Flex BeneFits

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					              2011
    Flex Be ne Fits
  se ni o r p roFe s s ion al staFF




January 1, 2011 through December 31, 2011
H e n ry F o r d H e a lt H S y S t e m                                                                                                                                                                                             Flex Benefits



Contents
Important Contact Information  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1
Introduction/Flex Benefits  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 2
Important Terms  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 3-4
Dependent Eligibility/Documentation  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 5-6
Your Flex Benefits Selections  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 6
Health Care Coverage  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 7-17
	 •		Medical/Vision	Plans  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 7-17
	 •		Prescription	Drug	Benefits .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 16-17
	 •		Sponsored	Dependents/Same	Sex	Domestic	Partner  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 17
	 •		Dental	Plans  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 18
	 •		Dental	Plan	Questions	and	Answers  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 19
	 •		Delta	PPO	/	Premier	USA  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 20
Income Replacement and Survivor Benefits  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 21-22
	 •		Employee	Life  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 21
	 •		Dependent	Life	(after	tax)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 21
	 •		Accidental	Death	and	Dismemberment	(AD&D)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 22
	 •		Long-Term	Disability  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 22
Health	Care	Flexible	Spending	Account	(FSA)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 22-25
Day	Care	Flexible	Spending	Account	(FSA)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 26-27
Web Enrollment Instructions  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 28
Additional	Information	About	Flex	Benefits .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 29
	 •		Coverage	for	HFHS	Couples .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 29
	 •		Leave	of	Absence  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 29
	 •		Termination	of	Benefits  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 29
	 •		Your	Rights	and	Responsibilities  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 29
	 •		Legal	Update  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 29
	 •		HIPAA	Rights  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 30
Additional	Benefits
	 •		Voluntary	Benefits  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 30
HFHS	Lifestyle	Rewards  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 30
Events	Permitting	Mid-Year	Changes	Chart  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 31-33




         Every	effort	has	been	made	to	ensure	the	accuracy	and	completeness	of	the	benefit	descriptions	contained	within	
         this	workbook.	However,	in	the	event	of	any	interpretation,	discrepancy,	application	and/or	decision	in	specific	
         circumstances,	the	official	text	or	terms	of	the	plan	document	will	govern.	This	workbook	is	not	intended	to	create	
         or	to	be	construed	as	a	contract	between	Henry	Ford	Health	System	and	its	employees	or	retirees	for	any	matter,	
         including for the provision of benefits described .
H e n ry F o r d H e a lt H S y S t e m                                                                                                                                                                                     Flex Benefits



important Contact information
Employee Services  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . (313)	874-7100
	 1	Ford	Place	-	4E,	Detroit,	Michigan	48202					                                                                                                                                                                                 employeeservices@hfhs.org
Health	Alliance	Plan  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . (313)	872-8100	
	 (Medical/Vision)		                                                                                                                                                                                                                                              www.hap.org
	 2850	W.	Grand	Boulevard,	Detroit,	Michigan	48202
Blue	Cross/Blue	Shield	of	Michigan  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1-800-392-2233
	 (Medical/Vision)																																																																									                                                                                                                                                                    www.bcbsm.com
	 600	East	Lafayette,	Detroit,	Michigan	48226
Delta	Dental	Plan	of	Michigan  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1-800-524-0149
	 (Fee-for-Service	Dental)																																													                                                                                                                                                                           www.deltadental.com
	 27500	Stansbury	Street,	Farmington	Hills,	Michigan	48334-3811
Delta	Dental	Plan	of	Michigan  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1-800-870-9988
	 (Delta	Care)																																																																		                                                                                                                                                                               www.ddpmi.com
	 27500	Stansbury	Street,	Farmington	Hills,	Michigan	48334-3811
Manulife  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1-800-268-3763
	 (Medical/Vision)		                                                                                                                                                                                                                                      www.coverme.com
	 557	Southdale	Road	East,	Suite	205,	London,	Ontario,	Canada	N6E	1A2	
	 (Canadian	Residents	Only)
Paramount	Health	Care .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . (419)	887-2525
	 (Medical/Vision)	                                                                                                                                                                                                                                    www.promedica.org
	 P.O.	Box	928,	Toledo,	OH	43697-0928	
	 (Community	Care	Services)
CIGNA	Group	Insurance  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1-800-238-2125
	 (Life	Insurance)																																																														                                                                                                                                                                                www.cigna.com
	 1600	West	Carson	Street,	Suite	300,	Pittsburgh,	Pennsylvania	15219
CIGNA	Disability	Management	Solutions  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1-800-362-4462
	 (Long-Term	Disability	Insurance)																																			                                                                                                                                                                                           www.cigna.com
	 12225	Greenville	Avenue,	Suite	1000,	Dallas,	Texas	75243
CIGNA	Group	Insurance  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1-800-238-2125
	 (AD&D	Insurance)																																																									                                                                                                                                                                                     www.cigna.com
	 P.O.	Box	22328,	Pittsburgh,	Pennsylvania	15222-0328
Benefit Express  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1-877-837-5017
	 (Flexible	Spending	Accounts)																																																									                                                                                                                           www.help@mybenefitexpress.com
	 P.O.	Box	189,	Arlington	Heights,	Illinois	60006-0189




        If you have questions about your enrollment, contact Employee Services or your local Human
        Resources department.




                                                                                                                                                                                                                                                                                1
H e n ry F o r d H e a lt H S y S t e m                                                               Flex Benefits



Introduction
________________________
                                                                  This	workbook	is	intended	to	summarize	the	key	
                                                                  features of each benefit offered under Flex Benefits . You
                                                                  are	encouraged	to	consult	with	your	financial	planner	or	
Flex	Benefits	allows	you	to	make	your	own	choices	from	a	         tax	advisor	before	making	your	benefit	selections.	Henry	
menu of selections that best fit your individual needs .          Ford Health System reserves the right to modify or
Annually,	you	will	have	the	opportunity	to	re-examine	            discontinue any of its benefits at any time .
your	benefit	needs	and	make	any	changes	you	choose.	
Once	Open	Enrollment	begins	on	Monday,	Nov.	8,	2010,	             TAX SAVINGS
you can log onto HR Connect or http://ebenefits .hfhs .org        The Social Security benefit you will be eligible to
and	make	your	benefit	elections	for	2011.                         receive is based in part on the amount of income you
                                                                  have that is subject to Social Security tax. By enrolling in
                                                                  Flex Benefits, you will have less income subject to Social
Flex Benefits
________________________                                          Security taxes. Consequently, the benefits you or your
                                                                  family may receive from Social Security may be reduced
HOW A FLEXIBLE BENEFIT PLAN WORKS                                 based on the amount of the reduction in your pay as a
Flex Benefits offers an array of options under each benefit       result of your pretax contributions for Flex Benefits.
category.	Each	option	has	a	different	cost,	corresponding	
to the degree of coverage provided . You can select a             USING THE WORKBOOK & PERSONAL
particular	benefit	category,	depending	on	your	changing	          ENROLLMENT SUMMARY
needs.	Flex	Benefits	provides	all	full	time	employees	with	       This workbook contains information you need to know
flex credits to assist in purchasing their benefit selections .   about your benefits, including descriptions of the Flex
Part	time	employees	do	not	receive	flex	credits.	Once	            Benefits options and enrollment instructions. In addition
you’ve	made	all	of	your	selections,	simply	add	up	the	costs	      to this workbook, your Personal Enrollment Summary,
of each option and subtract them from your total flex             which details your current coverage, your options and the
credits . If you’ve chosen to purchase more benefits than         associated price tags, will be available online during Open
you	have	credits	for,	the	difference	will	be	subtracted	from	     Enrollment beginning Monday, Nov. 8, through Monday,
your	pay	in	equal	amounts	per	pay	period.	Most	benefits	          Nov. 22, 2010.
can	be	purchased	on	a	pretax	basis,	with	the	exception	of	
Dependent	Life	Insurance.	If	you’ve	chosen	to	purchase	
fewer	benefits	than	you	have	credits,	you	may	direct	your	
excess	credits	to	a	Flexible	Spending	Account,	to	
maintain	the	tax	advantage,	or	take	them	as	taxable	
income in equal amounts per pay period .

CONSIDERATIONS
The benefits offered under Flex Benefits have been
designed to conform to Section 125 of the Internal
Revenue	Code,	and	as	such	may	provide	significant	tax	
advantages	to	you	as	well	as	Henry	Ford	Health	System.		In	
order	to	maintain	its	tax-qualified	status,	the	Flex	Benefits	
plan must adhere to the regulations established by the
Internal	Revenue	Service	(IRS).	These	requirements	will	be	
summarized	in	the	appropriate	sections	of	this	workbook.	




                                                                                                                                 2
H e n ry F o r d H e a lt H S y S t e m                                                                  Flex Benefits



Important Terms
________________________
                                                                     employee . See page 17 for the amount of imputed
                                                                     income	that	will	be	added	to	your	check	each	pay	for	
                                                                     these benefits .
It	may	be	helpful	for	you	to	review	some	of	the	following	
terms of the Flex Benefits program .                               •	 Effective	Date	–	All	benefits	will	be	effective	on	
                                                                   	 January	1.	For	employees	enrolling	outside	of	Open	
•	 Change	Event	–	An	event	which	permits	you	to	change	               Enrollment,	benefits	become	effective	the	first	of	the	
   your	election	mid-year.	The	change	you	wish	to	make	               month	following	date	of	hire	or	qualified	life	event.
   must	be	on	account	of	and	correspond	with	the	event.	              If	your	hire	date	is	the	first	of	the	month,	your	benefits	
   Please	see	the	chart	in	the	back	of	this	workbook	for	             will	be	effective	the	same	day.
   a	detailed	listing	of	when	changes	can	be	made	for	
   benefit coverages offered as part of Flex Benefits . If         •	 Enhanced	Plan	–	A	benefit	level	within	the	HFHS	
   you	change	from	part	time	to	full	time,	you	may	elect	             Preferred	Network	and	Full	HAP	option	that	involves	
   options	previously	not	available	to	you	or	options	which	          lower	co-pays	and	out-of-pocket	costs.
   were	available	only	at	a	higher	cost.	If	you	change	from	
   full	time	to	part	time,	you	must	drop	options	not	              •	 Flex	Credits	–	A	pool	of	dollars	full-time	employees	
   available to part time employees . Your same medical               receive	to	use	toward	the	purchase	of	benefits	each	
   and	dental	coverage	will	be	available	to	you	as	a	part	            year . Flex credits are based on your base annual salary
   time	employee,	but	at	a	higher	cost.	You	may	change	               and are adjusted as your salary changes .
   to	a	different	medical	or	dental	option,	but	may	not	
   change	to	a	“No	Coverage”	election	unless	you	show	             •	 Full	Time	Senior	Staff	Eligibility	–	Employees	who	are	
   you	are	now	covered	by	another	plan.	To	request	benefit	           regularly	scheduled	to	work	64	to	80	hours	every	two	
   changes	due	to	a	status	change,	obtain	an	Enrollment	              weeks	may	participate	in	the	Flex	Benefits	program.	
   Change	Request	(ECR)	Form	from	Employee	Services	or	               Full-time employees receive flex credits to assist in
   your	local	Human	Resources	department,	and	complete	               purchasing	medical/vision,	dental,	long-term	disability,	
   and	return	it	within	thirty	(30)	days	of	the	change	               and	AD&D	insurances.	
   in status .
                                                                   •	 Health	Engagement	–	A	component	of	the	HFHS	
•	 Comparison	Chart	–	A	chart	that	allows	you	to	                     Preferred	Network	and	Full	HAP	option	designed	to	
   compare the medical/vision or dental plans available               lower	costs	for	employees	who	make	healthy	choices.
   to you .
                                                                   •	 Health	Maintenance	Organization	(HMO)	–	A	type	
•	 Confirmation	Statement	–	A	statement	available	                    of managed care plan that focuses on prevention and
   online to confirm the selections you made .                        wellness.	Under	an	HMO	Plan,	members	are	required	to	
                                                                      seek	most	routine	covered	medical	care	services	from	
•	 Copayment	– The percentage or flat dollar amount of                their	Primary	Care	Physician	(PCP).	The	PCP	coordinates	
   covered expenses you must pay .                                    the member’s care and refers the member to a
                                                                      specialist	when	medically	necessary.	You	may	select	
•	 Deductible	– The expense you incur before the plan or              a	PCP	for	yourself	and	one	for	each	of	your	covered	
   insurance carrier begins paying your covered expenses .            dependents.	With	an	HMO,	you	must	utilize	providers	in	
                                                                      the	HMO	network.
•	 Domestic	Partner	–	An	individual	of	the	same	sex,	who	
   currently	resides	with	you	in	a	mutual	commitment,	             •	 In-Network	–	A	doctor	or	facility	that	participates	
   similar	to	marriage,	shares	financial	responsibility,	is	not	      in	the	PPO	Plan	or	HMO	network	and	has	agreed	to	a	
   legally married to another individual and is not a blood           reduced fee schedule .
   relative.	Medical,	vision	and	dental	coverage	for	a	
   same-sex domestic partner is a taxable benefit to the



                                                                                                                                    3
H e n ry F o r d H e a lt H S y S t e m                                                             Flex Benefits


•	 Options	– The choices you have in each benefit area .         cost.	Generally,	you	will	receive	a	higher	level	of	
                                                                 coverage	if	you	receive	care	in-network.
•	 Out-of-Network	–	A	doctor	or	facility	not	part	of	the	
   PPO	Plan	or	HMO	network.	Generally,	services	will	be	       •	 Price	tag	– This is the cost to you for a benefit option .
   covered	at	a	lower	percentage	than	if	your	doctor	were	        The	price	tag	represents	the	cost	of	providing	you	with	
   in	the	network .                                               that benefit option .

