery Benefits866-451-3399 press 1
www.discoverybenefits.com/employees
4321 20th Avenue S Fargo, ND 58103
Life InsurancePolicy #543088
Unum 800-445-0402 www.unum.com PO Box 100158
Columbia, SC 29202-3158Disability (STD & LTD)Policy #543088
Unum 800-858-6843 www.unum.com
AD&DPolicy #GTU 5091209
Zurich866-841-4771 www.zurichna.com PO Box 968041
Schaumburg, IL 60196-8041
Pet Insurance Nationwide 1-877-738-7874 www.petinsurance.com/goodsam
COBRA Administration Discovery Benefits866-451-3399 press 1
www.discoverybenefits.com/employees
4321 20th Avenue S Fargo, ND 58103
Identity TheftIdentity Force877-694-3367
[email protected] 40 Speen Street, Suite 403
Framingham, MA 01701
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Notes
Disclaimer:This guide outlines the benefits plan options sponsored by Good Samaritan Hospital (the Company) for eligible employees. All benefits, including eligibility for coverage, are subject to the Company’s terms and conditions as well as the provisions of the group insurance contracts. This guide is a brief summary of the Company’s benefits and not a complete and full description of the benefit plans nor is this guide a summary plan description (SPD) or the official plan document. In the event of any conflict or discrepancy between this guide and the official plan documents, the plan documents will govern. This document is subject to change without notice. Good Samaritan Hospital does not warrant that the material contained in this document is error free.
In addition, this guide is not a guarantee of current or future employment or benefits. The Company reserves the right to modify or terminate any of the described benefits or employee benefit plan at any time for any reason. For important details about the Company’s benefits, please review the SPDs, Summaries of Benefits and Coverage (SBCs) and other material made available from Human Resources or online by accessing the iPortal.
Contributors: Good Samaritan Human Resources
Copyright @ 2017 Good Samaritan Hospital. All rights reserved. Printed in the United States.
Restricted RightsThe information contained in this document is proprietary and confidential to Good Samaritan Hospital. No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying and recording, for any purpose without written permission of Good Samaritan Hospital.
Revised November 2016