The 2015 Jefferson Benefits Guidebook · This Guidebook contains a summary of the benefits offered...

The 2015

Jefferson BenefitsGuidebook

Important BenefIts enrollment InformatIon

Open Enrollment for the 2015 Plan Year is processed exclusively online from Oct. 14 – Oct. 31, 2014.

the benefits you elect during open enrollment will remain in effect for the entire plan year unless you experience a qualified life event. It’s the employees responsibility to contact the Hr service Center to report the qualified event. Changes must be made within 30 days of date of the event.

new hire elections are processed exclusively online and must be made within 30 days of hire otherwise you will be defaulted to no coverage.

the 2015 Jefferson Benefits Guidebook

DesIGnInG your BenefIt paCKaGe ...................... 2

Who’s eligible (including part-time employees) ...2

enrolling Dependents .................................................2

proof of Dependent status ........................................2

How long your options stay In effect ....................3

part-time employee Benefits program ...................3

When Coverage ends ..................................................3

CoBra .......................................................................... 4

life event Changes ..................................................... 4

selecting medical Coverage ..................................... 4

your medical options ................................................ 4

CDHP ........................................................................ 4

ACO Plus point of service plan ....................... 5-6

POS Service Area ................................................. 6

PPO Plan .............................................................. 6-7

POS Plan Summary ............................................8-9

PPO Plan Summary ........................................10-11

Livewell@Jeff .........................................................12

prescription Drug Benefits.................................12-13

Dental Insurance ................................................. 14-15

Vision Insurance .........................................................15

survivor Benefits ..................................................15-17

Your Basic Survivor Benefits ...............................15

Traveling on Jefferson Business ....................... 16

Optional Survivor Benefits ................................. 16

Life Insurance ...................................................... 16

Spousal and Dependent Life Insurance ...........17

Medical Evidence of Insurability ........................17

Supplemental AD&D Insurance .........................17

your Disability Benefits .......................................17-19

Short Term Disability ..................................... 17-18

Optional Short Term Disability Benefits .......... 18

Pre-Existing Conditions .............................. 18

Filing a STD Claim ........................................ 18

Working in New Jersey ............................... 18

Long Term Disability (LTD) ................................ 19

LTD Plan Options ......................................... 19

LTD Maximum Benefit Period ................... 19

using your flexible spending accounts:

An Overview ..........................................................20

Tax Advantages .....................................................20

Maximum Reimbursements ...............................20

Discrimination .......................................................20

Setting Up A Flexible Spending Account .........21

Eligible Medical Expenses ...................................21

Qualified Expenses — A Few Examples ...........21

Flexible Spending Account Worksheet ........... 22

Voluntary BenefIts ................................................... 23

your otHer BenefIts ...........................................23-24

Retirement Plans .................................................. 23

Tax Deferred Annuity Programs ....................... 23

Dependent Scholarship Program ..................... 23

Tuition Assistance Program ............................... 23

Earned Time Off ................................................... 23

Vacations ............................................................... 24

Other Voluntary Programs ................................. 24

Contents

For additional benefits information please view our website, www.JeffersonHr.org. Click on benefits located in the menu on the left side of the page.

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DesIGnInG your BenefIt paCKaGe

The Jefferson Benefits Program provides Basic Benefits which offer you a primary level of protection in most important areas. The program gives you the opportunity to supplement what’s provided through the optional Benefit Choices.

The Benefits Program enables you to design the optimal benefits package for yourself and for your family. In order for you to do this, you must understand how the program works, what your options are, and what the tax effects of your choices are. That’s why we’ve put together this Benefits Guide. It has all the information you need to design a benefits package that best meets your own needs. What you’ll find here is a general overview of the program and then details on the Basic and Optional Benefits.

This Guidebook contains a summary of the benefits offered under each plan. This summary is not a guarantee of current or future benefits. Actual payments will be based on the provisions of the Plan Documents, which may be reviewed by contacting the Human Resources Service Center, 215-503-HRSC (4772). summary plan descriptions may be viewed on our website, www.JeffersonHr.org.

WHo’s elIGIBle

All regular full-time employees scheduled to work at least 35 hours per week and regular part-time Jefferson employees scheduled to work 20 or more hours per week but less than 35 in job classifications designated as benefit eligible are eligible for the Benefits Program. Your waiting periods for coverage under each benefit appear in the table on page 3.

enrollInG DepenDents

You may enroll your spouse, eligible registered same sex domestic partner and eligible dependent children in any of the medical options. A child is an eligible dependent until he/she attains age 26. You and your partner/dependents must choose the same options. For additional information on enrolling dependents, contact the Human Resources Service Center at 215-503-HrsC (4772).

proof of DepenDent status

If you choose to enroll your dependents in benefits, you will need to submit dependent verification information within 30 days from the date you add them as a dependent. This information should be sent to [email protected] or faxed to 215-503-7455. See box at right for acceptable supporting documentation:

the Jefferson Benefits program

Basic Benefits

• Life and Accidental Death & Dismemberment Insurance

• Travel Accident Insurance

• Short Term Disability*

• Long Term Disability*

• Salary Continuation for Faculty, Senior Administration and House Staff *

Optional Benefit Choices

• Medical Insurance (including vision care & prescription drugs)

• Dental Insurance

• Supplemental Life Insurance

• Dependent Life Insurance

• Supplemental Accidental Death & Dismemberment

• Supplemental Short Term Disability*

• Supplemental Long Term Disability*

• Flexible Spending Accounts

* part-time employees not eligible

Dependent Type Acceptable Documentation

Spouse • Marriage Certificate • Prior Year joint tax return, if marriage

certificate is not available

Registered Same Sex Domestic Partner

• Marriage, Civil Union or Domestic Partner Certificate or

• At least three of the following items (one of which must have a date of one year or longer and all must include a common address): joint deed, joint mortgage or lease agreement; joint bank or other financial account; common ownership of motor vehicle; driver’s license listing a common address; designation as beneficiary on a life insurance policy (can include a Jefferson policy)

If unable to provide documents listed above, a signed and notarized affidavit may be presented attesting to the following: • The domestic partners have shared a

residence for twelve months or longer and are jointly responsible for common welfare and financial obligation, and

• The existence of an ongoing personal relationship between them.

Children up to age 26 • Birth Certificate • Prior year tax return, if birth certificate is

not available.

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HoW lonG your BenefIts stay In effeCt

Your Benefits stay in effect for the length of the Plan Year. The Plan Year is from January 1 to December 31. The annual election period will occur in the Fall of each year for the Plan Year that starts on the following January 1. See information on page 4 concerning “Life Event Changes” that permit a change during the plan year.

part-tIme employee BenefIts proGram

The Benefits Program includes subsidized benefits for eligible part-time employees who elect to participate. You are eligible if you are a regular part-time employee in a benefit-eligible job classification scheduled to work 20 hours or more per week but less than 35.

Eligible part-time employees may select options for Medical and Dental coverage, Life and Accidental Death and Dismemberment Insurance, Spousal and Dependent Life Insurance and the Flexible Spending Accounts. The medical and dental per pay contributions are higher for part-time employees. Part-time employees are not eligible to participate in Jefferson’s Disability Programs beyond sick time or Earned Time Off accruals.

WHen CoVeraGe enDs

for youJefferson benefits coverage ends for you upon the following events as follows:

• Medical and dental benefits end on the last day of the month in which your employment ends or you no longer meet the applicable eligibility requirements of the plans.

• Life insurance, disability and FSA benefits end on the date your employment ends or you no longer meet the applicable eligibility requirements of the plans.

for your DependentsJefferson benefits coverage ends for your dependents on the date:

• Your coverage ends

• Your dependent no longer meets the definition of an eligible dependent, or

• You remove a dependent from coverage due to a life event.

Coverage may also end if you stop making required payments, you misrepresent your dependent’s eligibility status or the plan ends.

eligibility table for Benefit Coverage*

When You Become Eligible for Coverage

Plan Faculty & House Postdoctoral Other Sr. Administrators Staff Fellows (full-time) Employees

Life Insurance 1st day at work (full-time) 1st of month following

1st of month following 1st day at work 1st day at work date of hire (full-time

date of hire (part-time) and part-time))

Accidental Death 1st day at work (full-time) 1st of month following

& Dismemberment 1st of month following 1st day at work 1st day at work date of hire (full-time

Insurance date of hire (part-time) and part-time)

Medical Insurance 1st day at work (full-time) 1st of month following


date of hire (part-time) and part-time)

Dental Insurance 1st day at work (full-time) 1st of month following



Flexible Spending 1st day at work (full-time) 1st of month following

Accounts 1st of month following 1st day at work 1st day at work date of hire (full-time


Short Term N/A N/A 1st day at work 1st of month following

Disability Plan date of hire (full-time only)

Long Term 1st day at work 1st day at work 1st day at work 1st of month following

Disability Plan (full-time only) (full-time only) (full-time only) date of hire (full-time only)

* Jefferson reserves the right to change or terminate benefit plan provisions at any time.

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CoBra

COBRA requires continuation coverage to be offered to covered employees, their spouses, their former spouses, and their dependent children when group health coverage would otherwise be lost due to certain specific events. The following chart shows the specific qualifying events, the qualified beneficiaries who are entitled to elect continuation coverage, and the maximum period of continuation coverage that will be offered, based on the type of qualifying event.