•	 Out-of-Pocket	Maximum	–	The	most	you	would	pay	in	          •	 Primary	Care	Provider	(PCP)	– The doctor you
   a	plan	year	for	eligible	medical	expenses,	excluding	          designate	from	the	HMO	participating	network	to	
   the deductibles .                                              coordinate	all	of	your	medical	needs,	including	referral	
                                                                  to a specialist or arrangement for hospitalization .
•	 Part	Time	Senior	Staff	Eligibility	–	Part	time	senior	
   staff	who	are	regularly	scheduled	to	work	at	least	40	      •	 Qualification	Period	–	The	period	of	time	when	
   hours	every	two	weeks	may	participate	in	the	Flex	             employees and their covered spouse/same-sex
   Benefits	program.	No	opt-out	credits	are	available.	Part	      domestic	partner	can	complete	the	Health	Risk	
   time senior staff have the same medical/vision and             Assessment,	Member	Qualification	Form	(MQF)	and	
   dental	options	as	full	time	employees,	but	they	may	           demonstrate	a	willingness	to	improve	their	health	status	
   only	purchase	reduced	levels	of	long-term	disability,	         by	scoring	85	points	or	higher	on	the	MQF.
   AD&D,	employee	and	dependent	life	insurance.
                                                               •	 Standard	Plan	–	A	benefit	level	within	the	HFHS	
•	 Personal	Enrollment	Summary	–	This online form                 Preferred	Network	and	Full	HAP	option	that	offers	
   displays	your	current	coverage,	the	available	benefit	         significantly	higher	out-of-pocket	costs	and	annual	
   options,	the	price	tag	for	each	option	and	available	          deductibles but the same access to quality care and
   benefit	credits.	This	online	summary	will	assist	you	in	       benefits as the Enhanced plan .
   your Flex Benefits Web enrollment .
                                                               •	 Tax	Savings	–	The	Social	Security	benefit	you	will	be	
•	 Plan	Year	–	The	Flex	Benefits	Plan	Year	is	January	1	          eligible to receive is based in part on the amount of
   through	December	31.	Each	fall,	you	will	make	your	            income you have that is subject to Social Security tax .
   selections	for	the	following	plan	year.                        By	enrolling	in	Flex	Benefits,	you	will	have	less	income	
                                                                  subject	to	Social	Security	taxes.	Consequently,	the	
•	 Point	of	Service	(POS)	Plan	–	A	type	of	managed	               benefits you or your family may receive from Social
   care plan that gives you the choice to obtain medical          Security may be reduced based on the amount of the
   services	from	a	network	or	non-network	provider.	Unlike	       reduction in your pay as a result of your pretax
   a	PPO,	you	must	select	a	Primary	Care	Physician	(PCP)	to	      contributions for Flex Benefits .
   coordinate	your	care	in-network.	You	can	also	self-refer	
   or	obtain	care	from	an	out-of-network	provider	at	a	
   lower	benefit	level.

•	 Preferred	Provider	Organization	(PPO)	–	A	type	of	
   managed care plan that gives you the choice to obtain
   medical	services	from	a	network	or	non-network	
   provider.	You	make	the	decision	at	the	time	that	you	
   need	medical	care.	In	a	PPO,	the	doctors	and	hospitals	
   have agreed to provide medical services at a reduced




                                                                                                                               4
H e n ry F o r d H e a lt H S y S t e m                                                              Flex Benefits



Dependent Eligibility/                                           Ineligible	Dependents

Documentation
________________________                                         •	 Your	spouse	becomes	ineligible	when	he	or	she	is	no	
                                                                    longer legally married to you .

Documentation	for	newly-added	dependents	and	full-               •	 Your	child	becomes	ineligible	for	dental,	dependent	life	
time college students is required . It is your responsibility       and	AD&D	insurance:
to	ensure	that	only	people	who	are	eligible	for	dependent	          ❑	 At	the	end	of	the	calendar	year	in	which	he	or	she			
coverage are covered by your HFHS health plan . This helps             reached 19 and is not a full time student
keep	health	care	costs	at	reasonable	levels	for	everyone.           ❑	 At	the	end	of	the	calendar	year	in	which	he	or	she	is		
                                                                    		 no	longer	a	full-time	student	and	is	between	the		 	
Use	the	following	guidelines	to	determine	if	your	enrolled	            ages of 20 and 25 for dental
dependents meet Henry Ford Health System’s eligibility              ❑	 At	the	end	of	the	calendar	year	in	which	he	or	she			
requirements:                                                          reaches age 25 and is still a full-time student for
                                                                       dental
Eligible	Dependents:                                                ❑	 On	the	date	of	marriage

•	 Your	Spouse                                                   •	 Your	young	adult	children	between	the	ages	of	
                                                                    20	and	26	who	become	eligible	for	their	employer’s	
•	 Your	Domestic	Partner	and	their	children                         medical plan .
•	 Your	unmarried	children	until	the	end	of	the	year	they	
                                                                 •	 Your	sponsored	dependent	when	he	or	she	no	longer	
   reach age 19
                                                                    resides	with	you	or	is	no	longer	claimed	on	your	
•	 Your	unmarried	children	until	the	end	of	the	year	               income tax .
   they	reach	age	25,	if	they	are	full	time	college	students.	
   Full time college students must maintain a curricula          ACCEPTAblE	FOrMS	OF	DOCuMENTATION	ArE:
   of 12 credit hours per semester to be eligible for
   dependent coverage for dental . Dependent life and            Spouse
   accidental	death	and	dismemberment	insurance	(AD&D)	          •	 Proof		of	Spousal	relationship	(any	one	of	the	following	
   end at age 25 .                                                  documents):	
•	 Young	adult	children	may	remain	on	your	medical/              	 -	 Copy	of	marriage	license	(must	include	date	of	
   vision plan through the end of the month they turn 26 .          		 Marriage)
   They	do	not	have	to	be	your	IRS	dependent,	full-time	         	 -	 Copy	of	legal,	presently	valid	marriage	certificate
   student,	or	live	with	you.	They	can	also	be	married.             - Copy of the first page of the most recently filed
                                                                       Federal income tax return that indicates
•	 Any	unmarried	disabled	child	regardless	of	age	who	              		 “married	filing	jointly”	(financial	amounts	may	be		 	
   depends	primarily	on	you	for	support,	provided	the	              		 blocked	out)
   physical or mental disability occurred before age 19 .           - Copy of the first page of the most recently filed
                                                                       federal income tax return that indicates
•	 “Child”	is	defined	as	natural	children,	legally	adopted	         		 “married	filing	separately”,	your	spouse’s	name	must		
   children	(including	children	placed	for	adoption	for	               appear on the tax form on the line provided after
   whom	legal	adoption	proceedings	have	started),	step-             		 the	“married	filing	separately”	status	(financial	
   children,	children	of	your	domestic	partner,	alternate	          		 amounts	may	be	blocked	out)
   recipients	under	Qualified	Medical	Child	Support	Orders	      	 -	 Canadian	employees	who	do	not	claim	dependents			
   (QMCSO),	and	any	other	child	for	whom	you	have	                  		 on	their	U.S.	Federal	income	tax	must	submit	their		
   obtained	legal	guardianship	and	who	is	in	a	regular	                Canadian income tax form listing eligible
   parent-child relationship .                                      		 dependents.		If	an	Identification	Number	is	used	in			
                                                                    		 place	of	a	dependent	name,	documentation	(such	as
•	 You	may	also	cover	certain	sponsored	dependents.	                		 the	Social	Insurance	Number	card)	must	be	
   Sponsored	dependents	are	age	20	or	older,	related	to	         	 		 submitted	that	links	the	dependent’s	name	to	the		 	
   you by blood or marriage and residing in your                    		 Identification	Number.		
   household,	and	claimed	as	dependents	on	your	most	
   recent tax return .
                                                                                                   (continued on next page)

                                                                                                                                 5
H e n ry F o r d H e a lt H S y S t e m                                                               Flex Benefits


Domestic	Partner	(same	sex)                                      	 AND
•	 Proof	of	Spousal	relationship	(any	one	of	the	
   following	documents):                                         •	 Official	college/university/institution	documentation	
   - Copy of the first page of the most recently filed              that indicates full-time student status during the last
       Federal income tax return that indicates your                quarter	of	2010	or	first	quarter	of	2011	(all	documents	
       domestic partner is your IRC Section 152 dependent           must	include	the	name	of	the	dependent,	the	name	of	
	 -	 Copy	of	a	Domestic	Partnership	Registration	                   the	school,	the	semester	or	quarter	in	which	the	student	
   		 Certificate	from	any	city,	county,	or	state	offering		 	      was	enrolled	and	total	number	of	credit	hours	(12)	or	
       the ability to register a domestic partnership               indication	of	full-time	status)
	 -	 Copy	of	Affidavit	of	Domestic	Partnership	(available		
   		 on	HR	Connect).                                            	 Or		

unmarried,	Natural,	&	legally	Adopted	Child,	                    •	 Documentation	from	Social	Security	or	Physician	
Step-Children,	and	Children	of	your	Domestic	                       certification of total and permanent disability incurred
Partner;	until	the	end	of	the	year	they	reach	                      before age 19
age	19
•	 Proof	of	Parent/Child	relationship	(any	one	of	the	           Sponsored	Dependent
   following	documents):													                            •	 Copy	of	the	first	page	of	the	most	recently	filed	federal	
	 -	 Copy	of	legal	birth	certificate	(Employee	must	be		 	          income	tax	return	showing	the	individual	listed	as	a	
   		 listed	as	a	parent),	Canadian	employees	must	provide          dependent	and	indication	that	they	lived	with	you	
       the long form birth certificate                              (financial	amounts	may	be	blocked	out)	
	 -	 Copy	of	hospital	certificate	(Employee	must	be	listed		
   		 as	parent	and	must	include	date	of	birth)                  •	 If	your	sponsored	dependent	is	Medicare	eligible,	
	 -	 Affidavit	of	Parentage	(must	be	certified	and	filed		 	        provide	a	copy	of	their	Medicare	Card	Parts	A	and	B	
   		 with	the	State).                                              AND		a	copy	of	the	first	page	of	the	most	recently	filed	
   - Copy of the first page of the most recently filed              federal income tax return as noted above .
   		 federal	income	tax	return	showing	the	child		         	
       listed as a dependent and indicating that child lived
   		 with	you	(financial	amounts	may	be	blocked	out).           Your Flex Benefits Selections
                                                                 ________________________
	 -	 Canadian	employees	who	do	not	claim	dependents			
   		 on	their	U.S.	Federal	income	tax	must	submit	their
                                                                 The Flex Benefits program provides eligible senior staff
       Canadian income tax form listing eligible
                                                                 with	the	opportunity	to	purchase	benefits	from	the	
   		 dependents.		If	an	Identification	Number	is	used	in			
                                                                 following	categories:
   		 place	of	a	dependent	name,	documentation	(such	as	
   		 the	Social	Insurance	Number	card)	must	be	                 •	 Medical/Vision
   		 submitted	that	links	the	dependent’s	name	to	the		 	       •	 Dental
   		 Identification	Number.                                     •	 Employee	Life	Insurance
	 -	 Copy	of	Qualified	Medical	Child	Support	Order	
                                                                 •	 Dependent	Life	Insurance
   		 (QMSCO).
                                                                 •	 Accidental	Death	and	Dismemberment	(AD&D)
                                                                 •	 Long-Term	Disability
unmarried,	Natural	&	legally	Adopted	Child,	Step-                •	 Health	Care	Flexible	Spending	Account	(FSA)
Children	and	Children	of	your	Domestic	Partner;	                 •	 Day	Care	FSA
until	the	end	of	the	year	they	reach	age	25
•	 The	same	documents	listed	for	Unmarried,	Natural	&	
   Legally	Adopted	Child,	Step-Children	and	Children	of	
   your	Domestic	Partner;	until	the	end	of	the	year	that	
   they reach age 19                                                                                (continued on next page)



                                                                                                                                 6
H e n ry F o r d H e a lt H S y S t e m                                                                     Flex Benefits



Health Care Coverage
________________________                                              CHOOSE HENRY FORD FOR PEDIATRIC CARE
                                                                      Did	you	know	that	Henry	Ford	has	more	than	60	
For	most	of	us,	health	care	coverage	is	the	first	thing	that	
                                                                      pediatricians at 16 locations to provide your child
comes	to	mind	when	we	hear	the	word	“benefits.”	
                                                                      with	the	highest	level	of	medical	care?	Infant	and	
Satisfying our family’s health care needs is a significant
                                                                      pediatric	specialties	include	genetics,	behavioral	services,	
concern for many of us . Henry Ford Health System
                                                                      dermatology,	allergy,	adolescent	medicine,	neurology,	
understands this and continues to offer medical/vision and
                                                                      orthopaedics,	urology,	special	needs,	and	more.	To	find	a	
dental options to meet these needs . You can enhance your
                                                                      Henry	Ford	pediatrician,	call	1-800-HENRY-FORD	or	log	
health	care	coverage	by	carefully	reviewing	every	option	
and	considering	how	each	will	work	with	the	other	plans	              on to www.henryford.com	and	click	on	Find	a	Doctor.
in the Flex Benefits program or other coverage you may
have.	For	example,	if	you	choose	a	medical/vision	plan	
option	with	co-pays,	you	may	want	to	put	pretax	dollars	
in	a	Health	Care	FSA	to	cover	the	total	co-pays	you	expect	
                                                                  HFHS Preferred Network:
                                                                  ________________________
to	incur	during	the	year.	Or,	if	you	are	covered	under	your	
spouse’s	dental	plan,	you	may	want	to	choose	no	coverage	         The	HFHS	Preferred	Network	has	been	designed	exclusively	
under Flex Benefits and use your excess credits to fund a         for	System	employees	at	the	lowest	employee	contribution	
Day	Care	FSA.	
                                                                  level compared to other medical options provided .
If	you	are	covered	by	another	group	medical	plan,	you	may	
choose	to	waive	coverage.	You	can	use	your	flex	credits	to	       •	 The	HFHS	Preferred	Network	includes	Henry	Ford	
purchase other benefits or have them returned to you in              Medical	Group	(HFMG)	physicians,	Medical	Center	
the form of taxable income .                                         physicians	and	private	practice	physicians	affiliated	with	
                                                                     Henry	Ford	Health	System	hospitals	as	follows:
MEDICAL/VISION PLANS
Flex Benefits offers a number of different options for            	   ❏	 Physicians	in	the	Greater	Macomb	IPA	or	
combined	medical	and	vision	coverage.	Please	keep	in	
                                                                  	   		 Independent	Physicians	of	Macomb	affiliated	with
mind your choice of plans may be limited due to your
primary place of residence or employment group . You              	   		 Henry	Ford	Macomb	–	Clinton	Township
will	be	able	to	choose	from	among	the	following	                  	   ❏	 Greater	Macomb	IPA	or	Warren	Physicians	who	have
medical/vision plans:                                             	   		 a	Henry	Ford	Macomb	Hospital	–	Warren	Campus
                                                                         affiliation
	•	Henry	Ford	Health	System	(HFHS)	                               	   ❏	 Eastern	Shores	physicians	with	admitting	privileges
	 Preferred	Network	–		(HMO)                                          		 to	Henry	Ford	Cottage	Hospital	and	who	have	a		 	
	•	Full	HAP	–	(HMO)                                                   		 direct	contract	with	HAP	(Not	all	physicians	who	are	
	•	HAP	Point	of	Service	(POS)                                         		 currently	in	the	Eastern	Shores	Network	are	part	of		
	•	Community	Blue	PPO	(BCBSM)                                         		 the	HFHS	Preferred	Network.)
	•	Manulife1                                                      	   ❏	 Wyandotte	IPA	physicians	affiliated	with	Henry	Ford		
	•	Paramount	Basic2                                                      Wyandotte Hospital
                                                                  	   ❏	 HAP	contracted	physicians	affiliated	with	Henry	Ford		
1
 		 Available	only	to	Canadian	residents.                                West Bloomfield Hospital
2
 		 Available	to	certain	Community	Care	Services	employees	who	   	   ❏	 Other	HAP	contracted	physicians	employed	through			
	 live	and	work	in	Ohio.                                                 Henry Ford Health System hospitals




