University of Pennsylvania Benefits 2011-2012 Open Enrollment GuideMonday, April 4 through Friday, April 22, 2011You Must Enroll by April 22, 2011 Human Resources
Attend an Open Enrollment FairRepresentatives from Penn’s health care insurance providers and administrators will be onsite to share information and answerquestions. Learn about medical plans (Independence Blue Cross and Aetna), prescription drug coverage (CVS Caremark),dental plans (Penn Faculty Practice and MetLife), vision coverage (Davis Vision), Pre-Tax Expense Accounts (ADP) and thePenn Benefits Center (ADP). Penn’s retirement vendors—TIAA-CREF and Vanguard—will also be onsite to answer questionsand provide information about retirement plans.At the Houston Hall fair on April 12, you can also take advantage of free health screenings and wellness information on severaltopics, including blood pressure, cholesterol and glucose, glaucoma, Body Mass Index, recreation and fitness, women’shealth, environmental safety and ergonomics, Employee Assistance Program, occupational and physical therapy, diabetesand heart health, oral and dental care and more. Pre-registration for some tests is required. To pre-register, visit the HumanResources online course catalog at www.hr.upenn.edu (Course Catalog > Browse by Category > Health Promotion).Date Time LocationTuesday, April 12 10:00 a.m. – 2:00 p.m. Houston Hall, Hall of FlagsThursday, April 14 10:00 a.m. – 2:00 p.m. New Bolton Center, Alumni HallAttend an Information SessionAetna will be onsite to hold information sessions about the new High Deductible Health Plan with Health Savings Account.Date Time LocationFriday, April 8 10:00 a.m. – 12:00 p.m. Learning and Education – 3624 Market Street, Suite 1B-SouthWednesday, April 13 1:00 p.m. – 3:00 p.m. Learning and Education – 3624 Market Street, Suite 1B-SouthTuesday, April 19 2:00 p.m. – 4:00 p.m. Learning and Education – 3624 Market Street, Suite 1B-South 3
Table of ContentsBefore You Enroll......................................................................................................................................1How to Enroll ............................................................................................................................................3Overview of What’s Changing for the 2011-2012 Plan Year ....................................................4Medical Coverage....................................................................................................................................6Health Savings Account Feature ........................................................................................................8Key Medical Plan Features....................................................................................................................9Prescription Drug Coverage ..............................................................................................................14Dental Coverage....................................................................................................................................15Vision Coverage ....................................................................................................................................16Life Insurance..........................................................................................................................................17Pre-Tax Expense Accounts ................................................................................................................18Important Information........................................................................................................................19Contact Information for the Health and Welfare Plans............................................................23
Before You EnrollThis Enrollment Guide, along with your Personalized Worksheet, will help you understand your 2011-2012 benefit optionsso you can make informed decisions about the benefits that are right for you and your family. This guide has informationabout the following benefits available to eligible employees:• Medical • Life Insurance• Dental • Pre-Tax Expense Accounts• VisionSee “Overview of What’s Changing for the 2011-2012 Plan Year” on page 4, for a list of the changes effective July 1, 2011.Even if you previously elected to go “paperless,” we’re sending information to all faculty and staff this year. We remaincommitted to the University’s sustainability goals, but some of the upcoming changes are significant and we want toensure you’re informed.Making Changes during Open Enrollment Enrollment DeadlinesDuring Open Enrollment you need to determine if your Open Enrollment is April through April 22, 2011.current benefits still meet your needs or if you need to If you are adding an adult child under the age of 26make a change, such as: who either lost coverage or was denied coverage based on his or her age, you will have until May 4, 2011• Enrolling in a health care plan for the first time, or to add him or her to your coverage to be effective July 1, 2011. See “Eligibility for Benefits” on page 3 dropping an existing plan. for more information.• Switching to a different medical or dental plan. Are You Newly Eligible for Bene ts or Have• Increasing or decreasing your life insurance coverage. You Experienced a Qualifying Event?• Changing how much you contribute to a Pre-Tax If either of these situations occur between now and Expense Account. May 15, 2011, you will need to enroll twice: once to elect or change your benefits for the current plan year• Adding or dropping a dependent from your (through June 30, 2011), and then again to elect your coverage for the 2011-2012 plan year (starting July 1, 2011). benefits coverage*. Please note that some plans offered to you now will not be available for the 2011-2012 plan year.* If you add a new dependent, you’ll receive a letter requesting that you provide verification of that dependent’s eligibility under Penn’s plan rules. You’ll also need to provide verification if you re-enroll a spouse/partner who had previously been covered.If You Don’t EnrollIf you don’t make changes during Open Enrollment, you’llreceive the same coverage you had last year, except forthe following:• UPHS Point of Service (POS) plan members will be enrolled in the new Aetna Choice POS II plan.• Aetna HMO plan members will be enrolled in the Keystone/AmeriHealth HMO plan.Note that existing PennCare/Personal Choice PPO andKeystone/AmeriHealth HMO plan members will remainin their current plans as these two plans remain part ofour medical plan offerings.This year only, you will not need to recertify your qualifiedadult children during Open Enrollment. If you're currentlycovering eligible children between the ages of 19 and 26,they will remain on your coverage as of July 1, 2011. Nextyear, however, you will need to actively recertify any qualifiedadult children. 1
Enrollment Checklist • Learn about your bene ts. Read this Enrollment Guide and review the options and costs on your Personalized Worksheet. • Plan for the year. Determine how much to contribute to the Pre-Tax Expense Accounts or the new Health Savings Account that comes with the Aetna High Deductible Health Plan. • Enroll online at www.pennbene ts.upenn.edu. For instructions, see “How to Enroll” on page 3. • Review and con rm your elections. Once the enrollment deadline has passed, you cannot change your benefit elections unless you experience a qualifying event, as described on page 3.More InformationYou can learn more about your benefits and options from the following resources:• Visit www.hr.upenn.edu where you can access plan summaries, benefit comparison charts, contribution charts and online provider directories. You can also use the new Medical Plan Cost Estimator to estimate your total out-of-pocket costs under each of the available plans.• Review your Personalized Worksheet to determine how much each medical plan will cost for each coverage tier.• For more specific plan questions, contact plan providers directly using the “Contact Information for the Health and Welfare Plans” on pages 23-24.• Attend an Open Enrollment Fair where health care and retirement providers will be onsite to answer questions and provide information.• Contact the Penn Benefits Center at 1-888-PENN-BEN (1-888-736-6236), Monday through Friday, between 8:00 a.m. and 6:00 p.m. EST.• Contact Human Resources at bene ts@hr.upenn.edu. 2
