Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks...

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ALASKA CONFERENCE OF CATHOLIC BISHOPS 2019/2020 Health Insurance Open Enrollment Lay Employee Plans May 1, 2019 through May 31, 2019 (For Policies effective July 1, 2019 through June 30, 2020) (Medical, Dental, & Vision)

Transcript of Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks...

Page 1: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

ALASKA CONFERENCE OF CATHOLIC BISHOPS

2019/2020

Health Insurance

Open Enrollment Lay Employee Plans

May 1, 2019 through May 31, 2019

(For Policies effective July 1, 2019 through June 30, 2020)

(Medical, Dental, & Vision)

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Guide to your Health Care 

 

 

Special Announcement          ……………………….1 

Enrollment Letter (important information)    ……………………….2 

Health Insurance Coverages        ……………………….3 

      Medical Plan Overviews              3a 

  Dental Plan Overview                3b 

  Vision Plan Overview        3c 

  Prescription Drug Program      3d 

Other Health Resources           ………………………4 

Online Health Management      4a 

Doc Find (Medical)        4b 

Doc Find (Dental)          4c 

Vision Assistance Online       4d 

Teledoc            4e 

Health Savings Account explanation    4f 

Benefit Pricing $$$ Explanation      ………………………5 

Enrollment/Change form        ………………………6 

Continuation of Benefits‐rate acknowledgement ……………………….7 

Spouse Eligibility Affidavit        ………………………8 

 

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ALASKA CONFERENCE OF CATHOLIC BISHOPS

Special Announcement

This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will be no mid-year open enrollment. The next chance you will have to make changes to your insurance elections (other then a qualifying life event) will be July of 2020. Very little is changing to our plans from the previous year. The plan coverages remain the same, and all premiums remain the same with the exception of a slight change to dental coverage rates. **Remember - Christian Brothers Services once again declared a “Premium Holiday” for June 2019! This means that, if you were insured through our plan, you did not pay your employee contribution or your dependent premiums for that month! This was a substantial benefit to our employees. Monika Scott, CFO - Archdiocese of Anchorage Susan Clifton, CFO - Diocese of Fairbanks Mike Monagle, CFO - Diocese of Juneau

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ALASKA CONFERENCE OF CATHOLIC BISHOPS

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Dear Employee, Your Employer participates in a cooperative group called the Alaska Conference of Catholic Bishops (ACCB) in order to provide Quality Health Benefits to our employees and their families. Our Health plans are administrated by Christian Brothers Services, a Catholic Healthcare Trust. ACCB is providing this packet to help you make informative decisions regarding your personal healthcare, and options available for your dependents. Your Healthcare choices can only be adjusted during the “Open Enrollment” period unless there is a “qualified event” during the year.

If you are enrolling for the first time, or are currently enrolled and wish to make changes to your plan coverages, you must return your completed, signed ‘Enrollment Form’ at the back of this package.

If you are currently enrolled and are not making changes, please sign and return the ‘Rate Acknowledgement’ form at the back of this package.

Open Enrollment begins May 1, 2019 and ends May 31, 2019.

During the Open Enrollment period, you will have the opportunity to add, change, or drop your health plan for yourself or your dependents. This includes adding family members who are not currently enrolled in our group insurance program, as well as increasing coverage for those members already participating.

Changes made to your benefits during this Open Enrollment will be effective July 1, 2019. The Open Enrollment period will close May 31, 2019. No exceptions. If you have any questions, please contact the appropriate person in your parish, school or agency, or call Eric Gustafson at 907-297-7725.

Eligibility An employee must work 30 hours or more per week (on average over a 12 month period) in order to be

eligible for health insurance benefits. A benefit eligible person may not waive insurance in lieu of additional compensation in wages, nor

may an employer make such an offer. The option for a non-benefit eligible employee to purchase our insurance plan is not available. Employee benefits are effective the first day of the month following a 30 day waiting period from their date

of hire. (ie: if hire date= May 28 (+ 30 days)= June 28 then the insurance effective date is July 1) Spouse/Dependent coverage is available for purchase. Dependents qualify until the age of 26, married or

unmarried. If adding spouse or dependents, documentation must be provided. (Marriage Certificate (spouse), and/or Birth certificate(s) for dependent(s)). Spouses may not be added if they are offered coverage through their own employment.

Health Plan choices: Medical - “Default” Higher Deductible Health Plan ($2,700 deductible) 85% coverage in network Medical - “Buy-up” Lower Deductible Health Plan ($500 deductible) 75% coverage in network Dental PPO - $1,500 allowance /$50 deductible Vision-VSP Choice/$10/$25 copay

Life/Ltd (Long Term Disability) Insurance:

Life insurance coverage is $50,000 (decreased benefit amounts at age 65 & 70) Employee only plans – a “Benefit Eligible” employee cannot waive these insurances

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Health

Insurance

Plans

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Health Plans - Section 3
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Lay "Default" Plan "Buy‐up" Plan

(July 1, 2019‐ June 30, 2020) (July 1, 2019‐ June 30, 2020)

Higher Deductible ‐PPO Lower Deductible ‐ PPO

Medical In Network In Network

Coinsurance 85% 75%

Deductible 2,700 Ind / 5,400 Fam 500 Ind / 1000 Fam

Out of Pocket Cost 5,400 Ind / 10,800 Fam 5,000 Ind / 10,000 Fam

PCP/Specialist Copay No Copay $40

ER Copay No Copay $100

InPatient Hospital Copay No Copay No Copay

Out of Network Out of Network

Coinsurance 75% 75%

Deductible 5,400 Ind / 10,800 Fam 500 Ind / 1000 Fam

Out of Pocket Cost 10,800 Ind / 21,600 Fam 5,000 Ind / 10,000 Fam

PCP/Specialist Copay No Copay $40

ER Copay No Copay $100

IP Hospital Copay No Copay No Copay

RX Prescription plan

 RX Plan Deductible 2,700 Ind / 5,400 Fam None

Out of Pocket Cost 5,400 Ind / 10,800 Fam 1,850 Ind / 3,700 Fam

Generic $10 / $20

Preferred Brand $20 / $40

Non Preferred Brand $30 / $60 

Retail Refill Allowance No   No

~HSA Qualified ~

Higher Deductible ‐PPO Lower Deductible ‐ PPO

Payment Responsibility:

Employer Employer Contribution for Employee $893.99 monthly 893.99

Employee Employee Cost for Self only $10 monthly $158 monthly

Employee Cost for +Spouse $1,176.09 monthly $1264.53 monthly

Employee Cost for +Child(ren) $460.63 monthly $502.14 monthly

Employee Cost for +Spouse+Child(ren) $1,636.72 monthly $1,766.67 monthly

ACCB Lay Employee Medical Plans ‐ Beginning July 1, 2019 ‐ Oveview (Summary)

Paid at  coinsurance level after 

deductible is met

Pricing for Plans

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Christian Brothers Employee Benefit Trust: MP G508 - Rx 0932 Coverage for: Individual+Family | Plan

Type: PPO

For more information about limitations and exceptions, see the plan or policy document at myCBS.org/health. SBC_508_G_0932_20171020 Plan Year January 1 Alaska Conference of Catholic Bishops Laity 1 of 7

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 800.852.4877 or visit us at www.myCBS.org/health or email at [email protected]. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 800.852.4877 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible?