                                                                                                          (continued on next page)



                                                                                                                                      7
H e n ry F o r d H e a lt H S y S t e m                                                                Flex Benefits


•	 These		include	Henry	Ford	Cottage,	Henry	Ford,	Henry	
                                                                    You	and	your	dependents	can	change	your	PCP	and	
   Ford	Macomb,	Henry	Ford	Macomb-Warren,	Henry	Ford	
                                                                    remain	part	of	the	HFHS	Preferred	Network,	as	long	as	
   West Bloomfield and Henry Ford Wyandotte hospitals .
                                                                    the	new	PCP	is	part	of	the	HFHS	Preferred	Network.		
                                                                    Changing	your	PCP	will	not	affect	your	contribution	
•	 Employees	will	be	able	to	select	any	HAP	pediatrician	           for	medical	coverage.	Changing	your	network	
   as	their	child’s	PCP.	For	additional	information	on	             assignment	will	affect	your	medical	contribution.	If	
   Pediatrics,	go	to	HR	Connect/Benefits.                           you	need	to	change	from	the	Henry	Ford	Preferred	
                                                                    Network	to	the	Full	HAP	Network,	you	will	continue	to	
•	 Women	may	self-refer	to	any	HAP	obstetrician/                    have a pre-tax deduction up to the cost of the Henry
   gynecologist for routine ob/gyn services .                       Ford	Preferred	Network	option.	The	added	contribution	
                                                                    will	be	an	after-tax	deduction.	
•	 Participants	enrolled	in	the	HFHS	Preferred	Network	will	
   be able to obtain outpatient diagnostic and therapeutic          For	example,	if	you	have	single	coverage	under	the	
   services	at	any	HFHS	facility.	For	example,	a	Henry	Ford	        Henry	Ford	Preferred	Option	at	$28.83	per	pay	pre-tax,	
   Medical	Group	enrollee	can	receive	an	x-ray	at	Henry	            and	you	change	your	network	selection	to	the	Full	HAP	
                                                                    Network	option,	which	is	$50.98	per	pay	pre-tax,	your	
   Ford Wyandotte Hospital .
                                                                    pre-tax	contribution	will	be	$28.83	and	your	after-tax	
                                                                    contribution	will	be	$22.15	per	pay	for	the	remainder	
•	 Employees	are	encouraged	to	enroll	in	the	Henry	Ford	
                                                                    of the year .
   Preferred	Network	option.	The	HFHS	Preferred	Network	
   provides System employees an opportunity to “Choose
   Henry	Ford.”	Employees	are	supporting	HFHS	in	
   promoting	the	System’s	growth	strategy	helping	to	
   ensure	a	healthy	future	not	only	for	your	own	family	
                                                               Healthcare Plan Changes
                                                               _______________________
   but	for	Henry	Ford	as	well.
                                                               Employees	who	choose	the	HFHS	Preferred	Network	
                                                               or	Full	HAP	option	for	their	medical	coverage	have	
                                                               an	opportunity	to	save	on	out-of-pocket	health	care	
Full HAP Network:
________________________                                       costs	and	improve	their	health	status	in	HAP’s	Health	
                                                               Engagement	program,	which	rewards	employees	who	take	
                                                               responsibility	for	their	own	health	with	lower	out-of-
•	 The	Full	HAP	Network	option	allows	employees	to	
                                                               pocket	costs.
   choose	from	a	broader	network	of	providers	at	a	higher	
   employee	contribution	level	than	the	HFHS	Preferred	        The	medical	chart	on	the	following	pages	outlines	the	level	
   Network	option.                                             of	benefits	associated	with	each	medical	option	available	
                                                               through the Flex Benefits program . Key changes include
•	 The	Full	HAP	Network	allows	members	to	access	any	          the	Enhanced	plan	and	Standard	plan	of	benefits	in	HAP’s	
                                                               Health Engagement program .
   network	with	which	HAP	is	affiliated.
                                                               The	Enhanced	plan	waives	co-pays	for	recommended	
                                                               preventive	care	and	screenings	as	well	as	pre-natal	
Additional Information:
________________________                                       services,	offers	lower	co-pays	for	other	services,	and	has	
                                                               no	annual	deductibles.		Preventive	services	include:

•	 To	find	out	if	your	physician	is	in	the	Henry	Ford	         •	   Cancer	screenings	(breast,	cervical,	prostate,	and	colon)
   Preferred	Network	or	Full	HAP	Network,	you	can	obtain	      •	   Recommended	physical,	eye	and	hearing	exams
   a	directory	online	at	www.hap.org.                          •	   Recommended	lab	tests
                                                               •	   Smoking	cessation	counseling
                                                               •	   Well	baby/child	exam	visits




                                                                                                                                8
H e n ry F o r d H e a lt H S y S t e m                                                           Flex Benefits


The	co-pay	for	an	OB/GYN	visit	will	be	reduced	to	the	        •	 Employees	hired	after		Jan.	1,	2011	will	be	placed	
same cost as a primary care physician office visit .             in	the	Enhanced	plan	of	benefits	for	2011	and	will	
                                                                 need to qualify in 2012 to remain in the Enhanced
The Standard plan of benefits offers the same access to          Plan	of	benefits.
quality	care	and	benefits	but	with	higher	out-of-pocket	
costs.	The	out-of-pocket	costs	under	the	Standard	            Employees	who	would	like	to	get	a	jump	start	on	
plan include higher co-pays and an annual deductible .        completing	the	HRA	and	MQF	can	take	action	now:
Effective	2011,	the	Standard	plan	includes	co-pay	            •	 The	MQF	is	currently	available	at	www.hap.org.	
waivers	for	recommended	preventive	screenings.                   Print	your	personalized	MQF	to	take	with	you	to	
                                                                 meet	with	your	PCP.		Otherwise,	you’ll	receive	your	
                                                                 MQF	in	your	HAP	enrollment	packet	in	January.	
Health Engagement
_______________________                                       •	 The	HRA	is	available	at	www.HRConnect.com/
                                                                 wellness.
The	Health	Engagement	Program	will	again	be	available	
to all employees and their covered spouses/same-sex           Changes to Health Engagement
domestic	partners	who	selected	the	HFHS	Preferred	            for 2011
Network	or	the	Full	HAP	option	in	2010	and	who	plan	to	       Please	note	there	are	changes	to	Health	Engagement	
re-elect	in	2011,	or	new	enrollees	in	either	plan.	           from last year . Employees and their spouses/same-
                                                              sex	domestic	partners	must	score	85	points	(up	
If	you	have	questions	about	Health	Engagement,	               from	80	points	in	2010)	on	the	MQF	and	agree	to	
log	on	to	www.hap.org/healthengagement.	Or,	contact	          treatment	plans	to	achieve	wellness	targets.	To	score	
HAP	directly	by	calling	Client	Services	toll	free	at	         85	points,	you	must	schedule	preventive	screenings	
888-819-2540 . Hearing or speech-impaired members             as	recommended	by	your	PCP.	Last	year,	employees	
may	call	HAP’s	Telecommunications	Device	for	the	Deaf	        and	their	spouses/same-sex	domestic	partners	were	
at	313-664-8000.	HAP	personnel	are	available	Monday	          only required to agree to schedule the recommended
through Friday from 7 a .m . to 7 p .m . and Saturdays from   screenings .
8 a .m . to noon .

remember:                                                     A Special Note for Tobacco Users
•	 Employees	and	their	covered	family	members	will	           Tobacco	users	who	qualified	for	HAP’s	Enhanced	
   continue	to	remain	in	the	Enhanced	or	Standard	Plan	       Plan	and	agreed	to	quit	smoking	in	2010	need	to	
   through	March	31,	2011.                                    document	efforts	to	quit	smoking	in	order	to	be	
•	 Employees	and	their	covered	spouses/same-sex	              eligible	for	the	Enhanced	Plan	in	2011.	There	is	still	
   domestic	partners	must	qualify	for	the	Enhanced	Plan	      time to document your 2010 efforts . Documentation
   every year .                                               will	automatically	be	sent	to	HAP	for:	
•	 Employees	and	their	spouses/same-sex	domestic	             •	 HFHS	Smoking	Intervention	Program	(SIP)
   partners	who	were	hired	after	Jan.		1,	2010	and	           •	 Counseling	services	provided	by	your	PCP	
   automatically	placed	in	the	Enhanced	Plan	will	have	to	    •	 HFHS	Tobacco	Free	For	Living	(TFFL)
   meet the qualifications for 2011 .                         •	 Prescription	drugs	
•	 A	spouse/same-sex	domestic	partner	who	was	added	to	
   your medical coverage due to a midyear life event in       Documentation must be sent by you for:
   2010	will	be	required	to	qualify	for	the	Enhanced	Plan	    •	 Over-the-counter	smoking	cessation	drugs	and	
   in 2011 .                                                     products
•	 Qualification	for	the	Enhanced	Plan	requires	              •	 Over-the-counter	nicotine	replacement	products
   completion	of	the	iStrive	Health	Media	SUCCEED®            •	 Smoking	cessation	counseling	programs	other	than	
   Health	Risk	Assessment	(HRA)	and	completion	of	the	           those listed above
   Member	Qualification	Form	(MQF).
•	 HAP’s	qualification	period	for	Health	Engagement	is	       Send	receipts	to	HAP	by	March	31,	2011.	Receipts	can	
   Saturday,	Jan.	1	through	Thursday,	March	31,	the	first	    be	mailed	to:	HAP,	Attn:	HAP	Correspondence,	2850	
   three	months	of	2011;	however,	employees	may	begin	        W.	Grand	Blvd.,	Detroit	MI	48202.	
   qualifying	now	and	are	encouraged	to	do	so.	




                                                                                                                        9
H e n ry F o r d H e a lt H S y S t e m                                                           Flex Benefits


Note:	Because	HAP	requires	that	tobacco	users	become	         Changes planned for 2013
tobacco-free	in	order	to	qualify	for	the	Enhanced	Plan	       In	addition	to	completing	the	HRA	and	MQF	with	a	
in	2012,	documentation	of	efforts	to	quit	will	not	be	        score	of	85	or	greater,	to	qualify	for	the	Enhanced	
required	after	your	2011	PCP	visit.	                          Plan,	an	employee	and	their	spouse/same-sex	
                                                              domestic partner must:
Is Quitting Smoking Part of Your MQF?                         •	 Be	up-to-date	on	preventive	screening,	as	
For	all	tobacco	users,	be	sure	to	try	to	quit	smoking	           recommended	by	their	PCP.
before	you	visit	your	physician	to	complete	your	MQF	         •	 Be	a	non-tobacco	user.
for	2011.	For	a	complete	list	of	free	and	low-cost	options	   •	 Have	a	BMI	of	<30	or	lose	5	percent	of	body	weight	
to	help	you	quit,	download	the	Employee	Wellness	                by	the	time	they	visit	their	PCP	in	2013	(during	the	
Resource	Guide	at	www.henryfordconnect.com/wellness.	            qualification	period,	which	is	Jan.	1	through	
For	information	on	HAP’s	smoking	cessation	benefits,	            March	31,	2013)
visit	www.hap.org/healthyliving	and	look	for	information	     •	 Have	a	blood	pressure	of	<140/90;	if	diabetic,	
by	the	topic	“smoking	cessation.”	If	you	have	questions,	        <130/90.
call	HAP	Client	Services	at	1-888-819-2540.                   •	 Have	an	acceptable	LDL-C	cholesterol	level.
                                                              •	 Have	normal	or	acceptable	HbA1C	(<8.0).
 In	2011,	co-pays	for	smoking	cessation	and	smoking	
                                                              MEDICAl/VISION	AND	DENTAl	COMPArISON	
 cessation	drugs	will	be	waived	at	HFHS	Pharmacies	
 for employees in the Enhanced and Standard plans of          CHArTS
 Health Engagement .                                          The medical/vision and dental comparison charts
                                                              that	follow	will	provide	you	with	a	description	of	the	
                                                              benefits available:
Make Health Engagement Part of
Your Future
Looking	ahead,	there	will	be	additional	changes	to	the	
Health	Engagement	Program	for	2012	and	2013.	By	
learning	about	these	changes	now,	you	can	plan	ahead	
either	by	making	changes	to	meet	the	new	criteria	or	
by being financially prepared for possible additional
costs	if	you	move	into	the	Standard	Plan.	Remember,	
the	Standard	Plan	offers	the	same	access	to	quality	
care	and	benefits	as	the	Enhanced	Plan,	but	with	higher	
out-of-pocket	costs	and	annual	deductibles.	The	annual	
deductible	for	an	individual	is	$500	per	year	and	$1,000	
per year for a family .

Changes planned for 2012
In	addition	to	completing	the	HRA	and	MQF	with	a	
score	of	85	or	greater,	to	qualify	for	the	Enhanced	
Plan,	an	employee	and	their	spouse/same-sex	domestic	
partner must:
•	 Be	up-to-date	on	preventive	screening,	as	
   recommended	by	their	PCP.
•	 Be	a	non-tobacco	user.
•	 Have	a	BMI	of	<30	or	lose	5	percent	of	body	weight	
   by	the	time	they	visit	their	PCP	in	2013	(during	the	
   qualification	period,	which	is	Jan.	1	through	
   March	31,	2012)
•	 Have	a	blood	pressure	of	<140/90;	if	diabetic,	<130/90.




