2017 employee benefits open enrollment - …365c8847-fc30-4c78-b574... · all employees must take...
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ALL EMPLOYEES MUST TAKE ACTION BEFORE NOVEMBER 30, 2016.
Enrollment in COOK employee health and life insurance benefits for 2017 begins November 1st. You must go online to www.mycookgroupbenefits.com to make your 2017 benefit plan elections. The deadline to enroll for your 2017 benefits is November 30, 2016. If you do not go online and submit your benefit choices by this deadline, you (and your dependents) will not have these benefits with COOK for 2017. As a reminder, you will need the social security numbers and birth dates for your dependents to complete the enrollment process unless you are not making any changes from the previous year. See the enclosed 2017 Online Benefit Enrollment Instructions for more details.
If you do not wish to enroll in benefits for 2017, you will need to decline benefits at www.mycookgroupbenefits.com.
COOK continually evaluates benefit plans and their costs to ensure the plan options are competitive and provide overall financial security and value for COOK employees and their family members. COOK is pleased to announce changes to the COOK Health Plan options and the addition of several new benefits for 2017.
CHANGES TO ALL COOK HEALTH PLAN OPTIONS (EFFECTIVE JANUARY 1, 2017)
Vision Plan - Exams and Eyeglass Lenses Covered Annually
The new enhanced COOK vision benefits allow you to use the Anthem Blue View provider network for discounts on vision products and services. You can also go to any vision provider and receive out-of-network benefits. See attached summary.
New Hearing Aid Benefit
The COOK Health Plan will pay $3,000 per person every five calendar years for hearing aid products and supplies. Eligible charges are applied to the medical deductible and covered at 80% in-network. See attached summary.
Screening CT Colonography
The CT Colonography has emerged as another screening tool for colon cancer in people who are at average risk for the disease. This new preventive service is covered by the COOK Health Plan in-network at 100% every 5 years for participants age 50 and over.
Dependent Care Flexible Spending Account (DCFSA)
Using a DCFSA is an excellent way to pay for dependent care expenses and lower your taxable income. You save by having money deducted from your pay pretax and deposited in a DCFSA to pay for eligible child care or elder care expenses. Reimbursements for these expenses from the DCFSA are tax free. See attached summary.
Limited Purpose Health Flexible Spending Account (LPHFSA) Option
For 2017, there will be two tax advantage HFSA options to choose from - the current General Purpose Health Flexible Spending Account (GPHFSA) and a new Limited Purpose Health Flexible Spending Account (LPHFSA). The LPHFSA is the option to elect if you have a spouse who is covered by a high deductible health plan and Health Savings Account (HSA) through their employer. Per IRS regulations, coverage in a GPHFSA is disqualifying coverage for a spouse to make or receive contributions to their HSA. The LPHFSA works just like the GPHFSA, but is limited to only reimbursing out-of-pocket dental and vision expenses and some preventive expenses. By limiting reimbursements to dental and vision expenses, your spouse remains eligible to participate in their employer’s HSA. See attached summary.
2017 EMPLOYEE BENEFITS OPEN ENROLLMENTNovember 1 – 30, 2016
CMI-Q30466-EN
HEALTH FLEXIBLE SPENDING ACCOUNT (HFSA)
Information for General Purpose and Limited Purpose HFSA OptionsYou may want to enroll in one of the HFSA options COOK is offering for 2017 and take advantage of the benefits listed below:
• A HFSA allows you to pay for out-of-pocket health care expenses including copayments, deductibles and coinsurance with pretax dollars and be reimbursed tax free.
• You have immediate access to your annual election on January 1, 2017.
• The annual HFSA maximum is $2,500.
• You are eligible to participate in a HFSA even if you are not enrolled in a COOK Health Plan option.
• You can only enroll in one HFSA option.
IMPORTANT: The last day (date of service) you can incur claims towards your 2017 GPHFSA or LPHFSA is December 31, 2017.However, you will have until March 31, 2018 to submit 2017 claims to the COOK Insurance Department for reimbursement. Funds remaining in a 2017 GPHFSA or LPHFSA after March 31, 2018 are forfeited.
Are You Making the Most of Your COOK Employee Benefits?Make certain to take full advantage of the benefits COOK offers because doing so can save you thousands of dollars in taxes. You get tax breaks on out-of-pocket health care expenses by contributing to a HFSA and now you can get additional tax breaks on day care and elder care expenses by contributing to a DCFSA. Don’t forget the tax breaks on the money you contribute to the COOK Profit Sharing 401k Plan. Make certain you are contributing at least 4% of your pay to the COOK Profit Sharing 401(k) Plan to maximize the 4% company match. All these benefits add up to significant tax savings over time.
New Health Plan ID CardYou will receive two new COOK Health Plan ID cards mailed to your home. In addition to the Anthem network information on the ID card, you will find contact and claim processing information for Delta Dental and TrueScripts.
2017 COOK Health Plan Employee Premiums
The partnerships with Anthem, TrueScripts, and Delta Dental have provided favorable discounts which have saved employees money and allowed COOK to only increase premiums by 4% even though projected increases in health care spending for the next year is 6%. COOK Health Plan employee premium rates include medical, dental, vision and prescription drug benefits. Employee premiums by pay period for 2016 and 2017 are shown in the tables below
Traditional & Clinic Plan Premiums
Weekly Bi-weekly Monthly
2016 2017 2016 2017 2016 2017
Employee Only $15.72 $16.35 $31.45 $32.71 $68.14 $70.87
Employee + Spouse $77.38 $80.47 $154.75 $160.94 $335.30 $348.71
Employee + Child(ren) $51.67 $53.73 $103.33 $107.47 $223.89 $232.85
Family $100.33 $104.34 $200.66 $208.69 $434.77 $452.16
Castlight: COOK’s Healthcare Shopping Tool
Castlight is a personalized healthcare shopping tool that allows you to shop for medical services based on cost, quality, and convenience. If you haven’t already registered with Castlight, you can register during open enrollment on the benefits enrollment system or you can register anytime by visiting Castlight’s website: www.mycastlight.com/cook. Castlight is provided free of charge to employees and their covered family members who are enrolled in the COOK Traditional or Clinic Plans that use the Anthem Blue Card PPO network.
ADDITIONAL INFORMATION
Anthem Employee Assistance Program
This is a reminder that the Anthem Employee Assistance Program is available to COOK employees and family members who need help meeting the demands and stresses of everyday life. Enrollment in the EAP or COOK Health Plan is not required. To talk with an EAP staff member 24/7 just call 1.800.865.1044 or visit www.anthemEAP.com and enter “COOK”.
Update Your Life Insurance and Profit Sharing Plan Beneficiaries
Remember to update your life insurance beneficiary with Prudential by logging on to Prudential’s website at www.prudential.com/mybenefits. You will need the COOK company control number, which is 50318. You can update your life insurance beneficiary at any time (not just during open enrollment) on the website.
You can update your COOK Profit Sharing 401(k) Plan beneficiary by logging on to Fidelity’s website at www.401k.com. Click on “Profile” and then click on “Beneficiary” to access the beneficiary update screen. You can also call Fidelity at 1.800.835.5091 and request a beneficiary designation form to complete and send back to Fidelity
COOK Group Long Term Care Insurance Program
COOK offers voluntary long term care insurance to full-time employees and to the employees’ spouses, parents, grandparents and children. Employees and eligible family members can apply at any time, not just during open enrollment. Contact Genworth at 1.800.416.3624 or visit www.genworth.com/groupltc for more information or to enroll. If visiting the website use Group ID “Cook” and Access Code “groupltc.” If you are already enrolled in long term care insurance you do not need to enroll again.
Benefits Fair
If you have questions about your employee benefits, representatives from Anthem, Castlight, Prudential, Fidelity, Delta Dental, and COOK Insurance Department will be at various COOK locations during open enrollment to provide assistance. Raymond Evans in COOK Medical’s Human Resources Department will be available at several locations to help you with questions about Castlight, Medicare, Medicaid, Social Security and other government health insurance programs. Employees who have questions and do not get the opportunity to meet with a representative should contact the COOK Insurance Department at 1.800.593.2080 or COOK Group Benefits Coordinator at 1.800.468.1379, ext. 102356 for assistance.
Your local human resources department will provide the dates and times the representatives will be at various COOK locations. Please contact your local human resources department or the contacts listed below if you have any questions concerning your 2017 employee benefit options or the online enrollment process.
For assistance contact:
Local Human Resources Department
COOK Insurance Department – 1.800.593.2080
COOK Group Benefits Coordinator (Jed Ehret) – 1.800.468.1379, ext. 102356
COOK Member Engagement Specialist (Raymond Evans) – 1.800.468.1379, ext. 102847
Attachments:
Vision Plan Summary
Hearing Aid Benefits Summary
Dependent Care Flexible Spending Account Summary
Dependent Care Flexible Spending Account FAQ
Limited Purpose Health Flexible Spending Account Summary
2017 COOK Health Plan Summary of Benefits and Coverage
2017 Online Enrollment Instructions
Women’s Cancer Rights Notice
Medicare Prescription Drug Notice
Medicaid Children’s Health Insurance Notice
Notice of Privacy Practices
Your Blue View Vision network
Blue View Vision offers you one of the largest vision care networks in the industry, with a wide selection of experienced ophthalmologists, optometrists, and opticians. Blue View Vision’s network also includes convenient retail locations, many with evening and weekend hours, including 1-800-CONTACTS, LensCrafters®, Sears OpticalSM, Target Optical®, JCPenney® Optical and most Pearle Vision® locations. Best of all – when you receive care from a Blue View Vision participating provider, you can maximize your benefits and money-saving discounts.
Out-of-network: If you choose to, you may receive covered benefits outside of the Blue View Vision network. Just pay in full at the time of service, obtain an itemized receipt, and file a claim for reimbursement of your out-of-network allowance. In-network benefits and discounts will not apply.
YOUR BLUE VIEW VISION PLAN AT-A-GLANCE
VISION PLAN BENEFIT IN-NETWORK OUT-OF-NETWORK
Routine eye exam Once every calendar year. • $0 copay, then covered in full • $42 allowance
Eyeglass framesOnce every two calendar years you may select an eyeglass frame and receive an allowance toward the purchase price.
• $200 allowance, then 20% off any remaining balance • $42 allowance
Eyeglass lenses (Standard)Once every calendar year you may receive any one of the following lens options:
• Standard plastic single vision lenses (1 pair)
• Standard plastic bifocal lenses (1 pair)
• Standard plastic trifocal lenses (1 pair)
• $0 copay, then covered in full
• $0 copay, then covered in full
• $0 copay, then covered in full
• $40 allowance
• $60 allowance
• $80 allowance
Eyeglass lens enhancementsWhen obtaining covered eyewear from a Blue View Vision provider, you may add any of the following lens enhancements at no extra cost.
• Transitions Lenses (for a child under age 19)
• Standard Polycarbonate (for a child under age 19)
• Factory Scratch Coating
• $0 after eyeglass lens copay
• $0 after eyeglass lens copay
• $0 after eyeglass lens copay
No allowance on lens enhancements when obtained out-of-network
Contact lensesOnce every calendar year. Prefer contact lenses over glasses? You may choose contact lenses instead of eyeglass lenses and receive an allowance toward the cost of a supply of contact lenses.
• Elective Conventional Lenses; or
• Elective Disposable Lenses; or
• Non-Elective Contact Lenses
• $105 allowance
• $105 allowance
• $210 allowance
• $200 allowance, then 15% off any remaining balance
• $200 allowance (no additional discount)
• Covered in fullYour contact lens allowance can only be applied toward the first purchase of contacts you make during a benefit period. Any unused amount remaining cannot be used for subsequent purchases made during the same benefit period, nor can any unused amount be carried over to the following benefit period.
EXCLUSIONS & LIMITATIONS (not a complete list)
Combined Offers. Not combined with any offer, coupon, or in-store advertisement.
Excess Amounts. Amounts in excess of covered vision expense.
Sunglasses. Sunglasses and accompanying frames.
Safety Glasses. Safety glasses and accompanying frames.
Not Specifically Listed. Services not specifically listed in this plan as covered services.
Lost or Broken Lenses or Frames. Any lost or broken lenses or frames are not eligible for replacement unless the insured person has reached his or her normal service interval as indicated in the plan design.
Non-Prescription Lenses. Any non-prescription lenses, eyeglasses or contacts. Plano lenses or lenses that have no refractive power.
Orthoptics. Orthoptics or vision training and any associated supplemental testing.
VISION PLAN SUMMARY
OPTIONAL SAVINGS AVAILABLE FROM IN-NETWORK PROVIDERS ONLYIN-NETWORK MEMBER COST
(AFTER ANY APPLICABLE COPAY)
Retinal Imaging - at member’s option can be performed at time of eye exam Not more than $39
Eyeglass lens upgradesWhen obtaining eyewear from a Blue View Vision provider, you may choose to upgrade your new eyeglass lenses at a discounted cost. Eyeglass lens copayment applies.
• Transitions lenses (Adults)
• Standard Polycarbonate (Adults)
• Tint (Solid and Gradient)
• UV Coating
• Progressive Lenses1
• Standard
• Premium Tier 1
• Premium Tier 2
• Premium Tier 3
• Anti-Reflective Coating2
• Standard
• Premium Tier 1
• Premium Tier 2
• Other Add-ons and Services
$75
$40
$15
$15
$65
$85
$95
$110
$45
$57
$68
20% off retail price
Additional Pairs of EyeglassesAnytime from any Blue View Vision network provider
• Complete pair
• Eyeglass materials purchased separately
40% off retail price
20% off retail price
Eyewear Accessories • Items such as non-prescription sunglasses, lens cleaning supplies, contact lens solutions, eyeglass cases, etc.
20% off retail price
Contact lens fit and follow-upA contact lens fitting and up to two follow-up visits are available to you once a comprehensive eye exam has been completed.
• Standard contact lens fitting3
• Premium contact lens fitting4
Up to $55
10% off retail price
Conventional Contact Lenses • Discount applies to materials only 15% off retail price
Laser vision correction surgery
LASIK refractive surgery
• Discount per eye For more information, go to anthem.com/specialoffers and select vision care.
Members can take advantage of savings opportunities from dozens of vendors on a variety of products and services, including LASIK vision surgery, hearing services and aids, wellness products, weight loss programs, fitness memberships, elder care services, 1-800-Contacts* and much more.1 Please ask your provider for his/her recommendation as well as the progressive brands by tier.2 Please ask your provider for his/her recommendation as well as the coating brands by tier.3 A standard contact lens fitting includes spherical clear contact lenses for conventional wear and planned replacement. Examples include but
are not limited to disposable and frequent replacement. 4 A premium contact lens fitting includes all lens designs, materials and specialty fittings other than standard contact lenses. Examples include
but are not limited to toric and multifocal.
OUT-OF-NETWORK
If you choose an out-of-network provider, please complete an out-of-network claim form available in your local HR department or on the www.cookmedicalclaims.com website submit it along with your itemized receipt to the fax number, email address, or mailing address below. When visiting an out-of-network provider, discounts do not apply and you are responsible for payment of services and/or eyewear materials at the time of service.