How to EnrollRead all information regarding benefit options beginning on page 4. From Monday, April 4 through Friday, April 22, you canmake changes to your benefits coverage online at www.pennbene ts.upenn.edu using your PennKey and password.If you don’t have internet access, go to one of the following locations on campus to enroll online, or contact the Penn BenefitsCenter at 1-888-PENN-BEN (1-888-736-6236), Monday through Friday, between 8:00 a.m. and 6:00 p.m. EST and completeyour enrollment over the phone.Human Resources Monday – Friday: 8:30 a.m. – 5:00 p.m.3401 Walnut Street, 5th Floor Monday – Thursday: 24 hours dailyGoldstein Undergraduate Study Center Friday: 8:30 a.m. – 12:00 a.m.Ground level of Van Pelt Dietrich Library Saturday: 10:00 a.m. – 2:00 a.m.3420 Walnut Street Sunday: opens at 10:00 a.m.Unique Advantage Monday – Friday: 8:30 a.m. – 5:30 p.m.3624 Market Street, Suite 1SDWhen Changes Are Effective Eligibility for BenefitsChanges made during Open Enrollment will be effective Before you enroll, it’s a good idea to ensure that youras of July 1, 2011. New rates for your existing medical, dependents are eligible for medical, dental, vision anddental and vision plans will be reflected in your June 2011 dependent life insurance coverage. In general, your eligiblepaycheck. Any elected Pre-Tax Expense Account and dependents include your spouse or domestic partner andHealth Savings Account payroll deductions will begin children. If you have a child between the ages of 19 and 26with your July 2011 paycheck. who had previously become ineligible for coverage, you will have the opportunity to re-enroll him or her during this year’sMaking Changes after Enrollment Open Enrollment. Here are additional details:The choices you make during Benefits Open Enrollment • Eligible children can be covered up to the end of thewill remain in effect through June 30, 2012, unless youexperience a qualifying event. Qualifying events include month in which they turn 26.the birth or adoption of a child, marriage or domesticpartnership, divorce or separation, death of a dependent, • Children are eligible for coverage regardless of theirand change in your dependent’s eligibility for benefits.Keep in mind that the IRS limits the types of changes you student, marital or IRS dependent status.can make for qualifying events. • Children do not have to live with you or depend on youIf you experience a qualifying event, please contact thePenn Benefits Center within 30 days at 1-888-PENN-BEN for financial support to be eligible.(1-888-736-6236), Monday through Friday, between8:00 a.m. and 6:00 p.m. EST. • Children over age 19 no longer have to be full-time college students to remain on coverage. • Disabled children who are unable to earn a living may be covered beyond age 26, provided the disability began before age 26 and has been certified by your insurance carrier. • The coverage does not extend to your child’s spouse/partner or children. • Although Open Enrollment ends on April 22, you have until May 4 to add qualified adult children to your coverage. Simply follow the instructions on the enrollment website at www.pennbene ts.upenn.edu. It’s important to note that there are specific eligibility rules that pertain to the new Aetna High Deductible Health Plan (HDHP) with a Health Savings Account (HSA). Please see pages 6-8 for more information about this plan. 3
Overview of What’s Changing for the 2011-2012 Plan Year• Health Care Reform Changes—Dependent children covered to age 26, no lifetime coverage limits and preventive care covered at 100%• Medical Plan Changes—Two medical plans no longer available, two new medical plans offered, and changes to out-of-pocket costs, in vitro fertilization and autism coverage• MetLife Dental Plan Changes—New deductible and increase in annual maximum benefit• Payroll Contributions—Move from three-tier to new four-tier structureHealth Care Reform Changes No Longer Available—UPHS POS and Aetna HMO• Dependent children covered to age 26. Penn will As of July 1, 2011, the UPHS Point of Service (POS) and extend medical, dental, vision and dependent life the Aetna HMO medical plans will no longer be offered. insurance coverage to eligible adult children up to If you’re currently enrolled in either of these plans, you’ll need the end of the month in which they turn age 26. to choose a new medical plan during Open Enrollment. If you See additional information on page 3. don’t make an election, you’ll automatically be enrolled in a new plan based on your current coverage. If you’re a UPHS POS• No lifetime coverage limits on essential plan bene ts. participant, you’ll be enrolled in the Aetna Choice POS II plan. If you’re an Aetna HMO participant, you’ll be enrolled in the This change only affects the PennCare/Personal Choice Keystone/AmeriHealth HMO plan. PPO plan. There will no longer be a lifetime coverage maximum when you use out-of-network providers in New Plans—Aetna Choice POS II and Aetna High this plan. Please note that some limits do apply to Deductible Health Plan with Health Savings Account non-essential health benefits, such as in vitro fertilization. The Aetna Choice POS II will replace the UPHS POS plan. The• Preventive care covered at 100%. Preventive care will new plan offers more freedom because you do not need to choose a Primary Care Provider or get referrals. You decide be covered at 100% with no copay for all medical plans. which providers you want to use at any time, whether This includes services such as routine physicals, pediatric in-network or out-of-network. immunizations and annual gynecological exams. Visit www.hr.upenn.edu for a full list of preventive services. In response to faculty and staff requests for this type of plan, Penn will also offer the Aetna High Deductible Health PlanMedical Plan Changes (HDHP) with a Health Savings Account (HSA)*. This plan is designed to give you more choice and control over howPenn will offer four medical plan options: two of these plans you spend your health care dollars. You can read more aboutare currently offered and two are new. You will still have the these new medical plan options on page 6.option to select from either the Aetna or IndependenceBlue Cross provider networks, but this new mix of plan * The Aetna High Deductible Health Plan with Health Savingsoptions provides greater choice for you and your family. Account is not available to Visiting Scholars or the membersSee the “Key Medical Plan Features” chart beginning on of Locals 54, 115 and 590.page 9 for more information about plan coverage details.Medical Plan Options for 2011–20122010–2011 2011–2012 Aetna HMO New Aetna HDHP with HSAUPHS POS New Aetna Choice POS IIPennCare/Personal Choice PPO Remain PennCare/Personal Choice PPO Keystone/AmeriHealth HMO in 2012 Keystone/AmeriHealth HMO
Out-of-Pocket Costs MetLife Dental PlanSeveral changes will be made in the PennCare/PersonalChoice PPO plan. The MetLife Preferred Dentist Program (PDP) will have a deductible of $50 per person for services. This deductible• A deductible will be introduced for the PennCare network, will not apply to preventive care services that are covered at 100%, such as cleanings and periodic x-rays. The annual and the deductible for the Personal Choice network will maximum benefit for the MetLife plan will increase from increase. $1,500 to $2,000 per person.• Some of the existing copays will be replaced with a Payroll Contributions coinsurance payment, and there will be higher copays There will be an increase in payroll deductions (the and coinsurance amounts for other services. amount you contribute through your pay) for the PennCare/Personal Choice PPO and the• The annual out-of-pocket maximum for families will Keystone/AmeriHealth HMO plans. Penn will continue to fund the majority of the premium costs for all of our health increase for the PennCare network, and the separate plans; your contribution is a portion of the total cost. copay maximums will be removed from the plan. Payroll contributions will move to a four-tier structure.For the Keystone/AmeriHealth HMO plan, copays will Our current structure offers three tiers: employee only,increase for some services. employee plus one, and employee plus two or more. We’re changing this to four tiers that distinguish the typeIn Vitro Fertilization Coverage of dependent you’re covering, which will provide a moreIn Vitro Fertilization (IVF) coverage will be offered under all equitable distribution of the rates across our entire population.medical plans for services at the Hospital of the University Some faculty and staff may actually see lower payrollof Pennsylvania (HUP) only. Coverage will be limited to two deductions as a result. The new structure is shown in thecycles per lifetime. chart below, and you can see the rates on your personalized enrollment worksheet.Autism CoverageThe University is expanding coverage for autism under all Current Premium New Premiummedical plans. All of our plans currently cover diagnostic Rate Structure Rate Structureassessments of autism spectrum disorders, prescriptionmedications and blood level tests, psychiatrist and Employee Only Employee Onlypsychologist services, therapies and other rehabilitative Employee + Child(ren)care services. As of July 1, our plans will also cover applied Employee + 1 Employee + Spouse/Partnerbehavioral analysis, which uses behavioral observation, Employee + Familypositive reinforcement and other principles to improve Employee + 2socially significant behaviors and skills. The New Medical Plan Cost Estimator Tool... Helps you answer the question, “What could the total out-of-pocket medical costs look like for me and my family in the year ahead?” and makes it easier for you to select the coverage option that works best for you and your family. It factors in the payroll deductions and the cost of your anticipated health care needs under each of the plans, based on whether you and your eligible dependents are low, medium or high users of health care services.