QualIfyInG eVent

QualIfIeD BenefICIarIes

maxImum perIoD of ContInuatIon CoVeraGe

Termination (for reasons other than gross misconduct) or reduction in hours of employment

Employee Spouse Dependent Child

18 months

Employee enrollment in Medicare

Spouse Dependent Child

36 months

Divorce or legal separation

Spouse Dependent Child

36 months

Death of employee Spouse Dependent Child

36 months

Loss of “dependent child” status under the plan

Dependent Child 36 months

Once the qualifying event has been reported to the HR Service Center, the qualified beneficiary will receive a COBRA notice in the mail to the home address on record by our third party administrator, ADP. For more information on COBRA, visit the DOL website, “An Employees’ Guide to Health Benefits under COBRA” at www.dol.gov/ebsa/pdf/cobraemployee.pdf, contact ADP at 800-778-0043 or the HRSC at (215) 503-4772.

lIfe eVent CHanGes

Ordinarily, your Benefit elections must remain in effect throughout the Plan Year. However, if a “life event” that affects your coverage occurs during a Plan Year, you may elect a different level of coverage, provided you submit appropriate documentation within 30 days* after the event takes place and your new selection is consistent with the life event change. Life events under the Program include:

• Legal marital status change (marriage, death of a spouse, divorce, legal separation or annulment).

• Change in the number of dependents (birth, adoption, placement for adoption, or death of a dependent).

• Change in employment or benefit eligibility (termination or commencement by the employee, spouse or dependent).

• Work schedule (reduction or increase in hours of employment of the employee, spouse or dependent affecting benefit status including a switch between part-time and full-time).

• Dependent change in eligibility (dependent either satisfies or ceases to satisfy the requirements for coverage due to attainment of certain age, or other such requirements under the plan).

• Residence or worksite (a change in the place of residence or work of the employee, spouse or dependent that places the member ouside of the geographic area the current plan covers).

* Marriage, birth and adoption life events can be submitted through Employee self service. Contact the Human Resources Service Center to report other life event changes.

seleCtInG meDICal CoVeraGe

Before you choose your medical option, read this Guidebook or information located in the benefits section of www.JeffersonHr.org.

You may choose coverage for yourself, for you and one dependent, or for you and two or more dependents. The biweekly cost varies depending on the medical option you choose and the number of people covered, your use of tobacco products and participation in our wellness programs LiveWell@Jeff.

remember: In the event of disability, Jefferson will continue medical insurance selected on the most recent election while disability income is being received for up to one year from date of illness or injury, provided employee pays active employee premium rate.

your meDICal optIons

Jefferson offers you a choice of medical plans:

• ACO Plus Point of Service (POS)

• Preferred Provider Organization (PPO)

• Consumer Driven Health Plan (CDHP) – This is a grandfathered plan and is only available to employees who were enrolled in it in 2014.

Consumer-DrIVen HealtH plan (CDHp)

The CDHP plan is a grandfathered medical plan that will be eliminated December 31, 2015. Only employees & dependents enrolled in the CDHP program in 2014 can remain in the plan for 2015. For CDHP plan summary go to www.JeffersonHr.org or log on to your account at www.ibx.com.

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note: employees who are newly eligible for benefits automatically default to no coverage if elections are not received.

The next section briefly describes each of your medical options. For a detailed comparison, read the POS and PPO benefits summaries on www.JeffersonHr.org or on page 8–11 of this Guidebook. All of the medical options include coverage for prescription or vision care services, as described later in this Guidebook.

Note: This brief review of your medical options does NOT include complete details about the benefit levels for each service. Limits apply to some treatment and services.

Usual, Customary And Reasonable Costs

For all of the plans, out-of-network coverage pays benefits based on the Usual, Customary and Reasonable (UCR) cost for each eligible expense. UCR costs are based on the going rate for the covered service or supplies in your geographic area. If your doctor charges more than the UCR rate, you will be responsible for the extra amount. If your doctor is a participating provider, he or she must accept the UCR allowance as payment in full.

aCo plus poInt of serVICe plan

The ACO Plus Point of Service Plan (POS) Plan is like an HMO with added flexibility. You must select a Primary Care Physician (PCP) and have your care provided by or referred by your PCP to receive the maximum benefit. The plan also has a self-referred level of benefit that allows you to recive care without a referral from any provider and pay more out of pocket.

Below describes the four options of care (Tiers) you may receive. See the charts on pages 8–9 for more detailed information on how specific services are covered by each tier.

tier 1 – Employees can minimize their out of pocket expense by having their care provided or referred by their ACO Plus Primary Care Physician.

tier 2 – You receive care from your Keystone PCP or are referred to a Keystone provider.

tier 3 – You self-refer to a provider that is in the ACO Plus or Keystone network

tier 4 – You self-refer to a provider that is out of network

tHe aCo plus netWorK

If you are enrolled in the ACO Plus Point of Service Plan, use the ACO Plus network to minimize out-of-pocket costs while maximizing quality care. Visit www.jeffnetworks.org and choose the ACO Plus network for the most up-to-date listing of facilities and providers.

the aCo plus network for the pos planIf you are enrolled in the ACO Plus Point of Service Plan, you will have the lowest out of pocket costs if you use one of the facilities listed below:

• TJUH

• Methodist Hospital Division, TJUH

• Bryn Mawr Hospital

• Bryn Mawr Rehab Hospital

• Holy Redeemer Hospital

• Lankenau Hospital

• Magee Rehabilitation Hospital

• Mirmont Treatment Center

• Paoli Memorial Hospital

• Riddle Memorial Hospital

• Nemours/Alfred I. duPont

pCp refers self-referral

tIer 3 : $$$ACO Plus and

Keystone Networks

tIer 4 : $$$$Out-of-Network

tIer 1 : $ACO Plus Providers

“Preferred” care provided or referred by your PCP

tIer 2 : $$Keystone Providers

care provided or referred by your PCP

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WHat’s an aCo?

Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

The Delaware Valley ACO, which is sponsored by Jefferson, Main Line Health, Magee and Holy Redeemer, is one of the few organizations in the area to be recognized by Medicare as an ACO. Jefferson is offering our employees the option to receive their health care through this high quality, coordinated care network and that is why we are rolling out the ACO Plus Point of Service Plan. It’s called ACO Plus because for our employee plan we are expanding the ACO network to include additional high quality providers to meet the needs of our employee population.

pos optIon

The POS option includes the ACO Plus Network that rewards you for using the ACO providers and facilities that are part of your ACO and POS’s Keystone network.

primary Care physician – You choose a primary care physician (PCP) who will provide your care or give you a referral to other POS network providers when necessary. Provider directories are available online: www.ibx.com (Keystone), and www.jeffnetworks.org.

POS Pre-Admission Certification

Prior to your admission, your physician should pre-certify your admission with your insurance carrier. If pre-certification is not obtained and you are admitted to the hospital, the financial responsibility is placed on the hospital, not you. The Pre-Admission Certification is to determine whether an employee or their dependent should be admitted to the hospital as an inpatient. Its intention is to determine the most appropriate setting for medical treatment. In no way is it an attempt to render medical judgment regarding the appropriateness of treatment.

POS Service Area

If you enroll in the POS, you must reside in the IBC POS Service Area. If you reside in Philadelphia, Bucks, Chester, Delaware, Montgomery, Northampton, Lehigh, Berks and Lancaster counties in Pennsylvania; Warren, Hunterdon, Mercer, Burlington, Camden, Gloucester and Salem counties in New Jersey; New Castle county in Delaware; or Cecil county in Maryland you are in

the IBC PA Service Area or Contiguous PA/NJ/DE/MD counties that are covered by Keystone. If you reside in IBC POS Non-Contiguous NJ/DE/MD Service Area and elect the POS you will receive an AmeriHealth POS ID card. The AmeriHealth benefits are identical to Keystone POS as explained in this booklet. The Non-Contiguous NJ/DE/MD counties are Sussex, Passaic, Bergen, Morris, Essex, Hudson, Union, Somerset, Middlesex, Monmouth, Ocean, Atlantic, Cumberland and Cape May counties in New Jersey; Kent and Sussex counties in Delaware; Harford, Kent, Caroline, Wicomico and Worcester counties in Maryland. If you do not reside in any of the counties listed above, you cannot enroll in the POS. You will need to select the PPO medical plan.

If you are looking for a provider in the Keystone service area, go to www.ibx.com. For an AmeriHealth provider, go to www.amerihealth.com. IBC customer service representatives for both Keystone and AmeriHealth can be reached at 800-275-2583.

preferreD proVIDer orGanIzatIon (ppo)

The PPO Plan offers 3 levels of care. Each time you need medical care, you decide whether to use JeffPLUS Network providers, IBC Personal Choice network provider or out-of-network providers. If you use JeffPLUS Network providers, you will have lower out-of-pocket expenses. If you use providers who are in the IBC Personal Choice network, the plan still covers a large portion of your expenses, but copays, deductibles and coinsurance apply. Choosing to see out of network providers has the highest out-of-pocket expense.