To Fax: 866-293-7373To Email: [email protected] Mail: Blue View Vision
Attn: OON ClaimsP.O. Box 8504 Mason, OH 45040-7111
Blue View Vision is for routine eye care only. If you need medical treatment for your eyes, visit a participating eye care physician from your medical network. If you have questions about your benefits or need help finding a provider, visit anthem.com or call us at 1-866-723-0515.
This is a primary vision care benefit intended to cover only routine eye examinations and corrective eyewear. Benefits are payable only for expenses incurred while the group and insured person’s coverage is in force.
This information is intended to be a brief outline of coverage. All terms and conditions of coverage, including benefits and exclusions, are contained in the plan document, which shall control in the event of a conflict with this overview. Discounts referenced are not covered benefits under this vision plan and therefore are not included in the plan document. Frame discounts may not apply to some frames where the manufacturer has imposed a no discount policy on sales at retail and independent provider locations. Discounts are subject to change without notice. This benefit overview is only one piece of your entire enrollment package.
Transitions and the swirl are registered trademarks of Transitions Optical, Inc. Photochromic performance is influenced by temperature, UV exposure and lens material. Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Ohio: Community Insurance Company. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue Shield Association. 7/12
OPTIONAL SAVINGS AVAILABLE FROM IN-NETWORK PROVIDERS ONLY In-network Member Cost (after any applicable copay)
Retinal Imaging - at member’s option can be performed at time of eye exam Not more than $39 Eyeglass lens upgrades
When obtaining eyewear from a Blue View Vision provider, you may choose to upgrade your new eyeglass lenses at a discounted cost. Eyeglass lens copayment applies.
£ lenses (Adults) £ Standard Polycarbonate (Adults) £ Tint (Solid and Gradient) £ UV Coating £ Progressive Lenses1
£ Standard £ Premium Tier 1 £ Premium Tier 2 £ Premium Tier 3
£ Anti-Reflective Coating2 £ Standard £ Premium Tier 1 £ Premium Tier 2
£ Other Add-ons and Services
$75 $40 $15 $15
$65 $85 $95
$110
$45 $57 $68
20% off retail price
Additional Pairs of Eyeglasses Anytime from any Blue View Vision network provider
£ Complete Pair £ Eyeglass materials purchased separately
40% off retail price 20% off retail price
Eyewear Accessories £ Items such as non-prescription sunglasses, lens cleaning supplies, contact lens solutions, eyeglass cases, etc.
20% off retail price
Contact lens fit and follow-up A contact lens fitting and up to two follow-up visits are available to you once a comprehensive eye exam has been completed.
£ Standard contact lens fitting3 £ Premium contact lens fitting4
Up to $55
10% off retail price
Conventional Contact Lenses £ Discount applies to materials only 15% off retail price
Laser vision correction surgery LASIK refractive surgery
£ Discount per eye
For more information, go to anthem.com/specialoffers
and select vision care. Members can take advantage of savings opportunities from dozens of vendors on a variety of products and services, including LASIK vision surgery, hearing services and aids, wellness products, weight loss programs, fitness memberships, elder care services, *and much more.
1 Please ask your provider for his/her recommendation as well as the progressive brands by tier. 2 Please ask your provider for his/her recommendation as well as the coating brands by tier.
3 A standard contact lens fitting includes spherical clear contact lenses for conventional wear and planned replacement. Examples include but are not limited to disposable and frequent replacement. 4 A premium contact lens fitting includes all lens designs, materials and specialty fittings other than standard contact lenses. Examples include but are not limited to toric and multifocal.
OUT-OF-NETWORK If you choose an out-of-network provider, please complete an out-of-network claim form available in your local HR department or on the www.cookmedicalclaims.com website submit it along with your itemized receipt to the fax number, email address, or mailing address below. When visiting an out-of-network provider, discounts do not apply and you are responsible for payment of services and/or eyewear materials at the time of service.
To Fax: 866-293-7373 To Email: [email protected] To Mail: Blue View Vision
Attn: OON Claims P.O. Box 8504 Mason, OH 45040-7111
Blue View Vision is for routine eye care only. If you need medical treatment for your eyes, visit a participating eye care physician from your medical network. If you have questions about your benefits or need help finding a provider, visit anthem.com or call us at 1-866-723-0515. This is a primary vision care benefit intended to cover only routine eye examinations and corrective eyewear. Benefits are payable only for expenses incurred while the group and insured person’s coverage is in force. This information is intended to be a brief outline of coverage. All terms and conditions of coverage, including benefits and exclusions, are contained in the plan document, which shall control in the event of a conflict with this overview. Discounts referenced are not covered benefits under this vision plan and therefore are not included in the plan document. Frame discounts may not apply to some frames where the manufacturer has imposed a no discount policy on sales at retail and independent provider locations. Discounts are subject to change without notice. This benefit overview is only one piece of your entire enrollment package.
Effective January 1, 2017
This benefit covers medically necessary hearing aids when ordered or purchased as a result of a written recommendation from an otolaryngologist or state certified audiologist.
What is Covered?
• Hearing aids (monaural or binaural) including ear mold(s).
• Hearing aid instrument, batteries, cords and other ancillary equipment.
What is NOT Covered?
• Charges for a hearing aid which exceeds specifications prescribed for the correction of the hearing loss.
• Surgically implanted hearing devices (i.e. cochlear implants, audient bone conduction devices). Medically necessary surgically implanted hearing devices may be covered under the COOK Health Plan’s medical benefits for prosthetic devices.
• Charges for a hearing aid which is not medically necessary
Hearing Aid Benefits
• The COOK Health Plan pays a maximum of $3,000 per person every 5 years for hearing aids and supplies.
• Network Benefits - Plan pays 80% after medical plan deductible. Charges apply to the annual out-of-pocket maximum. For network benefits you must use Blue Cross Blue Shield National Blue Card PPO network providers. Employees in Pennsylvania must use the FirstHealth providers for network benefits.
• Out-of-Network Benefits - Plan pays 60% after medical plan deductible. Charges do not apply to annual out-of-pocket maximum. Use any qualified provider.
This Summary of Benefits is a brief overview. Refer to you Cook Health Plan booklet for more details.
COOK HEALTH PLAN HEARING AID BENEFIT SUMMARY
Effective January 1, 2017
A DCFSA is a great way to pay dependent care expenses and lower your taxable income. It can be used to pay a child’s day care expenses or to pay custodial expenses for a disabled spouse or grandparent. The expenses must be incurred so you (and your spouse) can work. If you have a stay at home spouse, you should not enroll in a DCFSA.
How Does the DCFSA Work?
• Elect your DCFSA during open enrollment or during new hire open enrollment period.
• Contribute up to $5,000 maximum per year per family if your tax filing status is “married and filing jointly” and $2,500 maximum per year if tax filing is “married and filing single.” Minimum contribution amount is $100.
• Contributions are pre-tax; reimbursements are tax free.
• No advanced funding. You can only be reimbursed for funds in your DCFSA at the time you claim them.
• Reimbursements are processed on the Monday following each of your regular pay periods.
• Debit card and direct deposit available.
• “Use it or lose it.” Your DCFSA must be used for services incurred on or before December 31 of plan year. Funds remaining in your DCFSA after March 31 of the following plan year will be forfeited.
• Changes to a DCFSA election amount allowed outside of open enrollment with qualified IRS status change. The change must be consistent with the event.
• COOK Insurance Department processes your claims.
Qualifying Dependents
• A tax dependent of yours who is under age 13.
• A tax dependent of yours, such as a spouse or elderly parent, who is physically or mentally incapable of self-care and has the same principal residence as you.
Examples of Eligible DCFSA Expenses
• Before and after school care.
• Baby sitter in your home or outside your home. Provider cannot be an IRS tax dependent.
• Summer day camp for child.
• Expenses for licensed day care, preschool, and nursery school.
• Elder day care expenses.
Examples of Ineligible Expenses
• Payments to a spouse or to a person you or your spouse can claim as a dependent on IRS tax filings.
• Day care for child age 13 or older.
• Education fees/tuition/enrichment classes/summer school/overnight camps.
• Nursing home/long term care expenses.
• Meals, supplies, transportation costs.
This Summary of Benefits is a brief overview. Refer to you Cook Health Plan booklet for more details.
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (DCFSA)
What is a DCSA?
A DCFSA creates a tax break for dependent child care or day care expenses for children under age 13 or for children of any age who require custodial care because they are physically or mentally incapable of self-care. Additionally, it can be used for custodial day care for a disabled spouse or elderly parents who are considered an Internal Revenue Service (IRS) tax dependent and require someone to come into the home to assist with day-to-day living.
How do I save money on day care expenses?
You direct a portion of your pay into an account every regular pay period to pay for dependent care expenses. The money that you direct into a DCFSA is before taxes and reimbursements from the account are not taxed. You can use this account throughout the calendar year to pay dependent care expenses so you and, if married, your spouse can work. If you have a stay-at-home spouse you should not enroll in a DCFSA.
How do I enroll in a DCFSA?
You can enroll in a DCFSA during COOK’S annual open enrollment period. You cannot change your DCFSA election amount outside of open enrollment without experiencing a qualified IRS status change such as loss of a job or birth of a child. You can also enroll outside of open enrollment if you experience a qualified IRS status change.
Can my DCFSA contribution amount be changed?
You cannot change your DCFSA contribution amount outside of open enrollment without a qualified IRS status change.
How do I decide how much money to contribute to a DCFSA?
Estimate your day care expenses for the entire calendar year and take into consideration any school holidays, breaks or summer vacations. Before and after school expenses are allowable as well as some summer day camps. The maximum annual deduction is $5,000 per family if tax filing status is “married and filing jointly” and $2,500 if tax filing status is “married and filing separately.” The minimum contribution is $100.
What happens to unused funds in my DCFSA after the end of the year?
“Use it or lose it.” All funds in your DCFSA must be used for services incurred on or before December 31st of the plan year. You have until March 31st of the following plan year to submit claims for reimbursement from the prior year. Funds left in your account after March 31st of the following plan year are forfeited.
What happens if I stop working at COOK?
Your DCFSA contributions will stop. Expenses for dependent care expenses incurred after your termination date are not eligible for reimbursement. You have 60 days from your termination date to submit claims for services incurred on or before your termination date with COOK. Funds remaining in your account after 60 days will be forfeited.
If my spouse has a DCFSA, can we both contribute $5,000 each?
No. Your combined maximum contribution per family per calendar year is $5,000 or $2,500 for each account.
If I pay my 16-year old daughter to watch my 8-year old son after school, can I be reimbursed for payments made to my daughter?
No. You cannot be reimbursed for paying an older sibling that you (or your spouse) can claim as a dependent on your IRS tax filing. You also cannot be reimbursed for payments made to a child who is younger than age 19 at the end of the plan year.
If I have a DCFSA, do I need to report anything on my tax return at the end of the year?
Yes. You must list all people or organizations that provided care to your child or elderly dependent. You do this by filing Form 2441 – Child and Dependent Care Expenses along with Form 1040 (or Schedule 2 for Form 1040A).
If I have a DCFSA, can I claim the dependent care credit on my tax return?
No. You cannot claim any other tax benefit for the tax-free money you get under this DCFSA. Talk with your tax advisor for more details.
If I put $400 each month in my DCFSA and my actual expenses are $500 per month, should I submit a claim for $400 or 500?
You should submit a claim for the actual expense amount which is $500. If you have $500 in you DCFSA, you will be reimbursed for that amount. If not, the rest will be put on hold and reimbursed on the next reimbursement cycle when funds are in your account.
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (DCFSA) FREQUENTLY ASKED QUESTIONS
Can I pay for dependent care expenses with a debit card?
The DCFSA comes with a debit card for you to use to pay for dependent care expenses. You can only swipe the debit card for the amount that is in your account at that time; otherwise, the entire transaction will be declined.
How can I keep track of my DCFSA activity?
Your account information can be viewed anytime by logging on to www.cookmedicalclaims.com.
You can view your current balance, claim status, and reimbursement history. You can also contact the COOK Insurance Department at 800.593.2080 for this information. You will need your COOK Health Plan ID number to log on to the www.cookmedicalclaims.com website.
How do I file a dependent care claim?
Claims for reimbursement can be filed manually. You pay for the dependent care services and send in the receipt along with a Dependent Care Claim Form to the COOK Insurance Department. Your child’s day care or elder care provider’s current Tax ID or SSN will also be required. Claims forms are available in your local HR office or on www.cookmedicalclaims.com website.
When are dependent care claims reimbursed?
Your reimbursement will be processed on the Monday following each of your payroll contributions until the end of the year. Reimbursement checks will be mailed to your home unless you have signed up for direct deposit.
How can I be reimbursed for re-incurring dependent care expenses?
COOK offers a time-saving re-incurring Dependent Care Claim Form that can be found online at www.cookmedicalclaims.com. This form saves you time as it only needs to be completed once at the beginning of each new plan year. No further dependent care claim submissions will be required by you for that plan year. Please keep in mind that you must submit a new claim form each plan year. The form must be signed and dated by your day care provider. Your child’s day care provider’s current Tax ID or SSN will also be required.
Is direct deposit an option?
Yes. To receive the reimbursement faster, send along a Direct Deposit Enrollment Form which can also be found online at www.cookmedicalclaims.com or in your local human resources office. Your reimbursement will be deposited in your bank account the next business day after Monday’s weekly check cycle following your DCHFSA payroll contribution.
DCFSA TAX SAVINGS EXAMPLES:
A DCFSA offers a better way to manage dependent care expenses and realize more tax savings. Your actual savings is based upon several factors including income, IRS filing status, tax bracket, the amount of income taxes you pay, and yearly dependent care expenses.
IRS 2016 Tax Tables 15% Tax Bracket
Example 1: Single with 2 children With DCFSA Without DCF
Taxable Income before DCFSA ContributionDCFSA Pre-Tax Contributions from PayrollTaxable IncomeEstimated Federal/State/County WithholdingEstimated Social Security Tax -7.65%Dependent Care ExpensesTax Credit for Dependent Care ExpensesTake Home PayTax Savings
$40,000($2,500)$37,500($6,809)($2,869)($2,500) —
$27,822$126
$40,000 —$40,000($7,294)($3,060) —$550
$27,696
Example 2: Married with 2 children With DCFSA Without DCF
Taxable Income before DCFSA ContributionDCFSA Pre-Tax Contributions from PayrollTaxable IncomeEstimated Federal/State/County WithholdingEstimated Social Security Tax -7.65%Dependent Care ExpensesTax Credit for Dependent Care ExpensesTake Home PayTax Savings
$40,000($5,000)$35,000($5,861)($2,678) — —
$26,462$252
$40,000 —$40,000($6,831)($3,060)($5,000)$1,100
$26,210
Effective January 1, 2017
What is a LPHFSA?
The new LPHFSA option works like the current General Purpose HFSA, but tax free reimbursements are limited to out-of-pocket dental and vison care expenses and some preventive care expenses. It cannot be used for the reimbursement of out-of-pocket medical expenses.
