Aetna Medco Health - Rx Delta Dental Spectera Vision Hyatt Legal Plans

Mercy Medical Center, Sioux City

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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 or an approved Life Status Event to enroll new dependents in the plan.

Required Documents

Medical

You have the choice of two medical plan options - the PPO Standard Option and the PPO High Option.

Find an Aetna Participating Provider

Use the plan comparison tool to Estimate My Plan Costs.

Medical Comparison
PPO Standard Option SPD | PPO Standard Option Summary
PPO High Option SPD | PPO High Option Summary
Preventive Care Overview

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

Dental

You have a choice of two dental plan options - Delta Dental Premier Standard Option and Delta Dental Premier High Option.

Dental Comparison
Delta Premier Standard Option Summary
Delta Premier High Option 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 to MetLife during the Enrollment Period.

Life Insurance Certificate
Statement of Health Form
Beneficiary Designation Form

Short Term Disability

You have short-term disability benefits provided at 66 2/3% of your base annual salary. The length of your benefit is dependent upon your status and length of service with Mercy Medical Center.

Short Term Disability Certificate

Long Term Disability

Full Time Associates
Mercy Medical Center provides you with Long Term Disability (LTD) coverage at 60% of your base pay not to exceed a monthly benefit of $10,000. This income replacement benefit begins after you have exhausted your Short Term Disability benefits.

To provide choice and flexibility, there are two additional coverage levels from which you may choose. You have the option to "buy-up" your LTD coverage to 66 2/3% of base pay, or "buy-down" your LTD coverage to 50% of base pay. Your personalized enrollment worksheet will reflect the cost or credit associated with this "buy-up" or "buy-down."

If you currently have a 50% benefit and elect up to a 66 2/3% benefit, you must complete Evidence of Insurability Form. If you have been treated for the same illness or injury within the 3 months just prior to your effective date of coverage, you will be subject to the pre-existing conditions clause. Please refer to certificate for additional information.

Long Term Disability Certificate
Evidence of Insurability Form

Physicians
Please refer to your contract for details of the Physician LTD plan options.

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.

Streamline Enrollment -If you participate in a medical plan administered by Aetna, you may utilize the streamline enrollment process for any out-of-pocket costs related to your medical claims. Streamline enrollment allows you to receive reimbursement from your Health Care Spending account without submitting a paper claim. To initiate the streamline enrollment process please complete and return the streamline enrollment form to Aetna or sign up through Aenta Navigator.

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
Streamline Enrollment 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

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