If you are enrolled in the PPO Plan, you will have the lowest out-of-pocket costs if you use one of the facilities listed below:

Highlights of the PPO Plans

• freedom of Choice – The PPO allows you complete freedom to choose any doctor or health care provider but there is a tradeoff—lower benefits may be paid by the plan depending on your selection. Provider directories are available online: www.ibx.com (Personal Choice), and www.jeffnetworks.org. It is your responsibility to confirm and understand the level of benefit coverage before receiving services from a healthcare provider. you should contact your insurance carrier and provide pre-notification for certain categories of treatment so you will know prior to receiving treatment whether it is a covered service. If you go “out-of-network” you lose the advantage of the negotiated discounted rates, so you are paying a percentage of a higher rate.

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• no referrals required – You do not need to choose a primary care physician, and you do not need any referrals. Higher benefits are paid whenever you use “in-network” providers. Check the provider’s website for participating specialists. Remember, lower benefits are paid when you receive care from providers who are not in the PPO network.

• pre-certification required for some services – When you use a Personal Choice PPO provider/facility outside of the PPO’s local service area or out-of-network, you must obtain pre-certification for hospital stays and certain other services.

• Calendar year Deductible – The deductible is the annual amount you are required to pay before the plan will pay certain benefits.

• out-of-pocket limit – Once your costs reach a certain amount, the plan pays 100% of UCR charges for your eligible medical expenses for the rest of that year. The following amounts are not counted toward the out-of-pocket limit:

– Outpatient prescription drug expenses (your prescription drug benefits are provided under a separate plan);

– Charges that exceed UCR or the plan allowance for eligible expenses; or– Any charges you incur because you do not

call for pre-certification when required.

the JHs Jeffplus network for the ppo plan If you enroll in the PPO Plan use the JeffPLUS Network to minimize out-of-pocket costs while maximizing quality care. Visit www.jeffnetworks.org for the most up-to-date listing of facilities and providers.

ppo: You will have the lowest out of pocket costs if you use one of the home facilities listed below.

Jeffplus Home HospItals (Jefferson HealtH system)

• TJUH

• Methodist Hospital Division, TJUH

• Bryn Mawr Hospital

• Bryn Mawr Rehab Hospital

• Holy Redeemer Hospital

• Lankenau Hospital

• Magee Rehabilitation Hospital

• Mirmont Treatment Center

• Paoli Memorial Hospital

• Riddle Memorial Hospital

Jeffplus netWorK HospItals (non-JHs)

• Nemours/Alfred I. duPont Hospital for Children

VIrtua HospItals (Inpatient services only) • Berlin

• Marlton

• Memorial

• Voorhees

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Keystone aCo plus pos (poInt of serVICe) – 2015 plan summary

referreD aCo plus netWorK

Keystone netWorK self-referreD out-of-netWorK *

Deductible

Individual $0 $0 $500 $1,000

Family $0 $0 $1,500 $3,000

Benefit period Calendar year Calendar year Calendar year Calendar year

Coinsurance (percentage paid by plan) 100% unless

otherwise noted

100% unless

otherwise noted

70% or 80% after

deductible unless

otherwise noted

60% after deductible

unless otherwise noted

out-of-pocket maximum (includes copayments, deductible and coinsurance)

Individual2 $2,500 $2,500 $2,500 $5,000

Family2 $4,500 $4,500 $4,500 $10,000

lifetime maximum Unlimited Unlimited Unlimited Unlimited

Doctor’s office Visits

Primary Care Services $0 Copayment $20 Copayment $35 Copayment 60% after deductible

Specialist Services $10 Copayment $30 Copayment $40 Copayment 60% after deductible

preventive Care for adults and Children 100% 100% 100% NO deductible 60% after deductible

routine Gynecological exam/pap

one routine exam/pap test per calendar

year for women of any age

100% 100%, NO deductible 100% NO deductible 60% after deductible

mammogram (no referral required) 100% 100% 100% NO deductible 60% NO deductible

nutrition Counseling for Weight management

100% 100% 100% NO deductible 60% after deductible

outpatient Diagnostic services**

Routine Radiology $15 Copayment $30 Copayment 70%, after deductible 60% after deductible

MRI/MRA/CAT/PET $15 Copayment $30 Copayment 70%, after deductible 60% after deductible

outpatient Diagnostic services

Laboratory 100% 100% 100% NO deductible 60% after deductible

maternity – First OB Visit $0 Copayment $20 Copayment $20 Copayment 60% after deductible

Contraceptives 100% 100% 100% NO deductible 60% after deductible

Infertility treatment Not Covered Not Covered Not Covered Not Covered

Inpatient Hospital services3

Facility 100% $700 Copayment

per admission

$700 Copayment

per admission


Physician/Surgeon 100% 100% 100% 60% after deductible

emergency Care $150 Copayment

(Copayment waived

if admitted)

$150 Copayment

(Copayment waived

if admitted)

$150 Copayment

(Copayment waived

if admitted)

$150 Copayment

(Copayment waived

if admitted)

urgent Care Center $75 Copayment $75 Copayment $75 Copayment $75 Copayment

retail Clinic Not Available $20 Copayment $20 Copayment 60% after deductible

Benefits outside usa Coverage in full for emergencies only, applicable copay applies

outpatient surgery – Voluntary sterilization procedures included; Reversal of sterilization procedures excluded

Facility 100% $300 Copayment per

occurrence

$300 Copayment per

occurrence then 80%

after deductible


Physician/Surgeon 100% 100% 80% after deductible 60% after deductible

ambulance

Emergency 100% 100% 100% NO deductible 100% NO deductible

Non-Emergency 80% 80% 80% 60% after deductible

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referreD aCo plus netWorK

Keystone netWorK self-referreD out-of-netWorK *

therapy services

Physical and Occupational

60 visits per calendar year2

$15 Copayment $30 Copayment, $30 Copayment,

NO deductible


Cardiac Rehabilitation


$15 Copayment $30 Copayment $40 Copayment,

NO deductible


Pulmonary Rehabilitation



NO deductible


Speech



NO deductible


Hearing exam 100% 100% 100% NO deductible 60% after deductible

Hearing aid reimbursement

2 hearing aids every 36 months2

25% 25% 25% after deductible 25% after deductible

Cranial prosthesis

only covered for members receiving

cancer treatment, one per year


spinal manipulations


Not Available $30 Copayment $40 Copayment,

NO deductible


Chemo / radiation / Dialysis 100% 100% 80% after deductible 60% after deductible

outpatient private Duty nursing

360 hours per calendar year2


skilled nursing facility

120 days per calendar year2

100% $700 Copayment per

occurrence

$700 Copayment

per occurrence


Home Health Care

120 days per calendar year

100% 80% NO deductible 80% after deductible 60% after deductible

Hospice 100% 100% 70% after deductible 60% after deductible

mental Health Care/serious mental Illness Care

Outpatient Services $0 Copayment $30 Copayment $40 Copayment,

NO deductible


Inpatient Facility Services 100% $700 Copayment

per admission

$700 Copayment

per admission


substance abuse treatment

Outpatient/Partial Services $0 Copayment $30 Copayment $40 Copayment,

NO deductible


Inpatient Rehabilitation 100% $700 Copayment per

admission

$700 Copayment

per admission


Detoxification 100% $700 Copayment per

admission

$700 Copayment

per admission


Durable medical equipment Not Available 90%, NO deductible 80% NO deductible 60% after deductible

outpatient Diabetic education 100% 100% 100% NO deductible Not Covered

Diabetic equipment and supplies 100% 100% 100% NO deductible 60% after deductible

* Out-of-Network providers may bill you the difference between the plan allowance, which is the amount paid by the plan, and the provider’s actual charge. This amount may be significant.

** Copayment not applicable when service performed in Emergency Room or office setting.

1 Inpatient hospital day limit combined for all self-referred inpatient medical, maternity, mental health, serious mental illness, substance abuse and detoxification services.

2 Combined across all networks

3 If you are admitted through the emergency room at a non-ACO Plus facility within your carrier network directly to that facility, coverage is provided at 100%. Pre-certification may be required.