Why Would I Choose the LPHFSA?
The LPHFSA gives an employee who has a spouse covered by a Health Savings Account (HSA) through their employer a HFSA option. According to Internal Revenue Service Regulations, a person covered by a General Purpose HFSA is not eligible to participate in a HSA, but can enroll in a LPHFSA.
How Does it Work?
• Contribute up to $2,500 per calendar year into a LPHFSA to pay for eligible out-of-pocket dental and vision expenses. Cannot use for medical expenses.
• Elect your LPHFSA during open enrollment.
• Contributions are pretax.
• Reimbursements are tax free.
• Cook Insurance Dept. processes your claims.
• Debit card and direct deposit available.
• Use it or lose it – LPHFSA must be used for services incurred on or before December 31 of the plan year. Funds remaining in your LPHFSA after March 31 of the following calendar year are forfeited.
• Changes to a LPHFSA election amount allowed outside of open enrollment with qualified IRS status change.
Examples of Eligible Expenses
• Eligible out of pocket dental expenses for cleanings, x-rays, filings, crowns, orthodontia, dentures, and eligible dental expenses that exceed plan maximums.
• Eligible out-of-pocket vision expenses for exams, screening tests, eyeglasses, contact lenses, LASIK surgery and eligible vision expenses that exceed plan maximums.
Examples of Ineligible LPHFSA Expenses
• Medical expenses including deductibles, copays, and coinsurance
• Health plan premiums
• Cosmetic medical and dental procedures
• Over the counter medicines
This Summary of Benefits is a brief overview. Refer to your Cafeteria Plan booklet for more details.
LIMITED PURPOSE HEALTH FLEXIBLE SPENDING ACCOUNT (LPHFSA)
1 of 8
Coo
k Medical
Coo
k Group
Health
Plan: Clinic Plan (CP) Option Period: 01/01/2017 – 12/31/2017
Summary of Benefits and
Coverage: What this Plan Covers & What it Costs
Coverage for: Employee & Child(ren), Family| P
lan Type: P
PO
Que
stio
ns: C
all 1
.800
.593
.208
0 or
visi
t us a
t ww
w.c
ookm
edic
alcl
aim
s.co
m.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.coo
kmed
ical
clai
ms.
com
or c
all 1
.800
.593
.208
0 to
requ
est a
cop
y.
Thi
s is
onl
y a
sum
mar
y. If
you
wan
t mor
e de
tail
abou
t you
r cov
erag
e an
d co
sts,
you
can
get t
he c
ompl
ete
term
s in
the
polic
y or
pla
n do
cum
ent a
t w
ww
.coo
kmed
ical
clai
ms.
com
or b
y ca
lling
1-8
00-5
93-2
080.
Impo
rtan
t Que
stio
ns
Ans
wer
s
Wha
t is
the
over
all
dedu
ctib
le?
$500
per
indi
vidu
al a
nd $
1,00
0 pe
r fam
ily fo
r in-
netw
ork
serv
ices
. S
epar
ate
dedu
ctib
les (
$500
per
in
divi
dual
and
$1,
000
per f
amily
) fo
r out
-of-
netw
ork
serv
ices
. No
mor
e th
an $
500
per p
erso
n co
unts
tow
ards
the
fam
ily
dedu
ctib
le. I
n-ne
twor
k pr
even
tive
care
, clin
ic la
b w
ork,
den
tal a
nd
visio
n ca
re, a
nd p
resc
riptio
n dr
ugs
are
not s
ubje
ct to
thes
e de
duct
ible
s. D
enta
l and
visi
on
care
, pre
scrip
tion
drug
s, co
paym
ents
, sec
ond
or th
ird
surg
ical
opi
nion
s , an
d no
n-co
vere
d se
rvic
es c
anno
t be
used
to
satis
fy th
e de
duct
ible
s.
You
mus
t pay
all
the
cost
s up
to th
e de
duct
ible
am
ount
bef
ore
this
plan
beg
ins t
o pa
y fo
r cov
ered
se
rvic
es y
ou u
se. T
he d
educ
tible
star
ts o
ver J
anua
ry 1
of e
ach
year
. See
the
char
t sta
rting
on
page
3
for h
ow m
uch
you
pay
for c
over
ed se
rvic
es a
fter y
ou m
eet t
he d
educ
tible
.
Are
ther
e ot
her
dedu
ctib
les
for s
peci
fic
serv
ices
?
Yes
. The
re is
a $
300
fam
ily
dedu
ctib
le fo
r pre
scrip
tion
drug
ex
pens
es.
Ther
e ar
e no
oth
er
spec
ific
dedu
ctib
les.
You
mus
t pay
all
the
cost
s for
the
serv
ices
up
to th
e sp
ecifi
c de
duct
ible
am
ount
bef
ore
this
plan
be
gins
to p
ay fo
r the
serv
ices
.
Is th
ere
an o
ut-o
f-po
cket
lim
it on
my
expe
nses
?
Yes
. For
net
wor
k pr
ovid
ers,
ther
e is
an o
ut-o
f-po
cket
lim
it of
$2,
000
per i
ndiv
idua
l and
$4,
000
per
fam
ily. T
here
is n
o lim
it fo
r out
-of
-net
wor
k pr
ovid
ers.
The
out-o
f-po
cket
lim
it is
the
mos
t you
cou
ld p
ay d
urin
g a
cale
ndar
yea
r for
you
r sha
re o
f the
cos
ts
of c
over
ed se
rvic
es. T
his l
imit
help
s you
pla
n fo
r hea
lth c
are
expe
nses
. The
re's
no li
mit
on h
ow
muc
h yo
u ca
n pa
y du
ring
a ca
lend
ar y
ear f
or y
our s
hare
of t
he c
ost o
f out
-of-
netw
ork
cove
red
serv
ices
.
2 of 8
Coo
k Medical
Coo
k Group
Health
Plan: Clinic Plan (CP) Option Period: 01/01/2017 – 12/31/2017
Summary of Benefits and
Coverage: What this Plan Covers & What it Costs
Coverage for: Employee & Child(ren), Family| P
lan Type: P
PO
Que
stio
ns: C
all 1
.800
.593
.208
0 or
visi
t us a
t ww
w.c
ookm
edic
alcl
aim
s.co
m.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.coo
kmed
ical
clai
ms.
com
or c
all 1
.800
.593
.208
0 to
requ
est a
cop
y.
Wha
t is
not i
nclu
ded
in
the
out-
of-p
ocke
t lim
it?
Prem
ium
s, ba
lanc
e bi
lled
char
ges
(unl
ess b
alan
ce b
illin
g is
proh
ibite
d ), h
ealth
car
e th
is pl
an
does
n't c
over
, adu
lt de
ntal
, visi
on,
fam
ily p
lann
ing,
out
-of-
netw
ork
char
ges,
amou
nts r
eim
burs
ed
unde
r the
pre
scrip
tion
drug
sp
ecia
lty c
are
prog
ram
, and
pe
nalti
es fo
r fai
lure
to o
btai
n pr
eaut
horiz
atio
n .
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
do n
ot c
ount
tow
ard
the
out-o
f-po
cket
lim
it.
Is
ther
e an
ove
rall
annu
al
limit
on w
hat t
he p
lan
pays
?
No.
Th
e ch
art s
tarti
ng o
n pa
ge 3
des
crib
es a
ny li
mits
on
wha
t the
pla
n w
ill p
ay fo
r spe
cific
cove
red
serv
ices
, suc
h as
off
ice
visit
s.
Doe
s th
is p
lan
use
a ne
twor
k of
pro
vide
rs?
Yes
. See
ww
w.an
them
.com
or c
all
Ant
hem
’s Pr
ovid
er L
ocat
or
tele
phon
e nu
mbe
r 1.
800.
810.
2583
. You
can
also
cal
l C
ook
Insu
ranc
e D
ept.
1-80
0-59
3-20
80 fo
r ass
istan
ce fi
ndin
g ne
twor
k pr
ovid
ers.
If y
ou u
se a
net
wor
k do
ctor
or o
ther
hea
lth c
are
prov
ider
, thi
s pla
n w
ill p
ay so
me
or a
ll of
the
cost
s of
cov
ered
serv
ices
. Be
awar
e, y
our n
etw
ork
doct
or o
r hos
pita
l may
use
an
out-o
f-ne
twor
k pr
ovid
er
for s
ome
serv
ices
. Pla
ns u
se th
e te
rms “
netw
ork,
” “p
refe
rred
,” o
r “pa
rtici
patin
g” fo
r pro
vide
rs in
th
eir n
etw
ork.
See
the
char
t sta
rting
on
page
3 fo
r how
this
plan
pay
s diff
eren
t kin
ds o
f pro
vide
rs.
Do
I ne
ed a
refe
rral
to s
ee
a sp
ecia
list?
N
o.
You
can
see
the
spec
ialis
t you
cho
ose
with
out p
erm
issio
n fr
om th
is pl
an.
Are
ther
e se
rvic
es th
is
plan
doe
sn’t
cove
r?
Yes
. T h
e se
rvic
es th
is pl
an d
oesn
't co
ver a
re li
sted
on
page
5. S
ee y
our b
enef
its b
ookl
et o
r pla
n m
anua
l fo
r add
ition
al in
form
atio
n ab
out e
xclu
ded
serv
ices
.
OM
B Co
ntro
l Num
bers
154
5-22
29,
1210
-014
7, a
nd 0
938-
1146
Rele
ased
on
Apr
il 23
, 201
3 (c
orre
cted
)
3 of 8
Coo
k Medical
Coo
k Group
Health
Plan: Clinic Plan (CP) Option Period: 01/01/2017 – 12/31/2017
Summary of Benefits and
Coverage: What this Plan Covers & What it Costs
Coverage for: Employee & Child(ren), Family| P
lan Type: P
PO
Que
stio
ns: C
all 1
.800
.593
.208
0 or
visi
t us a
t ww
w.c
ookm
edic
alcl
aim
s.co
m.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.coo
kmed
ical
clai
ms.
com
or c
all 1
.800
.593
.208
0 to
requ
est a
cop
y.
• C
opay
men
ts a
re fi
xed
dolla
r am
ount
s (fo
r exa
mpl
e, $
15) y
ou p
ay fo
r cov
ered
hea
lth c
are,
usu
ally
whe
n yo
u re
ceiv
e th
e se
rvic
e. •
Coi
nsur
ance
is yo
ur sh
are
of th
e co
sts o
f a c
over
ed se
rvic
e, c
alcu
late
d as
a p
erce
nt o
f the
allo
wed
am
ount
for t
he se
rvic
e. F
or e
xam
ple,
if th
e pl
an’s
allo
wed
am
ount
for a
n ov
erni
ght h
ospi
tal s
tay
is $1
,000
, you
r coi
nsur
ance
pay
men
t of 2
0% w
ould
be
$200
. Th
is m
ay c
hang
e if
you
have
n’t m
et y
our
dedu
ctib
le.
• Th
e am
ount
the
plan
pay
s for
cov
ered
serv
ices
is b
ased
on
the
allo
wed
am
ount
. If a
n ou
t-of-
netw
ork
prov
ider
cha
rges
mor
e th
an th
e al
low
ed a
mou
nt,
you
may
hav
e to
pay
the
diff
eren
ce. F
or e
xam
ple,
if a
n ou
t-of-
netw
ork
hosp
ital c
harg
es $
1,50
0 fo
r an
over
nigh
t sta
y an
d th
e al
low
ed a
mou
nt is
$1,
000,
yo
u m
ay h
ave
to p
ay th
e $5
00 d
iffer
ence
. (Th
is is
calle
d ba
lanc
e bi
lling
.) •
This
plan
may
enc
oura
ge y
ou to
use
net
wor
k pr
ovid
ers
by c
harg
ing
you
low
er d
educ
tible
s, c
opay
men
ts a
nd c
oins
uran
ce a
mou
nts.
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
You
r Cos
t If Y
ou
Use
an
In
-net
wor
k Pr
ovid
er
You
r Cos
t If Y
ou
Use
an
O
ut-o
f-ne
twor
k Pr
ovid
er
Lim
itatio
ns &
Exc
eptio
ns
If y
ou v
isit
a he
alth
ca
re p
rovi
der’s
offi
ce
or c
linic
Prim
ary
care
visi
t to
treat
an
inju
ry o
r illn
ess
$15
co-p
ay p
er v
isit
Not
cov
ered
C
o-pa
y co
vers
lab
wor
k, m
inor
surg
ery
and
x-ra
ys in
phy
sicia
n's o
ffic
e
Spec
ialis
t visi
t $1
5 co
-pay
per
visi
t 40
% c
oins
uran
ce
Co-
pay
does
not
cov
er la
b w
ork,
min
or
surg
ery
and
x-ra
ys in
phy
sicia
n's o
ffic
e.
Oth
er p
ract
ition
er o
ffic
e vi
sit
20%
coi
nsur
ance
for
chiro
prac
tor
40%
coi
nsur
ance
Li
mite
d to
20
chiro
prac
tor v
isits
per
pe
rson
per
cal
enda
r yea
r. Pr
even
tive
care
/scr
eeni
ng/i
mm
uniz
atio
n N
o ch
arge
40
% c
oins
uran
ce
Non
e.
If y
ou h
ave
a te
st
Dia
gnos
tic te
st (x
-ray
, blo
od w
ork)
20
% c
oins
uran
ce
40%
coi
nsur
ance
N
one.
Imag
ing
(CT/
PET
scan
s, M
RIs)
20
% c
oins
uran
ce
40%
coi
nsur
ance
N
one.
If
you
nee
d dr
ugs
to
trea
t you
r illn
ess
or
cond
ition
M
ore
info
rmat
ion
abou
t pr
escr
iptio
n dr
ug
cove
rage
is a
vaila
ble
at
ww
w.c
ookm
edic
alcl
aim
s.co
m
Gen
eric
dru
gs
20%
coi
nsur
ance
20
% c
oins
uran
ce
50%
coi
nsur
ance
if d
rug
avai
labl
e in
ne
twor
k, b
ut p
urch
ased
out
-of-
netw
ork.
Se
para
te $
300
annu
al fa
mily
ded
uctib
le.
$100
coi
nsur
ance
max
imum
for 3
0 da
y su
pply
. Pr
efer
red
bran
d dr
ugs
20%
coi
nsur
ance
20
% c
oins
uran
ce
N
on-p
refe
rred
bra
nd d
rugs
20
% c
oins
uran
ce
20%
coi
nsur
ance
Spec
ialty
dru
gs
20%
coi
nsur
ance
20
% c
oins
uran
ce
If
you
hav
e ou
tpat
ient
su
rger
y Fa
cilit
y fe
e (e
.g.,
ambu
lato
ry su
rger
y ce
nter
) 20
% c
oins
uran
ce
40%
coi
nsur
ance
Pr
eaut
horiz
atio
n re
quire
d fo
r mos
t ou
tpat
ient
surg
erie
s or t
he su
rger
ies a
re
not c
over
ed.