Medical Coverage Keystone/AmeriHealth HMO—This is a managed care plan administered by Independence Blue Cross. You must selectPenn provides comprehensive medical coverage for you and coordinate your care through a network Primary Careand your family. For 2011-2012, you may choose from four Physician (PCP). You must obtain referrals from your PCP ifmedical plan options. For more information about plan you need to see other network providers for care. This plancoverage details, see the “Key Medical Plan Features” chart does not provide coverage if you go outside the HMO networkbeginning on page 9. of providers. Preventive care services are covered at 100%. Most other services are covered at 100% after copays.PennCare/Personal Choice PPO—This Preferred ProviderOrganization (PPO) plan administered by Independence New Plan—Aetna High Deductible Health Plan (HDHP)Blue Cross has three components. You may receive your care with a Health Savings Account (HSA)*—This is a new typethrough any provider you choose at any time, but your of plan designed to give you more choice and control overout-of-pocket costs are based on which component of the how you spend your health care dollars. Administered byplan you’re using at that time. You don’t need a Primary Care Aetna, this plan has two components: in-network orProvider (PCP) or referrals for this plan. out-of-network. You may receive your care through any provider you choose at any time, but your out-of-pocket• PennCare Network Providers: Use health care providers costs are based on which component of the plan you’re using at that time. You don’t need a Primary Care Provider (PCP) who are part of or affiliated with the UPHS network. or referrals for this plan. As the name implies, this plan carries Preventive care services are covered at 100%. Most other a high deductible and you need to meet that deductible services are covered at 90% after a deductible; you pay before the plan begins paying benefits. This applies to all only 10% of the covered charges. services, including prescription drugs and office visits. However, the deductible does not apply to in-network• Personal Choice Preferred Providers: Use health care preventive care and preventive generic prescription drugs. This plan has an HSA, a tax savings vehicle that you can providers who are part of the Personal Choice network. contribute to via payroll deduction and use the money to Preventive care services are covered at 100%. Provider offset the cost of care. What’s more, Penn will also contribute office visits are covered at 100% after copays. Most other money to the HSA on your behalf—$500 for employee only services are covered at 80% after a deductible; you pay coverage or $1,000 if you cover any dependents. 20% of the covered charges. • In-Network Providers: Use health care providers who are• Non-Preferred Providers: Use health care providers who part of the Aetna HDHP network. Preventive care services are not part of either the PennCare or Personal Choice are covered at 100%. Provider office visits are covered at networks. Most services, including preventive care, are 100% after copays. Most other services are covered at 90% covered at 60% after a deductible; you pay 40% of the after a deductible; you pay 10% of the covered charges. covered charges. • Out-of-Network Providers: Use health care providersNew Plan—Aetna Choice POS II—This will replace theUPHS Point of Service (POS) plan. Administered by Aetna, who are not part of the Aetna HDHP network. Mostthis is a new type of POS that offers more freedom: you services, including preventive care, are covered at 60%don’t need a Primary Care Provider (PCP) or referrals, even after a deductible; you pay 40% of the covered charges.when using in-network providers. It has two components:in-network or out-of-network. You may receive your care * The Aetna High Deductible Health Plan with Health Savingsthrough any provider you choose at any time, but your Account is not available to Visiting Scholars or the membersout-of-pocket costs are based on which component of of Locals 54, 115 and 590.the plan you’re using at that time.• In-Network Providers: Use health care providers who are part of the Aetna Choice POS II network. Preventive care services are covered at 100%. Provider office visits are covered at 100% after copays. Most other services are covered at 80% after a deductible; you pay 20% of the covered charges.• Out-of-Network Providers: Use health care providers who are not part of the Aetna Choice POS II network. Most services, including preventive care, are covered at 60% after a deductible; you pay 40% of the covered charges. 6
PennCare/ Aetna Choice POS II Keystone/AmeriHealth HMO Aetna High DeductiblePersonal Choice PPO Health Plan with HSANo PCP or referrals needed No PCP or referrals needed PCP and referrals required No PCP or referrals neededUse any provider Use any provider Use in-network providers only Use any providerDeductible must be met Deductible must be met Most services are covered Deductible must be met firstfirst for all non-preventive first for all non-preventive at 100% (copays apply) for all non-preventive services,services. After deductible services. After deductible including non-generic prescriptionis met, out-of-pocket costs is met, out-of-pocket costs drugs. After deductible is met,are based on whether you’re are based on whether you’re out-of-pocket costs are based onusing in-network or using in-network or whether you’re using in-networkout-of-network providers. out-of-network providers. or out-of-network providers.Not eligible for Health Not eligible for Health Not eligible for Health Eligible for HealthSavings Account Savings Account Savings Account Savings AccountEligible for Health Care Eligible for Health Care Eligible for Health Care Not eligible for Health CarePre-Tax Expense Account Pre-Tax Expense Account Pre-Tax Expense Account Pre-Tax Expense AccountHighest payroll deductions Second highest Second lowest Lowest payroll deductions payroll deductions payroll deductionsHow the High Deductible Health Plan Works Out-of-Pocket MaximumYou pay coinsurance until you reach theout-of-pocket maximum for the year. Then, Coinsurance Health Savingsthe plan pays 100% for covered medicalexpenses. You pay nothing. Annual Deductible Account (HSA)Once you meet the annual deductible, you share Preventive Care A tax advantagedin the cost of services by paying coinsurance (100%) savings accountbased on the discounted cost. You can use that you can usemoney from your HSA to pay these amounts. to meet your deductible, payYou pay the discounted cost for covered services coinsurance, andup to the deductible. You can use money in your reach yourHSA to satisfy the deductible. out-of-pocket maximum. Or, youThe plan provides preventive care, such as can save it for futureannual physicals and screenings, at no cost or health expenses.minimal cost to you, when you use a providerin the network. 7
Health Savings Account FeatureWhen you enroll in the High Deductible Health Plan, you may establish a Health Savings Account (HSA). An HSA is a pre-taxsavings account that you can use now to pay for eligible health care expenses for you and your eligible dependents, as wellas save to pay for future health care expenses.The HSA provides a triple tax advantage: money goes in tax-free, grows tax-free and is tax-free when used to pay for eligiblemedical expenses. If you don’t use all of the money in the HSA during the plan year, it rolls over to the next year. Once yourbalance reaches $2,000 you can invest your account in a selection of investment funds through J.P. Morgan Chase Bank N.A.You can also take the money in the HSA if you leave Penn or retire. Once money is in the account, it’s yours to keep or usetoward eligible medical plan expenses.How Does an HSA Work?For 2011, your Health High Protects you frommaximum HSA Savings Deductible big medical billscontribution is Account Insurance$2,550 for single Helps pay your deductibleand $5,150 for Plan + Tax-deductible depositsfamily coverage Total maximum Savings Tax-deferred growth + annual Account Tax-free medical carePenn will contributionscontribute $500 (you + Penn)for single or $1,000 are $3,00 forfor family coverage single coverageto your HSA and $6,10 for family coverageImportant HSA Rules Which Medical Plan Is Right for You?• You are not allowed to be enrolled in any other health coverage plan, Evaluate your Medical History and Usage including Medicare, or union plans (i.e., no secondary coverage permitted • How much and what type of health care services under spouse). did you need last year?• You cannot participate in the Health Care Pre-Tax Expense Account if you elect • Will your health care needs be similar this year? the Aetna HDHP with HSA. Also, your spouse cannot have a health care • How much do you think your out-of-pocket health pre-tax spending account. care costs will be this year?• For 2011, the maximum amount you can contribute to an HSA is $2,550 Consider Your Preferences for single coverage and $5,150 for family coverage. Penn will contribute $500 for single coverage or $1,000 for family coverage to your HSA. • How important is cost to you in your plan decision? • How much of a role do you want to play in• If you are age 55 or older, you can contribute an additional $1,000 per year.• Penn’s contribution amount and any post-tax contributions must be managing your health care costs? counted towards the HSA limits. • How much freedom and flexibility do you want• If you reach the pre-tax maximum in any year, you must stay in the when it comes to choosing providers and hospitals? Aetna HDHP for the following plan year. If you fail to do this, you’ll be • Are you more concerned with an affordable payroll subject to IRS tax penalties. deduction, or with how much you pay when you• Money must be in an HSA account to receive reimbursement. use health care services?• Contributions can be made by anyone to your account post-tax.• You may change your HSA pre-tax contribution amounts anytime during Plan for the Future the year. 2012 contribution limits will be released later this year and you’ll be • Do you have other coverage available (e.g., through able to modify contribution levels if you like, based on revised limits. your spouse’s/domestic partner’s employer)?• Please note: Expenses for domestic partners and/or children not claimed • Are you interested in receiving tax savings on as dependents on your tax return are ineligible for reimbursement under the Health Savings Account. money you set aside for health care expenses? 8 • Are you looking for a way to save for health care expenses in retirement?