In-Network $500 Individual / $1,000 Family Out-of-Network $500 Individual / $1,000 Family In-Network & Out-of-Network deductibles reduce each other.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. For Preventive care services the In-Network deductible does not apply.

This plan covers some items and services even if you haven’t yet met the deductible amount, but a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

No. You don’t have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

Medical In-Network $5,000 Individual / $10,000 Family Medical Out-of-Network $5,000 Individual / $10,000 Family In-Network & Out-of-Network out-of-pocket limits reduce each other.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

Prescription Out-of-Pocket $1,850 Individual / $3,700 Family

Buy-up Lower Deductible Plan

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For more information about limitations and exceptions, see the plan or policy document at myCBS.org/health. SBC_508_G_0932_20171020 Plan Year January 1 Alaska Conference of Catholic Bishops Laity 2 of 7

What is not included in the out-of-pocket limit?

Premiums, balance-billed charges, payments made by patient assistance programs, penalty for prescription retail refill allowances, penalty for non-notification of hospital admission and other services requiring pre-certification, and health care this plan does not cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Will you pay less if you use a network provider?

Yes. Your network is Aetna Signature Administrators. See myCBS.org/ppo-aetna or call 800.852.4877 for a list of participating medical network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider

(You will pay the least) Out-of-Network Provider (You will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

$40 Copayment / visit; deductible does not apply

25% Coinsurance after $40 Copayment / visit; deductible does not apply

None.

Specialist visit $40 Copayment / visit; deductible does not apply

25% Coinsurance after $40 Copayment / visit; deductible does not apply

In-Network Allergy injections $5 Copayment / visit; deductible does not apply. Out-of-Network Allergy injections $5 Copayment / visit; deductible does not apply.

Preventive care/screening/ immunization No Charge

Primary Care - 25% Coinsurance after $40 Copayment / visit; deductible does not apply Free Standing Clinic – 25% Coinsurance

You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Out-of-Network Payment may differ based on place of service.

If you have a test Diagnostic test (x-ray, blood work)

Lab Work – No Charge; deductible does not apply Radiology – 25% Coinsurance

25% Coinsurance Limited to services performed outside physician’s office. Payment may differ based on place of service.

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Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider

(You will pay the least) Out-of-Network Provider (You will pay the most)

Imaging (CT/PET scans, MRIs) 25% Coinsurance 25% Coinsurance

Limited to services performed outside physician’s office. Payment may differ based on place of service. Precertification is required. A 25% penalty up to $300 may apply. Penalty does not apply to out-of-pocket limit.

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.myCBS.org/health and click on My Prescription Drugs or call Express Scripts at 800-718-6601.

Generic drugs $10 / prescription (retail); $20 / prescription (mail)

Same as In-Network +20% coinsurance penalty Covers up to 30-day supply retail prescription;

90-day supply mail order prescription. Retail purchases for maintenance prescriptions are limited to an initial fill and two subsequent refills. Members who continue to use retail will pay the mail delivery copayment, however, only up to a 30-day supply will be dispensed. See your policy or plan document for additional information.

Preferred brand drugs $20 / prescription (retail); $40 / prescription (mail)

Same as In-Network +20% coinsurance penalty

Non-preferred brand drugs $30 / prescription (retail); $60 / prescription (mail)

Same as In-Network +20% coinsurance penalty

Specialty drugs Generic 10% up to a maximum of $150 Preferred 20% up to a maximum of $150 Non-Preferred 20% up to a maximum of $250

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) 25% Coinsurance 25% Coinsurance Limited to services performed outside

physician’s office. Payment may differ based on place of service. Precertification is required. A 25% penalty up to $300 may apply. Penalty does not apply to out-of-pocket limit.

Physician/surgeon fees 25% Coinsurance 25% Coinsurance

If you need immediate medical attention

Emergency room care – Facility fee

25% Coinsurance after $100 Copayment; deductible does not apply Copayment is waived if admitted.

Emergency room care – Physician/surgeon fees 25% Coinsurance

Emergency room care may include tests and services described elsewhere in the SBC (i.e. Diagnostic tests or Imaging.)

Emergency medical transportation 25% Coinsurance

For transportation service charges exceeding $5,000 by ground and/or air, payment will not exceed 150% of Medicare allowance for such incurred expenses. Charges include transportation and medical supplies used during transport.

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Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider

(You will pay the least) Out-of-Network Provider (You will pay the most)

Urgent care

Primary Care – $40 Copayment; deductible does not apply Free Standing Clinic – 25% Coinsurance Emergency Room – 25% Coinsurance after $100 Copayment; deductible does not apply

Primary Care – 25% Coinsurance after $40 Copayment; deductible does not apply Free Standing Clinic – 25% Coinsurance Emergency Room – 25% Coinsurance after $100 Copayment; deductible does not apply

Payment may differ based on place of service. This applies to emergency room or urgent care services.

If you have a hospital stay

Facility fee (e.g., hospital room) 25% Coinsurance 25% Coinsurance

Precertification is required. A 25% penalty up to $2,000 may apply. Penalty does not apply to out-of-pocket limit.

Physician/surgeon fees 25% Coinsurance 25% Coinsurance None.

If you need mental health, behavioral health, or substance abuse services

Outpatient services

Specialist – $40 Copayment / visit; deductible does not apply Outpatient Facility – 25% Coinsurance

Specialist – 25% Coinsurance after $40 Copayment / visit; deductible does not apply Outpatient Facility – 25% Coinsurance

Payment may differ based on place of service.

Inpatient services 25% Coinsurance 25% Coinsurance Precertification is required. A 25% penalty up to $2,000 may apply. Penalty does not apply to out-of-pocket limit.

If you are pregnant

Office visits $40 Copayment / visit; deductible does not apply

25% Coinsurance after $40 Copayment / visit; deductible does not apply

Copayment applies to initial prenatal visit only (per pregnancy). Cost sharing does not apply to preventive services.

Childbirth/delivery professional services 25% Coinsurance 25% Coinsurance

Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)

Childbirth/delivery facility services 25% Coinsurance 25% Coinsurance None.

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Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider

(You will pay the least) Out-of-Network Provider (You will pay the most)

If you need help recovering or have other special health needs

Home health care 25% Coinsurance 25% Coinsurance Limited to 100 visits per year maximum.

Rehabilitation services 25% Coinsurance / visit 25% Coinsurance / visit

Payment may differ based on place of service. Services for all State Licensed Practitioners, including Acupuncturist & Massage therapist visits, are limited to combined 24 visits per year.

Habilitation services Not covered. Not covered.

Skilled nursing care 25% Coinsurance 25% Coinsurance Limited to 120 day maximum for all confinements resulting from the same or a related illness or injury.

Durable medical equipment 25% Coinsurance 25% Coinsurance Check your plan document for limitations. Orthotics – Limited to $500 lifetime

Hospice services 25% Coinsurance 25% Coinsurance Limited to 180 day per year maximum.

If your child needs dental or eye care

Children’s eye exam No charge. Covered up to age 5. Children’s glasses Not covered. Unless covered by your vision plan. Children’s dental check-up Not covered. Unless covered by your dental plan.