4 of 8
Coo
k Medical
Coo
k Group
Health
Plan: Clinic Plan (CP) Option Period: 01/01/2017 – 12/31/2017
Summary of Benefits and
Coverage: What this Plan Covers & What it Costs
Coverage for: Employee & Child(ren), Family| P
lan Type: P
PO
Que
stio
ns: C
all 1
.800
.593
.208
0 or
visi
t us a
t ww
w.c
ookm
edic
alcl
aim
s.co
m.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.coo
kmed
ical
clai
ms.
com
or c
all 1
.800
.593
.208
0 to
requ
est a
cop
y.
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
You
r Cos
t If Y
ou
Use
an
In
-net
wor
k Pr
ovid
er
You
r Cos
t If Y
ou
Use
an
O
ut-o
f-ne
twor
k Pr
ovid
er
Lim
itatio
ns &
Exc
eptio
ns
Phys
icia
n/su
rgeo
n fe
es
20%
coi
nsur
ance
40
% c
oins
uran
ce
Prea
utho
rizat
ion
requ
ired
for m
ost
outp
atie
nt su
rger
ies o
r the
surg
erie
s are
no
t cov
ered
.
If y
ou n
eed
imm
edia
te
med
ical
atte
ntio
n
Em
erge
ncy
room
serv
ices
$1
00 c
o-pa
y; 2
0%
coin
sura
nce
$100
co-
pay,
20%
co
insu
ranc
e N
one.
Em
erge
ncy
med
ical
tran
spor
tatio
n 20
% c
oins
uran
ce
20%
coi
nsur
ance
N
one.
Urg
ent c
are
$50
co-p
ay; 2
0%
coin
sura
nce
$50
co-p
ay; 2
0%
coin
sura
nce
Non
e.
If y
ou h
ave
a ho
spita
l st
ay
Faci
lity
fee
(e.g
., ho
spita
l roo
m)
20%
coi
nsur
ance
40
% c
oins
uran
ce
Prea
utho
rizat
ion
requ
ired
for c
over
age.
Ph
ysic
ian/
surg
eon
fee
20%
coi
nsur
ance
40
% c
oins
uran
ce
Prea
utho
rizat
ion
requ
ired
for c
over
age.
If y
ou h
ave
men
tal
heal
th, b
ehav
iora
l he
alth
, or s
ubst
ance
ab
use
need
s
Men
tal/
Beha
vior
al h
ealth
out
patie
nt se
rvic
es
$15
co-p
ay p
er o
ffic
e vi
sit; 2
0%
coin
sura
nce
for
addi
tiona
l ser
vice
s
40%
coi
nsur
ance
N
one.
Men
tal/
Beha
vior
al h
ealth
inpa
tient
serv
ices
20
% c
oins
uran
ce
40%
coi
nsur
ance
Pr
eaut
horiz
atio
n re
quire
d fo
r cov
erag
e.
Subs
tanc
e-us
e di
sord
er o
utpa
tient
serv
ices
$15
co-p
ay p
er o
ffic
e vi
sit; 2
0%
coin
sura
nce
for
addi
tiona
l ser
vice
s
40%
coi
nsur
ance
N
one.
Subs
tanc
e-us
e di
sord
er in
patie
nt se
rvic
es
20%
coi
nsur
ance
40
% c
oins
uran
ce
Prea
utho
rizat
ion
requ
ired
for c
over
age.
If y
ou a
re p
regn
ant
Pren
atal
and
pos
tnat
al c
are
20%
coi
nsur
ance
40
% c
oins
uran
ce
Non
e.
Del
iver
y an
d al
l inp
atie
nt se
rvic
es
20%
coi
nsur
ance
40
% c
oins
uran
ce
Non
e.
5 of 8
Coo
k Medical
Coo
k Group
Health
Plan: Clinic Plan (CP) Option Period: 01/01/2017 – 12/31/2017
Summary of Benefits and
Coverage: What this Plan Covers & What it Costs
Coverage for: Employee & Child(ren), Family| P
lan Type: P
PO
Que
stio
ns: C
all 1
.800
.593
.208
0 or
visi
t us a
t ww
w.c
ookm
edic
alcl
aim
s.co
m.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.coo
kmed
ical
clai
ms.
com
or c
all 1
.800
.593
.208
0 to
requ
est a
cop
y.
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
You
r Cos
t If Y
ou
Use
an
In
-net
wor
k Pr
ovid
er
You
r Cos
t If Y
ou
Use
an
O
ut-o
f-ne
twor
k Pr
ovid
er
Lim
itatio
ns &
Exc
eptio
ns
If y
ou n
eed
help
re
cove
ring
or h
ave
othe
r spe
cial
hea
lth
need
s
Hom
e he
alth
car
e 20
% c
oins
uran
ce
40%
coi
nsur
ance
Pr
eaut
horiz
atio
n re
quire
d fo
r cov
erag
e.
Reha
bilit
atio
n se
rvic
es
20%
coi
nsur
ance
40
% c
oins
uran
ce
Non
e.
Hab
ilita
tion
serv
ices
20
% c
oins
uran
ce
40%
coi
nsur
ance
N
one.
Sk
illed
nur
sing
care
20
% c
oins
uran
ce
40%
coi
nsur
ance
N
one.
Dur
able
med
ical
equ
ipm
ent
20%
coi
nsur
ance
40
% c
oins
uran
ce
Som
e eq
uipm
ent m
ust b
e pr
eaut
horiz
ed
for c
over
age.
H
ospi
ce se
rvic
e 20
% c
oins
uran
ce
40%
coi
nsur
ance
N
one.
If y
our c
hild
nee
ds
dent
al o
r eye
car
e
Eye
exa
m
No
char
ge
See
limita
tions
and
ex
cept
ions
Out
-of-
netw
ork
- $42
tota
l allo
wan
ce fo
r an
ann
ual e
xam
and
$40
/$60
/$80
ann
ual
allo
wan
ce fo
r sta
ndar
d sin
gle/
bifo
cal/
trifo
cal l
ense
s. $
42
allo
wan
ce fo
r fra
mes
eve
ry 2
yea
rs.
Gla
sses
N
o ch
arge
Se
e lim
itatio
ns a
nd
exce
ptio
ns
In-n
etw
ork
- $20
0 al
low
ance
for f
ram
es
ever
y 2
year
s. D
enta
l che
ck-u
p N
o ch
arge
N
o ch
arge
Tw
o pe
r cal
enda
r yea
r.
Exc
lude
d Se
rvic
es &
Oth
er C
over
ed S
ervi
ces:
Serv
ices
You
r Pla
n D
oes
NO
T C
over
(Thi
s is
n’t a
com
plet
e lis
t. C
heck
you
r pol
icy
or p
lan
docu
men
t for
oth
er e
xclu
ded
serv
ices
.)
• A
cupu
nctu
re
• Lo
ng-te
rm c
are
• N
on-e
mer
genc
y ca
re w
hen
trave
ling
outs
ide
the
U.S
.
• Ro
utin
e fo
ot c
are
• W
eigh
t los
s pro
gram
s
Oth
er C
over
ed S
ervi
ces
(Thi
s is
n’t a
com
plet
e lis
t. C
heck
you
r pol
icy
or p
lan
docu
men
t for
oth
er c
over
ed s
ervi
ces
and
your
cos
ts fo
r the
se s
ervi
ces.
)
• C
hiro
prac
tic c
are
• C
osm
etic
surg
ery
to re
pair
an in
jury
or c
onge
nita
l de
form
ity o
r to
rest
ore
norm
al b
ody
func
tion
• Ba
riatri
c su
rger
y
• D
enta
l car
e (a
dult)
• In
ferti
lity
treat
men
t
• Pr
ivat
e du
ty n
ursin
g
• Ro
utin
e ey
e ca
re (a
dult)
• H
earin
g ai
ds
6 of 8
Coo
k Medical
Coo
k Group
Health
Plan: Clinic Plan (CP) Option Period: 01/01/2017 – 12/31/2017
Summary of Benefits and
Coverage: What this Plan Covers & What it Costs
Coverage for: Employee & Child(ren), Family| P
lan Type: P
PO
Que
stio
ns: C
all 1
.800
.593
.208
0 or
visi
t us a
t ww
w.c
ookm
edic
alcl
aim
s.co
m.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.coo
kmed
ical
clai
ms.
com
or c
all 1
.800
.593
.208
0 to
requ
est a
cop
y.
You
r Rig
hts
to C
ontin
ue C
over
age:
If
you
lose
cov
erag
e un
der
the
plan
, the
n, d
epen
ding
upo
n ci
rcum
stan
ces,
Fede
ral a
nd S
tate
law
s m
ay p
rovi
de p
rote
ctio
ns th
at a
llow
you
to k
eep
heal
th c
over
age.
Any
su
ch ri
ghts
may
be
limite
d in
dur
atio
n an
d w
ill re
quire
you
to p
ay a
pre
miu
m, w
hich
may
be
signi
fican
tly h
ighe
r tha
n th
e pr
emiu
m y
ou p
ay w
hile
cov
ered
und
er th
e pl
an.
Oth
er li
mita
tions
on
your
righ
ts to
con
tinue
cov
erag
e al
so a
pply
. Fo
r m
ore
info
rmat
ion
on y
our
right
s to
con
tinue
cov
erag
e, c
onta
ct th
e pl
an a
t 1-8
00-5
93-2
080.
Y
ou m
ay a
lso c
onta
ct y
our
stat
e in
sura
nce
depa
rtmen
t, an
d th
e U
.S.
Dep
artm
ent
of L
abor
’s E
mpl
oyee
Ben
efits
Sec
urity
Adm
inist
ratio
n at
1-8
66-4
44-3
272
or w
ww
.dol
.gov
/ebs
a/he
alth
refo
rm,
or t
he U
.S.
Dep
artm
ent
of H
ealth
and
H
uman
Ser
vice
s at 1
-877
-267
-232
3 ex
t. 61
656
or w
ww
.cci
io.c
ms.g
ov.
You
r Grie
vanc
e an
d A
ppea
ls R
ight
s:
If y
ou h
ave
a co
mpl
aint
or a
re d
issat
isfie
d w
ith a
den
ial o
f cov
erag
e fo
r cla
ims u
nder
you
r pla
n, y
ou m
ay b
e ab
le to
app
eal o
r file
a g
rieva
nce.
For
que
stio
ns a
bout
you
r rig
hts,
this
notic
e, o
r ass
istan
ce, y
ou c
an c
onta
ct: C
ook
Gro
up H
ealth
Pla
n A
dmin
istra
tor,
Coo
k G
roup
Inco
rpor
ated
, P.O
. Box
160
8 Bl
oom
ingt
on, I
N 4
7402
, 1.
800.
593.
2080
or D
epar
tmen
t of L
abor
, Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istra
tion
at 1
.866
.444
.EBS
A(3
272)
or w
ww
.dol
.gov
/ebs
a/he
alth
refo
rm.
Doe
s th
is C
over
age
Prov
ide
Min
imum
Ess
entia
l Cov
erag
e?
The
Aff
orda
ble
Car
e A
ct re
quire
s mos
t peo
ple
to h
ave
heal
th c
are
cove
rage
that
qua
lifie
s as “
min
imum
ess
entia
l cov
erag
e.”
Thi
s pl
an o
r pol
icy
does
pro
vide
m
inim
um e
ssen
tial c
over
age.
L
angu
age
Acc
ess
Serv
ices:
Span
ish (E
spañ
ol):
Para
obt
ener
asis
tenc
ia e
n E
spañ
ol, l
lam
e al
1.8
00.4
68.1
379.
C
hine
se (中文
): 如果需要中文的帮助,请拨打这个号码
1.8
00.4
68.1
379.
D
oes
this
Cov
erag
e M
eet t
he M
inim
um V
alue
Sta
ndar
d?
The
Aff
orda
ble
Car
e A
ct e
stab
lishe
s a m
inim
um v
alue
stan
dard
of b
enef
its o
f a h
ealth
pla
n. T
he m
inim
um v
alue
stan
dard
is 6
0% (a
ctua
rial v
alue
). T
his
heal
th
cove
rage
doe
s m
eet t
he m
inim
um v
alue
sta
ndar
d fo
r the
ben
efits
it p
rovi
des.
––––
––––
––––
––––
––––
–To s
ee ex
ample
s of h
ow th
is pla
n mi
ght c
over
costs
for a
samp
le me
dical
situa
tion,
see t
he n
ext p
age.–
––––
––––
––––
––––
––––
–
7 of 8
Coo
k Medical
Coo
k Group
Health
Plan: Clinic Plan (CP) Option Period: 01/01/2016 – 12/31/2016
Summary of Benefits and
Coverage: What this Plan Covers & What it Costs
Coverage for: Employee & Child(ren), Family| P
lan Type: P
PO
Que
stio
ns: C
all 1
.800
.593
.208
0 or
visi
t us a
t ww
w.c
ookm
edic
alcl
aim
s.co
m.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.coo
kmed
ical
clai
ms.
com
or c
all 1
.800
.593
.208
0 to
requ
est a
cop
y.
Having a baby
(n
orm
al d
eliv
ery)
Managing type 2 diabetes
(rout
ine
mai
nten
ance
of
a w
ell-c
ontro
lled
cond
ition
)
Abo
ut th
ese
Cov
erag
e E
xam
ples
: Th
ese
exam
ples
show
how
this
plan
mig
ht c
over
m
edic
al c
are
in g
iven
situ
atio
ns. U
se th
ese
exam
ples
to
see,
in g
ener
al, h
ow m
uch
finan
cial
pro
tect
ion
a sa
mpl
e pa
tient
mig
ht g
et if
they
are
cov
ered
und
er
diff
eren
t pla
ns.
n A
mou
nt o
wed
to p
rovi
ders
: $7,
540
n P
lan
pays
$5,
080
n P
atie
nt p
ays
$2,4
60
Sa
mpl
e ca
re c
osts
: H
ospi
tal c
harg
es (m
othe
r)
$2,7
00
Rout
ine
obst
etric
car
e $2
,100
H
ospi
tal c
harg
es (b
aby)
$9
00
Ane
sthe
sia
$900
La
bora
tory
test
s $5
00
Pres
crip
tions
$2
00
Radi
olog
y $2
00
Vac
cine
s, ot
her p
reve
ntiv
e $4
0 T
otal
$7
,540
Pa
tient
pay
s:
Ded
uctib
les
$1,2
00
Cop
ays
$0
Coi
nsur
ance
$1
260
Lim
its o
r exc
lusio
ns
$0
Tot
al
$2,4
60
n A
mou
nt o
wed
to p
rovi
ders
: $5,
400
n P
lan
pays
$3,
750
n P
atie
nt p
ays
$1,6
50
Sa
mpl
e ca
re c
osts
: Pr
escr
iptio
ns
$2,9
00
Med
ical
Equ
ipm
ent a
nd S
uppl
ies
$1,3
00
Off
ice
Visi
ts a
nd P
roce
dure
s $7
00
Edu
catio
n $3
00
Labo
rato
ry te
sts
$100
V
acci
nes,
othe
r pre
vent
ive
$100
T
otal
$5
,400
Pa
tient
pay
s:
Ded
uctib
les
$800
C
opay
s $9
0 C
oins
uran
ce
$760
Li
mits
or e
xclu
sions
$0
T
otal
$1
,650
This is
not a cost
estim
ator.