Keystone aCo plus pos (poInt of serVICe) – 2015 plan summary, ContInueD

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personal CHoICe ppo (preferreD proVIDer orGanIzatIon) – 2015 plan summary

BenefIts In-netWorK

Jeffplus netWorK

personal CHoICe netWorK out-of-netWorK *

Deductible

Individual None $500 $1,000

Family None $1,500 $3,000

Benefit period Calendar Year Calendar Year Calendar Year

Coinsurance (percentage paid by

plan except hearing aid benefit)

100% unless otherwise noted 70% or 80% after deductible

unless otherwise noted

60% after deductible unless

otherwise noted

out-of-pocket maximum***

Individual $3,0004 $3,0004 $5,000

Family $5,0004 $5,0004 $10,000

lifetime maximum Unlimited Unlimited Unlimited

Doctor’s office Visits

Primary Care Services $20 copayment $40 copayment, NO deductible 60% after deductible

Specialist Services $25 copayment $45 copayment, NO deductible 60% after deductible

preventive Care for adults and Children 100% 100% NO deductible 60% after deductible

routine Gynecological exam/pap

One routine exam/pap test per calendar year

for women of any age1

100% 100% NO deductible 60% after deductible

mammogram 100% 100% NO deductible 60% NO deductible

nutrition Counseling for Weight management


100% 100% NO deductible 100%, after deductible


Routine Radiology $15 copayment (JHS facility),

$20 Copayment (non-JHS

JeffPLUS facility)

$50 Copayment then



MRI/MRA/CAT/PET $15 copayment (JHS facility),

$50 Copayment (non-JHS

JeffPLUS facility)

$75 Copayment then




Laboratory 100% $20 Copayment per

occurrence, NO deductible


maternity – First OB Visit $15 Copayment $20 Copayment, NO deductible 60% after deductible

Contraceptives 100% 100%, NO deductible 60%, after deductible

Infertility Diagnosis and treatment

$20,000 per lifetime1

100% after applicable

copayment

80% after deductible and

applicable copayment


Inpatient Hospital services**

Facility 100% (JHS facility), $350

Copayment per admission3

(non-JHS JeffPLUS facility)

$700 Copayment per admission3

then 80% after deductible

60% after deductible2

Physician/Surgeon 100% 80% after deductible 60% after deductible

emergency Care $150 Copayment

(Copayment waived if admitted)

$150 Copayment,

NO deductible (Copayment

waived if admitted)

$150 Copayment,

NO deductible (Copayment

waived if admitted)

urgent Care Center $70 Copayment, NO deductible $70 Copayment, NO deductible 60% after deductible

retail Clinic Not Available $40 Copayment 60% after deductible

Benefits outside usa Coverage in full for emergencies, applicable copay applies.

Access to BlueCard Worldwide program.

outpatient surgery – Voluntary sterilization procedures included; Reversal of sterilization procedures excluded

Facility 100% (JHS facility), $100

Copayment per occurrence


$300 Copayment per

occurrence then 80% after

deductible


Physician/Surgeon 100% 80% after deductible 60% after deductible

11

BenefIts In-netWorK

Jeffplus netWorK

personal CHoICe netWorK out-of-netWorK *

ambulance

Emergency 100% 100%, NO deductible 100% NO deductible

Non-Emergency 100% 80% after deductible 60% after deductible

therapy services

Physical, Speech and Occupational 60

visits per calendar year1

$30 Copayment $40 Copayment, NO deductible 60% after deductible

Cardiac Rehabilitation 36 visits

per calendar year1


Pulmonary Rehabilitation 12 visits

per calendar year1


Hearing exam 100% 100%, NO deductible 60% after deductible

Hearing aid reimbursement

2 hearing aids every 36 months1

25% 25% after deductible 25% after deductible

Cranial prosthesis

only covered for members receiving cancer

treatment, one per year1


restorative services, including

Chiropractic Care


Not Available $40 Copayment, NO deductible 60% after deductible

Chemo / radiation / Dialysis 100% 80%, after deductible 60% after deductible

skilled nursing facility


100% (JHS facility), $350



$700 Copayment3 then



Home Health Care



Hospice 100% (JHS facility), $350






mental Health Care/serious mental Illness Care

Outpatient Services $25 Copayment $40 Copayment, NO deductible 60% after deductible

Inpatient Facility Services 100% (JHS facility), $350






substance abuse treatment

Outpatient/Partial Services $25 Copayment $40 Copayment, NO deductible 60% after deductible

Inpatient Rehabilitation 100% (JHS facility), $350






Detoxification 100% (JHS facility), $350






Durable medical equipment Not Available 80% NO deductible 60% after deductible

outpatient Diabetic education 100% 100% NO deductible Not Covered

Diabetic equipment and supplies 100% 100% NO deductible 60% after deductible

* Non–Preferred Providers may bill you the differences between the Plan allowance, which is the amount paid by Independence Blue Cross (IBC), and the actual charge of the provider. This amount may be significant. Claims for Non-Preferred Professional Providers (physicians) are based on the lesser of the Medicare Professional Allowable Payment or the actual charge of the provider. For covered services that are not recognized or reimbursed by Medicare, payment is based on the lesser of the Independence Blue Cross (IBC) applicable proprietary fee schedule or the actual charge of the provider. For covered services not recognized or reimbursed by Medicare or IBC’s fee schedule, payment is 50% of the actual charge of the provider. It is important to note that all percentages for out-of-network services are percentages of the Plan allowance, not the actual charge of the provider.

** NOTE: Your copay is waived if you are admitted to a “home” facility or if you are admitted through the emergency room at another JeffPLUS facility directly to that facility. For Non-JeffPLUS inpatient hospital admissions through the Emergency Room, the claim is to be processed as a JeffPLUS admission (deductible and coinsurance are waived), JeffPLUS PPO hospital admission copay applies.

*** In-network out-of-pocket maximum includes deductible, copays and coinsurance. Out-of-network out-of-pocket maximum includes deductible and coinsurance.

1 Combined all networks

2 Inpatient hospital day limit combined for all out-of-network inpatient medical, maternity, mental health, serious mental illness and substance abuse services

3 Inpatient Copayment waived if readmitted within 10 days of discharge

4 Combined JeffPLUS/Personal Choice Network

personal CHoICe ppo – 2015 plan summary, ContInueD

12

lIVeWell@Jeff

Jefferson’s Employee Wellness Program was established to enhance the quality of life of Jefferson employees by promoting healthy lifestyles and reducing the risk of illness by utilizing Jefferson’s wide range of educational and clinical resources. Jefferson has partnered with Redbrick to create a rewards program with an interactive online employee portal. Please visit www.jefferson.edu/livewell to learn how you can LiveWell@Jeff!

presCrIptIon DruG BenefIts

Prescription drug coverage is automatically included with each medical option. Optum Rx administers the prescription drug program under all medical options. Visit their website at: www.optumrx.com

The prescription drug program offers two ways to obtain your medications – at Jefferson Outpatient Pharmacies or at your local retail pharmacy.

Maintenance Drug Program

Medications that you take on a regular long-term basis (“maintenance medications”) are required to be filled at a Jefferson pharmacy after the first refill. You can receive up to a 90-day supply of medication for one maintenance copay.

Jefferson pharmacies will mail prescriptions upon request. You will be charged for shipping and handling.

Mandatory Generic Drugs

Whether you fill your prescriptions at a Jefferson or a retail pharmacy, you are required to purchase generic drugs when they are available. If you or your doctor choose a brand name drug when a generic is available, you will be required to pay the difference in cost between the generic and the brand, along with the applicable brand copay.

If you need to file an appeal to the Mandatory Generic program, you, or your covered dependent, must try a full prescription of the generic drug before requesting a brand name replacement. A Generic Exception Request form can be obtained from the Jefferson Apothecary.

Reduce your out-of-pocket expense when you use a Jefferson outpatient pharmacy.

Jefferson apothecary Jefferson pharmacy Jefferson pharmacy Walnut street 1st floor, Gibbon Building Lobby, 833 Chestnut Street 908 Walnut Street 111 S. 11th Street 215-955-4400 215-503-1135 215-955-8845 Hours: 8:30 a.m.–5:30 p.m. M–F Hours: 8:30 a.m.–5:30 p.m. M–F Hours: 7 a.m. – 6 p.m. M–F 9 a.m. – 1 p.m. Sat. 9 a.m. – 1 p.m. Sat. 9 a.m. – 4 p.m. Sat.

methodist Hospital apothecary 2301 S. Broad Street 215-952-9385 Hours: 8:30 a.m.–5 p.m. M–F non-maintenance medication maintenance medication (up to 30-day supply) (90-day supply)

Jefferson retail Jefferson

Generic* $10.00 copay $15.00 copay $30.00 copay

Brand Name (Formulary) $15.00 copay 20% with $30 minimum $40.00 copay and $50 maximum

Non-formulary $15.00 copay 40% with $50 minimum $40.00 copay and $100 maximum

Specialty $15.00 copay 40% with $50 minimum $40.00 copay and $100 maximum

*Generic drugs are mandatory when available. See page 12 for specifics.

save on prescriptions

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13

Mandatory In-house Drugs

Certain prescriptions must be filled at a Jefferson pharmacy. The mandatory in-house list includes drugs which are self-injected or require special handling, along with some that are more common.

Please note the following categories and examples:

• Proton Pump Inhibitors

• Smoking Cessation Prescriptions

• Arthritis and Dermatology (Enbrel, Humira, Kineret)

• Orally Administered Cancer Drugs (Gleevec, Lupron, Revlimid, Sprycel, Sutent, Tarceva, Temodar, Thalomid, Xeloda)

• Human Growth Hormones (Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Serostim, Tev-Tropin)

• Multiple Sclerosis Drugs (Avonex, Betaseron, Copaxone, Rebif)

• Hepatitis Treatments (Baraclude, Copegus, Hepsera, Pegasys, Peg-Intron, Rebetol)

• Other Genetically Engineered drugs, including, but not limited to:

- Transplant Medications (Myfortic, Neoral, Prograf, Rapamune)

- Pulmonary Hypertension (Adcirca, Flolan, Letairis, Revatio, Tyvaso, Ventavis)

If a prescription for a mandatory in-house drug is presented at a retail pharmacy, coverage will be denied. In such an instance, you should contact Optum Rx or a Jefferson pharmacy to clarify coverage and review the proper procedures for obtaining your prescription.