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Contraceptives • Cosmetic surgery • Dental care (Adult) • Eye exam over age 5

• Habilitation services • Hearing aids and related charges • Infertility treatment (except initial diagnosis) • Long-term care • Private-duty nursing

• Routine eye care (Adult) • Routine foot care • Sterilization or Abortion • Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric surgery • Chiropractic care (payable per medical necessity as specialist MD). • Non-emergency care when traveling outside the U.S. (only when on assignment by ER). • Services provided by State Licensed Practitioners within the scope of license not specifically covered under any other provisions of the medical plan, including

Acupuncture, Massage Therapy, and Nutritional Counseling – Limited to 12 combined visits per year for all services.

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Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. Church plans are not covered by the Federal COBRA continuation coverage rules. For more information on your rights to continue coverage, contact the plan at 800.852.4877. You may also contact your state insurance department. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the plan at 800.852.4877. A list of states with Consumer Assistance Programs is available at cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/. Does this plan provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al800.852.4877. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa800.852.4877. Chinese (中文): 如果需要中文的帮助,请拨打这个号码800.852.4877. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne'800.852.4877.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

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Peg is Having a Baby (9 months of in-network pre-natal care and a

hospital delivery)

Mia’s Simple Fracture (in-network emergency room visit and follow

up care)

Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well-

controlled condition)

The plan would be responsible for the other costs of these EXAMPLE covered services.

The plan’s overall deductible $ 500 Specialist copayment $ 40 Hospital (facility) coinsurance 25% Other coinsurance 25% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost $13,378 In this example, Peg would pay:

Cost Sharing Deductibles $ 500 Copayments $ 800 Coinsurance $2,281

What isn’t covered Limits or exclusions $ 60 The total Peg would pay is $3,641

The plan’s overall deductible $ 500 Specialist copayment $ 40 Hospital (facility) coinsurance 25% Other coinsurance 25% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

Total Example Cost $7,400 In this example, Joe would pay:

Cost Sharing Deductibles $ 500 Copayments $ 970 Coinsurance $ 432

What isn’t covered Limits or exclusions $ 55 The total Joe would pay is $1,957

The plan’s overall deductible $ 500 Specialist copayment $ 40 Hospital (facility) coinsurance 25% Other coinsurance 25% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost $1,925 In this example, Mia would pay:

Cost Sharing Deductibles $ 500 Copayments $ 280 Coinsurance $ 354

What isn’t covered Limits or exclusions $ 0 The total Mia would pay is $1,134

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Christian Brothers Employee Benefit Trust: MP G553 - Rx 1416 Coverage for: Individual+Family | Plan Type: HSA1

For more information about limitations and exceptions, see the plan or policy document at myCBS.org/health. SBC_553_G_1416_20171020 Plan Year January 1 Alaska Conference of Catholic Bishops Laity 1 of 7

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 800.852.4877 or visit us at www.myCBS.org/health or email at [email protected]. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 800.852.4877 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible?

Combined Medical & Prescription Drug In-Network $2,700 Individual / $5,400 Family Medical Out-of-Network $5,400 Individual / $10,800 Family In-Network & Out-of-Network deductibles reduce each other.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. For Preventive care services the In-Network deductible does not apply.

This plan covers some items and services even if you haven’t yet met the deductible amount, but a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

No. You don’t have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

Combined Medical & Prescription Drug In-Network $5,400 Individual / $10,800 Family Medical Out-of-Network $10,800 Individual / $21,600 Family In-Network & Out-of-Network out-of-pocket limits reduce each other.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Premiums, balance-billed charges, payments made by patient assistance programs, penalty for prescription retail refill allowances, penalty for non-notification of hospital admission and other services requiring pre-certification, and health care this plan does not cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Default High Deductible - HSA Plan

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Page 15: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

For more information about limitations and exceptions, see the plan or policy document at myCBS.org/health. SBC_553_G_1416_20171020 Plan Year January 1 Alaska Conference of Catholic Bishops Laity 2 of 7

Will you pay less if you use a network provider?

Yes. Your network is Aetna Signature Administrators. See myCBS.org/ppo-aetna or call 800.852.4877 for a list of participating medical network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider

(You will pay the least) Out-of-Network Provider (You will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness 15% Coinsurance / visit 25% Coinsurance / visit None.

Specialist visit 15% Coinsurance / visit 25% Coinsurance / visit None.

Preventive care/screening/ immunization No Charge

Primary Care - 25% Coinsurance / visit Free Standing Clinic – 25% Coinsurance

You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Out-of-Network Payment may differ based on place of service.

If you have a test

Diagnostic test (x-ray, blood work)

Lab Work – 0% Coinsurance Radiology – 15% Coinsurance

25% Coinsurance Lab Work paid at 100% after In-Network Deductible. Limited to services performed outside physician’s office. Payment may differ based on place of service.

Imaging (CT/PET scans, MRIs) 15% Coinsurance 25% Coinsurance

Limited to services performed outside physician’s office. Payment may differ based on place of service. Precertification is required. A 25% penalty up to $300 may apply. Penalty does not apply to out-of-pocket limit.

Page 16: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

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Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider

(You will pay the least) Out-of-Network Provider (You will pay the most)

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.myCBS.org/health and click on My Prescription Drugs or call Express Scripts at 800-718-6601.

Generic drugs 15% / prescription (retail & mail)

Same as In-Network +20% coinsurance penalty Covers up to 30-day supply retail prescription;

90-day supply mail order prescription. Retail purchases for maintenance prescriptions are limited to an initial fill and two subsequent refills. Members who continue to use retail will pay the entire cost, however, only up to a 30-day supply will be dispensed. See your policy or plan document for additional information.

Preferred brand drugs 15% / prescription (retail & mail)

Same as In-Network +20% coinsurance penalty

Non-preferred brand drugs 15% / prescription (retail & mail)

Same as In-Network +20% coinsurance penalty

Specialty drugs As categorized above

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) 15% Coinsurance 25% Coinsurance Limited to services performed outside

physician’s office. Payment may differ based on place of service. Precertification is required. A 25% penalty up to $300 may apply. Penalty does not apply to out-of-pocket limit.

Physician/surgeon fees 15% Coinsurance 25% Coinsurance

If you need immediate medical attention

Emergency room care – Facility fee 15% Coinsurance None.

Emergency room care – Physician/surgeon fees 15% Coinsurance

Emergency room care may include tests and services described elsewhere in the SBC (i.e. Diagnostic tests or Imaging.)

Emergency medical transportation 15% Coinsurance

For transportation service charges exceeding $5,000 by ground and/or air, payment will not exceed 150% of Medicare allowance for such incurred expenses. Charges include transportation and medical supplies used during transport.

Urgent care

Primary Care – 15% Coinsurance Free Standing Clinic – 15% Coinsurance Emergency Room – 15% Coinsurance

Primary Care – 25% Coinsurance Free Standing Clinic – 25% Coinsurance Emergency Room – 15% Coinsurance

Payment may differ based on place of service. This applies to emergency room or urgent care services.

Page 17: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

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Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider

(You will pay the least) Out-of-Network Provider (You will pay the most)

If you have a hospital stay

Facility fee (e.g., hospital room) 15% Coinsurance 25% Coinsurance

Precertification is required. A 25% penalty up to $2,000 may apply. Penalty does not apply to out-of-pocket limit.