Don
’t us
e th
ese
exam
ples
to
estim
ate
your
act
ual c
osts
und
er
this
plan
. The
act
ual c
are
you
rece
ive
will
be
diff
eren
t fro
m
thes
e ex
ampl
es, a
nd th
e co
st o
f th
at c
are
will
also
be
diff
eren
t.
See
the
next
pag
e fo
r im
porta
nt
info
rmat
ion
abou
t the
se
exam
ples
.
8 of 8
Coo
k Medical
Coo
k Group
Health
Plan: Clinic Plan (CP) Option Period: 01/01/2016 – 12/31/2016
Summary of Benefits and
Coverage: What this Plan Covers & What it Costs
Coverage for: Employee & Child(ren), Family| P
lan Type: P
PO
Que
stio
ns: C
all 1
.800
.593
.208
0 or
visi
t us a
t ww
w.c
ookm
edic
alcl
aim
s.co
m.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.coo
kmed
ical
clai
ms.
com
or c
all 1
.800
.593
.208
0 to
requ
est a
cop
y.
Que
stio
ns a
nd a
nsw
ers
abou
t the
Cov
erag
e E
xam
ples
: W
hat a
re s
ome
of th
e as
sum
ptio
ns b
ehin
d th
e C
over
age
Exa
mpl
es?
• C
osts
don
’t in
clud
e pr
emiu
ms.
•
Sam
ple
care
cos
ts a
re b
ased
on
natio
nal
aver
ages
supp
lied
by th
e U
.S. D
epar
tmen
t of
Hea
lth a
nd H
uman
Ser
vice
s, an
d ar
en’t
spec
ific
to a
par
ticul
ar g
eogr
aphi
c ar
ea o
r he
alth
pla
n.
• Th
e pa
tient
’s co
nditi
on w
as n
ot a
n ex
clud
ed o
r pr
eexi
stin
g co
nditi
on.
• A
ll se
rvic
es a
nd tr
eatm
ents
star
ted
and
ende
d in
the
sam
e co
vera
ge p
erio
d.
• Th
ere
are
no o
ther
med
ical
exp
ense
s for
any
m
embe
r cov
ered
und
er th
is pl
an.
• O
ut-o
f-po
cket
exp
ense
s are
bas
ed o
nly
on
treat
ing
the
cond
ition
in th
e ex
ampl
e.
• Th
e pa
tient
rece
ived
all
care
from
in-n
etw
ork
prov
ider
s. I
f the
pat
ient
had
rece
ived
car
e fr
om o
ut-o
f-ne
twor
k pr
ovid
ers,
cos
ts w
ould
ha
ve b
een
high
er.
Wha
t doe
s a
Cov
erag
e E
xam
ple
show
?
For e
ach
treat
men
t situ
atio
n, th
e C
over
age
Exa
mpl
e he
lps y
ou se
e ho
w d
educ
tible
s,
copa
ymen
ts, a
nd c
oins
uran
ce c
an a
dd u
p. It
al
so h
elps
you
see
wha
t exp
ense
s mig
ht b
e le
ft up
to
you
to p
ay b
ecau
se th
e se
rvic
e or
trea
tmen
t isn
’t co
vere
d or
pay
men
t is l
imite
d.
Doe
s th
e C
over
age
Exa
mpl
e pr
edic
t my
own
care
nee
ds?
û N
o. T
reat
men
ts sh
own
are
just
exa
mpl
es. T
he
care
you
wou
ld re
ceiv
e fo
r thi
s con
ditio
n co
uld
be d
iffer
ent b
ased
on
your
doc
tor’s
adv
ice,
yo
ur a
ge, h
ow se
rious
you
r con
ditio
n is,
and
m
any
othe
r fac
tors
. D
oes
the
Cov
erag
e E
xam
ple
pred
ict m
y fu
ture
ex
pens
es?
ûN
o. C
over
age
Exa
mpl
es a
re n
ot c
ost e
stim
ator
s. Y
ou c
an’t
use
the
exam
ples
to e
stim
ate
cost
s fo
r an
actu
al c
ondi
tion.
The
y ar
e fo
r co
mpa
rativ
e pu
rpos
es o
nly.
You
r ow
n co
sts
will
be
diff
eren
t dep
endi
ng o
n th
e ca
re y
ou
rece
ive,
the
pric
es y
our p
rovi
ders
cha
rge,
and
th
e re
imbu
rsem
ent y
our h
ealth
pla
n al
low
s.
Can
I u
se C
over
age
Exa
mpl
es to
com
pare
pl
ans?
üY
es. W
hen
you
look
at t
he S
umm
ary
of B
enef
its
and
Cov
erag
e fo
r oth
er p
lans
, you
’ll fi
nd th
e sa
me
Cov
erag
e E
xam
ples
. Whe
n yo
u co
mpa
re
plan
s, ch
eck
the
“Pat
ient
Pay
s” b
ox in
eac
h ex
ampl
e. T
he sm
alle
r tha
t num
ber,
the
mor
e co
vera
ge th
e pl
an p
rovi
des.
Are
ther
e ot
her c
osts
I s
houl
d co
nsid
er w
hen
com
parin
g pl
ans?
üY
es. A
n im
porta
nt c
ost i
s the
pre
miu
m y
ou
pay.
Gen
eral
ly, t
he lo
wer
you
r pre
miu
m, t
he
mor
e yo
u’ll
pay
in o
ut-o
f-po
cket
cos
ts, s
uch
as
copa
ymen
ts, d
educ
tible
s, a
nd c
oins
uran
ce.
You
shou
ld a
lso c
onsid
er c
ontri
butio
ns to
ac
coun
ts su
ch a
s hea
lth sa
ving
s acc
ount
s (H
SAs)
, fle
xibl
e sp
endi
ng a
rran
gem
ents
(FSA
s)
or h
ealth
reim
burs
emen
t acc
ount
s (H
RAs)
that
he
lp y
ou p
ay o
ut-o
f-po
cket
exp
ense
s.
1 of 9
Cook Medical
Cook Group Health Plan: Traditional Plan (TP) Option Coverage Period: 01/01/2017 – 12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Employee & Child(ren), Family| Plan Type: PPO
Que
stio
ns: C
all 1
.800
.593
.208
0 or
visi
t us a
t ww
w.c
ookm
edic
alcl
aim
s.co
m.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.coo
kmed
ical
clai
ms.
com
or c
all 1
.800
.593
.208
0 to
requ
est a
cop
y.
This is only a summary. If
you
wan
t mor
e de
tail
abou
t you
r cov
erag
e an
d co
sts,
you
can
get t
he c
ompl
ete
term
s in
the
polic
y or
pla
n do
cum
ent a
t w
ww
.coo
kmed
ical
clai
ms.
com
or b
y ca
lling
1-8
00-5
93-2
080.
Important Questions
Answers
Wha
t is
the
over
all
dedu
ctib
le?
$500
per
indi
vidu
al a
nd $
1,00
0 pe
r fa
mily
for i
n-ne
twor
k se
rvic
es.
Sepa
rate
ded
uctib
les (
$500
per
in
divi
dual
and
$1,
000
per f
amily
) fo
r out
-of-
netw
ork
serv
ices
. No
mor
e th
an $
500
per p
erso
n co
unts
to
war
ds th
e fa
mily
ded
uctib
le. I
n-ne
twor
k pr
even
tive
care
, den
tal o
r vi
sion
care
, and
pre
scrip
tion
drug
s ar
e no
t sub
ject
to th
ese
dedu
ctib
les .
Den
tal a
nd v
ision
car
e,
pres
crip
tion
drug
s, co
paym
ents
, se
cond
or t
hird
surg
ical
opi
nion
s, an
d no
n-co
vere
d se
rvic
es c
anno
t be
use
d to
satis
fy th
e de
duct
ible
s.
You
mus
t pay
all
the
cost
up
to th
e de
duct
ible
am
ount
bef
ore
this
plan
beg
ins t
o pa
y fo
r cov
ered
se
rvic
es y
ou u
se. T
he d
educ
tible
star
ts o
ver J
anua
ry 1
of e
ach
year
. See
the
char
t sta
rting
on
page
3
for h
ow m
uch
you
pay
for c
over
ed se
rvic
es a
fter y
ou m
eet t
he d
educ
tible
.
Are
ther
e ot
her
dedu
ctib
les
for s
peci
fic
serv
ices
?
Yes
. The
re is
a $
300
fam
ily
dedu
ctib
le fo
r pre
scrip
tion
drug
ex
pens
es. T
here
are
no
othe
r sp
ecifi
c de
duct
ible
s.
You
mus
t pay
all
the
cost
s for
the
serv
ices
up
to th
e sp
ecifi
c de
duct
ible
am
ount
bef
ore
this
plan
be
gins
to p
ay fo
r the
serv
ices
.
Is th
ere
an o
ut-o
f-po
cket
lim
it on
my
expe
nses
?
Yes
. For
net
wor
k pr
ovid
ers,
ther
e is
an o
ut-o
f-po
cket
lim
it of
$2,
000
per i
ndiv
idua
l and
$4,
000
per
fam
ily. T
here
is n
o lim
it fo
r out
-of-
netw
ork
prov
ider
s.
The
out-o
f-po
cket
lim
it is
the
mos
t you
cou
ld p
ay d
urin
g a
cale
ndar
yea
r for
you
r sha
re o
f the
cos
ts
of c
over
ed se
rvic
es. T
his l
imit
help
s you
pla
n fo
r hea
lth c
are
expe
nses
. The
re's
no li
mit
on h
ow
muc
h yo
u ca
n pa
y du
ring
a ca
lend
ar y
ear f
or y
our s
hare
of t
he c
ost o
f out
-of-
netw
ork
cove
red
serv
ices
.
Wha
t is
not i
nclu
ded
in
the
out-
of-p
ocke
t lim
it?
Prem
ium
s, ba
lanc
e bi
lled
char
ges
( u
nles
s bal
ance
bill
ing
is pr
ohib
ited)
, hea
lth c
are
this
plan
do
esn'
t cov
er, a
dult
dent
al, v
ision
, fa
mily
pla
nnin
g, o
ut-o
f-ne
twor
k ch
arge
s, am
ount
s rei
mbu
rsed
un
der t
he p
resc
riptio
n dr
ug
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
do n
ot c
ount
tow
ard
the
out-o
f-po
cket
lim
it.
2 of 9
Cook Medical
Cook Group Health Plan: Traditional Plan (TP) Option Coverage Period: 01/01/2017 – 12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Employee & Child(ren), Family| Plan Type: PPO
Que
stio
ns: C
all 1
.800
.593
.208
0 or
visi
t us a
t ww
w.c
ookm
edic
alcl
aim
s.co
m.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.coo
kmed
ical
clai
ms.
com
or c
all 1
.800
.593
.208
0 to
requ
est a
cop
y.
spec
ialty
car
e pr
ogra
m a
nd
pena
lties
for f
ailu
re to
obt
ain
prea
utho
rizat
ion.
Is th
ere
an o
vera
ll an
nual
lim
it on
wha
t the
pla
n pa
ys?
No.
Th
e ch
art s
tarti
ng o
n pa
ge 3
des
crib
es a
ny li
mits
on
wha
t the
pla
n w
ill p
ay fo
r spe
cific
cove
red
serv
ices
, suc
h as
off
ice
visit
s.
Doe
s th
is p
lan
use
a ne
twor
k of
pro
vide
rs?
Yes
. See
ww
w.an
them
.com
or c
all
Ant
hem
’s Pr
ovid
er L
ocat
or
tele
phon
e nu
mbe
r 1.8
00.8
10.2
583.
Y
ou c
an a
lso c
all C
ook
Insu
ranc
e D
ept.
1-80
0-59
3-20
80 fo
r as
sista
nce
findi
ng n
etw
ork
prov
ider
s.
If y
ou u
se a
net
wor
k do
ctor
or o
ther
hea
lthca
re p
rovi
der,
this
plan
will
pay
the
cost
of c
over
ed
serv
ices
. Be
awar
e, y
our n
etw
ork
doct
or o
r hos
pita
l may
use
an
out-o
f-ne
twor
k pr
ovid
er fo
r som
e se
rvic
es. P
lans
use
the
term
s of “
netw
ork,
” “p
refe
rred
,” o
r “pa
rtici
patin
g” fo
r pro
vide
rs in
thei
r ne
twor
k. S
ee th
e ch
art o
n pa
ge 3
for h
ow th
is pl
an p
ays f
or d
iffer
ent k
inds
of p
rovi
ders
.
Do
I ne
ed a
refe
rral
to s
ee
a sp
ecia
list?
N
o.
You
can
see
the
spec
ialis
t you
cho
ose
with
out p
erm
issio
n fr
om th
is pl
an.
Are
ther
e se
rvic
es th
is
plan
doe
sn’t
cove
r?
Yes
. So
me
of th
e se
rvic
es th
is pl
an d
oesn
't co
ver a
re li
sted
on
page
5. S
ee y
our b
enef
its b
ookl
et o
r pla
n m
anua
l for
add
ition
al in
form
atio
n ab
out e
xclu
ded
serv
ices
.
OM
B Co
ntro
l Num
bers
154
5-22
29, 1
210-
0147
, and
093
8-11
46
Rele
ased
on
Apr
il 23
, 201
3 (c
orre
cted
)
3 of 9
Cook Medical
Cook Group Health Plan: Traditional Plan (TP) Option Coverage Period: 01/01/2017 – 12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Employee & Child(ren), Family| Plan Type: PPO
Que
stio
ns: C
all 1
.800
.593
.208
0 or
visi
t us a
t ww
w.c
ookm
edic
alcl
aim
s.co
m.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.coo
kmed
ical
clai
ms.
com
or c
all 1
.800
.593
.208
0 to
requ
est a
cop
y.
• C
opay
men
ts a
re fi
xed
dolla
r am
ount
s (fo
r exa
mpl
e, $
15) y
ou p
ay fo
r cov
ered
hea
lth c
are,
usu
ally
whe
n yo
u re
ceiv
e th
e se
rvic
e. •
Coi
nsur
ance
is yo
ur sh
are
of th
e co
sts o
f a c
over
ed se
rvic
e, c
alcu
late
d as
a p
erce
nt o
f the
allo
wed
am
ount
for t
he se
rvic
e. F
or e
xam
ple,
if th
e pl
an’s
allo
wed
am
ount
for a
n ov
erni
ght h
ospi
tal s
tay
is $1
,000
, you
r coi
nsur
ance
pay
men
t of 2
0% w
ould
be
$200
. Th
is m
ay c
hang
e if
you
have
n’t m
et y
our
dedu
ctib
le.