Key Medical Plan Features PennCare/Personal Choice PPO* Plan Name PennCare Preferred Providers Personal Choice Preferred Non-Preferred ProvidersDeductible** Providers $500 individual/$1,500 family $100 individual/$300 family $250 individual/$750 familyHSA Seed N/A N/A N/AOut-of-Pocket Maximum**• Coinsurance and deductible $1,000 individual/$3,000 family $2,500 individual/$7,500 family $3,500 individual/$10,500 familyMaximum Lifetime Unlimited Unlimited UnlimitedBene t**Doctor’s Office Visits• Primary care $20 copay $25 copay 40% after deductible• Specialist $30 copay $40 copay 40% after deductibleUrgent Care Center $50 copay $50 copay 40% after deductiblePreventive Screenings• Routine physicals $0 copay $0 copay 40% after deductible• Routine eye exams $0 copay $0 copay 40% after deductible• Routine hearing screenings $0 copay $0 copay 40% after deductible $0 copay for children under 18• Pediatric immunizations $0 copay for children under 18 $0 copay 40% no deductible for children under 18• Annual GYN exam/Pap smear $0 copay 40% no deductible• Mammography $0 copay $0 copay 40% no deductibleMaternity• First OB visit $30 copay $40 copay 40% after deductible• OB/maternity care 10% after deductible 20% after deductible 40% after deductible• Hospital inpatient 10% after deductible 20% after deductible 40% after deductible Not covered Not covered• In vitro fertilization (limit two $30 copay cycles per lifetime at HUP only)Outpatient Services• Surgery 10% after deductible 20% after deductible 40% after deductible• Laboratory/pathology $0 copay $0 copay 40% after deductible• X-rays/radiology 10% after deductible 20% after deductible 40% after deductible* Pre-certification needed for certain services** Covers medical and behavioral health/substance abuse
PennCare/Personal Choice PPO* Plan Name PennCare Preferred Providers Personal Choice Preferred Non-Preferred Providers ProvidersHospitalization (semi-privateroom, board, surgery and 10% after deductible 20% after deductible 40% after deductible;anesthesia, specialists’ care limited to 70 daysand diagnostic testing)Emergency Room $100 copay (waived if admitted) $100 copay (waived if admitted) $100 copay (waived if admitted)Ambulance $0 copay for emergency; $0 copay for emergency; $0 copay for emergency; 10% after deductible for 20% after deductible 40% after deductibleTherapy Services (physical, non-emergency for non-emergency for non-emergencyspeech and occupational;60 visits per year) $30 copay $40 copay 40% after deductibleSpinal Manipulation Not available $40 copay 40% after deductible(30 visits per year)Home Health Care 10% after deductible 20% after deductible 40% after deductible 40% after deductibleDurable Medical Provider not currently available 20% after deductibleEquipment Out-of-NetworkBehavioral Health and Substance Abuse• Providers In-Network (Penn Behavioral In-Network (Penn Behavioral Health Staff ) Health Regional Network)• Outpatient $20 copay per visit; unlimited $20 copay per visit; unlimited 40% after deductible; unlimited visits if medically necessary visits if medically necessary visits if medically necessary 10% after deductible; unlimited 10% after $100 individual/ 40% after deductible; days if medically necessary• Inpatient $300 family deductible; unlimited unlimited days if medically days if medically necessary necessary* Pre-certification needed for certain servicesDefinitions Health Maintenance Organization (HMO): A network of health care providers offering relatively low out-of-pocketCoinsurance: After you meet the deductible, your health costs. HMOs generally operate in particular geographicplan pays a specified percentage of the charges for covered regions and require a Primary Care Physician toservices. You pay the remaining charges, called coinsurance. coordinate care.Co-payment/Copay: A flat per-service charge that you pay Health Savings Account (HSA): Available only to thosefor services such as doctor visits or prescriptions. who enroll in the High Deductible Health Plan (HDHP), HSAs provide you with a pre-tax way to save for futureDeductible: The dollar amount you must pay each year medical expenses, including those that will occur inbefore your medical and/or dental plan begins to pay retirement. There is no \"use it or lose it\" rule with thebenefits for certain covered expenses. The amount of the HSA—your unused funds roll over from year to year,deductible depends upon the plan you select. Each until you are ready to use them.covered individual will not be charged more than theindividual deductible. If multiple dependents are covered, High Deductible Health Plan (HDHP): HDHPs offer lowerthe aggregate total of the deductibles charged for all premiums but require you to pay for your full cost of care untilcovered members will not exceed the family deductible. you meet an annual deductible. If you enroll in the HDHP, you can use a Health Savings Account (HSA) to pay for your medical expenses with pre-tax paycheck deductions. 10
Aetna Choice POS II ( New) Keystone/AmeriHealth HMO* Plan Name In-Network In-Network Out-of-NetworkDeductible** $500 individual/$1,500 family $1,000 individual/$3,000 family None N/A N/A N/AHSA Seed N/A N/A $1,000 individual/$2,000 familyOut-of-Pocket Maximum** $2,000 individual/$6,000 family $3,000 individual/$9,000 family N/A• Copay Unlimited Unlimited Unlimited• Coinsurance and deductibleMaximum LifetimeBene t**Doctor’s Office Visits• Primary care $30 copay 40% after deductible $25 copay• Specialist $40 copay 40% after deductible $35 copay with referralUrgent Care Center $50 copay 40% after deductible $50 copayPreventive Screenings• Routine physicals $0 copay 40% after deductible $0 copay• Routine eye exams $0 copay 40% after deductible $35 copay***• Routine hearing screenings $0 copay 40% after deductible $0 copay• Pediatric immunizations $0 copay 40% after deductible $0 copay• Annual GYN exam/Pap smear $0 copay 40% after deductible $0 copay• Mammography $0 copay 40% after deductible $0 copayMaternity• First OB visit 20% after deductible 40% after deductible $25 copay• OB/maternity care 20% after deductible 40% after deductible $0 copay• Hospital inpatient 20% after deductible 40% after deductible $350 copay per admission• In vitro fertilization (limit two $40 copay Not covered $35 copay cycles per lifetime at HUP only)Outpatient Services• Surgery 20% after deductible 40% after deductible $150 copay with referral• Laboratory/pathology 20% after deductible 40% after deductible $0 copay• X-rays/radiology 20% after deductible 40% after deductible $30 (routine1) or $60 (complex2) copay with referral* Pre-certification needed for certain services** Covers medical and behavioral health/substance abuse*** $35 allowed for contacts or prescription eyeglasses every two years; see member handbook for vision exam benefit schedule1 Routine radiology procedures are those that do not require prior authorization (e.g., chest x-ray)2 Complex radiology procedures are those that require prior authorization (e.g., MRI, CT scan, PET scan) 11
Aetna Choice POS II (New) Keystone/AmeriHealth HMO* Plan Name In-Network Out-of-Network In-NetworkHospitalization (semi-privateroom, board, surgery and 20% after deductible 40% after deductible $350 copay per admissionanesthesia, specialists’ care with referral; no limit ifand diagnostic testing) medically necessaryEmergency Room $150 copay (waived if admitted) $150 copay (waived if admitted) $150 copay (waived if admitted)Ambulance 20% after deductible 40% after deductible $0 copay $40 copay 40% after deductibleTherapy Services (physical, $40 copay 40% after deductible $35 copayspeech and occupational; 20% after deductible 40% after deductible60 visits per year) $35 copaySpinal Manipulation $0 copay with coordination by(60 visits per year) patient management department $0 copay when medicallyHome Health Care necessary; pre-approval requiredDurable Medical Equipment 20% after deductible 40% after deductible Keystone HMO providers $25 copay per visit; unlimitedBehavioral Health and Substance Abuse Out-of-Network visits if medically necessary 40% after deductible $350 copay per admission• Providers In-Network (Penn Behavioral with referral; unlimited days Health Regional Network) if medically necessary• Outpatient $30 copay after deductible• Inpatient 20% after deductible 40% after deductible* Pre-certification needed for certain servicesDefinitions that service. If providers have an affiliation with the plan, they are obligated to accept the plan’s UCR or R&C as payment inOut-of-Pocket Maximum: The most you have to pay out full. However, if providers are not affiliated with the plan, theyof your own pocket during the benefit year in coinsurance are not obligated to accept the URC or R&C, and you mayafter you meet your deductible, as long as your providers have to pay any charges in excess of the payment made byaccept your plan’s UCR. Once you reach the out-of-pocket the plan.maximum, the plan pays 100% of UCR. Out-of-pocketmaximums stated by plans are based on your use of providers Referral: Authorization from a provider (typically a Primarywho accept the plan’s UCR. Care Physician in an HMO) for the insured person to consult a medical specialist.Each covered individual will not pay more than the individualout-of-pocket maximum. If multiple dependents are covered, Reimbursements: It is important to note that the medicalthe aggregate total of the out-of-pocket costs paid by all plans offered do NOT guarantee that all covered services willcovered members will not exceed the family maximum. be available through preferred or in-network providers. If a preferred or in-network provider is not available, the servicePreventive Care: Routine screenings to detect or prevent will be processed as an out-of-network expense.possible medical conditions. This includes, but is not limitedto, flu shots, mammograms and cholesterol testing. You should also note that in-network providers might refer you to providers who are outside the network. Anytime youPrimary Care Physician (PCP): In an HMO, your PCP is use an out-of-network provider, your services will bethe doctor responsible for providing routine care and processed accordingly (non-preferred or self-referred).referrals to specialists. You should always verify whether the provider is in-network by calling the number on the back of your ID card.UCR or R&C: UCR or R&C refers to the usual, customary, andreasonable fees that providers, health care facilities or otherhealth care professionals in the same geographical areacharge for similar services. Plans that pay 100% of UCR or R&Cpay 100% of the usual, customary, and reasonable fees for 12