                                                                                                                         10
H e n ry F o r d H e a lt H S y S t e m                                                                                                              Flex Benefits



HAP Medical Plan Options
                        Listed below are the various medical plan options available in the Flexible Benefits Plan.
                                             HFHS Preferred Network and Full HAP (HMO) Options                                   HAP Point Of Service (POS)

Health Care Services                        Enhanced Plan Coverage               Standard Plan Coverage                      In Network                      Out of Network

Benefit Period                                 January - December                 January - December                    January - December                 January - December
Annual Deductibles                                   None                     $500 Individual; $1,000 Family                  None                                 None
Out-of-Pocket Maximums                               None                                 None                                None                    $2,000 Individual; $3,000 Family
Lifetime Maximums                                    None                                 None                                None                                 None
Preventive Services
Preventive Office Visit                              Covered                            Covered                              $15 Co-Pay                       Plan pays 80%
Well Baby/Child Exams                                Covered                            Covered                              $15 Co-pay                       Plan pays 80%
Immunization                                         Covered                            Covered                               Covered                         Plan pays 80%
Related Laboratory and Radiology Services            Covered                            Covered                               Covered                         Plan pays 80%
Pap Smears and Mammograms                            Covered                            Covered                               Covered                         Plan pays 80%
Outpatient and Physician Services:
Primary Care Office Visit                           $15 Co-pay            $30 Co-pay - Deductibe does not apply              $15 Co-pay                       Plan pays 80%
Specialty Physician Office Visit                    $25 Co-pay            $50 Co-pay - Deductible does not apply             $25 Co-pay                       Plan pays 80%
Gynecology                                          $15 Co-pay            $30 Co-pay - Deductible does not apply             $25 Co-pay                       Plan pays 80%
Audiology Examinations                              $25 Co-pay            $50 Co-pay - Deductible does not apply             $25 Co-pay                       Plan pays 80%
Eye Examinations                                    $25 Co-pay            $50 Co-pay - Deductible does not apply             $25 Co-pay                       Plan pays 80%
Allergy Treatment and Injections                     Covered                     Covered after deductible                     Covered                         Plan pays 80%
Laboratory and Radiology Services                    Covered                     Covered after deductible                     Covered                         Plan pays 80%
Dialysis                                             Covered                     Covered after deductible                     Covered                         Plan pays 80%
Chemotherapy                                         Covered                     Covered after deductible                     Covered                         Plan pays 80%
Radiation                                            Covered                     Covered after deductible                     Covered                         Plan pays 80%
Outpatient Surgery Co-pay                          $100 Co-pay                 $100 Co-pay after deductible                 $100 Co-pay                       Plan pays 80%
Chiropractic                                       Not Covered                         Not Covered                          Not Covered                        Not Covered
Emergency/Urgent Care:
Emergency Room Services                      $125 Co-pay Non-System          $150 Co-Pay Non-System Facility       $125 Co-pay Non-System Facility   $125 Co-pay Non-System Facility
                                               Facility; $75 Co-pay at         $100 Co-pay at HFHS Facility;         $75 Co-pay at HFHS Facility       $75 Co-pay at HFHS Facility
                                                   HFHS Facility                 Deductible does not apply
Urgent Care Facility Services                      $50 Co-pay at            $50 Co-pay at Non-System Facility      $50 Co-pay Non-System Facility    $50 Co-pay Non-System Facility
                                                Non-System Facility             $40 Co-pay at HFHS Facility          $40 Co-pay at HFHS Facility       $40 Co-pay at HFHS Facility
                                            $40 Co-pay at HFHS Facility          Deductible does not apply
Emergency Ambulance Services                           Covered                   Covered after deductible                     Covered                         Plan pays 80%
Inpatient Hospital Services:
Hospital Inpatient stay in semi-private     $100 Co-pay per Admission          $150 Co-pay per Admission             $100 Co-pay per Admission                Plan pays 80%
room, specialty units as medically
necessary; physician services, surgery,
therapy, laboratory, radiology, hospital
services and supplies.
Bariatric Surgery & Related Services              $1,000 Co-pay               $1,000 Co-pay after deductible         $100 Co-pay per Admission                Plan pays 80%
Maternity Services:
Initial Office Visit to Confirm Pregnancy            Covered              $30 Co-pay - Deductible does not apply             $25 Co-pay                       Plan pays 80%
Subsequent Prenatal and Postnatal                    Covered              $30 Co-pay - Deductible does not apply             $25 Co-pay                       Plan pays 80%
Office Visits
Delivery and Nursery Care                   $100 Co-pay per Admission          $150 Co-pay per Admission             $100 Co-pay per Admission                Plan pays 80%
                                                                                    after Deductible
Mental Health:
Inpatient Services                                 $100 Co-pay                  $150 Co-pay per Admission            $100 Co-pay per Admission                Plan pays 80%
                                                                                     after Deductible
Outpatient Services                                 $15 Co-pay            $30 Co-pay - Deductible does not apply             $15 Co-pay              $15 Co-pay; then Plan pays 80%




                                                                                                                                                                                         11
H e n ry F o r d H e a lt H S y S t e m                                                                                                                Flex Benefits



HAP Medical Plan Options (continued)
                           Listed below are the various medical plan options available in the Flexible Benefits Plan.
                                                HFHS Preferred Network and Full HAP (HMO) Options                                  HAP Point Of Service (POS)

 Health Care Services                           Enhanced Plan Coverage             Standard Plan Coverage                       In Network                    Out of Network

 Chemical Dependency:
 Inpatient Services                            $100 Co-pay per Admission          $150 Co-pay per Admission            $100 Co-pay per Admission               Plan pays 80%
                                                                                       after deductible
 Outpatient Services                                   $15 Co-pay           $30 Co-pay - Deductible does not apply              $15 Co-pay             $15 Co-pay; then Plan pays 80%
 Other Services:
 Home Health Care                                      Covered                    Covered after deductible                         Covered                     Plan pays 80%
 Hospice Care                                  Covered; 210 days lifetime         Covered after deductible;             Covered; 210 days lifetime             Plan pays 80%
                                                                                       210 days lifetime           (combined in and out of network)
 Skilled Nursing Care                            Covered; up to 730 days,         Covered after deductible;              Covered; up to 730 days,              Plan pays 80%
                                                 renewable after 60 days up to 730 days, renewable after 60 days         renewable after 60 days
                                                                                                                   (combined in and out of network
 Durable Medical Equipment;                   Covered; Coverage provided Covered after deductible; Coverage           Covered; Coverage provided               Plan pays 80%
 Prosthetics & Orthotics                        for authorized equipment     provided for authorized equipment          for authorized equipment
 Hearing Aid (Hardware)                           Covered for authorized          Covered after deductible;               Covered for authorized               Plan pays 80%
                                               conventional hearing aids    Covered for authorized conventional         conventional hearing aids
                                                                                         hearing aids
 Physical, Speech and Occupational            Covered; up to 60 combined          Covered after deductible;            Covered; up to 60 combined              Plan pays 80%
 Therapy                                         visits per benefit period       up to 60 combined visits per            visits per benefit period
                                                                                        benefit period
 Voluntary Sterlizations                                 $100 Co-pay            $100 Co-pay after deductible                     $100 Co-pay                   Plan pays 80%
 Infertility Services                              Covered: Services for          Covered after deductible;         Covered; Services for diagnosis            Plan pays 80%
                                               diagnosis, counseling, and    Services for diagnosis, counseling,        counseling, and treatment
                                                 treatment of anatomical        and treatment of anatomical         of anatomical disorders causing
                                              disorders causing infertility      disorders causing infertility        infertility in accordance with
                                               in accordance with HAP’s      in accordance with HAP’s benefit,         HAP’s benefit, referral and
                                                    benefit, referral and       referral and practice policies               practice policies
                                                     practice policies
 Assisted Reproductive Technologies              Covered; One attempt of          Covered after deductible;              Covered: One attempt of               Plan pays 80%
                                                   artificial insemination  One attempt of artificial insemination        artificial insemination
                                                         per lifetime                     per lifetime                           per lifetime
 Pharmacy:*
 Generic / Preferred Brand / Non-Preferred        $4 / $17 / $35 Co-pay              $9 / $27 / $45 Co-pay                $4 / $17 / $35 Co-pay
 Brand                                            at System Pharmacy                 at System Pharmacy                   at System Pharmacy
                                                  $15 / $30 / $50 Co-pay             $20 / $40 / $60 Co-pay               $15 / $30 / $50 Co-pay                Not Covered
                                                 Non-System Pharmacy                Non-System Pharmacy                  Non-System Pharmacy



In case of discrepancies between this summary and the medical plan Contract, the terms and conditions of the Contract govern.

* See page 16 for 2011 Prescription Drug Pharmacy Benefit changes.




                                                                                                                                                                                        12
H e n ry F o r d H e a lt H S y S t e m                                                                                                              Flex Benefits



BCBSM Medical Plan Options
                        Listed below are the various medical plan options available in the Flexible Benefits Plan.
                                                                                              BCBSM Community Blue PPO

Health Care Services                                                    In Network                                                           Out of Network

Benefit Period                                                      January - December                                                      January - December
Annual Deductibles                           $250 Individual; $500 Family (Waived if services is performed in a      $500 Individual; $1,000 Family; Out of network deductible amounts
                                             physician’s office and for covered inpatient and outpatient facility               also apply toward the in network deductible
                                                             services provided at HFHS facilities)
Out-of-Pocket Maximums                                          $500 Individual; $1,000 Family                                        $1,000 Individual; $2,000 Family
Lifetime Maximums                                                                                             None
Preventive Services
Preventive Office Visit                                              Covered                                                      Covered at 60% after deductible
Well Baby/Child Exams                                                Covered                                                                Not Covered
Immunization                                                         Covered                                                                Not Covered
Related Laboratory and Radiology Services                            Covered                                                                Not Covered
Pap Smears and Mammograms                        Pap Smear Covered; Mammogram 80% after deductible                     Pap Smear Not covered; Mammogram 60% after deductible
Outpatient and Physician Services:
Primary Care Office Visit                                                 Covered                                                     Covered 60% after deductible
Specialty Physician Office Visit                                          Covered                                                     Covered 60% after deductible
Gynecology                                                               $15 Co-pay                                                   Covered 60% after deductible
Audiology Examinations                                                   $15 Co-pay                                                   Covered 60% after deductible
Eye Examinations                                                         $15 Co-pay                                                   Covered 60% after deductible
Allergy Treatment and Injections                                          Covered                                                     Covered 60% after deductible
Laboratory and Radiology Services                            Covered 80% after deductible                                             Covered 60% after deductible
Dialysis                                                     Covered 80% after deductible                                             Covered 60% after deductible
Chemotherapy                                                 Covered 80% after deductible                                             Covered 60% after deductible
Radiation                                                    Covered 80% after deductible                                             Covered 60% after deductible
Outpatient Surgery Co-pay                                    Covered 80% after deductible                                             Covered 60% after deductible
Chiropractic                                    $15 Co-pay per visit (up to a maximum of 24 visits member                             Covered 60% after deductible
                                                        per calendar year in and out of network)
Emergency/Urgent Care:
Emergency Room Services                                      $125 Co-pay Non-System Facility                                         $125 Co-pay Non-System Facility
                                                               $75 Co-pay at HFHS Facility                                             $75 Co-pay at HFHS Facility
Urgent Care Facility Services                               $50 Co-pay at Non-System Facility                                        Covered at 60% after deductible
                                                               $40 Co-pay at HFHS Facility
Emergency Ambulance Services                                  Covered 80% after deductible                                            Covered 60% after deductible
Inpatient Hospital Services:
Hospital Inpatient stay in semi-private     $250 Co-pay per Admission (Waived at HFHS); 80% after deductible;                         Covered 60% after deductible;
room, specialty units as medically
necessary; physician services, surgery,
therapy, laboratory, radiology, hospital
services and supplies.
Bariatric Surgery & Related Services             Covered 80% after deductible, must meet specific criteria              Covered 60% after deductible, must meet specific criteria
Maternity Services:
Initial Office Visit to Confirm Pregnancy                                Covered                                                               Covered
Subsequent Prenatal and Postnatal                                        Covered                                                      Covered 60% after deductible
Office Visits
Delivery and Nursery Care                   $250 Co-pay per Admission (Waived at HFHS) 80% after deductible           Covered 60% after deductible; Includes delivery provided by a
                                                      includes delivery by a certified nurse midwife                                    certified nurse midwife
Mental Health:
Inpatient Services                          $250 Co-pay per Admission (Waived at HFHS); 80% after deductible                          Covered 60% after deductible
Outpatient Services                                                    $15 Co-pay                                                     Covered 60% after deductible




                                                                                                                                                                                         13
H e n ry F o r d H e a lt H S y S t e m                                                                                                                  Flex Benefits



BCBSM Medical Plan Options (continued)
                        Listed below are the various medical plan options available in the Flexible Benefits Plan.
                                                                                                  BCBSM Community Blue PPO

 Health Care Services                                                      In Network                                                              Out of Network

 Chemical Dependency:
 Inpatient Services                             $250 Co-pay per Admission (Waived at HFHS); 80% after deductible                            Covered 60% after deductible
 Outpatient Services                                                       $15 Co-pay                                                       Cvoered 60% after deductible
 Other Services:
 Home Health Care                                                  Covered 80% after deductible                                            Covered 80% after deductible
 Hospice Care                                    Covered (Limited to dollar maximum that is reviewed and adjusted        Covered (Limited to dollar maximum that is reviewed and adjusted
                                                               periodically for in and out of network                                  periodically for in and out of network
 Skilled Nursing Care                               Covered 80% after deductible; up to 120 days per member                 Covered 80% after deductible; upt to 120 days per member
                                                                         per calendar year                                                       per calendar year
 Durable Medical Equipment;                                        Covered 80% after deductible                                            Covered 80% after deductible
 Prosthetics & Orthotics
 Hearing Aid (Hardware)                                                     Covered                                                                Not Covered
 Physical, Speech and Occupational               Covered 80% after deductible; Limited to a combined maximum of           Covered 60% after deductible; Limited to a combined maximum of
 Therapy                                                    60 visits per member per calendar year                                   60 visits per member per calendar year
 Voluntary Sterlizations                                         Covered 80% after deductible                                             Covered 60% after deductible
 Infertility Services                                                     Not Covered                                                              Not Covered
 Assisted Reproductive Technologies                                       Not Covered                                                              Not Covered
 Pharmacy:
 Generic / Preferred Brand / Non-Preferred                   $4 / $17 / $35 Co-pay at System Pharmacy                                   $4 / $17 / $35 Co-pay at System Pharmacy
                                                           $15 / $30 / $50 Co-pay Non-System Pharmacy                           $15 / $30 / $50 Co-pay Non-System Pharmacy plus 25% of
                                                                                                                                             the approved amount for the drug


In case of discrepancies between this summary and the medical plan Contract, the terms and conditions of the Contract govern.