Prescription Management Programs

Introducing three presciption management programs to improve care and help manage costs.

• Quantity limit program sets limits based on the FDA approved indications, the manufaturer’s package labeling instructions and well-accepted or published clinical recommendations.

• step therapy program encourages you to try first-line medications that deliver similar value, safety and effectiveness, but cost less than others.

• prior authorization program requires authorization for some medications that are only approved or effective in treating specific illnesses, cost more or may be prescribed for conditions for which safety and effective ness have not been well-established.

Getting Prescriptions Filled While Away From Home

Optum Rx is affiliated with over 63,000 pharmacies nationwide. You should have no problem filling a prescription at a participating pharmacy anywhere in the U.S. Simply present your I.D. card. Optum Rx participating pharmacies are online via computer with Optum Rx and will submit your claim electronically at the time the prescription is filled. You pay only your applicable copayment.

If you do not use a participating pharmacy, you must pay the full cost of the prescription, usually at the full retail cost – you will not benefit from the “plan discount.” You must complete and send a claim form to Optum Rx no later than 365 business days from the date the prescription was dispensed. You will then be reimbursed only for the amount which Optum Rx would have covered.

Charges Not Covered

Some prescription drugs and supplies are not covered under this plan. the plan does not cover:

• Allergy serum (covered under the medical plan if administered in your physician’s office);

• Dietary aids, cosmetics or other health and beauty aids;

• Over-the-counter drugs;

• Non-legend vitamins;

• Medical appliances, such as back braces, bandages, cervical collars;

• Ostomy products (covered under the medical plan);

• Charges for the administration of any drug.

Out-of-Pocket Maximum

The out-of-pocket maximum is $2,500 per person or $5,000 per family. Once you reach the out-of-pocket limit, all covered prescriptions will be paid by Jefferson at 100%.

Effective January 1, 2015, there is no longer a dollar limit on fertility drugs.

14

Dental InsuranCe

Dental care is an important part of the overall health care package. The benefits program offers you the choice between two dental plan options – Delta Dental of Pennsylvania and Aetna Dental Maintenance Organization® (DMO®) . Alternatively, you may choose no coverage. These plans cover a full range of preventive, diagnostic, basic, major and orthodontic services.

Your dental election is separate from your medical plan election. If you enroll, you may choose a coverage level which is different from your medical coverage level; however, covered family members must be enrolled in the same plan.

Here’s a brief summary of your dental plan choices.

Delta Dental of Pennsylvania

• Delta Dental offers the freedom to go to any dentist when you need dental care;

• Many services are covered at 100%; some other covered services are paid at 80% or 50%;

• You receive the greatest benefits when you receive care from a participating dentist; participating Delta Dental dentists charge you a discounted amount for services — so you generally pay less than you would when using non-Delta Dental dentists. You may obtain a list of participating providers on Delta Dental’s website, www.deltadentalins.com, or by calling 1-800-932-0783;

• By utilizing the PPO Network of Providers, you and each covered family member can receive up to $2,000 in benefits each year. The annual benefit maximum for Premier Network Providers or Non-participating providers is $1,700.

your Dental options at a Glance

plan feature Delta Dental ppo aetna Dmo6

annual Deductible $50 per person None $150 per family

annual maximum $2,000 PPO Unlimited $1,700 Premier Plan (Non-participating)

preventive and Diagnostic Care 100% (no deductible) 100% Oral exams (2x each year) Cleaning (2x each year)1 Fluoride treatments up to age 18 (once a year)2 Sealants for children up to age 14 Space maintainers 50% space maintainers Full-mouth x-rays (once every 3 years) Bitewing x-rays (2x each year)

Basic and restorative services 80% after deductible 100% X-rays and lab tests needed to diagnose a dental problem or 50% anesthesia check the progress of treatment (Delta is 100% for X-rays) Extraction Fillings Emergency treatment for pain Gum disease treatment (periodontia) Root canal (endodontia)7 Oral surgery Anesthesia3

major services 50% after deductible 50% Full or partial dentures or fixed bridgework (limits apply) Repairing existing crowns, inlays, bridgework or dentures Inlays and onlays4 Crowns and gold fillings (limits apply)4 Rebasing or relining dentures or adding teeth to fixed bridgework or partial dentures (limits apply) Implants (Delta Only)

Orthodontia5 50% after separate $50 deductible 50%* ($2,000 lifetime maximum) (of pre-negotiated fee)

* Employee pays 50% of the orthodontist’s normal orthodontic fee. Orthodontist agrees to accept the DMO payment as full payment for the remainder of the fee. This may be less than the remaining 50%.

1Cleanings are limited to twice a year.; 2Delta Dental will cover fluoride treatments twice a year to age 19; 3General anesthesia is covered at 50% when used in conjunction with covered oral surgical procedures; 4Inlays, onlays and crowns are covered when basic restorative care is not adequate; 5Orthodontia care is provided for you, your spouse and your eligible dependents; 6Aetna DMO will pay up to the percentage (listed) of a predetermined amount for certain dental services and treatments. For more information, contact your primary care dentist. 7Aetna DMO coverage for molars is 50%.

.

15

• Orthodontia is covered up to a separate lifetime maximum of $2,000 per person after a separate $50 deductible;

• You (or your dentist) must submit a claim form when you use a non-participating dentist.

• You can download Delta’s free smartphone app from the App Store or Google Play to search for dental providers, view an online ID card, or check benefits and claims.

Aetna Dental Maintenance Organization (DMO)

• The Dental Maintenance Organization (DMO) provides benefits through a participating network of dental professionals, similar to an HMO medical plan. You may obtain a list of participating providers on Aetna’s website, www.aetna.com, or by calling 1-800-THEDMO1;

• You must choose a personal dentist for you and each family member when you enroll. You may select a different dentist for each family member;

• Your personal dentist must provide dental care services, or a written referral for care by a DMO specialist, as appropriate. Otherwise, the plan will not pay benefits, except in an emergency;

• Many services are covered at 100%; some other covered services are paid at 50%, based on discounted, negotiated fees;

• Annual benefits are unlimited;

• There are no claim forms to complete when you use an Aetna DMO provider.

VIsIon InsuranCe

Jefferson includes vision coverage under all of our medical options. The chart below is for your use in reviewing which medical plan best meets your vision needs. Please review and if you have any further questions, please call the Human Resources Service Center at 215-503-HrsC (4772).

surVIVor BenefIts

Adequate survivor benefit protection is one way to ensure your family’s financial security in the event of your death. The Benefit Program’s Basic Benefits Plan automatically provides full-time employees with a primary level of protection. If you need more coverage, the Optional Benefits part of the program makes a wide range of additional protection available to you.

Your Basic Survivor Benefits

The Basic Benefits Plan provides every eligible full-time employee with Life and Accidental Death and Dismemberment (AD&D) Insurance. The amount of your coverage depends on your base annual salary and your employee classification, as shown in the chart below. Life insurance benefits are paid to your beneficiary if you die while you are covered under the Benefit Program. Accidental Death and Dismemberment (AD&D) coverage provide benefits in addition to your Life Insurance benefits if your death is the result of an accident. It also pays benefits to you for severe accidental injury.

ppo/CDHp – DaVIs netWorK

ppo/CDHp - out of netWorK

aCo plus poInt of serVICe - DaVIs or Keystone netWorK

eye examination Covered in full every 12 months $30.00 reimbursement every 12 months

Covered after $20 copay with ACO Plus or $40 copay with Keystone every 24 months

frames Choose from Davis Collection and member pays: • Fashion - $0 • Designer - $16 • Premier - $35 OR $30 allowance towards participating provider’s own collection every 24 months

Member receives allowance up to $30 every 24 months

Choose from Davis Collection and member pays: • Fashion - $0 • Designer - $16 • Premier - $35 OR $10 allowance towards participating provider’s own collection every 24 months

spectacle lenses - standard single vision, lined bifocal or trifocal lenses

Covered in full every 12 months Member receives allowance varying from $22 - $50 depending on lens type

Covered in full every 24 months at participating providers

Contact lenses (in lieu of eyeglasses)

Allowance up to $52 for contact lenses, evaluation and fitting every 12 months



16

Traveling on Jefferson Business

The Basic Benefits Plan also includes Business Travel Accident Insurance that provides additional coverage when you travel off Jefferson premises on Jefferson business. Coverage starts when you leave your home or office and ends when you return. Regular commuting is not covered. For more information, contact the Human Resources Service Center at 215-503-HrsC.

Optional Survivor Benefits

The need for survivor benefits can vary widely, so the Benefits Program allows you to select the level of protection best suited to your needs. Keep in mind that these life insurance benefits are in addition to your Basic Benefits plan protection. Also, you have the option of selecting any of the supplemental life insurance options and supplemental AD&D coverage.