Plan Name Aetna High Deductible Health Plan with HSA (New) In-Network Out-of-NetworkDeductible* $1,500 individual/$3,000 family $1,500 individual/$3,000 familyHSA Seed $500 employee/$1,000 familyOut-of-Pocket Maximum*• Copay N/A N/A• Coinsurance and deductible $3,000 individual/$6,000 family $3,000 individual/$6,000 familyMaximum Lifetime Bene t** Unlimited UnlimitedDoctor’s Office Visits• Primary care 10% after deductible 40% after deductible• Specialist 10% after deductible 40% after deductibleUrgent Care Center 10% after deductible 40% after deductiblePreventive Screenings• Routine physicals $0 copay 40% after deductible• Routine eye exams $0 copay 40% after deductible• Routine hearing screenings $0 copay 40% after deductible• Pediatric immunizations $0 copay 40% after deductible• Annual GYN exam/Pap smear $0 copay 40% after deductible• Mammography $0 copay 40% after deductibleMaternity• First OB visit 10% after deductible 40% after deductible• OB/maternity care 10% after deductible 40% after deductible• Hospital inpatient 10% after deductible 40% after deductible• In vitro fertilization (limit two cycles 10% after deductible Not covered per lifetime at HUP only)Outpatient Services• Surgery 10% after deductible 40% after deductible• Laboratory/pathology 10% after deductible 40% after deductible• X-rays/radiology 10% after deductible 40% after deductible 10% after deductible 40% after deductibleHospitalization (semi-private room, board,surgery and anesthesia, specialists’ care anddiagnostic testing)Emergency Room 10% after deductible 10% after deductibleAmbulance 10% after deductible 40% after deductibleTherapy Services (physical, speech and 10% after deductible 40% after deductibleoccupational; 60 visits per year)Spinal Manipulation (60 visits per year) 10% after deductible 40% after deductibleHome Health Care 10% after deductible 40% after deductibleDurable Medical Equipment 10% after deductible 40% after deductibleBehavioral Health and Substance Abuse• Providers Aetna network Out-of-Network• Outpatient 10% after deductible 40% after deductible• Inpatient 10% after deductible 40% after deductible* Covers medical, behavioral health/substance abuse and prescription drug** Covers medical and behavioral health/substance abuse 13
Prescription Drug CoverageThe Prescription Drug Plan is administered by CVS Caremark Prescription Services for all medical plans. However, the planstructure differs depending on which medical plan you select.PennCare/Personal Choice PPO, Aetna Choice POS II and Keystone/AmeriHealth HMO plansFor these three plans, the amount you pay for prescription drugs depends on how you use your coverage and the typeof prescription you fill (generic, brand name with or without a generic equivalent, or a maintenance medication).• When you purchase a prescription at a retail pharmacy, you’ll pay less if you use a participating in-network pharmacy (e.g., CVS, Genuardi’s, Giant, HUP pharmacy, Kmart, Pathmark, Rite Aid and Walgreens).• If you’re able to take a generic drug, you’ll save money—not only will you pay a lower coinsurance amount, but that lower coinsurance is a percentage of a lower base price for the drug.• You can use CVS Caremark’s mail order program for long-term maintenance medications. The mail order program offers several advantages including home delivery, three-month supplies, and lower minimum and maximum coinsurance amounts.Applies to those enrolled in the PennCare/Personal Choice PPO, Aetna Choice POS II and Keystone/AmeriHealth HMO plans Generics Brand Names With Brand Names With No Generic Equivalent Generic Equivalent*Coinsurance; Minimum and Maximum PaymentNon-maintenance• 34-day supply (any network 10%; $5 min/$20 max 30%; $15 min/$75 max 10%+; $15 min/$100 max* retail pharmacy)Maintenance• 34-day supply (any network 10%; $5 min/$20 max 30%; $15 min/$75 max 10%+; $15 min/$100 max* 20%; $10 min/$40 max 60%; $30 min/$150 max 20%+; $30 min/$200 max* retail pharmacy, up to 3 fills)** 10%; $10 min/$40 max 20%; $20 min/$100 max 10%+; $30 min/$200 max*• 34-day supply (any network retail pharmacy, after 3 fills)**• 90-day supply (CVS pharmacy or mail order)Annual Out-of-Pocket Maximum $2,000 individual/$6,000 family** For brand names with a generic equivalent, you pay a percentage of the brand name cost PLUS the cost difference between brand name and generic. The cost difference between brand name and generic does not count toward the minimums and maximums.** After three 34-day fills, you will pay double the normal coinsurance amount, as well as double the minimum and maximum coinsurance payments. You can save money by ordering 90-day supplies through the mail order program or at a CVS pharmacy.Aetna High Deductible Health Plan (HDHP) with HSAWhen you enroll in the Aetna High Deductible Health Plan (HDHP), the amount you pay for prescription drugs variesonly based on whether your prescription is a preventive generic drug or some other drug type. When you take genericpreventive drugs, you’re not subject to the deductible; for all other drugs, you must reach your deductible before the planbegins to pay benefits. Applies to those enrolled in the Aetna High Deductible Health Plan (HDHP) with HSAAnnual Deductible* $1,500 individual/$3,000 familyAnnual Out-of-Pocket Maximum* $3,000 individual/$6,000 familyPreventive Generic Drugs (any retail or mail order, maintenance 10%, no deductibleor non-maintenance)Preventive Brand Name Drugs (with or without generic equivalent, 10% after deductibleany retail or mail order, maintenance or non-maintenance)Non-Preventive Drugs (generic or brand, with or without generic equivalent, 10% after deductibleany retail or mail order, maintenance or non-maintenance)* Amounts you pay toward medical and behavioral health/substance abuse also count toward the deductible and out-of-pocket maximum. After the out-of-pocket maximum is reached, all covered prescription drugs are paid at 100%. 1
Dental CoveragePenn Faculty Practice (PFP) Dental Plan MetLife Preferred Dentist Program (PDP)The PFP dental plan provides coverage when you receive The MetLife dental plan provides coverage when youtreatment from dentists and specialists who have receive treatment from any dentist or specialist youappointments at the University of Pennsylvania School choose. Use MetLife preferred providers to pay lessof Dental Medicine. PFP office locations and coverage details out-of-pocket expenses because preferred providersare available online at www.hr.upenn.edu/bene ts/dental. accept the plan’s negotiated fees as payment in full. MetLife dental plan coverage details are available online at www.hr.upenn.edu/benefits/dental. Penn Faculty Practice MetLife Preferred Dentist Program (PDP)** (PFP) Plan*Deductible Preferred Provider Non-Preferred Provider None $50 individual $50 individualDiagnostic Care(e.g., exams, x-rays) $0 copay $0 copay $0 copay of R&C**Preventive Care(e.g., cleanings) $0 copay; limited to two visits $0 copay; limited to two visits $0 copay of R&C**; limited toRestorative Care(e.g., fillings) per plan year (7/1-6/30) per plan year (7/1-6/30) two visits per plan year (7/1-6/30)Oral Surgery(extractions) $0 copay 10% after deductible 10% of R&C** after deductibleEndodontics(e.g., root canal therapy) $0 copay $0 copay $0 copay of R&C**Periodontics(treatment of gums) 20% 20% after deductible 20% of R&C** after deductibleProsthodontics(e.g., bridges, dentures) 20% 20% after deductible 20% of R&C** after deductibleCrowns and Restorations 40% 50% after deductible 50% of R&C** after deductibleImplants 40% 50% after deductible 50% of R&C** after deductibleOrthodontics 50% ($1,000 lifetime max; Not covered Not covered(for children under age 19)*** lifetime limit of two implants) 50% ($1,000 lifetime 50% of R&C** ($1,000 lifetimeAnnual Maximum 40%**** ($2,000 lifetime max per child) max per child) max per child) $3,000 per individual $2,000 per individual $2,000 per individual* Please reference the plan document for limitations and exclusions. Note that if you receive dental treatment anywhere other than a Penn Faculty Practice (PFP) Plan office, no benefits will be paid unless due to an emergency that occurs outside of the Philadelphia area (outside a 50-mile radius of a PFP Plan office). Reimbursement will be at the PFP Plan coverage level, based on PFP network fees.** Benefits at a MetLife PDP provider are based on the fee negotiated by MetLife with the provider. Your responsibility is limited to the coinsurance amounts. Non-preferred provider benefits are based on the Plan’s reasonable and customary fees (R&C). Non-preferred dentists are not required to accept the plan’s R&C as payment in full, so you may pay not only your coinsurance amount but also the difference between R&C and the dentist’s actual charges.*** Any amounts applied to the lifetime maximums for orthodontics apply toward the annual benefit maximums as well.**** For the Penn Faculty Practice Plan, there is a 12-month waiting period for orthodontic services for children age five or older. 1
