BCBSM Medco Health - Rx Priority Health HMO Delta Dental Spectera Vision Hyatt Legal

Mercy Hospital, Port Huron

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My Health & Welfare | Enrollment Forms

Medical | Dental | Vision | Life Insurance
Short Term Disability | Long Term Disability | Flexible Spending | Legal

Planning to add dependents?

In order for new family members to be eligible for coverage under any Trinity Health benefit plan, you are required to provide proof of their dependent status. If you are planning to add family members during annual enrollment, you must submit dependent verification information to Human Resources within 31 days. If you do not submit the required paperwork by the deadline, your newly added dependents will not be enrolled in coverage and you will be required to wait until the next annual enrollment period to enroll new dependents in the plan.

Required Documents

Medical

You have the option of choosing from two medical plan options - High Option B PPO and Priority Health HMO.

Find a BCBSM Community Blue Participating Provider.

Use the plan comparison tool to Estimate My Plan Costs.

High Option PPO SPD | High Option PPO Summary
PPO Preventive Care Overview
Priority Health HMO Summary

> Looking for a Mercy Hospital Doctor? Visit the Mercy Hospital website and search our Find a Physician directory!

Dental

You have the option of electing dental coverage provided by Delta Dental.

Delta Premier Summary
Delta Premier Certificate

Vision

You have the option of electing vision coverage through Spectera Vision.

Spectera Vision Summary
Spectera Vision SPD

Life Insurance

Full-time and Part-time associates have Basic Life Insurance provided at 1x annual salary.

In addition, you have the option to purchase additional coverage for yourself and your dependents in the following increments:

Please Note: some elections may require a Statement of Health. It is your responsibility to complete and return your Statement of Health during the Enrollment Period.

Life Insurance Certificate
Statement of Health Form
Beneficiary Designation Form

Short Term Disability

Full-time associates are provided Short Term Disability coverage at 66 2/3% base annual salary. This income replacement benefit begins after you have exhausted your 7 calendar day elimination period.

Short Term Disability Certificate

Long Term Disability

Full-time and Part-time associates are provided Long Term Disability coverage at 66 2/3% base annual salary not to exceed a monthly benefit of $10,000. This income replacement benefit begins after being off of work for six months.

Long Term Disability Certificate

Flexible Spending

A Flexible Spending Account (FSA) gives you a way to pay for your out-of-pocket health care and / or dependent care expenses with before-tax dollars.

Click here to help estimate your health care and / or dependent care expenses.

Health Care Spending - you may contribute pre-tax dollars in any amount between $130 and $5,000 annually. Contributions made to the HCSA during the 2008 calendar year will be eligible for reimbursement on services incurred from January 1, 2008 through March 15, 2009. The claim submission deadline will continue to be March 31st. This 2-½ month extension is allowed under new IRS guidelines. Please consider this extension when making your 2008 elections.

Over-the-counter Medications (OTC) - Certain OTC items qualify as "medical care" and are eligible for reimbursement through an HCSA. Examples of such items include asprin, allergy and sinus medications, antacids and more.

Dependent Care Spending - you may contribute pre-tax dollars in any amount between $130 and
$5,000 annually.

Click here for additional information regarding HCSAs and DCSAs.

Direct Deposit - You can elect to have your reimbursements automatically depositied into your checking or savings account by signing up for direct deposit. Simply complete a Direct Deposit Authorization Form and submit your completed form to Aetna.

Aetna Navigator - HCSA participants can track HCSA account statuses through Aetna Navigator, Aetna's member self-service website. Navigator is available 24 hours a day, 7 days a week. Through Aetna Navigator, you can check the status of your HCSA, review your HCSA balance, sign up for Direct Deposit, print claim forms, and much more. Once you enroll in an HCSA, you can register to use Aetna Navigator.

Healthcare Spending Account Claim Form
Dependent Spending Account Claim Form
Over-The-Counter Drug Claim Form
Direct Deposit Authorization Form
Flexible Spending Accounts Summary Plan Description

Legal

You have the choice of electing legal coverage through Hyatt Legal for yourself and your family.

Hyatt Legal Brochure
Hyatt Legal SPD