                                                                                                                                                                                         14
H e n ry F o r d H e a lt H S y S t e m                                                                                                                                 Flex Benefits



Medical/Vision Plan Options
___________________________________________________
                         Vision Care (The vision coverage available is based on the medical option selected.)
                              HFHS Preferred Network                                    HAP Point of Service (POS)                                          BCBSM Community Blue PPO
                             and Full HAP (HMO) Options
Services          Enhanced Plan Coverage        Standard Plan Coverage               In Network                   Out of Network                          In Network                     Out of Network
 Eye Exam         $25 Co-Pay; unlimited        $50 Co-Pay; deductible does    $25 Co-Pay; unlimited         Plan pays 80%                        Annual Exam covered in full up to approved charges
                  exams (Waived for            not apply; unlimited eye       eye exams; $15 Co-pay         Unlimited eye exams
                  preventive care)             exam. $30 Co-pay for           preventive care
                                               preventive care
 Frames           Covered up to $40; One       Covered up to $40; One         Covered up to plan         Not Covered                             Covered up to $40; one pair every 24 months
                  pair every 12 months with    pair every 12 months with      maximum, subject to plan
                  prescription change;         prescription change;           limitations; Covered up to
                  otherwise one pair every     otherwise one pair every       $40; one pair every 12
                  24 months                    24 months                      months; otherwise, one
                                                                              pair every 24 months
 Lenses           Covered in full up to the    Covered in full up to the      Covered up to plan        Not Covered                              Covered in full up to the approved charge; one
                  approved charges; one        approved charges; one          maximum, subject to plan                                           pair every 12 months
                  pair every 12 months with    pair every 12 months with      limitations; Covered in
                  prescription change;         prescription change;           full up to the approved
                  otherwise, one pair every    otherwise, one pair every      charges; one pair every
                  24 months                    24 months                      12 months with
                                                                              prescription change;
                                                                              otherwise, one pair every
                                                                              24 months
 Contact Lenses   Covered in full up to $80    Covered after deductible       Covered up to plan            Not Covered                          Covered in full up to the approved charges in lieu
                  in lieu of eyeglasses;       in full up to $80 in lieu of   maximums; subject to                                               of eye glasses
                  contact lens fitting exams   eyeglasses; contact lens       plan limitations; covered
                  are not covered              fitting exams are              in full up to $80 in lieu
                                               not covered                    of eyeglasses; contact
                                                                              lens fitting exams are
                                                                              not covered


In	addition	to	the	vision	plan	you	choose,	additional	                                          Ford identification badge and indicate that you are a
savings	on	out-of-pocket	expenses	are	available	to	you	as	                                      System employee at the time the eligible service is
an employee of Henry Ford Health System through Henry                                           provided.	Locations	include:	
Ford	OptimEyes.	After	applying	insurance	benefits,	the	
following	discounts	will	apply	to	your	balance:                                                 Henry	Ford	OptimEyes	Super	Vision	Centers	-	
                                                                                                Open	7	days	&	Week	Days	until	9	p.m.
•	   An	additional	10%	on	frame	(after	current	frame	                                           Roseville  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 586-294-0120
	    promotion)                                                                                 Southgate  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .734-324-0996
•	   10%	on	all	lenses	and	upgrades                                                             Sterling	Heights	(Lakeside)	  .  .  .  .  .  .  .  .  .  .  .  .  . 586-247-5910
•	   10%	on	all	contacts	(based	on	regular	retail	pricing)                                      Troy  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .248-544-3290
•	   10%	on	accessories                                                                         Westland  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .734-427-5200
•	   25%	on	all	ready	made	sunglasses                                                           West Bloomfield .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 248-661-5100
•	   May	not	be	combined	with	coupons	or	other	
     promotions                                                                                 Other	Henry	Ford	OptimEyes	locations:
                                                                                                Dearborn	(Fairlane)	  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 313-982-8297
Discounts	are	not	available	on:
                                                                                                Dearborn .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 313-562-8000
•	   Professional	fees
                                                                                                Detroit	(HF	Hospital)	  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 313-916-3226
•	   Co-pays
                                                                                                Detroit  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 313-387-8800
•	   Warranty	replacements
                                                                                                Farmington Hills  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .248-477-9300
•	   Industrial	safety	glasses
                                                                                                Grosse	Pointe  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 313-822-6000
•	   Exams
                                                                                                Lake	Orion  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .248-693-3380
•	   Eye	glass	and	contact	lens	savings	program
                                                                                                Milford  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .248-684-1229
Discounts	may	not	be	combined	with	other	discounts,	                                            Owosso  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 989-725-7410
coupons or promotions . Sale price merchandise is not                                           Port	Huron  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 810-385-4000
included in the discount program .                                                              Shelby	Township  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 248-651-3937
                                                                                                Southfield  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .248-647-9790
These benefits are available to you and your immediate
family	members	(spouse	and	dependents.)	To	take	                                                Call	toll	free	1-800-EYECARE	(393-2273)	or	go	online	to	
advantage	of	these	discounts,	simply	present	your	Henry	                                        www.optimeyes.com

                                                                                                                                                                                                                      15
H e n ry F o r d H e a lt H S y S t e m                                                                 Flex Benefits


Special Medical Credit
________________________                                                 Application Date              Credit appears on
                                                                                                         Check Dated
                                                                            March 21, 2011                April 15, 2011
•	 A	Special	Medical	Credit	will	be	offered	to	certain	
                                                                             June 20, 2011                July 22, 2011
   full-time	benefits	eligible	employees	(32	standard	hours	
   and	above)	who	have	multiple	dependents	and	lower	                     September 19, 2011            October 14, 2011
   total	family	incomes.	Employees	who	enroll	in	the	HFHS	             Open Enrollment for 2012   First full pay of January 2012
   Preferred	Network	with	two	person	or	family	coverage	
   may be eligible for this special medical credit . Eligibility
   for	the	taxable	credit	will	be	based	on	the	total	family	       Prescription Drug Benefits
   income as indicated on the most recently filed 1040 tax         ________________________
   return and the number of dependents indicated on that
                                                                   Employees and their family members enrolled in any of
   tax	return(s)	as	follows:
                                                                   the	medical	plans	provided	by	HFHS	will	continue	to	pay	
                                                                   reduced co-pays for their prescriptions filled at a System
         Family Size                    1040 Earnings
                                                                   Pharmacy.	HFHS	employees	enrolled	in	the	HFHS	Preferred	
                2                          $29,140                 Network,	Full	HAP	Network	and	HAP	Point-of-Service	
                                                                   will	be	required	to	use	a	HFHS	pharmacy	versus	a	retail	
                3                          $36,620
                                                                   pharmacy.	Currently,	74	percent	of	employees	and	their	
                4                          $44,100                 dependents use HFHS pharmacies . This change supports
                5                          $51,580                 the	System’s	growth	strategy,	which	is	directly	linked	to	
                6                          $59,060                 jobs and financial stability .
                7                          $66,540                 There are some exceptions for using HFHS pharmacies:
                8                          $74,020                 •	 Employees	may	use	a	non-HFHS	Pharmacy	in	an	
                                                                      emergency	or	urgent	situation	when	a	prescription	of	
The	Special	Medical	Credit	will	be:	Two-person	coverage:	             14	days	or	less	duration	is	prescribed;	and
                                                                   •	 Any	prescription	for	a	specific	medication,	including	
$30	per	month;	Family	coverage:	$48	per	month.	The	
                                                                      maintenance	drugs,	may	be	filled	up	to	three	times	per	
application	process	will	occur	in	November	and	Decem-                 member,	per	plan	(HFHS	Preferred,	Full	HAP	and	HAP	
ber	2010.	The	deadline	for	submitting	the	Special	Medical	            Point-of-Service)	within	the	existing	HAP	pharmacy	
Credit	application	is	Monday,	Dec.	13,	2010,	in	order	                network.	Drugs	listed	on	the	Maintenance	Drug	List	may	
for	the	credit	to	appear	on	your	first	paycheck	in	                   be filled for up to a 90-day supply .
January 2011 .                                                     •	 Active	employees	and	retirees	enrolled	in	BCBSM,	
                                                                      Manulife	and	Paramount	medical	options	may	continue	
•	 Employees	may	also	apply	for	the	Special	Medical	Credit	           to	use	either	HFHS	Pharmacies	or	the	existing	HAP	
   on	a	quarterly	basis	due	to	life	events,	status	changes	           Pharmacy	Network.
   and	new	hire	eligibility.		
                                                                   A	“Frequently	Asked	Questions”	document	
                                                                   regarding	the	Pharmacy	change	will	be	available	on	
•	 Applications	can	be	obtained	from	HR	Connect	                   http:henryfordconnect .com/HRconnect
   beginning	Monday,	Nov.	8,	2010.
                                                                   All	medical	options	have	a	three-tier	prescription	drug	
•	 After	review	of	the	application	and	tax	return	                 benefit to include:
   information,	Employee	Services	will	send	an	acceptance	
   letter to you .                                                 Generic	drugs	(First	Tier)	These drugs are the most
                                                                   affordable	way	for	you	to	obtain	quality	medications	at	
                                                                   your	lowest	copayment.	A	generic	drug	is	labeled	with	the	
•	 Cancellation	of	the	Special	Medical	Credit	will	occur	if	
                                                                   medication’s basic chemical name and usually has a brand-
   you are no longer a full-time employee enrolled in the          name	equivalent.	The	U.S.	Food	and	Drug	Administration	
   HFHS	Preferred	Network	option,	you	change	to	                   (FDA)	requires	that	generic	drugs	have	the	same	active	
   employee only coverage or you are no longer eligible
   for benefits .

                                                                                                                                   16
H e n ry F o r d H e a lt H S y S t e m                                                                 Flex Benefits


chemical	composition,	same	potency	and	be	offered	in	the	
                                                               Sponsored Dependents
same form as their brand-name equivalents . Generic drugs
must	meet	the	same	FDA	standards	as	brand-name	drugs	          ________________________
and	are	tested	and	certified	by	the	FDA	to	be	as	effective	
as their brand-name counterparts .                             You	may	also	cover	certain	sponsored	dependents,	
                                                               but no credits are given for this coverage . For related
Preferred	brand	name	drugs	(Second	Tier) These are             information,	see	pages	5-6.		Below	are	the	rates	per	
preferred brand-name drugs that have no generic                pay period for sponsored dependent medical coverage .
equivalent . You’re covered for these medications at a         (Sponsored	dependents	are	not	eligible	for	
slightly higher co-payment .                                   dental	coverage.)

Non-preferred	brand	name	drugs	(Third	Tier) These
are brand-name drugs that either have equally effective        Medical Option            Sponsored    Sponsored
and	less	costly	generic	alternative(s)	or	one	or	more	                                   Dependent Dependent without
preferred-brand	(second	tier)	options.	You	or	your	doctor	                              with Medicare  Medicare
may decide that a medication in this category is best for
                                                               HFHS Preferred Network   $190.26 per pay    $238.31 per pay
you.	If	you	choose	a	Third	Tier	drug,	you’re	covered	at	
the	highest	co-payment	or	coinsurance	level	–	which	still	     Full HAP                 $190.26 per pay    $238.31 per pay
represents a significant savings compared to its full retail   HAP Point of Service      Not eligible      $313.09 per pay
cost.	In	cases	where	brand	name	drugs	are	dispensed	when	
                                                               Community Blue PPO        Not eligible      $405.32 per pay
an	equivalent	generic	drug	is	available,	the	employee’s	
prescription	charge	will	reflect	the	appropriate	brand	
name	drug	co-pay	or	the	net	difference	in	cost	between	
the brand name drug and equivalent generic drug plus the       Same-Sex Domestic Partners
generic	drug	co-pay	–	whichever	is	greater.                    ________________________
Contact	HAP	(www.hap.org)	or	Community	Blue	PPO	
                                                               You may cover a same sex domestic partner for medical/
(www.bcbsm.com)	to	obtain	their	current	three	tier	
prescription drug information .                                vision	and/or	dental	coverage.	For	related	information,	see	
                                                               pages 5-6 . Your pre-tax deduction is based on the level
Employees and their dependents enrolled in a System            of	coverage	you	select	(i.e.,	employee	plus	one	or	family	
medical	plan,	may	receive	up	to	$15	off	each	prescription	     coverage).	The	premiums	for	this	coverage	are	a	taxable	
filled at an HFHS System outpatient pharmacy .                 benefit	to	you.	Each	pay,	additional	income	will	be	added	
Review	the	medical	comparison	chart	on	page	11	for	more	
                                                               to	your	paycheck	and	taxes	will	be	applied.	A	full-or	
information .
                                                               part-time	benefits	eligible	employee	will	have	an	addition-
                                                               al	$217	added	to	his/her	check	every	pay	for	medical	and	
                                                               $4.80	per	pay	for	dental	regardless	of	the	options	selected.
  FrEE	PrESCrIPTION	HOME	DElIVErY
  Have your medications shipped right to your door .
  Henry	Ford	Pharmacy	offers	free	home	delivery	of	
  your	medications,	whether	you	need	a	simple	refill	or	
  even	a	new	prescription.	To	find	out	how,	call	
  1-800-456-2112	or	ask	a	Henry	Ford	pharmacist.		
  Or	go	to	henryford.com>pharmacies	and	click	on	the	
  home	delivery	link	on	the	right.	Fill	out	the	enrollment	
  form and fax it to 248-358-9335 .




                                                                                                                             17
H e n ry F o r d H e a lt H S y S t e m                                                                                                                  Flex Benefits


Dental Benefits
___________________________________________________
Henry Ford Health System offers you and your eligible                                             two	networks	from	which	to	choose	a	Delta	Dental	partici-
dependents	the	opportunity	to	seek	quality	dental	care	on	                                        pating	provider.	The	following	chart	indicates	the	services	
a	regular,	preventive	basis.	Changes	to	your	dental	option	                                       covered	by	Delta	Dental	Plan	of	Michigan.	It	shows	your	
may be made every year . Employees enrolled in the Delta                                          copayment,	if	any,	for	the	services	listed:
PPO	/	Premier	Basic	or	Comprehensive	options	now	have	




                                                                      Dental Plan Comparison Chart
Service                                                                                                 Delta PPO/Premier         DeltaCare*              Delta PPO/Premier
                                                                                                        Basic                                             Comprehensive
                                                                                         Class I
Diagnostic and Preventive Service – Used to diagnose and/or prevent dental abnormatlities or          You pay 20%                 You pay 0%              You pay 0%
disease (includes exams, cleanings and fluoride treatments).

Emergency Palliative Treatment – Used to temporarily relieve pain.                                    You pay 20%                 You pay 0%              You pay 0%

Radiographs – X-rays.                                                                                 You pay 20%                 You pay 0%              You pay 0%
                                                                                         Class II
Oral Surgery Services – Extractions and dental surgery, including preoperative and                    You pay 50%                 Fixed Co-pay            You pay 15%
postoperative care.                                                                                                               Schedule

Relines and Repairs – Relines and repairs to bridges and dentures.                                    You pay 50%                 Fixed Co-pay            You pay 15%
                                                                                                                                  Schedule

Minor Restorative Services – Used to repair teeth damaged by disease or injury                        You pay 50%                 Fixed Co-pay            You pay 15%
(for example, amalgam [silver] and resin [white] fillings).                                                                       Schedule

Major Restorative Services – Used when teeth can’t be restored with another filling material          You pay 50%                 Fixed Co-pay            You pay 15%
(for example, crowns).                                                                                                            Schedule

Periodontic Services – Used to treat diseases of the gums and supporting structures of the teeth. You pay 50%                     Fixed Co-pay            You pay 15%
                                                                                                                                  Schedule

Endodontic Services – Used to treat teeth with diseased or damaged nerves                             You pay 50%                 Fixed Co-pay            You pay 15%
(for example, root canals).                                                                                                       Schedule
                                                                                         Class III
Prosthodontic Services – Used to replace missing natural teeth                                        You pay 50%                 Fixed Co-pay            You pay 40%
(for example, bridges and dentures).                                                                                              Schedule
                                                                                         Class IV
Orthodontic Services (to age 19) – Used to correct malposed teeth and/or facial bones                 No coverage                 You pay $2000           You pay 40%
(for example, braces).