Vision CoverageThe Davis Vision plan provides coverage when you obtain vision care from the provider of your choice. Use in-networkproviders to receive higher coverage and pay less out-of-pocket. Most services are covered once every 12 months, althoughyou may receive discounts for additional services provided by preferred providers. Coverage details are available online atwww.hr.upenn.edu/bene ts/vision. Scheie Eye Providers Davis Vision Providers Out-of-Network ProvidersGlasses (covered once every 12 months)• Eye Exam and Refraction $0 copay $10 copay Up to $32 reimbursement• Frames Up to $30 reimbursement Up to $100 retail allowance Up to $65 retail allowance or select from designer or select from designer frame collection frame collection• Standard Lenses• Single $0 copay $0 copay Up to $30 reimbursement• Bifocal $0 copay $0 copay Up to $36 reimbursement• Trifocal $0 copay $0 copay Up to $50 reimbursement• Aphakic/Lenticular $0 copay $0 copay Up to $72 reimbursement• Polycarbonate Lenses• Single $0 copay if under age 19; $0 copay if under age 19; Up to $30 reimbursement• Bifocal discounted prices if age 19 discounted prices if age 19 Up to $36 reimbursement• Trifocal Up to $50 reimbursement and over and over• Progressive Lenses Discounted prices Discounted prices Up to $36 reimbursementContact Lenses (evaluation and fitting covered once every 12 months; contact lenses covered once every 12 months in lieu of glasses)• Evaluation and Fitting $0 copay $0 copay Up to $20 reimbursement• Daily Wear• Extended Wear $0 copay $0 copay Up to $30 reimbursement• Disposable $0 copay $0 copay Up to $75 reimbursement• Standard Contact Lenses• Medically Necessary Up to $200 allowance Up to $200 allowance Up to $200 reimbursement• Disposable Up to $80 allowance Up to $75 allowance Up to $75 reimbursement• Specialty Contact Lenses Up to $110 allowance Up to $75 allowance Up to $60 reimbursementAdditional Discounts (available only at the point of purchase)• Lens options (e.g., tints) Discounted prices Discounted prices Not covered ($0 copay for tints) ($0 copay for tints)• Additional Eyewear Discounted prices Discounted prices* Not covered• Laser Vision Correction $1,000 discount Up to 25% off usual and Not covered customary fees or 5% off advertised specials, whichever is less* Members selecting non-covered materials (e.g., second pair of eyeglasses, sunglasses, etc.) will receive up to a 20% courtesy discount and up to a 10% discount on disposable contacts at most participating providers. 16
Life Insurance Supplemental Life InsuranceUpdate your life insurance beneficiary information You can increase your Supplemental Life Insurance byvia the benefits online enrollment system at a maximum of one times your salary. Your Basic andwww.pennbene ts.upenn.edu. For more information Supplemental coverage combined cannot exceedabout any of the insurance offerings described below, $1,000,000. If the combined total of your Basic andplease see the Summary Plan Description online at Supplemental coverage exceeds $500,000, you mustwww.hr.upenn.edu/bene ts/spd_healthwelfare.pdf. provide Evidence of Insurability (EOI) to the insurance company. You may choose to limit your coverage toNote: Your benefits base salary for life insurance purposes $500,000 so you don’t have to submit EOI.is calculated and frozen in March of each year. This amountwill not change even if your salary changes during the Dependent Life Insurancecourse of the plan year. You may purchase life insurance for your eligibleBasic Life Insurance dependents in the amount of $15,000 of coverage for your spouse/domestic partner, and/or $7,500 of coveragePenn provides you with Basic Life Insurance of one times for each eligible dependent child.your benefits base salary (maximum of $300,000) at no costto you. If your base salary is more than $50,000, you canchoose to reduce your Basic Life Insurance to $50,000 toavoid imputed income tax. You may increase this freeinsurance amount by electing supplemental coverage.Accidental Death and DismembermentInsurance (AD&D)You will automatically receive Accidental Death andDismemberment Insurance (AD&D) at no cost to you.This feature pays benefits of up to two times your benefitsbase salary, based on your annual benefits base salary,if you die or have other losses directly caused by anaccident (some exclusions apply). 17
Pre-Tax Expense Accounts Important IRS RulesPenn offers Health Care and Dependent Care Pre-Tax Expense When you enroll in a Pre-Tax Expense Account, the followingAccounts. These Pre-Tax Expense Accounts provide you with IRS rules apply:a way to pay for certain out-of-pocket expenses with pre-taxdollars. They’re designed to save you taxes when you pay • You must use all available funds by the end of the plan yearfor certain eligible expenses that are not covered by otherbenefit plans. deadline or you will forfeit any remaining balance.When you participate, your contribution is deducted from • You have until September 15 of the following plan year toyour paycheck before federal taxes are taken, and yourcontributions are put into an account on your behalf. incur expenses, and until September 30 of the followingThen, when you incur eligible expenses, you submit a plan year to submit eligible claims. For example, if youclaim form to be reimbursed from your account. You may enroll in a Pre-Tax Expense Account during the 2011-2012make contributions to a: plan year, you’ll have until September 15, 2012 to incur expenses and until September 30, 2012 to submit eligible• Health Care Pre-Tax Expense Account—For health care expenses for reimbursement. expenses (incurred by you and your eligible tax • Expenses paid through a Pre-Tax Expense Account cannot dependents) that are not eligible to be paid by insurance (for example, copays, coinsurance, etc.). also be claimed as a tax deduction on your federal income tax return.• Dependent Care Pre-Tax Expense Account—For dependent Direct Deposit care (daycare, elder care) expenses that allow you to work, but not for dependent health care expenses. You can make the process even more convenient by signing up to have your reimbursements directly depositedEligible expenses incurred by adult children up to age 26 will into either your checking or savings account. This way yoube eligible for reimbursement from your Health Care Pre-Tax will not have to cash or deposit each reimbursement youExpense Account beginning July 1, 2011. As a reminder, receive and your check will not be delayed, destroyed,effective January 1, 2011, over-the-counter drugs are no or lost in the mail. To access the Pre-Tax Expense Accountlonger considered an eligible expense for reimbursement Direct Deposit Authorization Form, visitfrom the Health Care Pre-Tax Expense Accounts unless they www.hr.upenn.edu/Bene ts/Forms.aspx.are prescribed by a qualified provider. AdministrationEligibility is limited to PennCare/Personal Choice PPO,Aetna Choice POS II and Keystone/AmeriHealth HMO If you have a pre-tax expense account, you can accessparticipants. If you enroll in the Aetna HDHP with HSA plan, your account details securely online through Penn's onlineIRS regulations do not permit you to be enrolled in the benefits enrollment site. Just log in with your PennKey andHealth Care Pre-Tax Expense Account. If you select the password, continue until you reach the \"EnrollmentAetna HDHP and you’re currently enrolled in the Health Options\" page, and click the link titled \"Access Your Pre-TaxCare Pre-Tax Expense Account, you must exhaust your Expense Accounts.\"pre-tax expense account dollars before your HSA accountcan be opened. ADP Benefit Services (ADP) administers the Pre-Tax Expense Accounts. ADP is also responsible for processing claims, issuing checks to plan participants and answering questions regarding the benefit. If you have any questions about the benefit or your account, call the Penn Benefits Center at 1-888-PENN-BEN (1-888-736-6236). To obtain reimbursement on a claim, visit our forms website to download the appropriate form and mail your claim to: ADP FSA Services, P.O. Box 1853, Alpharetta, GA 30023-1853. 18
Important Information Newborns’and Mothers’Health Protection ActWomen’s Health and Cancer Rights Act Under federal law, group health plans and health insuranceof 1998 issuers cannot restrict benefits for any hospital length of stay in connection with childbirth for the mother or newbornOn October 21, 1998, Congress enacted the Women’s Health child to less than 48 hours following a vaginal delivery, or lessand Cancer Rights Act of 1998. This notice explains the than 96 hours following a Cesarean section.most important provisions of the Act. Please review thisinformation carefully. If your spouse is covered under any However, federal law generally does not prohibit theof the PennChoice Benefit Program plans, please make mother’s or newborn’s attending provider, after consultingcertain that she or he also has the opportunity to review with the mother, from discharging the mother or herthis information. newborn earlier than 48 hours (or 96 hours as applicable).The Women’s Health and Cancer Rights Act of 1998 requires Premium Assistance through Medicaidthat all group health plans that provide medical and surgical and CHIPbenefits for a mastectomy also must provide coverage for: If you are unable to afford the premiums for Penn’s• Reconstruction of the breast on which the mastectomy coverage, you may be able to get free or low-cost coverage through Medicaid or the Children’s Health has been performed; Insurance Program (CHIP). For more information, visit www.hr.upenn.edu/Benefits/Medical.