You may choose any of the following optional benefits:

• Life Insurance

• Supplemental AD&D Insurance

• Dependent Life Insurance

Life Insurance

If you want to add to your Basic Benefits Life Insurance protection, you may buy additional coverage up to 4x base pay (including Basic Life) or $1,000,000 maximum. Your biweekly cost for life insurance will be shown on your enrollment website. The cost is based on your age and the amount of coverage you select. Please note: when you enter a new age bracket, the cost of your optional life insurance will change to reflect your new age in the pay period containing your birthday. If your salary increases, or decreases, the cost of your optional life insurance will change to reflect your new rate in the pay period containing the change. Basic and optional coverage reduce by one-half on your 70th birthday. The cost of your optional life insurance will change to reflect the reduced age 70 rate and coverage level in the pay period containing your birthday. The rates for optional life insurance are listed below.

The IRS requires employers who provide more than $50,000 of life insurance coverage to calculate the value of the coverage over $50,000 and report it as taxable income. This is called imputed income.

In the event of long term disability, Jefferson will continue the life insurance selected on the most recent election while disability income is being received for up to one year from date of illness or injury, provided employee pays active employee premium rate (If employee payment is not remitted, coverage will be at Basic Amount.)

Request for conversion of Life Insurance should be made within 30 days of termination of coverage/employment. Insurance company must receive completed application within 60 days of termination of coverage/employment. Contact the Human Resources Service Center for a conversion application.

Employee Basic Life Basic AD&D Classification Coverage Coverage

Faculty and Senior Two times base annual salary One and one-half base annual Administrators salary to a maximum of $50,000

House Staff, Postdoctoral Fellows One and one-half times base annual salary One times base annual salary to maximum of $50,000

All Other Employees One times base annual salary One-half base annual salary Including Part-time to a maximum of $50,000

• Life Insurance coverage reduces by one-half for employees age 70 and over. Life Insurance coverage is rounded to the next $500 increment.

• Evidence of Insurability for anyone of basic or optional life benefit combined that exceeds $500,000.

• Maximum Life Benefit $1,000,000.

Basic survivor Benefits

life Insurance optional Coverage - 2015 rates

Per $1,000 Employee’s Age Unit of Coverage under 30 $ .019

30 to 34 .032

35 to 39 .032

40 to 44 .045

45 to 49 .057

50 to 54 .109

55 to 59 .191

60 to 64 .293

65 to 69 .471

70+ .503

17

Spousal and Dependent Life Insurance

The Spousal and Dependent Life Insurance Options give you an opportunity to insure the lives of your spouse, registered domestic partner and your children. Your biweekly cost for this coverage will be indicated on your enrollment website. You can choose one of the following options:

Medical Evidence of Insurability (MEOI)

You will have to complete a MEOI questionnaire and submit it directly to our life insurance carrier for review and approval before your coverage becomes effective if:

• Your Basic life insurance exceeds $500,000.

• You did not elect any additional level of employee life insurance during any previous election in which you were eligible and are now making your first election.

• You were previously declined for additional coverage or withdrew an application for additional coverage.

• You wish to increase your current level of additional employee life insurance by more than one level.

• You wish to increase your current level of additional employee life insurance to a level that is equal or greater to four times your salary or in excess of $500,000.

• You are a newly eligible employee making your first election and are choosing coverage equal or greater to four times your salary or coverage in excess of $500,000.

• You did not elect Spousal Life Insurance during your initial period of eligibility and are now making your first election or increasing by more than one level.

Note: Additional coverage include Basic Life amounts over $500,000 will not be effective until MEOI is approved.

Supplemental AD&D Insurance

If you want to add to your basic AD&D Insurance, you may buy supplemental AD&D protection by selecting one of (up to) six options. The minimum is $50,000. amounts above $300,000 may not exceed lesser of ten times annual salary or $500,000. If you wish, you may also buy this type of coverage for your dependents. Dependent coverage provides a spouse’s benefit equal to 60% of yours; each dependent child’s benefit equals 30% of yours. Your eligible dependent children are covered until age 26. Domestic partners are eligible for AD&D coverage.

Your cost for additional AD&D Insurance depends on the amount of coverage you elect and whether you include your dependents.

your DIsaBIlIty BenefIts

The Benefits Program offers you protection from income loss while you are out of work for a non-work related illness or injury. You are considered to be disabled when a treating health professional certifies that your illness, injury or medical condition keeps you from working. Disability benefits at Jefferson are made up of different programs, depending upon your position, including:

• Earned Time Off (ETO), Sick Pay or Salary Continuation

• Short Term Disability

• Long Term Disability

Short Term Disability

Fortunately most disabilities are not long lasting and people recover and return to work after a few weeks or months of absence. The Jefferson Short Term Disability programs are designed to provide income protection for up to 26 weeks for a non-work related illness or injury approved by our third party administrator. The STD program is made up of different benefits depending upon your position as described on the table on page 18. Jefferson pays the cost of all of the programs, except the Optional STD Plan, where employees pay the cost of the additional 16 ²/₃% of coverage.

Coverage for Your Spouse* Coverage for Each Child**

$ 2,000 $1,000

$ 5,000 $2,000

$10,000 $3,000

$15,000 $4,000

$20,000 $5,000

Dependent life options

* Spousal eligibility terminates at spouse’s 70th birthday.

** Your eligible dependent children are covered from the 14th day after birth to age 26.

supplemental aD&D Insurance

Loss AD&D Benefit

Life Full amount of your coverage

paid to your beneficiary

Both hands, feet, The full amount of your

sight of both eyes or coverage paid to you

any combination of

these losses

One hand, foot or One-half the amount of your

sight of one eye coverage paid to you

18

To qualify for short or long term disability you must be actively at work prior to your date of disability. Matrix Absence Management must approve your disability for benefits to be paid under any of the programs beyond the first seven consecutive calendar days. You may be paid up to 26 weeks (6 months) under any of the programs as long as you remain disabled. To be paid ETO or EIB time, you must have an unused balance of time in either bank.

Optional Short Term Disability

All eligible employees are covered by the STD program but there are circumstances where you may want to add to your protection under the Basic Plan. You can increase your benefit from 50% of base salary to 66 ²/₃% of base salary by selecting the Optional STD Plan.

You may wish to elect the Optional STD benefit if:

• The 50% Basic STD benefit will not meet your income needs while disabled or

• You do not have enough EIB time to carry you in the event of a disability that lasts up to 26 weeks (6 months)

The price you pay for the Optional STD Plan is based upon your base salary. The cost per pay will be reflected on the enrollment website.

pre-existing Conditions Pre-existing condition limits apply to the Optional STD Plan. A pre-existing condition exists if you have received medical treatment, consultations, diagnostic services or have taken prescription drugs for a condition in the three month period before your effective date of coverage. The pre-existing condition limitation applies for the next 12 months, unless you go without treatment or medication for any three month period within the same 12 month period. If you have a pre-existing condition, Optional STD benefits (66 ²/₃%) will be paid for the first four weeks of disability; then Basic STD benefits (50%) will be paid.

Filing an STD claim

All employees covered by one of the STD plans; salary continuation, sick time or ETO must file an STD claim with Matrix Absence Management, our Third Party Administrator. Matrix determines if the disability qualifies and initiates STD payments for employees covered by that plan. There are three ways to file a claim with Matrix:

1. Call 1-888-477-5110 2. File on-line at www.matrixeservices.com. 3. Use a smartphone application

It is recommended you file a claim as soon as you are aware that you will be out of work for an extended period of time, preferably within the first 30 days, but

no later than 12 months after the date of disability. You may file an STD claim with Matrix at the same time you apply for FMLA or another leave. STD benefits may apply independent of the type of leave you qualify for. In all instances Matrix will review your application for STD and notify you whether your disability is approved or denied.

Attention employees working in New Jersey:

If you work in New Jersey, both you and Jefferson pay a tax to fund the New Jersey short-term disability plan. The New Jersey State Disability Plan is mandatory and covers approximately 66 ²/₃% of your salary up to a maximum of $595.00 per week. If you work in New Jersey, you may elect to waive the Jefferson optional short-term disability option on your online election due to coverage from the New Jersey State Plan, or you may choose to make a selection if you desire coverage over and above the New Jersey Plan limits. The benefit you receive from Jefferson will be offset automatically by your New Jersey State benefit. For example, if you choose option B, which is 66 ²/₃% of your weekly salary, and your present weekly salary is $1,000.00 you would be entitled to a benefit of $667.00 per week. You would receive the maximum benefit from the State of New Jersey which is presently $595.00 per week. The additional $72.00 per week would be paid to you from Jefferson’s Disability Plan.

STD Program Based upon Position Your STD Benefits

Full-time, regular employees

scheduled to work 35 hours

or more per week, including

Bargaining Unit employees who

participate in the Jefferson

Benefits program

Earned Time Off (ETO) pays

100% of your base salary for the

first seven consecutive calendar

days. The Extended Illness Bank

(EIB) pays 100% of base salary

beginning on calendar day 8,

until EIB is exhausted.* Then, the

Basic STD Plan pays 50% of your

base salary or The Optional Plan

pays 66 2/3% of your base salary

(depending upon the plan you

select). ETO hours will be used

to supplement STD until ETO is

exhausted.