Physician/surgeon fees 15% Coinsurance 25% Coinsurance None.

If you need mental health, behavioral health, or substance abuse services

Outpatient services Specialist – 15% Coinsurance / visit Outpatient Facility – 15% Coinsurance

Specialist – 25% Coinsurance / visit Outpatient Facility – 25% Coinsurance

Payment may differ based on place of service.

Inpatient services 15% Coinsurance 25% Coinsurance Precertification is required. A 25% penalty up to $2,000 may apply. Penalty does not apply to out-of-pocket limit.

If you are pregnant

Office visits 15% Coinsurance / visit 25% Coinsurance Coinsurance applies to initial prenatal visit only (per pregnancy). Cost sharing does not apply to preventive services.

Childbirth/delivery professional services 15% Coinsurance 25% Coinsurance

Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)

Childbirth/delivery facility services 15% Coinsurance 25% Coinsurance None.

If you need help recovering or have other special health needs

Home health care 15% Coinsurance 25% Coinsurance Limited to 100 visits per year maximum.

Rehabilitation services 15% Coinsurance / visit 25% Coinsurance / visit Payment may differ based on place of service. Services for all State Licensed Practitioners, including Acupuncturist & Massage therapist visits, are limited to combined 24 visits per year.

Habilitation services Not covered. Not covered.

Skilled nursing care 15% Coinsurance 25% Coinsurance Limited to 120 day maximum for all confinements resulting from the same or a related illness or injury.

Durable medical equipment 15% Coinsurance 25% Coinsurance Check your plan document for limitations.

Orthotics – Limited to $500 lifetime Hospice services 15% Coinsurance 25% Coinsurance Limited to 180 day per year maximum.

Page 18: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

For more information about limitations and exceptions, see the plan or policy document at myCBS.org/health. SBC_553_G_1416_20171020 Plan Year January 1 Alaska Conference of Catholic Bishops Laity 5 of 7

Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider

(You will pay the least) Out-of-Network Provider (You will pay the most)

If your child needs dental or eye care

Children’s eye exam No charge. Covered up to age 5. Children’s glasses Not covered. Unless covered by your vision plan. Children’s dental check-up Not covered. Unless covered by your dental plan.

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Contraceptives • Cosmetic surgery • Dental care (Adult) • Eye exam over age 5

• Habilitation services • Hearing aids and related charges • Infertility treatment (except initial diagnosis) • Long-term care • Private-duty nursing

• Routine eye care (Adult) • Routine foot care • Sterilization or Abortion • Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric surgery • Chiropractic care (payable per medical necessity as specialist MD). • Non-emergency care when traveling outside the U.S. (only when on assignment by ER). • Services provided by State Licensed Practitioners within the scope of license not specifically covered under any other provisions of the medical plan, including

Acupuncture, Massage Therapy, and Nutritional Counseling – Limited to 12 combined visits per year for all services. Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. Church plans are not covered by the Federal COBRA continuation coverage rules. For more information on your rights to continue coverage, contact the plan at 800.852.4877. You may also contact your state insurance department. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the plan at 800.852.4877. A list of states with Consumer Assistance Programs is available at cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/. Does this plan provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Page 19: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

For more information about limitations and exceptions, see the plan or policy document at myCBS.org/health. SBC_553_G_1416_20171020 Plan Year January 1 Alaska Conference of Catholic Bishops Laity 6 of 7

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 800.852.4877. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 800.852.4877. Chinese (中文): 如果需要中文的帮助,请拨打这个号码 800.852.4877. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 800.852.4877.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

Page 20: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

For more information about limitations and exceptions, see the plan or policy document at myCBS.org/health. SBC_553_G_1416_20171020 Plan Year January 1 Alaska Conference of Catholic Bishops Laity 7 of 7

Peg is Having a Baby (9 months of in-network pre-natal care and a

hospital delivery)

Mia’s Simple Fracture (in-network emergency room visit and follow

up care)

Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well-

controlled condition)

The plan would be responsible for the other costs of these EXAMPLE covered services.

The plan’s overall deductible $2,700 Specialist coinsurance 15% Hospital (facility) coinsurance 15% Other coinsurance 15% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost $12,731 In this example, Peg would pay:

Cost Sharing Deductibles $2,700 Copayments $ 0 Coinsurance $1,763

What isn’t covered Limits or exclusions $ 60 The total Peg would pay is $4,523

The plan’s overall deductible $2,700 Specialist coinsurance 15% Hospital (facility) coinsurance 15% Other coinsurance 15% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

Total Example Cost $7,389 In this example, Joe would pay:

Cost Sharing Deductibles $2,700 Copayments $ 0 Coinsurance $1,058

What isn’t covered Limits or exclusions $ 55 The total Joe would pay is $3,813

The plan’s overall deductible $2,700 Specialist coinsurance 15% Hospital (facility) coinsurance 15% Other coinsurance 15% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost $1,925 In this example, Mia would pay:

Cost Sharing Deductibles $1,636 Copayments $ 0 Coinsurance $ 289

What isn’t covered Limits or exclusions $ 0 The total Mia would pay is $1,925

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Page 21: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

Dental P 3 / Ortho 1000

Christian Brothers Employee Benefit Trust Dental Plan

DEDUCTIBLE $50 / Individual - $150 / Family

YEARLY MAXIMUM $1,500

PREVENTIVE DENTAL: Oral exam each 6 months Emergency exam X-rays with frequency limits Prophylaxis (Cleaning) each 6 months Fluoride each 6 months for children under 16 Sealants each 24 months for children under 16

100 % No Deductible

PREVENTIVE (Special provisions with Medical Necessity) Prophylaxis (Cleaning) Fluoride

The Plan may allow up to 3 cleanings and fluoride treatments per year if you are being treated for a serious medical condition. Your medical doctor must submit documentation to the Plan for pre-approval. Benefits will be paid at the Preventive Dental level of benefits.

BASIC DENTAL: Fillings Stainless steel crown for children Extraction of teeth Oral Surgery Periodontal services; each with frequency limits Endodontic services General anesthesia for complex oral surgery Repairs to bridges or dentures Relining of dentures with frequency limits

80 % After Deductible

MAJOR DENTAL: Gold inlays/onlays; replacements; limited to 5

years from last placement Crowns; replacements limited to 5 years from last

placement Implant Services Fixed bridges & full or partial dentures;

Initial placement limited to extractions while on the plan Replacements limited to 5 years from last placement

Temporomandibular Joint Disorders (TMJ)

50 % After Deductible

SOME SERVICES NOT COVERED (All Charges Subject to Prevailing Fees)

Cosmetic services, occlusal analysis or adjustments, oral hygiene instruction, services to alter vertical dimension, duplication or replacing lost or stolen prosthetics, temporary services, and orthodontics. Non-emergency service performed outside USA.

This Benefit Summary provides a brief outline of the services covered by CBEBT. THIS IS NOT A CONTRACT. The complete terms of the plan are contained in Your Employee Benefits booklet issued to members. For more information regarding benefits, please call Customer Service at 1.800.807.0400.