• Surgery and reconstruction of the other breast to produce Children’s Health Insurance Program (CHIP) a symmetrical appearance; and Update to HIPAA Special Enrollment• Prostheses and treatment for physical complications of This notice is being provided to all employees eligible for medical coverage under the University of Pennsylvania the mastectomy, including lymphedema. Medical Plan. If you are declining enrollment for medical coverage for yourself or your dependents (including yourThe Act requires that coverage be provided in a manner spouse) because of other health insurance or group healthdetermined to be in consultation with the attending plan coverage, you may be able to enroll yourself and yourphysician and the patient. The coverage may be subject to dependents for medical, prescription, dental and visionannual deductibles and coinsurance provisions consistent coverage under this plan in the following circumstances:with those established for other benefits under the plan. • If you or your dependents lose eligibility for that otherThe Act prohibits any group health plan from: denying aparticipant or a beneficiary eligibility to enroll or renew coverage (or if the employer stops contributing towardscoverage under the plan in order to avoid the requirements your or your dependents’ other coverage),of the Act; penalizing, reducing, or limiting reimbursementto the attending provider (e.g., physician, clinic, or hospital) • If you or your dependents lose Medicaid or Children’sto include the provider to provide care inconsistent withthe Act; and providing monetary or other incentives to an Health Insurance Program (“CHIP”) coverage as a resultattending provider to induce the provider to provide care of a loss of eligibility for such coverage, orinconsistent with the Act. • If you or your dependents become eligible for a premiumThe Women’s Health and Cancer Rights Act of 1998 will applyto University of Pennsylvania health care plans on effective assistance subsidy under Medicaid or CHIP.dates of coverage subsequent to July 1, 1999. Note: This enrollment right does not apply to the HealthPlease keep this information with your other group health Spending Account.plan documents. If you have any questions about this Plan’scoverage of mastectomies and reconstructive surgeries, You must request enrollment within 30 days after yourplease call the Penn Benefits Center at 1-888-PENN-BEN or your dependents’ other coverage ends (or after the(1-888-736-6236). employer stops contributing toward the other coverage), or within 60 days in the case of changes related to Medicaid or CHIP. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents for medical coverage under this plan. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption. 1
Notice of Privacy Practices: University of Uses and Disclosures for PaymentPennsylvania Health and Welfare Program We will make uses and disclosures of your protected health information as necessary for payment-related purposes.This notice describes how medical information about you For instance, the Program may provide information to themay be used and disclosed and how you can get access to Plan sponsor or its Agents in order to assist in resolvingthis information. Please review it carefully. disputes for the payment for services provided to you or an eligible covered dependent.The terms of this Notice of Privacy Practices apply to theUniversity of Pennsylvania’s Health and Welfare Program Uses and Disclosures for Health Care Operations(the Program). We will use and disclose your protected health information as necessary, and as permitted by law, for our operations.Individually identifiable information about your past, present, For instance, this information may be used or disclosedor future health condition, the provision of health care to for the purposes of utilization review, cost analysis, andyou, or payment for health care is considered “protected designing the Program for your health benefits.health information.” We are committed to safeguarding yourprotected health information as required by law, and we will Persons Involved in Your Carenot use or disclose your protected health information except Unless you object, we may disclose to a family member,for certain permitted or required purposes. a close friend, or any other person you identify, your protected health information that relates to that person’s involvementWe are required by law to maintain the privacy of your in payment for your health care. We may use or discloseprotected health information and to provide you with protected health information to assist in notifying a familynotice of our legal duties and privacy practices with respect member, personal representative or any other person thatto your protected health information. We are required to is responsible for your care and general condition. We mayabide by the terms of this Notice (or other Notice in effect at also disclose limited protected health information to a publicthe time of the use or disclosure) so long as it remains in or private entity that is authorized to assist in disaster reliefeffect. We reserve the right to change the terms of this Notice efforts in order for that entity to locate a family memberof Privacy Practices as necessary and to make the new or other persons that may be involved in some aspect ofNotice effective for all protected health information caring for you.maintained by us. All notices will be posted on our website atwww.hr.upenn.edu, or you may receive a paper copy at the Health Products and ServicesDivision of Human Resources, 3401 Walnut Street, 5th Floor. We may from time to time use your protected healthYou have the right to obtain a copy by completing the information to communicate with you about treatmentrequest form and mailing it to us at the “Contact Us” address alternatives and other health-related benefits and serviceson page 22. that may be of interest to you.Uses and Disclosures of Your Protected Health Disclosures to the Plan SponsorInformation We may disclose protected health information to the PlanThe following categories detail the various ways in which sponsor for Plan administration purposes.we may use or disclose your protected health information.For each category of uses or disclosures, we will give you The information disclosed will not be used by the Universityillustrative examples. It should be noted that while not every for any employment-related purposes.use or disclosure will be listed, each of the ways we arepermitted to use or disclose information will fall into one We may also disclose a summary of your health informationof the following categories. to the Plan sponsor so that the Plan sponsor may solicit premium bids from other health plans. Your summary healthUses and Disclosures with Authorization information may be disclosed to the Plan sponsor to modify,Except as outlined below, we will not use or disclose your amend or terminate the Plan. Summary health informationprotected health information for any purpose unless you is information that does not contain identifying informationhave signed a Health Insurance Portability and Accountability except that certain geographic information may be included.Act (HIPAA) authorization form authorizing the use or Summary health information can contain a summary ofdisclosure. You have the right to revoke that authorization claims history, claims expenses, or type of claims experiencedin writing unless we have taken any action in reliance on by you for which a Plan sponsor has provided health benefitsthe authorization. under a group health plan. In addition to summary health information, we may disclose information to the Plan sponsorUses and Disclosures without Authorization about whether you are enrolled or have disenrolled in a health insurance plan offered by us and/or informationUses and Disclosures for Treatment about your participation in the Plan.We are permitted by law to make uses and disclosures ofyour protected health information as necessary for yourtreatment. However, in the ordinary course of business,such disclosures are not expected to occur. 20
Other Uses and Disclosures • We may release your protected health information if youWe are permitted or required by law to make certain otheruses and disclosures of your protected health information are a member of the military for activities set out by certainwithout your consent or authorization. Subject to conditions military command authorities as required by armedspecified by law: forces services; we may also release your protected health information if necessary for national security, intelligence,• We may release your protected health information for any or protective services activities; and purpose when required by federal, state or local law; • We may release your protected health information if• We may release your protected health information for necessary for purposes related to your Workers’ Compensation benefits. public health activities, such as required reporting of certain communicable diseases, injuries, birth and death, Rights That You Have and for required public health investigations; Access to Your Protected Health Information Generally, you have the right to access, inspect, and/or• We may release your protected health information to copy protected health information that we maintain about you. All requests for access must be made in writing and certain governmental agencies if we suspect child abuse signed by you or your representative. If we deny your request, or neglect; we may also release your protected health we will give you written reasons for the denial and explain information to certain governmental agencies if we believe any rights you may have to have the denial reviewed. you to be a victim of abuse, neglect or domestic violence; We may charge you for copying services if the quantity of information to be copied and mailed is high. A determination• We may release your protected health information to of any applicable charges will be made after your request has been submitted, and you will be advised of any such entities regulated by the Food and Drug Administration charges in advance. if necessary to report adverse events, product defects, or to participate in product recalls; Amendments to Your Protected Health Information If you believe that there are errors or missing information• We may release your protected health information in your records that are maintained by us, you have the right to