• Th
e am
ount
the
plan
pay
s for
cov
ered
serv
ices
is b
ased
on
the
allo
wed
am
ount
. If a
n ou
t-of-
netw
ork
prov
ider
cha
rges
mor
e th
an th
e al
low
ed a
mou
nt,
you
may
hav
e to
pay
the
diff
eren
ce. F
or e
xam
ple,
if a
n ou
t-of-
netw
ork
hosp
ital c
harg
es $
1,50
0 fo
r an
over
nigh
t sta
y an
d th
e al
low
ed a
mou
nt is
$1,
000,
yo
u m
ay h
ave
to p
ay th
e $5
00 d
iffer
ence
. (Th
is is
calle
d ba
lanc
e bi
lling
.) •
This
plan
may
enc
oura
ge y
ou to
use
net
wor
k pr
ovid
ers
by c
harg
ing
you
low
er d
educ
tible
s, c
opay
men
ts a
nd c
oins
uran
ce a
mou
nts.
Com
mon
Medical Event
Services You May Need
Your Cost If You
Use an
In-network
Provider
Your Cost If You
Use an
Out-of-network
Provider
Limitations & Exceptions
If y
ou v
isit
a he
alth
ca
re p
rovi
der’s
offi
ce
or c
linic
Prim
ary
care
visi
t to
treat
an
inju
ry o
r illn
ess
$15
co-p
ay p
er v
isit
40%
coi
nsur
ance
C
o-pa
y do
es n
ot c
over
lab
wor
k, m
inor
su
rger
y an
d x-
rays
in p
hysic
ian'
s off
ice.
Spec
ialis
t visi
t $1
5 co
-pay
per
visi
t 40
% c
oins
uran
ce
Co-
pay
does
not
cov
er la
b w
ork,
min
or
surg
ery
and
x-ra
ys in
phy
sicia
n's o
ffic
e.
Oth
er p
ract
ition
er o
ffic
e vi
sit
20%
coi
nsur
ance
for
chiro
prac
tor
40%
coi
nsur
ance
fo
r chi
ropr
acto
r Li
mite
d to
20
chiro
prac
tor v
isits
per
pe
rson
per
cal
enda
r yea
r.
Prev
entiv
e ca
re/s
cree
ning
/im
mun
izat
ion
No
char
ge
40%
coi
nsur
ance
N
one.
If y
ou h
ave
a te
st
Dia
gnos
tic te
st (x
-ray
, blo
od w
ork)
20
% c
oins
uran
ce
40%
coi
nsur
ance
N
one.
Im
agin
g (C
T/PE
T sc
ans,
MRI
s)
20%
coi
nsur
ance
40
% c
oins
uran
ce
Non
e.
If y
ou n
eed
drug
s to
tr
eat y
our i
llnes
s or
co
nditi
on
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
co
vera
ge is
ava
ilabl
e at
w
ww
.coo
kmed
ical
clai
ms.
com
.
Gen
eric
dru
gs
20%
coi
nsur
ance
20
% c
oins
uran
ce
Pref
erre
d br
and
drug
s 20
% c
oins
uran
ce
20%
coi
nsur
ance
Se
para
te $
300
annu
al fa
mily
ded
uctib
le.
$100
coi
nsur
ance
max
imum
for 3
0-da
y su
pply
. N
on-p
refe
rred
bra
nd d
rugs
20
% c
oins
uran
ce
20%
coi
nsur
ance
Spec
ialty
dru
gs
20%
coi
nsur
ance
20
% c
oins
uran
ce
If y
ou h
ave
outp
atie
nt
surg
ery
Faci
lity
fee
(e.g
., am
bula
tory
surg
ery
cent
er)
20%
coi
nsur
ance
40
% c
oins
uran
ce
Prea
utho
rizat
ion
requ
ired
for m
ost
outp
atie
nt su
rger
ies o
r the
surg
erie
s are
no
t cov
ered
.
4 of 9
Cook Medical
Cook Group Health Plan: Traditional Plan (TP) Option Coverage Period: 01/01/2017 – 12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Employee & Child(ren), Family| Plan Type: PPO
Que
stio
ns: C
all 1
.800
.593
.208
0 or
visi
t us a
t ww
w.c
ookm
edic
alcl
aim
s.co
m.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.coo
kmed
ical
clai
ms.
com
or c
all 1
.800
.593
.208
0 to
requ
est a
cop
y.
Com
mon
Medical Event
Services You May Need
Your Cost If You
Use an
In-network
Provider
Your Cost If You
Use an
Out-of-network
Provider
Limitations & Exceptions
Phys
icia
n/su
rgeo
n fe
es
20%
coi
nsur
ance
40
% c
oins
uran
ce
Prea
utho
rizat
ion
requ
ired
for m
ost
outp
atie
nt su
rger
ies o
r the
surg
erie
s are
no
t cov
ered
.
If y
ou n
eed
imm
edia
te
med
ical
atte
ntio
n
Em
erge
ncy
room
serv
ices
$1
00 c
o-pa
y; 2
0%
coin
sura
nce
$100
co-
pay;
20%
co
insu
ranc
e N
one.
Em
erge
ncy
med
ical
tran
spor
tatio
n 20
% c
oins
uran
ce
20%
coi
nsur
ance
N
one.
Urg
ent c
are
$50
co-p
ay; 2
0%
coin
sura
nce
$50
co-p
ay; 2
0%
coin
sura
nce
Non
e.
If y
ou h
ave
a ho
spita
l st
ay
Faci
lity
fee
(e.g
., ho
spita
l roo
m)
20%
coi
nsur
ance
40
% c
oins
uran
ce
Prea
utho
rizat
ion
requ
ired
for c
over
age.
Ph
ysic
ian/
surg
eon
fee
20%
coi
nsur
ance
40
% c
oins
uran
ce
Prea
utho
rizat
ion
requ
ired
for c
over
age.
If y
ou h
ave
men
tal
heal
th, b
ehav
iora
l he
alth
, or s
ubst
ance
ab
use
need
s
Men
tal/
Beha
vior
al h
ealth
out
patie
nt se
rvic
es
$15
co-p
ay p
er o
ffic
e vi
sit; 2
0%
coin
sura
nce
for
addi
tiona
l ser
vice
s
40%
coi
nsur
ance
N
one.
Men
tal/
Beha
vior
al h
ealth
inpa
tient
serv
ices
20
% c
oins
uran
ce
40%
coi
nsur
ance
Pr
eaut
horiz
atio
n re
quire
d fo
r cov
erag
e.
Subs
tanc
e-us
e di
sord
er o
utpa
tient
serv
ices
$15
co-p
ay p
er o
ffic
e vi
sit; 2
0%
coin
sura
nce
for
addi
tiona
l ser
vice
s
40%
coi
nsur
ance
N
one.
Subs
tanc
e-us
e di
sord
er in
patie
nt se
rvic
es
20%
coi
nsur
ance
40
% c
oins
uran
ce
Prea
utho
rizat
ion
requ
ired
for c
over
age.
If y
ou a
re p
regn
ant
Pren
atal
and
pos
tnat
al c
are
20%
coi
nsur
ance
40
% c
oins
uran
ce
Non
e.
Del
iver
y an
d al
l inp
atie
nt se
rvic
es
20%
coi
nsur
ance
40
% c
oins
uran
ce
Non
e.
5 of 9
Cook Medical
Cook Group Health Plan: Traditional Plan (TP) Option Coverage Period: 01/01/2017 – 12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Employee & Child(ren), Family| Plan Type: PPO
Que
stio
ns: C
all 1
.800
.593
.208
0 or
visi
t us a
t ww
w.c
ookm
edic
alcl
aim
s.co
m.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.coo
kmed
ical
clai
ms.
com
or c
all 1
.800
.593
.208
0 to
requ
est a
cop
y.
Com
mon
Medical Event
Services You May Need
Your Cost If You
Use an
In-network
Provider
Your Cost If You
Use an
Out-of-network
Provider
Limitations & Exceptions
If y
ou n
eed
help
re
cove
ring
or h
ave
othe
r spe
cial
hea
lth
need
s
Hom
e he
alth
car
e 20
% c
oins
uran
ce
40%
coi
nsur
ance
Pr
eaut
horiz
atio
n re
quire
d fo
r cov
erag
e Re
habi
litat
ion
serv
ices
20
% c
oins
uran
ce
40%
coi
nsur
ance
N
one.
H
abili
tatio
n se
rvic
es
20%
coi
nsur
ance
40
% c
oins
uran
ce
Non
e.
Skill
ed n
ursin
g ca
re
20%
coi
nsur
ance
40
% c
oins
uran
ce
Non
e.
Dur
able
med
ical
equ
ipm
ent
20%
coi
nsur
ance
40
% c
oins
uran
ce
Som
e eq
uipm
ent m
ust b
e pr
eaut
horiz
ed
for c
over
age.
H
ospi
ce se
rvic
e 20
% c
oins
uran
ce
40%
coi
nsur
ance
N
one.
If y
our c
hild
nee
ds
dent
al o
r eye
car
e
Ann
ual e
ye e
xam
N
o ch
arge
Se
e lim
itatio
ns a
nd
exce
ptio
ns
Out
-of-
netw
ork
- $42
tota
l allo
wan
ce fo
r an
ann
ual e
xam
and
$40
/$60
/$80
ann
ual
allo
wan
ce fo
r one
pai
r of s
tand
ard
singl
e/bi
foca
l/tri
foca
l len
ses.
$42
al
low
ance
for f
ram
es e
very
2 y
ears
.
Eye
glas
ses
No
char
ge
See
limita
tions
and
ex
cept
ions
In
-net
wor
k - $
200
allo
wan
ce fo
r fra
mes
ev
ery
2 ye
ars.
Den
tal c
heck
-up
No
char
ge
No
char
ge
Tw
o pe
r cal
enda
r yea
r
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (T
his
isn’
t a c
ompl
ete
list.
Che
ck y
our p
olic
y or
pla
n do
cum
ent f
or o
ther
exc
lude
d se
rvic
es.)
• A
cupu
nctu
re
• Lo
ng-te
rm c
are
• N
on-e
mer
genc
y ca
re w
hen
trave
ling
outs
ide
the
U.S
.
• Ro
utin
e fo
ot c
are
• W
eigh
t los
s pro
gram
s
6 of 9
Cook Medical
Cook Group Health Plan: Traditional Plan (TP) Option Coverage Period: 01/01/2017 – 12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Employee & Child(ren), Family| Plan Type: PPO
Que
stio
ns: C
all 1
.800
.593
.208
0 or
visi
t us a
t ww
w.c
ookm
edic
alcl
aim
s.co
m.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.coo
kmed
ical
clai
ms.
com
or c
all 1
.800
.593
.208
0 to
requ
est a
cop
y.
Oth
er C
over
ed S
ervi
ces
(Thi
s is
n’t a
com
plet
e lis
t. C
heck
you
r pol
icy
or p
lan
docu
men
t for
oth
er c
over
ed s
ervi
ces
and
your
cos
ts fo
r the
se s
ervi
ces.
)
• Ba
riatri
c su
rger
y
• C
hiro
prac
tic c
are
• C
osm
etic
surg
ery
to re
pair
an in
jury
or c
onge
nita
l de
form
ity o
r to
rest
ore
norm
al b
ody
func
tion
• D
enta
l car
e (a
dult)
• I n
ferti
lity
treat
men
t
• Pr
ivat
e du
ty n
ursin
g
• Ro
utin
e ey
e ca
re (a
dult)
• H
earin
g ai
ds
You
r Rig
hts
to C
ontin
ue C
over
age:
If
you
lose
cov
erag
e un
der
the
plan
, the
n, d
epen
ding
upo
n ci
rcum
stan
ces,
Fede
ral a
nd S
tate
law
s m
ay p
rovi
de p
rote
ctio
ns th
at a
llow
you
to k
eep
heal
th c
over
age.
Any
su
ch ri
ghts
may
be
limite
d in
dur
atio
n an
d w
ill re
quire
you
to p
ay a
pre
miu
m, w
hich
may
be
signi
fican
tly h
ighe
r tha
n th
e pr
emiu
m y
ou p
ay w
hile
cov
ered
und
er th
e pl
an.
Oth
er li
mita
tions
on
your
righ
ts to
con
tinue
cov
erag
e al
so a
pply
. Fo
r m
ore
info
rmat
ion
on y
our
right
s to
con
tinue
cov
erag
e, c
onta
ct th
e pl
an a
t 1-8
00-5
93-2
080.
Y
ou m
ay a
lso c
onta
ct y
our
stat
e in
sura
nce
depa
rtmen
t, an
d th
e U
.S.
Dep
artm
ent
of L
abor
’s E
mpl
oyee
Ben
efits
Sec
urity
Adm
inist
ratio
n at
1-8
66-4
44-3
272
or w
ww
.dol
.gov
/ebs
a/he
alth
refo
rm,
or t
he U
.S.
Dep
artm
ent
of H
ealth
and
H
uman
Ser
vice
s at 1
-877
-267
-232
3 ex
t. 61
656
or w
ww
.cci
io.c
ms.g
ov.
You
r Grie
vanc
e an
d A
ppea
ls R
ight
s:
If y
ou h
ave
a co
mpl
aint
or a
re d
issat
isfie
d w
ith a
den
ial o
f cov
erag
e fo
r cla
ims u
nder
you
r pla
n, y
ou m
ay b
e ab
le to
app
eal o
r file
a g
rieva
nce.
For
que
stio
ns a
bout
you
r rig
hts,
this
notic
e, o
r ass
istan
ce, y
ou c
an c
onta
ct: C
ook
Gro
up H
ealth
Pla
n A
dmin
istra
tor,
Coo
k G
roup
Inco
rpor
ated
, P.O
. Box
160
8, B
loom
ingt
on, I
N 4
7402
, 1.
800.
593.
2080
or D
epar
tmen
t of L
abor
, Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istra
tion
at 1
.866
.444
.EBS
A(3
272)
or w
ww
.dol
.gov
/ebs
a/he
alth
refo
rm.
Doe
s th
is C
over
age
Prov
ide
Min
imum
Ess
entia
l Cov
erag
e?
T he
Aff
orda
ble
Car
e A
ct re
quire
s mos
t peo
ple
to h
ave
heal
th c
are
cove
rage
that
qua
lifie
s as “
min
imum
ess
entia
l cov
erag
e.”
Thi
s pl
an o
r pol
icy
does
pro
vide
m
inim
um e
ssen
tial c
over
age.
D
oes
this
Cov
erag
e M
eet t
he M
inim
um V
alue
Sta
ndar
d?
The
Aff
orda
ble
Car
e A
ct e
stab
lishe
s a m
inim
um v
alue
stan
dard
of b
enef
its o
f a h
ealth
pla
n. T
he m
inim
um v
alue
stan
dard
is 6
0% (a
ctua
rial v
alue
). T
his
heal
th
cove
rage
doe
s m
eet t
he m
inim
um v
alue
sta
ndar
d fo
r the
ben
efits
it p
rovi
des.
Lan
guag
e A
cces
s Se
rvic
es:
Span
ish (E
spañ
ol):
Para
obt
ener
asis
tenc
ia e
n E
spañ
ol, l
lam
e al
1.8
00.4
68.1
379.