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Page 22: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

Dental P 3 / Ortho 1000

Christian Brothers Employee Benefit Trust Orthodontia

DEDUCTIBLE ( Separate from Dental Plan Deductible )

$50 / Individual - $150 / Family

LIFETIME MAXIMUM ( Separate from Dental Plan Maximum )

$1,000

ELIGIBILITY Covered Dependent Only Under Age 19

COVERED PROCEDURES:

Formal, full-banded retention and treatment X-rays Other diagnostic procedures Removable or fixed appliances for tooth or bony

structure guidance or retention.

50 % after Deductible

SOME SERVICES NOT COVERED Cosmetic services, implants, occlusal analysis, oral hygiene instruction, services to alter vertical dimension or restore occlusion (except for orthodontic related charges), duplication or replacing lost or stolen prosthetics, and temporary services.

This Benefit Summary provides a brief outline of the services covered by CBEBT. THIS IS NOT A CONTRACT. The complete terms of the plan are contained in Your Employee Benefits booklet issued to members. For more information regarding benefits, please call Customer Service at 1.800.807.0400.

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Page 23: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

Your VSP Vision Benefits SummaryALASKA CONFERENCE OF CATHOLIC BISHOPS and VSP provide you with anaffordable eye care plan.

VSP Coverage VSP Provider Network: VSP ChoiceFrequencyCopayDescriptionBenefit

Your Coverage with a VSP Provider

Every 12 months$10WellVision Exam Focuses on your eyes and overall wellness

See frame and lenses$25Prescription Glasses

Every 24 monthsIncluded inPrescription

GlassesFrame

$130 allowance for a wide selection of frames$150 allowance for featured frame brands20% savings on the amount over your allowance$70 Costco® frame allowance

Every 12 monthsIncluded inPrescription

GlassesLenses Single vision, lined bifocal, and lined trifocal lenses

Polycarbonate lenses for dependent children

Every 12 months$0

Lens EnhancementsProgressive lenses

$0Anti-reflective coatingAverage savings of 20-25% on other lens enhancements

Every 12 monthsUp to $60Contacts (instead ofglasses)

$130 allowance for contacts; copay does not applyContact lens exam (fitting and evaluation)

Glasses and Sunglasses

Extra Savings

Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details.20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12months of your last WellVision Exam.

Retinal ScreeningNo more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam

Laser Vision CorrectionAverage 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities

Your Coverage with Out-of-Network Providers

Get the most out of your benefits and greater savings with a VSP network doctor. Your coverage with out-of-network providers will be less or you’llreceive a lower level of benefits. Visit vsp.com for plan details.

Exam .............................................................................. up to $45Frame ............................................................................ up to $70Single Vision Lenses ........................................... up to $30

Lined Bifocal Lenses ........................................... up to $50Lined Trifocal Lenses ......................................... up to $65

Progressive Lenses ............................................. up to $50Contacts .................................................................... up to $105

Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change. In the event of a conflict between thisinformation and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. In the state of Washington, VSP Vision Care, Inc.,is the legal name of the corporation through which VSP does business.

Contact us. 800.877.7195 | vsp.com1. Brands/Promotion subject to change.2. Savings based on network doctor's retail price and vary by plan and purchase selection; average savings determined after benefits are applied. Available only through VSP network doctors to VSPmembers with applicable plan benefits. Ask your VSP network doctor for details.

©2017 Vision Service Plan. All rights reserved.VSP, VSP Vision care for life, eyeconic.com, and WellVision Exam are registered trademarks, and "Life is better in focus." is a trademark of Vision Service Plan. Flexon is a registered trademark of MarchonEyewear, Inc. All other company names and brands are trademarks or registered trademarks of their respective owners.

Page 24: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

Prescription Drug Program

Instant Access to Express ScriptsWhen you register at mycbs.org/health and click on My Prescription Drugs, you will have instant access to:

• My Rx Choices®

• Prescriptions• Claims & Balances• Order Status• Locate a Pharmacy• Price a Medication• Bene�t Highlights• Forms and Cards• Learn About Formularies• Drug Information

Express Scripts�e Christian Brothers Employee Bene�t Trust has chosen Express Scripts to manage the prescription drug bene�t for our members. Express Scripts has captured the No. 1 position in the Health Care: Pharmacy and Other Services sector on the Fortune World’s Most Admired Companies List, and it’s No. 2 in the world for Social Responsibility and Long-Term Investment. Of all companies surveyed globally, Express Scripts was ranked No. 5 in Innovation and No. 10 in People Management. With Express Scripts’s sophisticated dispensing technology and mail-order pharmacies, our Trust members are provided high-quality prescription drugs at discounted prices.

Express Scripts by MailIn the mail-order pharmacies, quality process activities as well as customer satisfaction are driven by performance measurement in four key areas: Compliance, Quality, Service, and Cost. Each of Express Scripts pharmacies adheres speci�cally to the requirements of the state in which it is located. In addition, Express Scripts and each of its mail-order pharmacies are fully accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and are diligent in adhering to all applicable standards of that organization.Each mail-order pharmacy has a Director of Pharmacy Practice who is a registered pharmacist. It is the Director of Pharmacy Practice who is responsible for all dispensing-related activities. Additional registered pharmacists supervise every activity in the dispensing process, including maintenance of dispensing records. All prescriptions are checked by registered pharmacists who are licensed in the state in which they practice.

Visit mycbs.org/health for more information

Contact Express Scripts at (800) 718-6601

1/2015

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Page 25: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

Other Resources Section 4

Other

Helpful

Resources

Available!

Page 26: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

  Online Health Management    4a 

 

Be sure to visit myCBS.org/health  to “activate” your Health ID 

Card!  This site will provide valuable resources, health news, 

access to your benefit information, and much more! 

Online EOBs (explanation of benefits paid) 

Medical plan summaries 

Find Network providers 

Current Health News 

RX Drug information 

 

www.myCBS.org/health  

 

Page 27: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

�e Simplest Way to Find a DentistSelecting a dentist for you and your family is important. DocFind online directory, available 24 hours a day, 7 days a week, makes it easy. DocFind is updated three times per week, providing access to the latest available information.

To access DocFind, simply log on to mycbs.org/health.1) Click on "Find a PPO Provider", then click "Dental PPOs" on the righthand side.2) Click the orange "Start a New Search" button.3) From the "Search for" dropdown, under Dental, select either Dentists (Primary Care) or Dental Specialists.4) From the "Type" dropdown, make the selection which best �ts your needs.5) Enter the geographic information for the area where you wish to �nd a participating dentist.6) From the "Select a Plan" dropdown, select Aetna Dental Administrators SM.7) You can also narrow your search by specialty, language spoken and/or name, as well as request a list of all dentists who match your geographic and plan requirements. If you already know the name of the dentist you are looking for, use the “Search by Name” link.

1) From the "Search for" dropdown, select Dentists/Dental Professionals.2) Type in the name of the dentist you wish to �nd.3) Enter the geographic information for the area the participating dentist is located.4) From the "Select a Plan" dropdown, select Aetna Dental Administrators SM.5) You will be presented with a list of dentists which match your criteria. You can obtain additional information about each provider by clicking on the "View Details" link.