request that this protected health information about you if required by law to a government oversight agency be amended or corrected. We are not obligated to make all conducting audits, investigations, inspections, and requested amendments, but will give each request careful related oversight functions; consideration. All amendment requests, in order to be considered by us, must be in writing, signed by you or• We may use or disclose protected health information your representative, and must state the reasons for the amendment/correction request. Any denial will state the in emergency circumstances; reasons for the denial, your rights to have the denial reviewed, and your right to attach your objection to our• We may use or disclose protected health information denial to your record. If an amendment or correction you request is made by us, we will also notify others who work to avert a serious threat to health or safety to law with us and have copies of the uncorrected record if we enforcement or other persons who can reasonably believe that such notification is necessary. prevent or lessen the threat of harm; Accounting for Disclosures of Your Protected Health• We may release your protected health information if Information You have the right to receive an accounting of certain required to do so by a court or administrative ordered disclosures made by us of your protected health information. subpoena or discovery request; in most cases, you will Your request must include the time period for which you are have notice of such release; requesting an accounting that may not exceed six years and may not include dates prior to April 14, 2003. This accounting• We may release your protected health information to will tell you what protected health information was disclosed, to whom, and for what purpose. You do not have the right law enforcement officials; to receive an accounting of disclosures made for the purposes of treatment, payment, and health care operations• We may release your protected health information to or for certain other limited purposes. Requests for an accounting must be made in writing and signed by you or coroners, medical examiners, and/or funeral directors; your personal representative.• We may release your protected health information if necessary to arrange an organ or tissue donation from you or a transplant for you;• Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, and legal services. At times it may be necessary for us to provide some of your protected health information to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we contract with and require these outside persons or organizations to appropriately safeguard the privacy of your information; 21
Restrictions on Use and Disclosure of Your Protected Health University of PennsylvaniaInformation Non-Discrimination StatementYou have the right to request restrictions on certain of ourpermitted uses and disclosures of your protected health The University of Pennsylvania values diversity and seeksinformation for treatment, payment, or health care talented students, faculty and staff from diverse backgrounds.operations, though we cannot agree to restrict or limit any The University of Pennsylvania does not discriminate on theuse or disclosure that is required by law. We will consider your basis of race, color, sex, sexual orientation, gender identity,request, but are not legally required to agree to it. However, religion, creed, national or ethnic origin, citizenship status,we will attempt to accommodate reasonable requests where age, disability, veteran status or any other legally protectedappropriate, and if we agree to accommodate your request, class status in the administration of its admissions, financialwe will abide by it. We retain the right to terminate an agreed aid, educational or athletic programs, or other Universityto restriction if we believe such termination is appropriate. administered programs or in its employment practices.In the event of a termination by us, we will notify you of such Questions or complaints regarding this policy should betermination. Requests for restriction(s) must be made in directed to the Executive Director of the Office of Affirmativewriting and signed by you or your personal representative. Action and Equal Opportunity Programs, Sansom Place East, 3600 Chestnut Street, Suite 228, Philadelphia, PA 19104-6106;Confidential Communications or 21-88-63 (Voice) or 21-88-7803 (TDD).You have the right to request to receive communicationsregarding your protected health information from us by Plan Governancealternative means or at alternative locations. You mustrequest such confidential communication in writing. We The selected benefit highlights in this guide are basedwill attempt to accommodate all reasonable requests. on Plan documents that govern the operation of the Plans. If there is any conflict between the information presentedPaper Copy of Notice here and the information in the Plan documents, the PlanYou retain the right to obtain a paper copy of this Notice of documents always govern and are the controlling legalPrivacy Practices, even if you have requested such copy by documents. Benefits descriptions are not terms ofe-mail or other electronic means. employment, nor are they intended to establish a contract between the University and its faculty and staff. PlanComplaints documents are available for inspection in the Benefits Office.If you believe your privacy rights have been violated, you can Copies are available for a small copy fee. The Universityfile a complaint with the Penn Benefits Center by calling reserves the right to change, amend or terminate any of its1-888-PENN-BEN (1-888-736-6236). You may also file a PennChoice Benefit Plans for any reason at any time.complaint with the Secretary of the U.S. Department ofHealth and Human Services in Washington, D.C. There will Statement on Collective Bargainingbe no retaliation for filing a complaint. AgreementsContact Us The provisions of applicable collective bargainingIf you have questions or need further assistance regarding agreements govern the health and welfare benefitsthis notice, please consult our website for forms at of employees in collective bargaining units.www.hr.upenn.edu or contact the Penn Benefits Centerat 1-888-PENN-BEN (1-888-736-6236). Or mail to:Penn Benefits Center2835 S. Decker Lake Dr.Salt Lake City, UT 84119Effective DateThis Notice of Privacy Practices is effective April 14, 2003. 22
Contact Information for the Health and Welfare Plans Plan and Administrator Group/Policy# Send Claims To: Member ServicesThe Penn Benefits Center 1-888-PENN-BEN (1-888-736-6236)Medical N/A Penn Benefits CenterPennCare/Personal Choice PPO P.O. Box 26745 Salt Lake City, UT 84126-0745Aetna Choice POS IIKeystone/AmeriHealth HMO 606132 Non-Preferred Providers: 1-800-ASK-BLUE (1-800-275-2583) 811778 Personal Choice Claims 501906 P.O. Box 69352 1-888-302-8742 Harrisburg, PA 17106-9352 859-455-8650 (fax) 1-800-ASK-BLUE (1-800-275-2583) Aetna P.O. Box 981106 El Paso, TX 79998-1106 Keystone Claims P.O. Box 69353 Harrisburg, PA 17106-9352Aetna High Deductible Health Plan 811778 Aetna 1-888-302-8742with Health Savings Account N/A P.O. Box 981106 859-455-8650 (fax)Penn Behavioral Health El Paso, TX 79998-1106 1-888-321-4433Prescription Drug PENRX 3535 Market StreetCVS Caremark Fourth Floor 1-800-378-0802 N/A Philadelphia, PA 19104Dental 300187 215-898-4615 (Schattner Center)Penn Faculty Practice Plan 442173 CVS Caremark 215-573-8400 (University City) P.O. Box 52196 610-520-4600 (Bryn Mawr)MetLife N/A Phoenix, AZ 85072-2196 1-800-942-0854 CVS Caremark Mail ServiceVision P.O. Box 2110 1-800-ASK-BLUE (1-800-275-2583)Davis Vision Pittsburgh, PA 15230-2110 1-888-393-2583 (claims/benefit questions)Pre-Tax Expense Accounts N/A 1-888-PENN-BEN (1-888-736-6236), option 3ADP FSA Services Out-of-Network Only: MetLife Dental Claims P.O. Box 981282 El Paso, TX 79998-1282 Out-of-Network Only: Vision Care Processing Unit P.O. Box 1525 Latham, NY 12110 ADP FSA Services P.O. Box 1853 Alpharetta, GA 30023-1853 23
Plan and Administrator Website Other InformationThe Penn Benefits Center www.pennbenefits.upenn.edu Call for general benefit questions, life event changes (within 30 days), and claims adjudication.Medical www.ibx.com For inpatient admission (except for maternity orPennCare/Personal Choice PPO emergency admissions), precertification is required. http://pennhealth.com/penncareppo/ Call 215-241-2990 or 1-800-275-2573.Aetna Choice POS II index.html www.aetna.com For an emergency out of area, go to the nearest hospital. Hospital must call 1-888-632-3862.Keystone/AmeriHealth HMO www.ibx.com Call both Primary Care Physician (PCP) and HMO within 48 hours of emergency care. For an emergency out of area, goAetna High Deductible Health Plan www.aetna.com to the nearest hospital. Hospital must call 1-800-ASK-BLUEwith Health Savings Account www.pennbehavioralhealth.org (1-800-275-2583). Sick Care out of area: 1-800-810-BLUE.Penn Behavioral Health For an emergency out of area, go to the nearest hospital. Hospital must call 1-888-632-3862. Behavioral Health benefits for PennCare/Personal Choice PPO and Aetna Choice POS II plans.Prescription Drug www.caremark.comCVS CaremarkDental www.dental.upenn.edu/patient_care/ After hours, call any network office for instructions on how toPenn Faculty Practice Plan penn_faculty_dental_plan reach the doctor on call. Or, call the emergency answering service at 215-952-8029. For emergency treatment outsideMetLife a 50-mile radius of any office, use any dentist.Vision www.metlife.com/dental Contact your family dentist for emergencies.Davis Vision www.ibx.com IBC vision plan administered by Davis Vision.Pre-Tax Expense Accounts www.pennbenefits.upenn.eduADP FSA Services 2
April 2011 Human ResourcesFor questions visit www.hr.upenn.edu or call 1-888-PENN-BEN (1-888-736-6236)
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