Maximum Payment – Per person per contract year.                                                       $750                        No limit                $1,500

Ortho Lifetime Maximum                                                                                No coverage                 $1,500                  $1,500

Deductible                                                                                            None                        None                    None

* If you select DeltaCare, your dentist must be part of the Delta Care Network and accepting new patients. To find out if your dentist participates in Delta Care before you enroll, go to
www.ddpmi.com or call 1-800-870-9988.




                                                                                                                                                                                             18
H e n ry F o r d H e a lt H S y S t e m                                                                                                Flex Benefits



                                                         Dental Plan Questions and Answers
                                       Delta PPO USA                                                                              DeltCare

 What is Delta PPO Premier USA        Delta Dental PPO is Delta Dental’s preferred provider orga-       DeltaCare is a dental HMO-type program.
 and DeltaCare?                       nization plan that offers you and your family quality dental
                                      benefits at great savings. Plus, you now have access to two of
                                      the nation’s largest networks of participating dentists –Delta
                                      Dental PPO and Delta Dental Premier networks.

 How do I find a participating        To find out whether your dentist participates in DeltaPPO USA     To find out whether a particular dentist participates in
 dentist?                             or Delta Premier USA, you can call his or her office, check our   DeltaCare, you can call our DeltaCare department at (800)
                                      Web site at www.deltadental.com or call our Customer and          870-9988. You can also check our Web sites at www.ddpmi.
                                      Claims Services department at (800) 524-0149.                     com (for Michigan dentists) or www.ddpoh.com (for Ohio
                                                                                                        dentists).
 Do I have to go to a participating   No. You can go to any licensed dentist anywhere, regardless       Yes. You and your family must choose the same primary
 dentist?                             of whether he or she participates in Delta PPO or Delta           care dentist for a full benefit year from our DeltaCare dentist
                                      Premier USA. However, your out-of-pocket costs may be             directory. This would include eligible dependents residing in
                                      higher if you go to a nonparticipating dentist.                   or attending schools outside the state of Michigan.
 Can I change dentists whenever       Yes. You can change dentists at any time.                         No. We encourage you to stay with the same primary care
 I’d like?                                                                                              dentist for a full year. However, you can change dentists
                                                                                                        with written request if you demonstrate a sufficient reason
                                                                                                        for change, such as a move, or if the change will not nega-
                                                                                                        tively affect the operation of DeltaCare. (You cannot change
                                                                                                        dentists if you are in the middle of treatment.)

 Can each member of my family         Yes. Each member of your family may see a different dentist.      No. You and your family members must see the same
 choose a different dentist?                                                                            primary care dentist. This would include eligible depen-
                                                                                                        dents residing in or attending schools outside the state of
                                                                                                        Michigan.

 Am I covered if I go to a nonpar-    Yes. However, when you seek care from a nonparticipating          No. If you go to another dentist without written referral from
 ticipating dentist?                  dentist, you are responsible for all fees charged. We will        your primary care dentist, you will be responsible for all
                                      reimburse you up to our nonparticipating dentist fee, which is    charges for the services rendered.
                                      generally lower than our fee for participating dentists.

 Am I covered for Emergency           Yes.                                                              Yes. Your primary care dentist is responsible for providing
 Services?                                                                                              emergency treatment for a covered procedure. However,
                                                                                                        if you have a dental emergency when you are more than
                                                                                                        50 miles away from your DeltaCare primary dentist’s office,
                                                                                                        DeltaCare will reimburse you for the cost of such emer-
                                                                                                        gency dental care which exceeds your co-payment up to a
                                                                                                        $50 maximum per occurence. Any further treatment of the
                                                                                                        cause of emergency dental care must be preauthorized from
                                                                                                        DeltaCare or provided by the assigned primary Dentist.

 Will I receive dental cards?         No. Your dentist can verify your eligibility through our Cus-     No. Your dentist can verify your eligibility through our
                                      tomer Service department or our online Dental Office Toolkit.     Customer Service department .

 Who do I call if I have questions?   If you have questions, please call our Customer and Claims        If you have questions, please call our DeltaCare department
                                      Services department at (800) 524-0149.                            at (800) 870-9988.




                                                                                                                                                                          19
H e n ry F o r d H e a lt H S y S t e m                                                                                                                                     Flex Benefits



Delta Dental PPO / Delta Premier
___________________________________________________
DElTA	DENTAl	PPO	/	DElTA	PrEMIEr	                                                                                                      NONPArTICIPATING	DENTIST:
PArTICIPATING	DENTIST:                                                                                                                 If	you	choose	Delta	Premier	and	you	go	to	a	
If	you	choose	Delta	Dental	PPO	or	Delta	Premier	and	you	                                                                               nonparticipating	dentist,	you’ll	still	be	covered.	
go	to	a	Delta	Dental	PPO	/	Premier	participating	dentist,	                                                                             However,	you	may	have	to	pay	more.	That’s	because	Delta	
Delta	Dental	will	pay	that	dentist	the	fee	he	or	she	                                                                                  Dental’s payment is based on the fee charged or the
submitted	to	Delta	Dental	or	our	customary	fee,	whichever	                                                                             nonparticipating	dentist’s	fee,	whichever	is	less.	We’ll	send	
is	less.	And	if	our	payment	is	lower	than	the	dentist’s	                                                                               our payment directly to you and you’ll be responsible for
submitted	fee,	the	dentist	can’t	charge	you	the	difference.	                                                                           paying	the	dentist	whatever	he	or	she	charges.	And	
That means you’re responsible only for your copayment                                                                                  because nonparticipating dentists don’t have to adhere to
and	the	deductible	for	covered	services.	If,	for	example,	                                                                             our	requirements,	you	might	have	to	pay	the	dentist	at	the	
a	Delta	PPO	/	Premier	participating	dentist	charges	$100	                                                                              time	of	your	appointment	and	file	your	own	claim	form	for	
for	a	service	covered	at	100	percent,	and	if	Delta	Dental’s	                                                                           reimbursement . That means if a nonparticipating dentist
customary	fee	for	that	service	is	$90,	Delta	Dental	will	pay	                                                                          charges	$100	for	a	service	covered	at	100	percent,	and	if	
the	dentist	$90	and	you’ll	owe	nothing.	The	dentist	can’t	                                                                             Delta Dental’s nonparticipating dentist’s fee for that service
charge	the	$10	difference	to	you.	                                                                                                     is	$80,	Delta	Dental	will	pay	you	$80.	You’ll	owe	another	
_______________________________________________                                                                                        $20	and	be	responsible	for	paying	the	dentist	the	full	fee.		
Fee charged:  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $100	               _______________________________________________
Delta Dental customary fee:  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $90	                                     Fee	charged:	$100	
You pay:  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $0	   Delta	Dental	nonparticipating	dentist’s	fee:	$80
                                                                                                                                       You	pay:	$20
                                                                                                                                       _______________________________________________
Delta	PPO	/	DeltaPremier	participating	dentists	accept	
Delta	Dental’s	customary	fee.	The	$10	difference	cannot	be	
                                                                                                                                       For	nonparticipating	dentists,	Delta	Dental	pays	based	
charged to you .
_______________________________________________                                                                                        on	the	fee	charged	or	the	nonparticipating	dentist’s	fee,	
                                                                                                                                       whichever	is	less.	You’re	responsible	for	the	difference.	
Let’s	look	at	another	example,	using	a	service	covered	at	                                                                             Because	we	send	payment	to	you,	you	must	make	full	
50	percent.	If	a	Delta	PPO	/	Premier	dentist	charges	$100	                                                                             payment	to	the	dentist.	In	this	case,	you	would	pay	$100	
for	a	service	covered	at	50	percent,	and	Delta	Dental’s	                                                                               and	be	reimbursed	$80	by	Delta	Dental.	Here’s	another	
customary	fee	for	that	service	is	$90,	Delta	Dental	will	                                                                              example,	using	a	service	covered	at	50	percent.	
pay	the	dentist	$45.	You’ll	owe	another	$45,	since	the	                                                                                If	a	nonparticipating	dentist	charges	$100	for	a	
coverage level is 50 percent . But the dentist still can’t                                                                             service	covered	at	50	percent,	and	if	Delta	Dental’s	
charge	you	the	$10	difference.		                                                                                                       nonparticipating	dentist’s	fee	for	that	service	is	$80,	
_______________________________________________                                                                                        Delta	Dental	will	pay	you	$40,	or	half	of	Delta	Dental’s	
Fee charged:  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $100                   nonparticipating	dentist’s	fee.	You’ll	owe	another	$60	and	
Delta Dental customary fee:  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $90                                         be responsible for paying the dentist the full fee .
Delta Dental pays 50 percent:  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $45                                          _______________________________________________
You pay:  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $45         Fee	charged:	$100
                                                                                                                                       Delta	Dental	nonparticipating	dentist’s	fee:	$80
Delta Dental pays 50 percent of the customary fee and you                                                                              You	pay:	$60	
                                                                                                                                       _______________________________________________
pay	50	percent.	Again,	the	$10	difference	can’t	be	charged	
to you .
_______________________________________________                                                                                        Delta Dental pays 50 percent of the non participating
                                                                                                                                       dentist’s	fee,	or	$40.	You	are	responsible	for	the	difference	
                                                                                                                                       between	Delta	Dental’s	payment	and	the	fee	charged.


                                                                                                                                                                                                   20
H e n ry F o r d H e a lt H S y S t e m                                                                                                                     Flex Benefits



Income Replacement and Survivor Benefits
___________________________________________________
Protecting	our	family’s	income	in	the	event	of	a	serious	                                          COVErAGE	AFTEr	AGE	65
injury or death is a concern that many of us have .                                                If	you	continue	to	work	after	age	65,	the	amount	of	your	
Financial security can be achieved through personal                                                life	insurance	will	reduce	on	January	1	following	your	65th	
financial	planning,	including	employer-sponsored	                                                  birthday	as	follows:	
voluntary life and disability insurance .
                                                                                                   •	Age	65-69	  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 65%	of	elected	option
EMPlOYEE	lIFE	INSurANCE                                                                            •	Age	70-74	  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 50%	of	elected	option	
While	there	is	no	one	way	to	determine	the	amount	of	                                              •	Age	75+	  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 20%	of	elected	option
life	insurance	you	should	purchase,	careful	consideration	
should	be	given	to	all	of	your	financial	obligations,	                                             Dependent	Life	Insurance	coverage	does	not	reduce	if	you	
including	mortgage	payments,	children’s	schooling	and	                                             continue	working	past	age	65.
lifestyle maintenance for your family . Flex Benefits
provides	you	with	an	array	of	life	insurance	options.	You	                                         IMPuTED	INCOME	
may	choose	either	more	or	less	coverage,	in	the	increments	                                        When	you	purchase	insurance	in	excess	of	$50,000,	you	
shown	below,	based	on	your	projected	needs.	Coverage	can	                                          are subject to the IRS’ Imputed Income rules . Imputed
be	purchased	with	pretax	dollars.	The	maximum	protection	                                          Income is the value of your life insurance more than
you	can	receive	from	this	benefit	is	$1,000,000.                                                   $50,000.You	are	required	to	pay	federal	and	state	
                                                                                                   income	taxes	as	well	as	Social	Security	tax	on	this	“excess”	
Coverage	                                                           Maximum	benefit                amount . The amount of tax you pay is based on your age .
•	1	x	Your	Base	Pay  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$250,000   The	value	of	the	life	insurance	in	excess	of	$50,000	will	be	
•	2	x	Your	Base	Pay  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$500,000   reported on your W-2 .
•	3	x	Your	Base	Pay	  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$750,000
•	4	x	Your	Base	Pay  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $1,000,000      TErMINAl	IllNESS	bENEFIT	
•	$10,000*                                                                                         Enrollees	who	are	diagnosed	with	a	terminal	illness	(life	
•	$25,000*                                                                                         expectancy	of	12	months	or	less)	may	apply	to	have	up	to	
•	$50,000*                                                                                         50	percent	of	their	Employee	Life	Insurance	paid	out	to	
                                                                                                   them in advance . Information is available from
•	Opt	out*
                                                                                                   Employee Services .
*Options	available	to	part	time	employees.	
                                                                                                   DEPENDENT	lIFE	INSurANCE	
Note:	If	you	move	up	more	than	one	coverage	level,	you	                                            Flex	Benefits	also	provides	Dependent	Life	Insurance	
must	furnish	evidence	of	insurability	(EOI).	                                                      options	on	an	after-tax	basis.	Because	of	IRS	regulations,	
                                                                                                   no pretax dollars or flex credits may be used for this
If	you	are	a	Senior	Professional	Staff	member	with	three	                                          coverage.	Your	Dependent	Life	Insurance	options	are:
or	more	years	of	service	with	the	Medical	Group	by	July	
1,	1997,	you	are	enrolled	in	a	permanent	life	insurance	                                              $50,000	spouse;	$10,000	each	child
plan	in	an	amount	equal	to	two	times	your	salary	to	a	                                             			$25,000	spouse;	$5,000	each	child	
maximum	of	$400,000.	Because	of	IRS	regulations	regard-
ing	permanent	life	insurance	plans,	your	permanent	life	                                           			$10,000	spouse;	$5,000	each	child	
insurance coverage cannot be part of the Flex Benefits                                             			$5,000	spouse;	$2,000	each	child*	
Program.	In	addition	to	the	permanent	life	plan,	you	must	                                         			$2,000	spouse;	$1,000	each	child*
elect	additional	term	life	coverage	of	$10,000,	$25,000	
or	$50,000	through	Flex	Benefits.	If	you	continue	to	work	                                         *Options	available	to	part	time	employees.
after	age	64,	your	permanent	life	insurance	stops.	You	will	
be	notified	by	the	insurance	company	and	will	be	provided	                                         If	you	choose	to	enroll,	you	must	designate	who	will	
options to continue this coverage .                                                                be	covered	by	the	Dependent	Life	Insurance.	You	may	
                                                                                                   choose	spouse-only	coverage,	child(ren)-only	coverage	or	
                                                                                                   spouse and children coverage . For dependent eligibility
                                                                                                   requirements,	see	pages	5-6	of	this	workbook.	


                                                                                                                                                                                              21
H e n ry F o r d H e a lt H S y S t e m                                                                   Flex Benefits


Employees	who	have	a	same	sex	domestic	partner	may	             COVErAGE	AT	AGE	75	AND	OlDEr
enroll their partner in dependent term life insurance           When	you	or	your	spouse	reach	age	75,	the	coverage	
by	selecting	the	coverage	level	for	spouse.	(You	are	the	       amount	is	reduced	on	the	January	1	following	the	75th	
beneficiary	for	your	spouse	or	dependent’s	life	insurance.)	    birthday	as	follows	:
Note:	If	you	move	up	more	than	one	coverage	level	or	           •	Age	75-79  .  .  .  . 57.5%	of	the	elected	coverage	amounts	
if	you	are	electing	dependent	coverage	when	you	have	           •	Age	80-84  .  .  .  . 37.5%	of	the	elected	coverage	amounts	
previously	waived	coverage,	you	must	furnish	evidence	of	       •	Age	85+  .  .  .  .  .  .  .  .20%	of	the	elected	coverage	amounts	
insurability	(EOI)	for	your	spouse;	children	do	not	
require	EOI.                                                    This reduction also applies to any dependents you have
                                                                chosen to cover .