DocFind is the premier online search tool from Aetna providing up-to-date listings of participating dentists. With the easy-to-use format, you can search online by name, specialty, language, and/or if they are accepting new patients. DocFind allows you to make an informed choice, and gives you easy access to information about dental care professionals, including information that is not available in paper directories. �is includes information about which plans the provider accepts, medical school attended, board certi�cation status, gender, and information on the provider’s o�ce(s), as well as maps and driving directions.

You can use DocFind anywhere you have Internet access. If you have questions while searching for a dentist, just click on the “Contact DocFind” link located at the top of any DocFind page to send a comment or question.

Step-by-Step Instructions

Locate dental professionals and facilities using the criteria that’s best suited to your needs.

Visit mycbs.org/health for more information

DocFind Online Dental Directory

2/2015

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Page 28: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

�e Simplest Way to Find a DoctorSelecting a doctor and other health care professionals for you and your family is important. �e Find a Provider online directory, available 24 hours a day, 7 days a week, makes it easy.

Find a Provider is the premier online search tool from Aetna. Up-to-date listings of participating doctors, medical professionals, and facilities are available at your �ngertips. With the easy-to-use format, you can search online by name, specialty, gender and/or hospital a�liation.

What Does Find a Provider Allow me to do? Choose the search option that works for you. Search by using a variety of criteria such as specialty, gender and/or hospital a�liation, or search using the health care professional’s name.

Make the informed choice. Find a Provider gives you easy access to information about health care professionals. �is includes information about medical school attended, board certi�cation status and gender, as well as information about the provider’s o�ce(s), such as handicapped access, etc.

Get up-to-date information. Find a Provider is typically updated daily, giving you access to the latest available information.

Review a list of transplant facilities and pediatric congenital heart surgery facilities in our Institutes of Excellence™ network.

To access Find a Provider, simply log on to mycbs.org/ppo-aetna.1) On the Aetna “Find a Provider” page, click on the “Medical” button. 2) Under the “What type of provider are you looking for?” heading, select one of the options for provider type. 3) Under the “Do you want to search by ZIP or state?” heading, enter the geographic information for the area where you wish to �nd a participating provider. Under the “Search by state” option, you can further narrow your selection by county and city. 4) You can run a search with the information you provided at this point or click on the “+ Advanced Search” link to open more options.NOTE: You must enter the information in steps 2 and 3 in order to access the Advanced Search options. Under the Advanced Search options, you can also narrow your search by doctor or facility name and/or specialty type or medical condition.5) If you already know the name of the provider or facility you are looking for, type the name in the “Doctor/Facility name” box. 6) Under “Specialty Type,” you may add up to �ve specialties by clicking on the list provided and clicking “Add.” If you want to change the specialty criteria, click on the “Remove” button. 7) You may also search for a specialist based on medical condition by clicking on the “Condition” button.8) Click “Search.”9) You will be presented with a list of providers matching your criteria. You can obtain additional information about each provider by clicking on the "More Details" link under the provider’s contact information.10) You can create a list of providers you are interested in by clicking on the yellow “Add to my list” button under the contact information. �ere is also a “Compare side by side” button to help you �nd the right provider.

Step-by-Step Instructions

Locate health care professionals and facilities using the criteria that’s best suited to your needs.

Visit mycbs.org/health for more information

Find a Provider Online Doctor Directory

7/2017

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Page 29: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

Get access to the best in eye care andeyewear with ALASKA CONFERENCEOF CATHOLIC BISHOPS and VSP®

Vision Care.Why enroll in VSP? As a member, you’ll receive access to carefrom great eye doctors, quality eyewear, and the affordabilityyou deserve, all at the lowest out-of-pocket costs.

You’ll like what you see with VSP.Value and Savings. You’ll enjoy more value and the lowest out-of-pocketcosts.

High Quality Vision Care. You’ll get the best care from a VSP networkdoctor, including a WellVision Exam®—the most comprehensive examdesigned to detect eye and health conditions.

Choice of Providers. The decision is yours to make—choose a VSPnetwork doctor, a participating retail chain, or any out-of-network provider.

Great Eyewear. It’s easy to find the perfect frame at a price that fits yourbudget.

Using your VSP benefit is easy.Create an account at vsp.com. Once your plan is effective, review yourbenefit information.

Find an eye doctor who’s right for you. Visit vsp.com or call 800.877.7195.

At your appointment, tell them you have VSP. There’s no ID cardnecessary. If you’d like a card as a reference, you can print one onvsp.com.

That’s it! We’ll handle the rest—there are no claim forms to complete whenyou see a VSP provider.

Choice in EyewearFrom classic styles to the latest designer frames, you’ll find hundreds ofoptions. Choose from featured frame brands like bebe®, Calvin Klein,Cole Haan, Flexon®, Lacoste, Nike, Nine West, and more.1 Visit vsp.com tofind a Premier Program location that carries these brands. Plus, save up to40% on popular lens enhancements.2 Prefer to shop online? Check out allof the brands at eyeconic.com®, VSP's preferred online eyewear store.

Enroll in VSP today.You'll be glad you did.Contact us. 800.877.7195vsp.com

Life is better in focus. TM

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Members enrolled for medical coverage in the trusts administered by Christian Brothers Services have 24/7 access to a panel of 16,000 physicians, 365 days a year through Teladoc. �e telemedicine bene�t o�ers accessible and convenient care, as well as providing patients and physicians a way to communicate, which bypasses the traditional o�ce visit yet provides excellent care through the use of technology. Members can talk with a doctor anytime, anywhere about non-emergent medical condi-tions via telephone, secure email, video or mobile app.

Teladoc’s network of board-certi�ed physicians can discuss symptoms, recommend treatment options, diagnose many common, minor and/or brief illnesses and prescribe medication, when appropriate. �e technology also features a content-rich member health portal, My Personal Health Manager, that combines 24/7 physician access with cutting edge health applications and empowers individuals and families to take an active role in health, prevention and disease management.

When to Use Teladoc? • Primary care doctor is not available or accessible • A�er normal business hours, evenings and weekends • When traveling for business or vacation • To request needed prescription (Rx) medication or re�ll • For non-emergent medical questions/advice • When seeking a second opinion • When seeking advice about an existing condition • To discuss lab results or wellness panel

Getting Started with Teladoc1) Set Up your Account Set up your account by:

Phone: Teladoc can help you register your account over the phone. Call 800.835.2362.

Online: Go to MyDrConsult.com and click “set up account.”

Mobile app: Visit teladoc.com/mobile to download the app. Click “Activate account.”

Text: Text “Get Started” to 469.844.5637 2) Provide Medical History Your medical history provides Teladoc doctors with the information they need to make an accurate diagnosis.

3) Request a Consult Once your account is set up, request a consult anytime you need care. You can talk to a doctor by phone, web or mobile app.

Teladoc saves time by avoiding waiting for an appointment or driving, sitting and waiting in a doctor’s office for hours. A doctor is always on call or a click away – 24/7. Additionally, members save money with the lower cost alternative to a doctor’s office, urgent care or emergency room. What’s more, this benefit is offered at no additional cost to participants.* Never wait for a doctor again!