C
hine
se (中文
): 如果需要中文的帮助,请拨打这个号码
1.8
00.4
68.1
379.
7 of 9
Cook Medical
Cook Group Health Plan: Traditional Plan (TP) Option Coverage Period: 01/01/2017 – 12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Employee & Child(ren), Family| Plan Type: PPO
Que
stio
ns: C
all 1
.800
.593
.208
0 or
visi
t us a
t ww
w.c
ookm
edic
alcl
aim
s.co
m.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.coo
kmed
ical
clai
ms.
com
or c
all 1
.800
.593
.208
0 to
requ
est a
cop
y.
––––
––––
––––
––––
––––
––To
see e
xamp
les of
how
this
plan
migh
t cov
er cos
ts for
a sa
mple
medic
al sit
uatio
n, se
e the
nex
t pag
e.–––
––––
––––
––––
––––
–––
8 of 9
Cook Medical
Cook Group Health Plan: Traditional Plan (TP) Option
Coverage Period: 01/01/2017 – 12/31/2017
Coverage Exam
ples
Coverage for: Employee & Child(ren), Family | Plan Type: PPO
Que
stio
ns: C
all 1
.800
.593
.208
0 or
visi
t us a
t ww
w.c
ookm
edic
alcl
aim
s.co
m.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.coo
kmed
ical
clai
ms.
com
or c
all 1
.800
.593
.208
0 to
requ
est a
cop
y.
Having a baby
(n
orm
al de
liver
y)
Managing type 2 diabetes
(rout
ine
main
tena
nce
of
a w
ell-c
ontro
lled
cond
ition
)
About these Coverage Exam
ples:
Thes
e ex
ampl
es sh
ow h
ow th
is pl
an m
ight
cov
er
med
ical
car
e in
giv
en si
tuat
ions
. Use
thes
e ex
ampl
es
to se
e, in
gen
eral
, how
muc
h fin
anci
al p
rote
ctio
n a
sam
ple
patie
nt m
ight
get
if th
ey a
re c
over
ed u
nder
di
ffer
ent p
lans
.
n Amount owed to providers: $7,540
n Plan pays $5,080
n Patient pays $2,460
Sample care costs:
Hos
pita
l cha
rges
(mot
her)
$2
,700
Ro
utin
e ob
stet
ric c
are
$2,1
00
Hos
pita
l cha
rges
(bab
y)
$900
A
nest
hesia
$9
00
Labo
rato
ry te
sts
$500
Pr
escr
iptio
ns
$200
Ra
diol
ogy
$200
V
acci
nes,
othe
r pre
vent
ive
$40
Tot
al
$7,5
40
Patient pays:
Ded
uctib
les
$1,2
00
Cop
ays
$0
Coi
nsur
ance
$1
,260
Li
mits
or e
xclu
sions
$0
T
otal
$2
,460
n Amount owed to providers: $5,400
n Plan pays $3,750
n Patient pays $1,650
Sample care costs:
Pres
crip
tions
$2
,900
M
edic
al E
quip
men
t and
Sup
plie
s $1
,300
O
ffic
e V
isits
and
Pro
cedu
res
$700
E
duca
tion
$300
La
bora
tory
test
s $1
00
Vac
cine
s, ot
her p
reve
ntiv
e $1
00
Tot
al
$5,4
00
Patient pays:
Ded
uctib
les
$800
C
opay
s $9
0 C
oins
uran
ce
$760
Li
mits
or e
xclu
sions
$0
T
otal
$1
,650
This is
not a cost
estim
ator.
Don
’t us
e th
ese
exam
ples
to
estim
ate
your
act
ual c
osts
un
der t
his p
lan.
The
act
ual c
are
you
rece
ive
will
be
diff
eren
t fr
om th
ese
exam
ples
, and
the
cost
of t
hat c
are
will
also
be
diff
eren
t.
See
the
next
pag
e fo
r im
port
ant
info
rmat
ion
abou
t the
se
exam
ples
.
9 of 9
Cook Medical
Cook Group Health Plan: Traditional Plan (TP) Option
Coverage Period: 01/01/2017 – 12/31/2017
Coverage Exam
ples
Coverage for: Employee & Child(ren), Family | Plan Type: PPO
Que
stio
ns: C
all 1
.800
.593
.208
0 or
visi
t us a
t ww
w.c
ookm
edic
alcl
aim
s.co
m.
If
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.coo
kmed
ical
clai
ms.
com
or c
all 1
.800
.593
.208
0 to
requ
est a
cop
y.
Questions and answers about the Coverage Exam
ples:
What are som
e of the assumptions
behind the Coverage Exam
ples?
• C
osts
don
’t in
clud
e pr
emiu
ms.
•
Sam
ple
care
cos
ts a
re b
ased
on
natio
nal
aver
ages
supp
lied
by th
e U
.S. D
epar
tmen
t of
Hea
lth a
nd H
uman
Ser
vice
s, an
d ar
en’t
spec
ific
to a
par
ticul
ar g
eogr
aphi
c ar
ea o
r he
alth
pla
n.
• Th
e pa
tient
’s co
nditi
on w
as n
ot a
n ex
clud
ed o
r pr
eexi
stin
g co
nditi
on.
• A
ll se
rvic
es a
nd tr
eatm
ents
star
ted
and
ende
d in
the
sam
e co
vera
ge p
erio
d.
• Th
ere
are
no o
ther
med
ical
exp
ense
s for
any
m
embe
r cov
ered
und
er th
is pl
an.
• O
ut-o
f-po
cket
exp
ense
s are
bas
ed o
nly
on
treat
ing
the
cond
ition
in th
e ex
ampl
e.
• Th
e pa
tient
rece
ived
all
care
from
in-n
etw
ork
prov
ider
s. I
f the
pat
ient
had
rece
ived
car
e fr
om o
ut-o
f-ne
twor
k pr
ovid
ers,
cos
ts w
ould
ha
ve b
een
high
er.
What does a Coverage Exam
ple show?
For e
ach
treat
men
t situ
atio
n, th
e C
over
age
Exa
mpl
e he
lps y
ou se
e ho
w d
educ
tible
s,
copa
ymen
ts, a
nd c
oins
uran
ce c
an a
dd u
p. It
al
so h
elps
you
see
wha
t exp
ense
s mig
ht b
e le
ft up
to
you
to p
ay b
ecau
se th
e se
rvic
e or
trea
tmen
t isn
’t co
vere
d or
pay
men
t is l
imite
d.
Does the Coverage Exam
ple predict m
y own care needs?
û N
o. T
reat
men
ts sh
own
are
just
exa
mpl
es. T
he
care
you
wou
ld re
ceiv
e fo
r thi
s con
ditio
n co
uld
be d
iffer
ent b
ased
on
your
doc
tor’s
adv
ice,
yo
ur a
ge, h
ow se
rious
you
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The online enrollment will take you through a series of easy to read screens to validate your personal information, add or delete dependents, and allow you to select your benefits for 2017.
For 2017, the online enrollment system offers you two ways to enroll in benefits:
1) If you don’t want to make any changes for 2017, you can use the “Quick Enrollment” screen to easily transfer your 2016 benefit elections into 2017.
2) If you need to make changes to your benefits for 2017, you must go through each benefit enrollment screen and make your individual benefit plan elections or declinations.
Whichever method you choose, please read the instructions on the enrollment screens before making your elections! The screens will display a per pay period cost for each selection and a cumulative 2017 cost per pay for all selections you have made up to that point. Selecting your benefits is a simple click of the button next to the plan best for you! If you choose not to elect a benefit, you must click on the “DECLINE” button. To save your elections at the end of the session make certain you click on the “SUBMIT ELECTION” button. “PRINT” and “SAVE” your 2017 Benefit Election Confirmation Statement. The internet address for the online benefits enrollment site is: www.mycookgroupbenefits.com
To begin your enrollment session:
1) You will need your 5 digit employee number. This can be found on your check stub. On the stub, your employee number is the last 5 numbers of the ID Number. A human resource representative can also help you determine your employee number.
2) The system will use your birth date as your temporary personal identification number (“PIN”) the first time you log into the system. The format of your birth date PIN is MMDDYY. If your birth date was May 10, 1955 you would enter 051055 in the system. You will then be asked to establish a new PIN that is different from your birth date, which should be used for all other times you use the system. However, you can continue to use your birth date as your new PIN.
ENROLLMENT SCREENS
Personal Information Screen
Please verify your personal information and make any changes in the non-shaded areas. Notify a human resource representative of any changes in the shaded areas. Make certain your home address is accurate.
Medical, Optional Term Life Insurance and Optional Accidental Death and Dismemberment Covered Dependents Screen
If you are enrolling your spouse and/or dependents in the COOK Health Plan (health plan), optional life insurance plan or the optional accidental death and dismemberment insurance plan, please have their social security numbers and birth dates handy before you begin your session. You will not be able to go to the next screen without this information. Make certain you click on the “DISK” symbol next to the dependent information you entered to ensure you have saved the information and enrolled your dependent.
Your spouse is NOT eligible for the COOK Health Plan if their employer offers health insurance, and the premium is less than $250 per month for single coverage. An ex- spouse cannot remain on the COOK Health Plan following a divorce unless the ex-spouse elects COBRA. It is your responsibility to notify the COOK Insurance Department within 30 days of a divorce and by the end of the month in which a son or daughter turns age 26.
Quick Enrollment Screen
The screen called “Quick Enroll “ allows you to make one click on “Elect 2017 Benefits the same as 2016” and you will be enrolled in the same benefits for 2017 that you had in 2015. This button is located at the bottom of the screen. Just click on it and you will be enrolled in the same health plan option, same health flexible spending account amount, the same optional term life insurance amount, the same accidental death and dismemberment insurance amount, and voluntary disability insurance options for 2017 that you had in 2015. New 2017 employee premiums will be highlighted in “red.”
2017 ONLINE BENEFITS ENROLLMENT INSTRUCTIONS
Health Care Flexible Spending Account (HFSA) Screen
The maximum annual election for your 2017 health flexible spending account is $2,500, and the minimum election is $100. You may elect this benefit, even if you are not participating in the health insurance. If you do not want to participate in a health flexible spending account for 2017, you must select “DECLINE” to continue. Your 2017 HFSA can only be used for out of pocket expenses incurred between January 1, 2017 and December 31, 2017.
You can also elect to have your health flexible spending account reimbursements deposited directly into your checking or savings account. Simply print off the Direct Deposit Form under Forms and Materials at the top of the screen, complete it, and mail it to the COOK Insurance Department. The address is on the form.
Optional Employee and Dependent Term Life Insurance Screen
Term life Insurance is optional. Keep in mind effective January 1, 2017 if your annual earnings are less than $50,000, you have $75,000 of company paid term life insurance coverage. If you annual earnings are $50,000 or more, you have company paid term life insurance coverage equal to 1.5 times annual earnings up to a maximum of $150,000.
If you are currently not enrolled in optional employee term life insurance and have not been denied coverage in the past, you can elect up to $40,000 with no evidence of insurability required. If you are increasing current coverage for more than $40,000, you must complete the Prudential Evidence of Insurability Form that pops up on the enrollment screen and be approved for your coverage election by Prudential. If you are electing new or additional coverage for your spouse, you must complete a Prudential Evidence of Insurability Form and be approved by Prudential.
Optional Accidental Death and Dismemberment Insurance Screen
Accidental death & dismemberment insurance is optional. Keep in mind if your annual earnings are less than $50,000, you have $75,000 of company paid accidental death and dismemberment insurance coverage. If your annual earnings are $50,000 or more, you have company paid accidental death and dismemberment coverage equal to 1.5 times annual earnings up to a maximum of $150,000.
Voluntary Long Term Disability Screen
If you are enrolling in the voluntary long term disability plan for the first time, you must fully complete and submit the Prudential Evidence of Insurability Form online that pops up during the enrollment process. Paper enrollment forms will not be accepted. Your Evidence of Insurability Form must be approved by Prudential which could take several weeks. If coverage is denied, any payroll deductions taken during the Evidence of Insurability approval process will be refunded.
Enrollment Preview Screen
Review your elections and make any necessary corrections then click “SUBMIT ELECTIONS” to process your 2017 benefit elections. Continue to the next screen. Note: You will have until the end of November to log back in and make changes to your 2017 benefit elections. Each time you log back in and make a change, you are required to re-elect all of your benefits and click “SUBMIT ELECTIONS” again. Your last benefits enrollment election is the one that will be used for 2017.
2017 Benefits Confirmation Screen
Print your 2017 Benefits Confirmation Statement and save it for future reference. Make sure you double-check all dependent information for accuracy. You may now log off. If you have not already registered for Castlight you can do it now by clicking “Castlight.” It requires you to provide an email address and create a password. After you print your 2017 Benefits Confirmation Statement promptly remove it from the printer as it contains your personal information.
Please contact your human resource representative if you have any questions about your benefits or the online enrollment process.
Because the COOK Group Health Plan (“Plan”) covers medical and surgical services for mastectomies, a federal law called the “Women’s Health and Cancer Rights Act of 1998” requires the Plan to also cover reconstructive surgery.
Therefore, if a participant or beneficiary of the Plan receives benefits in connection with a mastectomy and, in consultation with the patient’s attending physician, elects breast reconstruction in connection with the mastectomy, the Plan will cover the following services and supplies:
• Reconstruction of the breast on which the mastectomy has been performed
• Surgery and reconstruction of the other breast to produce a symmetrical appearance
• Prostheses
• The treatment of physical complications arising in all stages of mastectomy, including lymphedemas
Such coverage is, however, subject to the regular annual deductibles and coinsurance provisions of the Plan.
COOK GROUP HEALTH PLAN COVERAGE UNDER THE WOMEN’S HEALTH AND CANCER RIGHTS ACT
Please read this notice carefully and keep it where you can find it.
This notice has information about your current prescription drug coverage with the Cook Group Health Plan and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
IMPORTANT NOTICE FROM THE COOK GROUP HEALTH PLAN ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND MEDICARE 2017
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2. Cook Group has determined that the prescription drug coverage offered by the Cook Group Health Plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage.
Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide To Join A Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current Cook Group Health Plan coverage will not be affected. The Clinic Plan and Traditional Plan each have a prescription drug deductible of $300 per family per year. Generally, the Plan pays 80% of the cost of the drug and you pay the remaining 20% up to a $100 maximum for each 30-day supply. If you are a participant in the Clinic Plan and you do not purchase drugs from the Clinic pharmacy, then the Plan will pay only 50% of the cost of the drug. Brand name and generic drugs are covered by the Plan. There is no annual or lifetime maximum drug benefit. See pages 7-9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance available at https://www.cms.gov/Medicare/PrescriptionDrug-Coverage/CreditableCoverage/downloads/Updated_Guidance_02_15_07.pdf which outlines the prescription drug provisions/options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D.
If you decide to join a Medicare drug plan and drop your current Cook Group Health Plan coverage, you and your dependents will be able to get this coverage back during open enrollment.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with the Cook Group Health Plan and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without credible prescription drug coverage, your monthly premium may go up at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go 19 months without credible coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay the entire premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.