Accidental Death and                                            lONG-TErM	DISAbIlITY	(lTD)
                                                                If	you	are	a	Senior	Staff	Professional	Staff	member	with	
Dismemberment
________________________
                                                                six	or	more	months	of	service	with	the	Henry	Ford	Medical	
                                                                Group	who	works	64	to	80	hours	per	pay,	you	have	a	
                                                                comprehensive	long-term	disability	plan,	which	is	
Coverage level and maximum benefits .                           provided	by	the	Medical	Group.	This	plan	was	designed	
                                                                and	structured	for	Senior	Professional	Staff	and	is	not	
 5	x	base	annual	salary	for	employee	($1,250,000)               compatible	with	the	Long-Term	Disability	Plan	provided	to	
 2.5	x	employee’s	base	annual	salary	for	spouse	($625,000)      other	employees.	Consequently,	you	may	not	elect	more	
 0.5	x	employee’s	base	annual	salary	for	each	child	($50,000)   or less coverage for long-term disability benefits under
 4	x	base	annual	salary	for	employee	($1,00,000)                the	Flex	Benefits	Plan.	Part	time	Senior	Staff	(20	hours	per	
 2	x	employee’s	base	annual	salary	for	spouse	($500,000)        week)	are	eligible	to	elect	the	50	percent	option	with	a	
 0.5	x	employee’s	base	annual	salary	for	each	child	($50,000)   maximum	monthly	benefit	of	$10,700.
 3	x	base	annual	salary	for	employee	($750,000)
 1.5	x	employee’s	base	annual	salary	for	spouse	($375,000)        50%	of	base	annual	salary:
 0.5	x	employee’s	base	annual	salary	for	each	child	($50,000)   		maximum	monthly	benefit	of	$10,700*
 $100,000	employee                                              		60%	of	base	annual	salary:	
 $50,000	spouse                                                 		maximum	monthly	benefit	of	$12,850
 $10,000	each	child
 $50,000	employee*                                              		70%	of	base	annual	salary:
 $25,000	spouse                                                 		maximum	monthly	benefit	of	$15,000
 $5,000	each	child
 $20,000	employee*                                              *Option	available	to	part	time	employees.
 $10,000	spouse
 $5,000	each	child
 *Options	available	to	part	time	employees.
                                                                Health Care Flexible
                                                                Spending Account (FSA)
                                                                ________________________
AD&D	insurance	provides	protection	against	financial	
hardship	when	you	or	a	covered	dependent	suffer	an	
accidental	death,	loss	of	limb,	paralysis	or	loss	of	sight.	    The	Health	Care	FSA	is	designed	to	cover	specific	
Your	Flex	Benefits	AD&D	coverage	options	are	indicated	in	      out-of-pocket	expenses	you	may	anticipate	during	the	
the above chart .                                               course	of	the	plan	year.	The	Health	Care	FSA	allows	you	to	
                                                                use pretax dollars to pay for health expenses not covered
If	you	choose	to	enroll	in	AD&D	coverage,	you	must	             by insurance . Expenses payable through the Health Care
designate	who	will	be	covered.	You	may	choose	either	           FSA	may	include	charges	for	contact	lenses,	eyeglasses,	
employee-only coverage or employee and dependents               dental	expenses,	plus	deductibles	and	copayments.	In	fact,	
coverage.	For	dependent	eligibility	requirements,	see	pages	    any	medical,	dental,	hearing	or	vision	expenses	that	would	
5-6	of	this	workbook.	Employees	who	have	a	same	sex	            otherwise	qualify	as	a	deduction	on	your	income	tax	
domestic	partner	may	enroll	their	partner	in	Accidental	        return	will	qualify	for	reimbursement,	as	long	as	the	
Death and Dismemberment Insurance by selecting the              expense is not paid by another benefit plan . You	must	
coverage level for family .                                     re-enroll	each	year.

                                                                                                                                    22
H e n ry F o r d H e a lt H S y S t e m                                                             Flex Benefits


Effective	January	1,	2011,	only	those	over-the-counter	       2.	 Equal	deposits	will	be	made	over	26	pay	periods,	
medications	or	drugs	purchased	with	a	prescription	may	           starting	with	the	first	pay	period	in	January.
be reimbursable . See page 25 for a list of eligible and
ineligible expenses .                                         3.	 If	you	enroll	in	the	Health	Care	FSA	mid-year,	your	
                                                                  annual	amount	will	be	divided	by	the	number	of	pay	
PlAN	YEAr                                                         periods remaining in the year .
After	the	date	you	are	no	longer	enrolled	in	the	plan,	or	
the	end	of	the	plan	year,	whichever	comes	first,	you	will	
                                                              4 . You may only submit expenses incurred on or after
have 90 days to submit eligible expenses .
                                                                  your participation date .
Note:	Claims	received	beyond	90	days	after	your	
termination	date	or	the	date	you	are	no	longer	enrolled,	     HOW	TO	rECEIVE	rEIMburSEMENT
will	be	denied.	The	plan	year	ends	December	31.	If	you	       1.		 Once	you	pay	an	expense	for	health	care	services,	you	
have	not	terminated	employment,	you	have	through	April	            may request reimbursement .
30 to submit eligible expenses .                              2 . Submit a completed Request for Reimbursement Form
                                                                   and original receipts to the plan administrator .
You	may	deposit,	pretax,	from	$30	to	$3,000	annually	to	      3.		 Reimbursement	checks	are	generally	processed	every	
your	account.	Deposits	to	your	account	will	be	made	each	          week	but	are	guaranteed	within	two	pay	periods.	
pay period throughout the plan year .                         4.		 Each	participant	is	responsible	for	keeping	records	to	
                                                                   support these expenses .
TAX	ADVANTAGES
The	following	table	shows	the	approximate	dollar	amount	      HEAlTH	CArE	FSA	CArD
you	may	save	by	using	the	Health	Care	FSA,	depending	on	      Senior	staff	who	enroll	in	the	Health	Care	FSA	
your	combined	tax	bracket.		                                  automatically	receive	an	FSA	Card.	You	can	use	your	
                                                              Health	Care	FSA	Card	at	most	medical	providers	(including	
     Account       Tax Savings by Combined Tax Bracket*
     Deposit                                                  doctors’	offices,	pharmacies,	dental	providers,	vision	care	
                     27%           37%          40%
                                                              providers	and	hospitals)	that	accept	the	card.	It	is	linked	to	
       $100	          $27	          $37	          $40         your	Health	Care	FSA	account	balance.	When	you	incur	an	
 	     $200	          $54	          $74	            $80       eligible	health	care	expense,	you	simply	swipe	your	Health	
 	     $500	         $135	         $185	           $200       Care	FSA	Card	at	the	point	of	purchase	and	go.	
 	 $1,000	           $270	         $370	           $400
                                                              Additional	detailed	information	will	be	mailed	home	to	
*Combined	Tax	Bracket	Information	(rounded):                  senior	staff	who	enroll	in	the	Health	Care	FSA.

•	   27	percent	combined	tax	bracket	(15	percent	federal,     ESTIMATING	HEAlTH	CArE	EXPENSES
	    4.35	percent	state	and	7.65	percent	FICA	[rounded])      To	estimate	how	much	money	the	Health	Care	FSA	may	
•	   37	percent	combined	tax	bracket	(25	percent	federal,     help	you	save,	make	a	list	of	medical,	dental,	vision	or	
	    4.35	percent	state	and	7.65	percent	FICA	[rounded])	     hearing expenses not covered by any insurance program
•	   40	percent	combined	tax	bracket	(28	percent	federal,     that	you	expect	to	incur	during	the	plan	year	(January	1,	
	    4.35	percent	state	and	7.65	percent	FICA	[rounded])      2011	through	December	31,	2011).	The	reimbursable	
                                                              expense	listing	on	the	following	pages	may	help	you	to	
HOW	TO	ENrOll                                                 determine	which	expenses	to	include.	Estimate	the	dollar	
Enrolling	in	the	Health	Care	FSA	is	a	simple	procedure	and	   value of these expenses and multiply the total by your
consists	of	the	following	steps:                              combined	tax	rate	for	federal,	state	and	Social	Security	
                                                              taxes to estimate your savings .
1.	 Select	the	option	to	participate.	Decide	how	much	
    you	want	to	deposit	in	your	account	from	January	1	
    through	December	31,	2011.	Enter	this	annual	amount	
    in the space provided . Remember you may elect to                                            (continued on next page)
    deposit	between	$30	per	year	and	$3,000	per	year	into	
    the	Health	Care	FSA.

                                                                                                                           23
H e n ry F o r d H e a lt H S y S t e m                                                                                                                   Flex Benefits


The	following	examples	illustrate	possible	savings	incurred	                                                            enroll again . You may change your payroll
by	participating	in	the	Health	Care	FSA.	                                                                               deduction	amount	for	your	Health	Care	FSA	during	the	
                                                                                                                        plan	year,	only	if	you	have	a	change	in	status.	
Example	One:	(Single	Participant)                                                                                       IRS-approved changes include a change in marital
Pat	Smart	is	single,	earning	$27,000	and	has	approximately	                                                             status,	death	of	spouse	or	child,	birth	or	adoption	of	a	
a	27	percent	tax	rate	(15	percent	federal,	4.35	percent	                                                                child and termination of employee’s or spouse’s
state,	and	7.65	percent	FICA	[rounded]).	She	has	the	                                                                   employment.	It	will	be	your	obligation	to	notify	
following	expenses:                                                                                                     Employee Services or your local Human Resources
                                                                                                                        immediately if there is a change in status .
Eligible	Expenses	                                                                                  Amount
Medical	Plan	Deductible  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $150                  •	 Any	balance	in	the	Health	Care	FSA	that	is	not	used	
Medical	Copayment .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 200              for	eligible	expenses	within	the	plan	year	must	be	
Routine	Physical  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 60      forfeited.	You	will	have	90	days	after	the	end	of	the	
Eyeglass/Contact	Lens	Expense  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 100                               plan year or the date you are no longer enrolled in the
Dental Expenses  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 187      plan	(whichever	comes	first),	to	submit	eligible	expenses	
                                                                                              _________
                                                                                                                         for	reimbursement.	For	2011,	expenses	incurred	
Total	Out-Of-Pocket	Expenses	. . . . . . . . . . . . . . $697
                                                                                                                         between	January	1,	2011	and	March	15,	2012	are	
                                                                                                                         eligible	for	reimbursement;	however	you	have	until	
By	paying	for	expenses	through	the	Health	Care	FSA,	Pat	
                                                                                                                         April	30,	2012	to	submit	for	reimbursement.	
Smart	could	save	approximately	$188	per	year	
($697	x	27	percent).
                                                                                                                      •	 Please	note	that	some	of	the	“Change	Events”	described	
                                                                                                                         on	the	chart	at	the	back	of	this	workbook	are	not	
Example	Two:	(Married	Participant)
                                                                                                                         available	for	Health	Care	FSA.	
Mr.	and	Mrs.	Smith,	a	working	couple	with	a	combined	
income	of	$124,000,	pay	approximately	40	percent	in	
taxes	(28	percent	federal,	4.35	percent	state,	and	7.65	
percent	FICA	[rounded]).	They	have	the	following	expenses:                                                             Health	Care	FSA	rule	Change
                                                                                                                       The	plan	year	for	the	Health	Care	FSA	is	January	1,	2011	
Eligible	Expenses	                                                                                  Amount             through	December	31,	2011.	A	grace	period	has	been	
Medical	Plan	Deductible  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $300                   established	after	the	end	of	the	plan	year,	which	
Medical	Copayment .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 300            allows	you	to	continue	to	incur	expenses	into	2012	and	
Routine	Physical  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 120      submit them for reimbursement from your 2011 Health
Eyeglass/Contact	Lens	Expense  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 70                           Care	FSA	account	balance.	You	may	continue	to	incur	
Dental Expenses  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 135    expenses	from	January	1,	2012	through	March	15,	2012.	
                                                                                              _________                The deadline for submitting health care expenses for
Total	Out-Of-Pocket	Expenses	. . . . . . . . . . . . . . $925                                                          reimbursement	is	April	30,	2012.	

By	paying	for	expenses	through	the	Health	Care	FSA,	Mr.	
and	Mrs.	Smith	could	save	approximately	$370	per	year	                                                                  You	are	required	to	keep	copies	of	your	Health	Care	
($925	x	40	percent).                                                                                                    FSA	receipts	in	the	event	you	are	audited	by	the	IRS.

PlANNING	CArEFullY
The	following	IRS	regulations	apply	to	Health	Care	FSAs:

•	 Once	you	decide	to	participate	in	the	Health	Care	FSA,	
   your decision must remain in effect until the end of the
   plan	year.	Each	year	you	will	have	an	opportunity	to	



                                                                                                                                                                                 24
H e n ry F o r d H e a lt H S y S t e m                                                                                  Flex Benefits



Health Care Reimbursement Expenses
___________________________________________________
The	general	rule	is	that	allowable	expenses	are	those	                        GENErAl	ElIGIblE	rEIMburSAblE	EXPENSES
medical,	dental	and	vision	expenses	eligible	under	Treasury	                  •	 Medical	plan	copayment	and	deductible
Regulation 213 and not compensated by insurance plans .
                                                                              •	 Dental	plan	copayment	and	deductible
The	following	items	are	examples	of	eligible	expenses	and	
are in addition to the deductible and co-pay amounts                          •	 Vision	plan	copayment	and	deductible
from	the	medical	and	dental	plans.	ALL	MEDICAL,	DENTAL	                       •	 Prescription	co-pays
and	VISION	CLAIMS	(including	all	prescriptions)	must	be	                      •	 Laboratory	and	X-ray	co-pays	and	deductible
incurred during the plan year and processed by your
insurance	carriers	(primary	and	secondary)	FIRST,	
before	submitting	them	to	your	Health	Care	FSA	
for reimbursement .