Faculty, Senior Administrators and

House Staff

Salary Continuation pays 100% of

your base salary

Post Doctoral Fellows Earn 5 sick days a year which pay

100% of your base salary for the

first seven consecutive calendar

days. STD insurance then pays

50% or 66 ²/₃% of your base salary

(depending upon the plan you

select)

* ETO is the Jefferson time off program effective April 21, 2012. EIB is a grandfathered benefit available to employees who satisfied their probationary period before April 21, 2012.

19

Long Term Disability

To qualify for long term disability, you must be actively at work prior to your date of disability. All benefits eligible employees listed on the STD table (page 18) qualify for Long Term Disability coverage equal to 50% of their monthly base salary to maximum of $12,500 for most employees. If you want to increase your coverage you may purchase an optional amount described below.

Pre-existing condition limits apply to the LTD Options. If you increase your coverage level and you have a pre-existing condition, the benefits will be paid for four weeks, at the higher Optional level, and drop to your original coverage level for the remainder of your disability. LTD benefits are reduced by income from other sources of disability income such as Social Security, other government programs and Workers Compensation so that no more than 100% of the benefit due under the plan is paid when considering other payments.

All LTD benefits, except those for House Staff have a 24 month own occupation and mental illness limit. Maximum benefit periods are listed in the table on this page.

Full-time JUP Clinicians have Employer and Employee paid Long Term Disability options. The benefit coverage is for total disability following initial 180 days of disability. Pre-existing conditions may apply. JUP provides a base benefit of 50% of pay up to a $15,000 monthly benefit. You can also elect an individual policy for 60% of pay up to a monthly benefit of $2,500. JUP pays for this individual policy. Additional employee paid individual coverage up to $7,500 per month may be available based upon your income. The maximum benefit period is age 65. For disabilities occurring between ages 65 and 75, the maximum benefit period is 24 months. For disabilities occurring after age 75, the maximum benefit period is 12 months.

A representative from Aon Hewitt, our broker for the individual plans, will be in touch with newly eligible JUP Clinicians to offer more information and help with enrollment.

For more information on disability benefits consult the disability insurance section under “Benefits” on the HR website: www.JeffersonHr.org.

Your Benefit Duration

60% of your base monthly salary. The maximum is $12,500 for most employees; the maximum is $15,000 for house staff.

Benefits start after 180 days of total disability. LTD benefits may continue for as long as you remain totally disabled, up to age 65 or older. (See table above which outlines maximum benefit periods.)

66 ²/₃% of your base salary. The maximum is $12,500 for most employees; the maximum is $15,000 for house staff. (This option for house staff is 70% of base salary.)

Benefits start after 180 days of total disability. LTD benefits may continue for as long as you remain totally disabled, up to age 65 or older. (See table above which outlines maximum benefit periods.)

long-term Disability (ltD) plan options

ltD maximum Benefit period**

Based on your age at disability OR your year of birth, the maximum benefit period will be the longer of: Duration stated in Chart A or Normal Retirement Age stated in Chart B

Chart a – age at DisabilityAge at Disability Maximum Benefit Period

Prior to age 62 To age 65 62 42 Months 63 36 Months 64 30 Months 65 24 Months 66 20 Months 67 18 Months 68 15 Months 69 and over 12 Months

Chart B – normal retirement age*Year of Birth Normal Retirement Age

1937 or before 65 years 1938 65 years and 2 months 1939 65 years and 4 months 1940 65 years and 6 months 1941 65 years and 8 months 1942 65 years and 10 months 1943 - 1954 66 years 1955 66 years and 2 months 1956 66 years and 4 months 1957 66 years and 6 months 1958 66 years and 8 months 1959 66 years and 10 months 1960 and after 67 years

* as defined by the 1983 amendments to the United States

Social Security Act and determined by your year of birth

**This chart doesn not apply to JUP clinicians

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usInG your flexIBle spenDInG aCCounts: an oVerVIeW

You may use your Flexible Spending Accounts (FSA) to pay eligible medical and dependent care expenses. Salary that you direct to your Flexible Spending Accounts will then be used to reimburse you for your qualified expenses incurred during the course of the Plan Year. expenses are considered incurred on the date the services are provided, not when paid. Reimbursement works differently for the medical and dependent care FSAs.

• For the Healthcare FSA you may use your debit card (explained later in this section) which may require proof of the services you receive

• If you pay for out of pocket medical expenses you may have to submit a claim and proof of your payment, as well as an Explanation of Benefits from your medical or dental insurance company

• For dependent care expenses you must submit a claim with a copy of the receipt (showing the Social Security number or tax ID number of the provider)

You can submit claims to ADP, our FSA administrator by:

• Mailing or faxing a paper claim form. The claim forms are available on-line at myspendingaccount.adp.com or www.JeffersonHr.org, in the Human Resource Service Center on the Center City Campus or at the Human Resources office at the Methodist campus

• Setting up a personal account with ADP at myspendingaccount.adp.com where you can file claims on-line

You may have payment for claims sent to your home or direct deposited.

Additional information on Flexible Spending Accounts is available on-line at spendingaccounts.info or at www.JeffersonHr.org. You may also call the FSA Hotline at 1-800-228-5762.

Important Guidelines

The Internal Revenue Service imposes certain regulations on the use of your Flexible Spending Account. For example, IRS regulations define what types of expenses qualify for tax-free reimbursement. The amount you may direct to your Flexible Spending Accounts and your total reimbursements for each type of qualified expense are also limited.

IRS regulations currently require that all salary directed to your Flexible Spending Accounts in any one year must be used to reimburse you for qualified expenses incurred during that plan year.

This means you will forfeit any unused balance remaining in your flexible spending accounts at the end of the plan year. You will have until June 30, 2016 to submit expenses incurred between January 1, 2015 and march 15, 2016.

In addition, the IRS requires that once you specify any amount of salary for reimbursement of a particular type of qualified expense, you cannot use them for reimbursement of any other type of expense. For example, you cannot be reimbursed for dependent care expenses (i.e., day care) for your Healthcare FSA nor can you be reimbursed for medical expenses from your Dependent Care Account. You will forfeit any unused balance that was assigned to a particular type of qualified expense.

Tax Advantages

The Flexible Spending Account lets you pay qualified health care and dependent care expenses on a pre-tax basis, instead of paying for these expenses from your take-home pay after federal income and FICA taxes have been deducted. This is done by directing a portion of your salary to your Flexible Spending Accounts before federal income, FICA taxes and Delaware income tax are deducted from your pay. This lowers your taxable income. Since lower taxable income translates into savings on your federal income and FICA taxes, you’ll actually spend less money to pay for the same qualified expenses.

Since there is an element of risk, it is very important to plan ahead before you elect to redirect salary to your Flexible Spending Accounts. Use the Flexible Spending Accounts only if you can anticipate your qualified expenses for the coming Plan Year. For example, if you are certain that you will have qualified expenses during the Plan Year, but are unsure of the amount, be conservative in the amount of salary you direct to your Flexible Spending Accounts.

The worksheet on page 22 is provided to help you estimate the amount of salary to direct to your Flexible Spending Accounts. You can view a list of eligible expenses at spendingaccounts.info.

Maximum Reimbursements

The maximum amount of salary that you may direct to your Healthcare Flexible Spending Accounts is $2,500. The maximum Dependent Care Account limit for the plan year is $5,000 per household. If married and filing separate income tax returns, the maximum amount is $2,500.

Discrimination

IRS regulations require us to perform annual nondiscrimi-nation testing on Dependent care FSA’s. It ensures highly compensated employees who participate in the plan are not receiving more than the legally allowed portion of this qualified benefit. We may be required to reduce the contributions for all highly compensated employees. Impacted employees will be notified.

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To receive your medical or dependent care reimbursements via direct deposit, visit myspend-ingaccount.adp.com and click “Direct Deposit.” The minimum amount that will be processed for reimbursement, via direct deposit or check, is $50. You may submit claims for less than this amount, but payment will not be issued until your pending claims balance reaches the minimum amount.

If you enroll in a Healthcare FSA, you will receive a debit card which you can use for copays, other out of pocket expenses or qualified medical services not covered by our medical and dental plans. Please find examples of qualified expenses to the right. The card will be accepted by any provider who accepts VISA. When you swipe your debit card the amount of your cost for services will be deducted from the balance of your Healthcare FSA and you do not have to submit a claim form. In most cases you will not have to provide evidence of your purchase of medical care but should ADP, our FSA administrator, request proof of purchase you must respond to their request in order for your purchase to be approved. We recommend that you save receipts and Explanation of Benefit forms sent by your medical or dental insurance companies so that you can establish proof of your purchase if it is required.

Please note: Over-the-counter (OTC) medications (except insulin) are not eligible for reimbursement unless the medication is prescribed.

Your debit card cannot be used for daycare expenses. You must submit a claim form for reimbursement.

Setting Up A Flexible Spending Account

Flexible Spending Account elections can be made on the Benefit enrollment website.

No more than $2,500 of salary can be directed to your Healthcare Flexible Spending Accounts. Dependent care maximum contribution is $5,000 per household. If you are married and filing separate income tax returns, the maximum amount is $2,500.

The minimum bi-weekly amount you may contribute to each account is $5.00 per pay period.