CMS Form 10182-CC
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938–0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to-CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C-4–26–05, Baltimore, MD 21244–1850.2.
Updated April 1, 2011
Continued on reverse side
For More Information About This Notice Or Your Current Prescription Drug Coverage:
Contact the person listed below for further information or call the Cook Group Benefits Coordinator at 800.468.1379.
Note: You’ll get this notice each year before the next period you can join a Medicare drug plan, and if this coverage through the Cook Group Health Plan changes. You may also request a copy of this notice at any time.
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage
• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help
• Call 800.MEDICARE (800.633.4227). TTY users should call 877.486.2048
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security’s website www.socialsecurity.gov, or call them at 800.772.1213 (TTY 800.325.0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and whether or not you are required to pay a higher premium (a penalty).
Date: January 20, 2016
Name of Entity/Sender: Cook Group Health Plan
Contact--Position/Office: Ms. Debbie Snyder
Address: P.O. Box 1029, Bloomington, IN 47402
Telephone Number: 812.355.2528 or 800.593.2080
CMS Form 10182-CC
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938–0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to-CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C-4–26–05, Baltimore, MD 21244–1850.2.
Updated April 1, 2011
Continued on reverse side
PREMIUM ASSISTANCE UNDER MEDICAID AND THECHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
IF YOU LIVE IN ONE OF THE FOLLOWING STATES, YOU MAY BE ELIGIBLE FOR ASSISTANCE PAYING YOUR EMPLOYER HEALTH PLAN PREMIUMS. THE FOLLOWING LIST OF STATES IS CURRENT AS OF JULY 31, 2016. CONTACT YOUR STATE FOR MORE INFORMATION ON ELIGIBILITY.
ALABAMA – Medicaid Website: www.myalhipp.com Phone: 855.692.5447
ALASKA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone 866.251.4861 Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
ARKANSAS – Medicaid Website: http://myarhipp.com/ Phone: 855.MyARHIPP (855.692.7447)
COLORADO – Medicaid Medicaid Website: http://www.colorado.gov/hcpf Medicaid Customer Contact Center: 800.221.3943
FLORIDA – Medicaid Website: https://www.flmedicaidtplrecovery.com/hipp/ Phone: 877.357.3268
GEORGIA – Medicaid Website: : http://dch.georgia.gov/medicaid Click on “Health Insurance Premium Payment (HIPP)” Phone: 404.656.4507
INDIANA – Medicaid Healthy Indiana Plan for low income adults 19-64 Website: http://www.hip.in.gov Phone: 877.438.4479 All other Medicaid Website: http://www.indianamedicaid.com Phone: 800.403.0864
IOWA – Medicaid Website: www.dhs.state.ia.us/hipp Phone: 888.346.9562
KANSAS – Medicaid Website: http://www.kdheks.gov/hcf Phone: 785.296.3512
KENTUCKY – Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 800.635.2570
LOUISIANA – Medicaid Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 888.695.2447
MAINE – Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/ index.html Phone: 800.442.6003 TTY: Maine relay 711
MASSACHUSETTS – Medicaid and CHIP Website: http://www.mass.gov/MassHealth Phone: 800.462.1120
MINNESOTA – Medicaid Website: http://mn.gov/dhs/ma/ Phone: 800.657.3739
MISSOURI – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573.751.2005
MONTANA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 800.694.3084
NEBRASKA – Medicaid Website: http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/acessnebraska_index.aspx Phone: 855.632.7633
NEVADA – Medicaid Medicaid Website: http://dwss.nv.gov Medicaid Phone: 800.992.0900
NEW HAMPSHIRE – Medicaid Website: www.dhhs.nh.gov/oii/documents.hippapp.pdf Phone: 603.271.5218
NEW JERSEY – Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid Medicaid Phone: 609.631.2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 800.701.0710
NEW YORK – Medicaid Website: http://www.nyhealth.gov/health_care/medicaid Phone: 800.541.2831
NORTH CAROLINA – Medicaid Website: http://www.ncdhhs.gov/dma Phone: 919.855.4100
NORTH DAKOTA – Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid Phone: 844.854.4825
OKLAHOMA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 888.365.3742
OREGON – Medicaid and CHIP Website: http://www.healthcare.oregon.gov/Pages/ index-aspx Website: http://www.oregonhealthcare.gov/index-es.html Phone: 800.699.9075
PENNSYLVANIA – Medicaid Website: http://www.dpw.pa.gov/hipp Phone: 800.692.7462
RHODE ISLAND – Medicaid Website: www.eohhs.ri.gov Phone: 401.462.5300
SOUTH CAROLINA – Medicaid Website: http://www.scdhhs.gov Phone: 888.549.0820
SOUTH DAKOTA – Medicaid Website: http://dss.sd.gov Phone: 888.828.0059
TEXAS – Medicaid Website: www.gethipptexas.com Phone: 800.440.0493
UTAH – Medicaid and CHIP Medicaid: http://health.utah.gov/medicaid CHIP: http://health.utah.gov/chip Phone: 877.543.7669
VERMONT– Medicaid Website: http://www.greenmountaincare.org Phone: 800.250.8427
VIRGINIA – Medicaid and CHIP http://www.coverva.org/programs_premium_assistance. cfm Medicaid Phone: 800.432.5924 CHIP Website: http://www.coverva.org/programs_premium_assistance. cfm CHIP Phone: 855.242.8282
WASHINGTON – Medicaid Website: http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program Phone: 800.562.3022, ext. 15473
WEST VIRGINIA – Medicaid Website: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspx Phone: 877.598.5820, HMS Third Party Liability
WISCONSIN – Medicaid & CHIP
Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 800.362.3002
WYOMING – Medicaid Website: https://wyequalitycare.acs-inc.com/ Phone: 307.777.7531
To see if any other states have added a premium assistance program since July 31, 2016, or for more information on special enrollment rights, contact either:
U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/ebsa 866.444.EBSA (3272)
U.S. Department of Health and Human Services Centers for Medicare and Medicaid Services www.cms.hhs.gov 877.267.2323, Menu Option 4, ext. 61565
OMB Control Number 1210-0137 (expires 10/31/2016)
Overview
This Notice of Privacy Practices is provided by the Cook Group (“Cook”), to participants of our Group Health Plan or Group Cafeteria Plan (“Health Plans”), and to patients who receive treatment at the Cook Family Health Center (“Health Center”) by healthcare staff or physicians. It describes how your health information (called “Protected Health Information” or “PHI”) may be collected, used and disclosed by the Health Plans and/or Health Center, as well as your rights in relation to that information. Please use the contact information contained in this Notice if you have any questions or would like to contact us.
How We Protect Your Privacy
The Cook Health Plans and the Health Center are required to comply with federal and state privacy, security and genetic information protection laws in connection with your health information. This means that they can collect and use your health information only for purposes that are allowed under those laws, and must take steps to safeguard your data in accordance with the legal requirements. With respect to the privacy of your genetic information, it also means that the Health Plans, the Health Center and the third parties assisting them (Business Associates or subcontractors) are specifically prohibited from using your genetic information for purposes of insurance underwriting (i.e., setting rates or insurance coverage terms based upon genetic data).
How We Use and Disclose Your Protected Health Information
This section describes the ways that the Health Plans and the Health Center may use and disclose your protected health information without first seeking written authorization from you. Please note that for any of these disclosures, only the minimum necessary information (i.e., that which is necessary and relevant) from your medical record is disclosed.
• Treatment Your information may be used or disclosed in connection with treatment, such as sharing relevant information with other healthcare providers involved in your care.
• Payment Your information may be used or disclosed in connection with obtaining payment for your healthcare services or administering your insurance coverage.
• Healthcare Operations Your information may be used or disclosed for certain types of approved administrative purposes, such as to conduct an audit.
• Outside Service Providers (Business Associates) Your information may be used or disclosed in connection with outside service providers (“Business Associates”) retained by the Health Plans or Health Center.
• Public Health Activities Your information may be used or disclosed in connection with public health activities that are authorized by law, such as to prevent or control disease, injury or disability.
• Health or Safety Your information may be used or disclosed to prevent or lessen a serious threat to your health or safety or that of the general public.
• Health Oversight Activities Your information may be used or disclosed in connection with government or regulatory oversight or compliance, such as to health authorities to report adverse events or product defects, to enable recalls or for similar safety reasons. It may also be accessible to agencies that evaluate billing or other legal or healthcare matters.
• Victims of Abuse, Neglect, or Domestic Violence Your information may be used or disclosed in connection with reporting to government agencies authorized by law to receive reports of abuse, neglect or domestic violence.
• Certain Limited Research Purposes Your information may be used or disclosed in connection with certain limited research purposes, as authorized by law.
• Workers Compensation Your information may be used or disclosed in connection with complying with workers’ compensation laws and regulations.
• Judicial, Administrative, Government and Legal Obligations Your information may be disclosed to the police, other law enforcement officials, or the government in connection with legal proceedings, compliance with a court order, or for other legal or judicial or law enforcement processes as authorized or required by law.
COOK GROUP HEALTH PLAN AND COOK GROUP CAFETERIA PLANNOTICE OF PRIVACY PRACTICES
Uses and Disclosures With Your Written Authorization
Other than the uses and disclosures described in this Notice, the Health Plans and Health Center may not use or disclose your information without your written authorization. This includes, for example, any proposed use or disclosure of your information for a marketing or sales purpose. You may revoke any such authorization in writing except to the extent that the Health Plans and Health Center have already taken action in reliance on your authorization.
Your Individual Rights
Right to Request Additional RestrictionsYou have the right to request additional restrictions on certain uses and disclosures of your PHI to carry out treatment, payment or healthcare operations functions as described in this Notice. For example, you can request that your PHI be disclosed to certain family members or others who may assist with your medical care, and not be disclosed to others. While the Health Plans and Health Center will consider all requests carefully, they are not always required to agree to the requested restriction. If they agree to honor your request, the Health Plans/Health Center will not use or disclose your personal health information in the way you specified unless the information is needed to provide emergency treatment. If they are required to disclose restricted information due to an emergency, they will request assurances from the service provider that the service provider will not further disclose your personal health information.
Right to Avoid Disclosures to Health Plans for Payment or Healthcare OperationsYou have the right to request that your PHI not be provided to the Health Plans and/or Health Center in situations where the disclosure (1) is related to payment or healthcare operations, and (2) you paid for the service in full yourself, without any insurance reimbursement. This right must generally be exercised in advance of any treatment, and there are certain requirements to do so. Please ask the Benefits Department or Health Center medical staff for additional information.
Right to Receive Confidential CommunicationsIn certain circumstances, you may ask to receive confidential communications of PHI in a manner outside of the Health Plans’ or Health Center’s normal procedures. While all reasonable requests will be carefully considered, those entities are regrettably not able to agree to all requests.
Right to Inspect and Obtain a Copy of Your Personal Health InformationYou may ask to inspect or to obtain a copy of your personal health information that is included in certain records maintained by the Health Plans or Health Center. Under limited circumstances, they may deny you access to a portion of your records. In addition, this right does not apply to certain types of information – psychotherapy notes; information that may be used in a civil, criminal, or administrative action or proceeding; and information that is not part of the records they maintain. You have the right to request your information in electronic format, provided that it is maintained in that format.
Right to Amend Your RecordsYou have the right to ask the Health Plans and/or Health Center to amend your personal health information that is included in certain records that they maintain. If it is determined by authorized representatives of those entities that the record is inaccurate, and the law permits the Health Plans/Health Center to amend the record, they will amend it. If your doctor or another person created the information that you want to change, you should ask that person to amend the information.
Right to Receive an Accounting of DisclosuresUpon request, you may obtain an accounting of disclosures of your personal health information made by the Health Plans, the Health Center or their respective business associates. The accounting will not include disclosures made earlier than three years before the date of your request, and certain other disclosures that are excluded by law. If you request an accounting more than once during any 12-month period, you will be charged a reasonable fee for each accounting statement after the first one. If you request an accounting relating to disclosures by business associates, the Health Plans/Health Center will either provide you with such an accounting directly, or they may choose to provide you with the contact information for those business associates, such that you may request an accounting directly from them.
Right to be Notified of Security Breaches Involving Your InformationIn accordance with the federal and state breach notification laws and requirements, you have the right to receive notification in the event that the Health Plans, Health Center or their respective Business Associates or subcontractors suffer a security breach involving your personal information.
Right to Receive a Paper Copy of this NoticeYou may contact the Cook Benefits Department or the Health Center to obtain an additional copy of this Notice at any time.
Copying FeesYou may be charged a reasonable fee to cover costs related to copying or preparing your information, in connection with requests for copies of your health records.
Revisions to this Notice
The terms of this Notice may be changed from time to time. If so, the additional protections contained in the updated Notice terms may be made effective for all of your PHI maintained by the Health Plans/Health Center, including any information that was created or received before the new Notice was issued. If this Notice is revised, the revised notice will be promptly delivered to all enrollees.
Amendment to The Health Plans
This Notice is also intended to serve as an amendment to the Health Plans. It is also a summary of material modifications to update your summary plan descriptions for the Health Plans. To the extent of these changes, this summary of material modifications takes precedence over your summary plan descriptions. You may inspect copies of the Health Plan documents themselves during normal business hours by contacting the Cook Group Benefits Department. As always, the Health Plan sponsor retains the right to terminate the Health Plans at any time and may amend or otherwise modify the Health Plans at any time.
Complaints
If you believe the Health Plans or Health Center has violated your privacy rights, you may file a complaint with the Health Plans, Health Center, or with the U.S. Secretary of Health and Human Services. Complaints to the Health Plans or Health Center should be filed in writing with the Cook Global Privacy Office, P.O. Box. 1608, Bloomington, Indiana, 47402. The Health Plans and Health Center have put in place a process for handling all complaints. Cook Group also has a process for ensuring there is no retaliation against anyone who files a complaint based upon a legitimate belief that their privacy or security has been violated by these entities
Contact Information to Exercise Your Rights
If you want to exercise any of your rights from the Health Plans or Health Center as described in this Notice, the contact information is as follows:
CATEGORY EXAMPLES OF INFORMATION COOK DEPARTMENT CONTACT INFORMATION
Privacy Security • Privacy or security question
• Protection of genetic data
• Complaint
Cook Group Privacy Office
Megan J. CharlesworthPrivacy OfficerCook Group Health Plan TrustP.O. Box 1608Bloomington, Indiana [email protected]
Benefits Coverage
• Benefits question Cook Group Benefits Department
Cook Benefits DepartmentCook Group Health PlanCook Group Cafeteria PlanP.O. Box 1608Bloomington, Indiana 47402800.593.2080 or 812.355.2528
Changes Copies
• Individual access request
• Request for amendment
• Request for disclosures
• Change of address, name
• Copies of records
Cook Family Health Center
Cook Family Health Center402 North Rogers StreetBloomington, IN 47404812.330.9944
Contact Information to Exercise Your Rights
This Notice is effective as of July 31, 2016.