Consult A Doctor 24/7Where the Doctor is Always In

* Due to the Internal Revenue Service (IRS) requirements of Health Savings Account (HSA) plans, in order to preserve the pre-tax status of your members’ HSA, an employee who has a HSA and uses Teladoc will now be required to pay a $40.00 up front consult fee. �is fee will then be processed (and/or reimbursed, if the member has reached their Out of Pocket Maximum) under the medical plan. * Please Note: Teladoc is not currently available in Arkansas. You may use Teladoc in Texas via phone only, and in Idaho via video only.

Common Conditions Treated• Allergies • Bronchitis • Cold/Flu • Eye/Ear Infections• Headaches • Sinus Infections • Rash/Skin Irritation • Stomach Ache/Diarrhea • Upper Respiratory Infections • Urinary Tract Infections • Yeast Infections • And More …

�e Doctor is ALWAYS in – connect today - visit teladoc.com or call 800.835.2362.

06/2017

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HSA High Deductible Health Plans

A Health Savings Account (HSA) is a personal savings account that allows the member to pay for medical expenses with tax-free dollars. HSAs are designed to complement a special type of health plan called a HSA-quali�ed high deductible health plan (HDHP). Enrolling in a Christian Brothers Employee Bene�t Trust (CBEBT) HDHP HSA-quali�ed plan is the �rst step for you to be eligible to open a Health Savings Account.

A high-deductible plan typically o�ers lower monthly premiums than a traditional health plan. You can take the money saved on premiums and invest it in a HSA. While you are responsible for your initial health care costs until the deductible is met, the advantage is that the money saved in the HSA is available to pay for quali�ed medical and prescription drug expenses. HDHPs provide 100 percent coverage for preventive care services, such as routine doctor’s visits and annual physicals.

Beyond the lower premiums a�orded by an HSA-quali�ed HDHP, a HSA account o�ers several bene�ts and can be a good choice for: ■ People interested in trading higher out-of-pocket costs for lower premiums.■ People who want more control over their health care spending.■ �ose interested in the tax bene�ts of a HSA.■ Anyone interested in using a personal savings account to

pay for quali�ed medical expenses.

Ownership and portability. You own the account. Money you contribute accumulates from year to year—no “use-it-or-lose-it” rules. And your account travels with you whether you change jobs, become unemployed, or switch insurance carriers.

Flexibility. You can use the money in your account to pay for qualified medical expenses, such as office visits, dental expenses, prescription copays, Teladoc charges, eye wear, prescription medication, deductibles, and coinsurance—as well as expenses your plan doesn’t cover, such as laser vision correction. �e funds in your account can be used in future years. If you leave a job and �nd yourself without health bene�ts, the IRS allows you to pay for continuation of coverage using funds from your HSA. You can even use your HSA to pay for medical expenses for your spouse or dependent children claimed on your tax return who aren’t covered by your plan.

Tax-free savings.* You can save funds on a pre-tax basis in your HSA for future medical expenses and earn interest on the total, tax-free. �e combined employer/employee contribution limit for 2018 is $3,450 for individual coverage and $6,900 for family coverage. An additional $1,000 of catch-up contribution can be made by individuals 55 and older.

Tax bene�ts may also include: deductions for yearly contribu-tions, tax-free investment earnings, and tax-free withdrawals for quali�ed medical expenses.

10/2017

* Christian Brothers Services does not provide tax, legal or accounting advice. �ismaterial provided is for informational purposes only. Talk with your tax advisor to verifywhich tax bene�ts apply to you. While you can invest your HSA money in stocks, bonds,and mutual funds, there is no guarantee that these investments will increase in value. Like any investment, risk is involved. Furthermore, withdrawing funds for non-medicalexpenses results in a penalty, plus you will have to pay taxes on the amount withdrawn.

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What is an HSA?

HSA What is it? A Health Savings Account is a personal bank account to help you save and pay for

covered health care services and qualified medical expenses. How do I get it? You have to sign up for a high deductible health plan that meets a deductible

amount set by the IRS. You also have to meet other IRS guidelines to be eligible to have it. You can learn about these at irs.gov.

Who owns it? You do. Who puts money in it? You. Your employer, family, and others can put money into it if they choose. How is money put in it? You can make deposits like you do with other personal bank accounts. Your

employer and family can also put money into the account. Your employer may allow you to deposit money straight from your paycheck, before the money is taxed.

Is there a limit on how much I can put in it?

Yes. The IRS sets a limit on how much you can put into it each year. You can usually find the limits in your health plan documents and at irs.gov. While there are annual limits, there is no limit to how much you can save over time.

If I don’t spend it all this year, can I use it next year?

Yes. Since you own the account, the money will stay in it until you choose to spend it. You can save and use it into retirement.

Can I cash it out at any point? Yes. But if you cash it out and do not use the money for qualified medical expenses, you will have to pay taxes on it. And you may also have to pay a 20% tax penalty.

Can I keep it if I leave my employer? What happens to the money?

Yes. You own the account.

When can I start spending it? You can start spending the HSA once you have signed up for a high-deductible health plan and have opened the account.

Do I have to pay taxes on it? No. You don’t have to pay federal or, in most instances, state income taxes on: - Deposits you or others make to an HSA - Money you spend from an HSA on qualified medical expenses - Interest earned from an HSA If you put money into an HSA using pre-tax payroll deposits through your employer You don’t have to pay Social Security taxes on it either.

If I don’t spend it, will it earn interest for me?

Yes, an HSA can earn interest. But the amount you can earn depends on the bank you use and how much you have in the account.

What can I pay for with it? You can pay for hundreds of qualified medical expenses, which are determined by the IRS. This can include services covered by a health plan. You can also use it to pay for dental, vision and many other health care services and supplies that are listed under Section 213(d) of the Internal Revenue Code.

Can I use it for things other than health care?

No, as long as you are under the age of 65. And if you use it for services that aren’t qualified medical expenses, you could pay a 20% penalty tax. If you are over the age of 65, you can use it for pretty much anything.

Can I have any other accounts with it?

Yes. You can have a limited-purpose Flexible Spending Account or limited-purpose HRA, which can only be used for eligible dental and vision services.

Can I use it to pay for Extension of Benefit plan premiums or other plan premiums?

Yes.

What’s the difference between a qualified medical expense and an eligible medical expense? A qualified medical expense is a health care service, treatment or item that the IRS says can be purchased without

having to pay taxes. An eligible medical expense is a health care service, treatment or item that the IRS says can be covered or reimbursed

(paid back) by a benefit plan.

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Page 36: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

Plan Description

Covered Person

Total Premium

Monthly Amount Paid by Employer

Monthly Amount Paid by Employee

Medical "Default" Employee only 903.99 893.99 10.00

Spouse 1,176.09 - 1,176.09

Child(ren) 460.63 - 460.63

Family 1,636.72 - 1,636.72

Medical "Buy-up" Employee only 1,051.15 893.99 157.16

Spouse 1,264.53 - 1,264.53

Child(ren) 502.14 - 502.14

Family 1,766.67 - 1,766.67

Dental PPO Employee only 47.40 47.40 -

1 Dependent 47.40 - 47.40

Child(ren) 45.74 45.74

Family 93.14 - 93.14

Vision VSP Employee only 12.82 12.82 -

1 Dependent 5.76 - 5.76

Family 20.50 - 20.50

Please note the following

► Employees may choose any combination of medical, vision, and dental benefits► Dependents may not have a benefit that the employee does not have.