Note: To convert an annual amount to a biweekly figure, divide the annual amount by the remaining pay periods in the calendar year. (There are 26 pay periods in a full Benefits calendar year.)

Healthcare Flexible Spending Account Eligible Expenses

Health Expenses which qualify as a medical deduction under IRS rules are eligible for reimbursement from your Healthcare Flexible Spending Account. The IRS has historically considered these expenses deductible for

income tax purposes; however, because tax rules are constantly changing, we recommend that you check with your attorney or tax advisor if you are uncertain as to the eligibility of a specific expense.

Current FSA participants can view an Eligible Expense Guide in the e-learning center at myspendingaccount.adp.com. The pre-enrollment website to learn about eligible expenses is spendingaccounts.info; click on “Eligible Expense Guide.”

FSA Store

ADP has a relationship with fsastore.com. If you shop at the FSA Store you will have access to thousands of FSA-eligible products. You can pay for your purchases with your FSA debit card, or other major credit card. The FSA Store clearly designates which over-the-counter items for sale are available for purchase with and without a doctor’s prescription. Visit fsastore.com for more information.

QualIfIeD expenses – a feW examples

The following are considered qualified expenses eligible for reimbursement through the Flexible Spending Accounts:

Healthcare Spending Account

Any medical expense that has not been paid by the Benefits Program’s Medical and Dental Plans, or by any other health coverage may be eligible for reimbursement through your Healthcare Care Flexible Spending Account. Please note that when you file your federal income tax return, you may not claim a tax deduction for any healthcare expense, including vision care, that is reimbursed through your Healthcare Flexible Spending Account. Expenses deemed cosmetic in nature by the IRS are not eligible for reimbursement. Please see above for listing of eligible expenses.

Dependent Care Account

Qualified dependent care expenses include the cost of day care, before/after-school care, summer day camp services during a Plan Year rendered by any person (other than a dependent under age 19 or any person you claim as a dependent for tax purposes) or licensed institution. The cost of household services is also considered a qualified expense; if it is at least partly for the care of a qualifying individual.

Qualified individuals include your children under age 13 who are claimed by you as dependents for tax purposes or any dependent (including your spouse) who is physically or mentally incapable of caring for him or herself.

The maximum limit for the plan year is $5,000 per household. If married filing separately, the maximum amount is $2,500.

Your contribution cannot exceed your earned income or your spouse’s earned income, whichever is less.

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flexible spending account Worksheet

Child or Dependent Care

If your child attends a day care center, what are your annual fees? $ $ $

How much do you spend in a year for babysitters during your working hours? $ $ $

Annual cost for a nurse to care for a disabled dependent? $ $ $

total Dependent Care expenses $ $ $

An online FSA worksheet is available at spendingaccounts.info; click on “Contribution Calculator.” This calculator will help you estimate your FSA contribution and potential annual tax savings.

2013 2014 2015 Type of Expense Actual Actual Estimated

HealthMedical, Dental, and Vision Care Plans

Out-of-pocket expenses to meet the deductible required under the Medical Option you select? $ $ $

Your portion of the co-insurance through your medical insurance plan? $ $ $

Dental Plan out-of-pocket expenses to meet the deductible? $ $ $

Expenses reimbursed under medical, dental and vision that exceed the usual, customary and reasonable (UCR) customary amounts or annual maximums? $ $ $

Medical services not covered by the plan? $ $ $

Dental services not covered by the plan? $ $ $

Over-the-counter expenses? $ $ $

Vision expenses which exceed health plan maximum? $ $ $

total medical expenses $ $ $

How much should you put in your Healthcare and Dependent Care Flexible Spending Account? The answer to that question depends on your answers to several other questions. This worksheet asks some questions you should consider before you decide how much of your salary to direct to the Flexible Spending Account. It provides space to record your expenses for the past two years and your estimates of the expenses you may have in 2015. See a list of eligible expenses at spendingaccounts.info.

Total your estimated expenses for 2015. The total is the maximum salary you should consider directing to your Flexible Spending Accounts. The most you can direct to your Healthcare Account is $2,500 per year. However, for dependent care, the maximum limit for the plan year is $5,000 per household. If married filing separately, the annual maximum is $2,500. Part-time employees’ contributions cannot exceed your earned income or your spouse’s earned income, whichever is less. You’ll be able to pay those expenses with before-tax dollars – dollars that are not subject to federal income or Social Security taxes. Remember, you should be certain of the amount you direct to the Accounts, because you will lose any unspent balance at the end of the plan year.

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aDDInG It upIf you are setting up an Flexible Spending Account for 2015, making coverage changes, or are a new employee, be sure to make your elections online during open enrollment or as a new hire or newly benefit eligible. FSA elections do not roll over from year to year. You must reelect FSA benefits each year at open enrollment.

Voluntary BenefIts

Benefits Plus

Benefits Plus is Jefferson’s Voluntary benefit program that includes Critical Illness and Accident Insurance, Vision, pre-paid Legal Benefits, Auto and Home Owners insurance, Pet Insurance, Purchasing Power for big-ticket items and shopping Discounts. Visit the Benefits Plus section of the Human Resources website, www.JeffersonHr.org for more information.

your otHer BenefIts

We have reviewed all of the Benefits available to you, as well as the Basic Benefits (if any) related to those options. In addition to these benefits, your other benefits may include the following, depending on your employment status:

• Retirement Plan

• Dependent Scholarship for Faculty and Senior Administrators

• Tuition Assistance Program

• Vacation or Earned Time Off

Here’s a brief look at each of these benefits. Additional information on each of the benefit programs is available at www.JeffersonHR.org. If you have questions about any of these benefits, contact the Human resources service Center at 215-503-HrsC.

Retirement Plans

Jefferson provides Retirement Plans for eligible employees.

The Retirement Plans for TJU Faculty, TJU/TJUH Senior Administrators, and Employees and Clinicians of Jefferson University Physicians provide contributions toward retirement income.

The TJUH, Inc. and TJU Defined Contribution Retirement Plans provide fixed contributions and partial matching of employees’ contributions toward retirement income.

The TJU Employees’ Pension Plan and TJUH Employees’ Pension Plan for other non-bargaining employees provide monthly benefits when an eligible participant reaches retirement age. Benefits are determined by the Plan’s formula, which takes into account your earnings and length of service with Jefferson.

Tax Deferred Annuity Programs

All employees are eligible to participate in Jefferson’s Tax Deferred Annuity programs. Voluntary pre-tax contributions may be made to a 403(b) account to supplement your retirement income. For more information, please contact TIAA-CREF at 800-842-2888.

Dependent Scholarship Program

Full-time Faculty and Senior Administrators are eligible for Jefferson’s Dependent Scholarship Program, which provides eligible, unmarried dependent children up to age 30 with yearly assistance for educational expenses as undergraduate students at any CHEA accredited college, university or school of nursing. Dependent scholarship benefits are payable for up to four years of study towards an undergraduate degree.

Tuition Assistance Program

Regular full-time non-bargaining employees are eligible for the Tuition Assistance Program. You must be employed for 60 days before starting classes at Jefferson. You must be employed full-time for at least six months before starting classes in an approved course at an external institution. Approved courses include accredited college courses that are Jefferson-related and courses taken at the Associate, Bachelor or Graduate level. For additional information, contact the Human Resources Service Center at 215-503-HrsC (4772).

Earned Time Off (ETO)

All eligible non-bargaining emplyees receive ETO based upon their job title and length of service. Generally, ETO is allotted to the following schedules:

Service ETO up to 5 years 23 days up to 10 years 28 days 10 or more years 33 days

ETO does not apply to Full Time Faculty, Full Time Senior Administrators, Post Doctoral Fellows and House Staff.

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Vacations

Full Time Faculty, Senior Administrators, Post Doctoral Fellows and House Staff receive vacation time based upon their job title and length of service. Generally, vacation time is allotted according to the following schedules:

• Faculty and Senior Administrators: 20 days a year

• House staff G-1 level, 10 days per year. All others, 20 days per year

• Post Doctoral Fellows, 10 days per year

otHer Voluntary proGrams anD faCIlItIes offereD By Jefferson

• Adoption Assistance

• Blood Donor Programs

• Carebridge

• Commuter Services and Discounts

• Day Care Services & Discounts

• Direct Payroll Deposit

• Fast Pass (Atrium)

• First Call (EAP )

• Freedom Credit Union

• Jefferson–Independence Blue Cross Wellness Center

• Library Privileges

• University Health Services

please note: Specific eligibility requirements apply to the benefit plans identified in this booklet. Your entitlement to any of the benefits listed herein is expressly conditioned upon, and subject to, your meeting such eligibility requirements as provided in the plans. You may not rely upon this booklet as a determination as to your qualification or eligibility for such benefits. Detailed information is provided during the benefits orientation and enrollment session. If there is a difference between the statements in this booklet and in the contracts regarding the nature and extent of the benefits, the benefits will be determined in accordance with the language of the insurance contracts.

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notes:

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notes:

CS 14-2139

The 2015 Jefferson Benefits Guidebook · This Guidebook contains a summary of the benefits offered...

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Transcript of The 2015 Jefferson Benefits Guidebook · This Guidebook contains a summary of the benefits offered...