Lay Plan

Lay Plan

Lay Plan

Lay Plan

Benefit Election Pricing

Health Benefits - Effective July 01, 2019

Employee copay for self

Employee cost for 1 Dependent

Employee cost for 2 or more Dependents

Employer pays this for employee only

No Employee copay for "self" on Dental

Employee pays for Dependents on Dental

No Employee copay for "self" on Vision Plan

Employee pays for Dependents on Vision

Employer pays this for employee only

Employee copay for self

Employee cost for 1 or more Children

Employee cost for Family (Spouse + Child(ren)

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ACCB Alaska Conference of Catholic Bishops – Insurance Division Employee Benefits ENROLLMENT / CHANGE FORM

This form can be used as an initial enrollment or to report a change in information. Please complete all information by printing clearly and firmly or by typing. If additional space is needed, please attach a statement with the appropriate information. Please check the applicable boxes below.

I. Location Name Term Date:

New Enrollment Re-Enroll Waiver Change Transfer from Location # _____ to # _____ Extended Benefits Terminate

II. EMPLOYEE INFORMATION LAY EMPLOYEE DIOCESAN PRIEST OTHER

LAST NAME FIRST MI SOC. SEC. NO.

STREET ADDRESS CITY STATE ZIP

DATE OF HIRE DATE FULL TIME OCCUPATION ANNUAL SALARY HOURS WORKED PER WEEK

EMPLOYEE EMAIL:

DATE OF BIRTH SEX MARITAL STATUS Home Phone (including area code)

( )

CELL PHONE (Including area code )

( )

III. DEPENDENT INFORMATION (Required if dependent coverage is to be added or changed) SEX DATE OF RELATIONSHIP Medical Dental Vision

FULL NAME (Including middle initial) SOC. SEC. NO. (M/F) BIRTH TO EMPLOYEE (X) (X) (X)

SPOUSE

DEPENDENT #1

DEPENDENT #2

DEPENDENT #3

IV. EMPLOYEE COVERAGE ELECTION LAY MEDICAL Default LAY MEDICAL “Buy-up” DENTAL VISION

SEMINARIAN MEDICAL PRIEST MEDICAL NONE, COMPLETE WAIVER SECTION

V. LIFE/AD&D & LTD INSURANCE COVERAGES – Eligible employees are automatically enrolled in the Basic Life and AD&D Plan, sponsored by ACCB.

NAME OF PRIMARY BENEFICARY ADDRESS CITY STATE ZIP CODE

RELATIONSHIP DATE OF BIRTH

NAME OF CONTINGENT BENEFICARY ADDRESS CITY STATE ZIP CODE

RELATIONSHIP DATE OF BIRTH

NOTE: If you require additional space for additional Dependents or Contingent Beneficiaries, please attach separate sheets

PLEASE READ SECTIONS VI. & VII. CAREFULLY (if waiving coverage-please sign both!)

VI. RELEASE and APPLICATION SIGNATURE: I hereby certify that I am an eligible employee/beneficiary as defined in the Summary Plan Document, that the above information is complete and accurate, and all claims submitted will be for individuals who are eligible members of the health plan. I hereby authorize the Plan Sponsor to deduct, from my pay, my contributions to the cost of the benefits, which I indicated above and for which I am or may become eligible. The current benefits have been explained to me thoroughly. I understand that I am responsible for a greater portion of my health costs when in excess of the amounts payable under the plan. I also authorize any physician or other health care professional, hospital or other health care facility, counselor, therapist, or any other medical or medically related facility or professional to give the health plan, respective agents or representatives any and all information or records relating to health history, health examinations, services rendered, or treatment given including treatment for alcohol, substance abuse or mental or emotional disorders, A.I.D.S., or A.R.C. of me or any of my dependents applying for coverage or of any claim for benefits. I also authorize the health plan to disclose all such health or personal information related to myself or any covered dependent, to a health care provider, a health care service plan, a self-insurer, or any insurance company for the purpose of investigating or evaluating any claim for benefits. If my coverage is under a master policy held by my employer, an association, trust fund, union or similar entity, this authorization also permits disclosure of them for the purpose of administering my coverage, utilization review or financial audit. This authorization is effective immediately and shall remain in effect for use in connection with any claim for benefits for as long as any health coverage may be in effect. A photocopy of this authorization is as valid as the original.

I HAVE READ AND UNDERSTOOD SECTION VI – APPLICANT SIGNATURE X _______________________________________________________________ DATE ____________________

VII. WAIVER of COVERAGES The current benefits have been explained to me thoroughly. I DO NOT wish to enroll in the following coverage(s) ENROLLEE : MEDICAL DENTAL VISION DEPENDENT: MEDICAL DENTAL VISION Is the coverage being waived due to coverage by another health plan? YES NO I understand that by waiving the coverage above, I will not be entitled to any benefits provided by the plan.

THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I HAVE READ, UNDERSTOOD, AND AGREE TO SECTIONS VI AND THE TERMS OF THIS ENROLLMENT FORM.

WAIVER OF COVERAGE SIGNATURE X __________________________________________________________________________________________________________________ DATE ____________________________

TO BE COMPLETED BY LOCATION ADMINISTRATOR ONLY

EFFECTIVE DATE

VIII. REASON FOR THE CANCELLATION / CHANGE

EMPLOYEE COVERAGE:

Discharged Deceased: Date ____________ Last day worked: ____________ Retirement: Date________ Resignation: Date___________ Date of disability: ____________ Reduction of work hours New dependent (Spouse or Child) New name:_______________________________ Increase of work hours New address Other please specify: _______________________________________________________________

DEPENDENT COVERAGE: Death of covered employee Date of divorce / legal separation __________________ Eligible for Medicare No longer an eligible dependent Termination of dependent’s health coverage

LOCATION ADMINISTRATOR NAME

SIGNATURE DATE

File Location: Finance/AOA Health Ins/FY 2016/ Enrollment Package

Page 38: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

ALASKA CONFERENCE OF CATHOLIC BISHOPS

Continuation of Coverage – Rate Acknowledgement

This Open Enrollment period, the plan coverages remain the same. All premiums also remain the same with the exception of a small increase to dental premiums.

I have reviewed the new medical rate schedules for plans beginning July 1, 2019, and I wish to continue my coverage “as is” without changes. ________________________________________________ ___________________________ Employee signature Date

Page 39: Health Insurance - Archdiocese of Anchorage€¦ · Special Announcement This open enrollment marks a return to the annual enrollment period. Note that, unlike last year, there will

ACCB Alaska Conference of Catholic Bishops – Insurance Division  

Spouse Eligibility Affidavit  

(check & complete one of the options)  

o My spouse is not currently employed and is eligible for this plan. If my spouse’s employment status changes and he/she becomes eligible for insurance at his/her place of employment, I will notify the benefits person of his/her status change.   

o My spouse is employed by _______________________ but is not eligible for their medical coverage or they do not offer medical coverage.   

o My spouse is employed by _______________________ and will be covered on their insurance plan.    Signature of Employee__________________________  Date_______________    Employee’s Printed Name________________________    Signature of ACCB Benefits Representative_______________________  Date________    Printed Name of ACCB Benefits Representative________________________