                                    Examples	of	Sample	Eligible	reimbursable	Expenses
 •	   Acupuncture	(with	medical	diagnosis)          •	   Hospital	Services	(excluding	phone	&	TV)      •	 Prescription:	Eyeglasses,	Sunglasses	and	
 •	   Alcoholism	Treatment                          •	   Immunizations                                    Reading	Glasses	(excluding	sunglass	
 •	   Ambulance	Service	                            •	   Injections                                       clips)
 •	   Artificial	Limbs                              •	   Insulin                                       •	 Psychiatric	Fees
 •	   Aspirin	                                      •	   In	Vitro	Fertilization                        •	 Psychologist	Fees
 •	   Birth	Control	Pills                           •	   Lab	Fees                                      •	 Psychotherapy	(by	an	approved	provider)
 •	   Braille	Books	and	Magazines                   •	   Lamaze	Classes	(mother’s	cost	only)           •	 Radial	Keratotomy,	PRK
 •	   Car	Controls	for	the	Handicapped              •	   Lasik	Surgery	                                •	 Services	for	Diagnosed	Severe	Learning	
 •	   Chiropractic	Care                             •	   Legal	Abortion	                                  Disabilities
 •	   Condoms                                       •	   Long-Term	Storage	of	Sperm	or	Embryo          •	 Smoking	Cessation	Drugs	&	Programs	
 •	   Contact	Lenses	and	Solutions                  •	   Medical	Nursing	Home	Services                    (prescribed	by	doctor	and	dispensed	by	a	
 •	   Crutches                                      •	   Midwife                                          pharmacist)
 •	   Dental	Fees	(excludes	bleaching	or	           •	   Mileage	to	and	from	Medical	Services          •	 Special	Schools	for	the	Disabled
      whitening)                                    •	   Nursing	Services                              •	 Sterilization
 •	   Dental	Implants                               •	   Optometrist	Fees                              •	 Substance	Abuse	Treatment
 •	   Dermatologist	Fees                            •	   Ophthalmologist	Fees                          •	 Surgery	(medically	necessary)
 •	   Diagnostic	Tests                              •	   Organ	Transplants                             •	 Telephone	for	the	Deaf
 •	   Doctor	Fees                                   •	   Orthodontia	Treatment                         •	 Therapy	for	Mental/Nervous	Disorders
 •	   Durable	Medical	Equipment	(with	              •	   Orthotics                                     •	 Transportation	for	Medical	Care
      prescription and letter of medical            •	   Osteopath	Fees                                •	 Vaccinations
      necessity)                                    •	   Oxygen                                        •	 Vitamins	(requiring	a	prescription)
 •	   Equipment	for	the	Disabled                    •	   Periodontal	Fees                              •	 Weight-Loss	Programs	(must	be	
 •	   Flu	Shots                                     •	   Physical	Exams                                   prescribed by a physician to treat a
 •	   Hearing	Aids	and	Batteries                    •	   Physical	Therapy                                 specific	medical	condition)
 •	   Hearing	Exams                                 •	   Prenatal	Care                                 •	 Wheelchairs
 •	   Hearing	Treatment                             •	   Prescription	Drugs	(dispensed	by	a	           •	 X-ray	Fees
                                                    	    pharmacist)


                                Examples	of	Sample	Non-Eligible	reimbursable	Expenses
 •	   Baldness	Treatments                           •	   Doula	Expenses                                •	 Insurance	Premiums
 •	   Breast	Pump	Rental	or	Purchase                •	   Electrolysis                                  •	 Marijuana	or	other	controlled	substances	
 •	   COBRA	Premiums                                •	   Electronic	Toothbrushes                          (even	for	medical	purposes)
 •	   Cosmetic	Surgery,	Procedures,	Services	and	   •	   Exercise	Equipment                            •	 Maternity	Clothes
      Products	(non-medically	necessary)            •	   Expenses	for	a	Vacation	(even	if	             •	 Pregnancy	Test	(over	the	counter)
 •	   Childcare	Classes	(in	any	other	form	than	         recommended	by	a	doctor)                      •	 Special	Diet	Foods	and	Supplements
      Lamaze)                                       •	   Family/Marriage	Counseling                    •	 Swimming	Lessons
 •	   Dancing	Lessons                               •	   Funeral	Services                              •	 Teeth	Bleaching	or	Whitening
 •	   Dental	Veneers	or	Bonding	(non-medically	     •	   Hair	Transplants                              •	 Temporomandibular	Joint	Disorder	(TMJ)
      necessary)                                    •	   Health	Club	Dues	and	Memberships              •	 Varicose	Vein	Treatment
 •	   Diaper	Service                                •	   Herbal	&	Holistic	Drugs	or	Remedies

  This	list	summarizes	regulations	that	are	frequently	amended	or	updated	by	the	IRS	and	should	be	used	as	a	guide.	Actual	expense	eligibility	
  will	be	determined	at	the	time	of	utilization	and	submission.	This	list	may	be	amended	or	changed	during	the	plan	year	without	notice.


                                                                                                                                                  25
H e n ry F o r d H e a lt H S y S t e m                                                              Flex Benefits



Day Care FSA
___________________________________________________
The	Day	Care	FSA	allows	you	to	use	pretax	                       PlAN	YEAr
dollars to pay for day care expenses for a child or other        After	the	date	you	are	no	longer	enrolled	in	the	plan,	or	
dependent.	By	planning	for	such	expenses,	you	can	reduce	        the	end	of	the	plan	year,	whichever	comes	first,	you	will	
your tax bill . You	must	re-enroll	each	year .                   have 30 days after the end of your plan year to submit
                                                                 eligible expenses .
This	account	will	reimburse	you	for	day	care	expenses	to	
enable	you	and	your	spouse	to	work	outside	the	home.	            Note:	Claims	received	beyond	30	days	after	your	
This	includes	the	cost	of	a	childcare	center,	a	babysitter	      termination date or the date you are no longer enrolled
or other caregiver for a disabled dependent spouse or            will	be	denied.	The	plan	year	ends	December	31.	If	you	
parent.	Eligible	caregivers	may	include	relatives.	However,	     have	not	terminated	employment,	you	have	through	
you	cannot	pay	a	dependent	(a	teenage	daughter,	for	             January 31 to submit eligible expenses .
example)	to	take	care	of	another	dependent.	
                                                                 HOW	THE	DAY	CArE	FlEXIblE	SPENDING	
Under	current	IRS	regulations,	day	care	expenses	will	           ACCOuNT	WOrKS
qualify for reimbursement under the plan if they meet the        The	Day	Care	FSA	operates	much	like	a	bank	
following	requirements:                                          account.	You	may	deposit	to	your	account,	pretax,	as	little	
                                                                 as	$50	per	plan	year	and	up	to	$5,000	per	plan	year	per	
•	 The	services	provided	must	enable	you	and,	if	married,	       household	($2,500	for	married	couples	filing	separately).	
   your spouse to be employed .                                  Deposits	to	your	account	will	be	made	each	pay	period	
•	 If	married,	your	spouse	must	be	employed,	a	full	time	        throughout the plan year .
   student or permanently disabled .
                                                                 TAX	ADVANTAGES
•	 The	dependent	must	be	under	13	years	of	age	or	
                                                                 The	following	table	shows	the	approximate	dollar	amount	
   physically or mentally incapable of caring for himself or
                                                                 you	may	save	by	using	the	Day	Care	FSA,	depending	on	
   herself,	and	you	must	be	able	to	claim	this	dependent	
                                                                 your	combined	tax	bracket .
   on your income taxes .
•	 If	the	services	are	provided	outside	your	household,	they	        Account     Tax Savings by Combined Tax Bracket*
   must	be	provided	for	a	dependent	who	spends	at	least	             Deposit       27%           37%          40%
   eight hours each day in your household .
                                                                      $100	         $27	          $37	          $40
•	 If	the	services	are	provided	by	a	day	care	facility	that	
   cares	for	six	or	more	children	at	the	same	time,	it	must	     	    $200	          $54	           $74	            $80
   be a qualified day care center                                	    $500	         $135	         $185	            $200
•	 The	amount	to	be	reimbursed	must	not	be	greater	than	         	 $1,000	          $270	          $370	           $400
   your	income	or	that	of	your	spouse,	whichever	is	lower.	
                                                                 *Combined	Tax	Bracket	Information	(rounded):
If	you	decide	to	utilize	the	Day	Care	FSA,	you	                  •	 27	percent	combined	tax	bracket	(15	percent	federal,
cannot use the Federal Tax Credit for the same expenses .        	 4.35	percent	state	and	7.65	percent	FICA	[rounded])
                                                                 •	 37	percent	combined	tax	bracket	(25	percent	federal,
                                                                 	 4.35	percent	state	and	7.65	percent	FICA	[rounded])	
                                                                 •	 40	percent	combined	tax	bracket	(28	percent	federal,
                                                                 	 4.35	percent	state	and	7.65	percent	FICA	[rounded])

  IMPOrTANT	NOTICE	–	2011	DAY	CArE	rEIMburSEMENT	lIMITATIONS
  The	Internal	Revenue	Code	(IRC)	requires	that	a	test	be	performed	on	an	annual	basis	to	measure	the	amount	of	
  Day	Care	Reimbursement	Accounts	for	highly	compensated	employees	(those	making	$110,000	or	more	per	year),	
  versus	those	who	are	not	highly	compensated.	Based	on	the	results	of	the	test,	HFHS	is	required	to	limit	your	maximum	
  day	care	reimbursement.	You	will	be	notified	during	the	first	quarter	of	2011	if	your	contribution	is	limited.	If	so,	you	
  will	be	informed	of	the	options	available	to	you	at	that	time.


                                                                                                                              26
H e n ry F o r d H e a lt H S y S t e m                                                             Flex Benefits


HOW	TO	ENrOll                                                  expenses.	When	Pat	Smart	has	paid	the	day-care	expenses	
Enrolling	in	the	Day	Care	FSA	is	a	simple	procedure	and	       and	has	the	funds	in	the	account,	a	receipt	may	be	
consists	of	the	following	steps:                               submitted to be reimbursed for that expense .

1.	 Select	the	option	to	participate.	Decide	how	much	         By	paying	for	expenses	through	the	Day	Care	FSA,	Pat	
    you	want	to	deposit	in	your	account	from	January	1	        Smart	could	save	approximately	$972	per	year	
    through	December	31,	2011.	Enter	this	annual	amount	       ($3,600	x	27	percent).	Remember	to	reduce	the	number	
    in the space provided . Remember you may elect to          of	weeks	you	use	day	care	by	the	number	of	holidays	and	
    deposit	between	$50	per	year	and	$5,000	per	year	into	     vacation days you have allotted .
    the	Day	Care	FSA.
                                                               PlANNING	CArEFullY
2.	 Equal	deposits	will	be	made	over	26	pay	periods	           The	following	IRS	regulations	apply	to	Day	Care	FSAs:
    starting	with	the	first	pay	period	in	January.
                                                               •	 Once	you	decide	to	participate	in	the	Day	Care	FSA,	
3.	 If	you	enroll	in	the	Day	Care	FSA	mid-year,	your	annual	      your decision must remain in effect until the end of the
    amount	will	be	divided	by	the	number	of	pay	periods	          plan	year.	Each	year	you	will	have	an	opportunity	to	
    remaining in the year .                                       enroll again . You may change your payroll
                                                                  deduction	amount	for	the	Day	Care	FSA	during	the	plan	
4.	 You	will	be	required	to	provide	information	about	your	       year,	only	if	you	have	a	change	in	status.	The	IRS	defines	
    dependents	and	your	day	care	provider	such	as	receipts,	      a	change	in	status	for	the	Day	Care	FSA	as	the	death	of	
    Social Security numbers or Federal Tax Identification         a	dependent	parent,	the	change	in	your	spouse’s	student	
    numbers .                                                     status,	death	of	child	or	loss	of	child	custody.	It	will	be	
                                                                  your obligation to notify Employee Services or your
5 . You may only submit expenses incurred on or after             local Human Resources department immediately if there
    your participation date .                                     is a change in status .

HOW	TO	rECEIVE	rEIMburSEMENT                                   •	 Any	balance	in	the	Day	Care	FSA	that	is	not	used	for	
1 . Submit a completed Request for Reimbursement Form             eligible	expenses	within	the	plan	year	must	be	forfeited.	
     along	with	original	receipts	to	the	plan	administrator.      You	will	have	30	days	after	the	end	of	the	plan	year	
2.		 Reimbursement	checks	are	generally	processed	every	          or the date you are no longer enrolled in the plan
     week	but	are	guaranteed	within	two	pay	periods.	             (whichever	comes	first),	to	submit	eligible	expenses	
3.		 Each	participant	is	responsible	for	keeping	records	to	      for	reimbursement.	For	2011,	only	expenses	incurred	
     support these expenses .                                     between	January	1,	2011,	and	December	31,	2011,	are	
                                                                  eligible	for	reimbursement;	however,	you	have	until	
ESTIMATING	DAY	CArE	EXPENSES                                      January	31,	2012,	to	submit	for	reimbursement.	
If	you	are	or	will	be	incurring	day	care	expenses,	the	
following	example	may	help	to	show	you	how	the	
Dependent	Care	FSA	can	save	you	tax	dollars.	

Example:	Pat	Smart	is	a	single	parent	earning	$27,000	
and	has	approximately	a	27	percent	tax	rate	(15	percent	
federal,	4.35	percent	state,	and	7.65	percent	FICA	
[rounded]).	Each	year,	Pat	Smart	pays	$3,600	for	day	care	




                                                                                                                           27
H e n ry F o r d H e a lt H S y S t e m                                                              Flex Benefits



Flex Benefits Web Enrollment Instructions
___________________________________________________
During	Open	Enrollment,	employees	must	make	their	              •	 Step	5	–		Make	your	benefits	selections	for	2011.
benefit	selections	online.	This	continues	to	be	the	only	way	
                                                                •	 Step	6	–		After	completing	your	benefit	selections,	you	
to	make	your	benefit	selections.	The	Flex	Benefits	Web	site	
                                                                   will	see	a	summary	of	your	benefit	choices	and	their	
will	be	available	during	Open	Enrollment	from	Monday,	
                                                                   costs.	If	you	are	satisfied	with	your	choices,	proceed	to	
Nov.	8	through	Monday,	Nov.	22,	2010.	Computer	kiosks	
                                                                   receive your confirmation number . Record this
are located throughout the health system . If you need help
                                                                   number	on	your	enrollment	worksheet.	You	must	obtain	
enrolling	or	have	questions	about	benefits	choices,	call	
                                                                   a confirmation number . This completes your enrollment
Employee	Services	at	(313)	874-7100.
                                                                   and confirms your benefit selections have been
                                                                   properly recorded .
HOW	TO	ENrOll
•	 Step	1	– Go to http://ebenefits .hfhs .org from any          •	 Step	7	–			Print	your	temporary	confirmation	
   computer	which	has	access	to	the	web	starting	                  statement.	Confirmation	statements	will	not	be	
   Monday,	Nov.	8,	2010.                                           mailed home .
•	 Step	2	–	 Enter your six-digit employee identification       •	 Step	8	–	Review	the	Confirmation	Statement	for	
   number . Then enter your Employee Self Service                  accuracy	and	keep	it	as	proof	of	your	enrollment.
   password,	which	is	also	your	password	for	Open	
   Enrollment.		If		you	don’t	remember	your	password,	          •	 Step	9	–		A	final	Confirmation	Statement	will	be	
   click	on	Forgot	Your	Password.	If	you	need	to	reset	your	       available	online	beginning	the	week	of	Dec.	13,	2010.	
   password,	click	on	Contact	IT	Help	Desk	or	call	(248)	          You can go to Employee Self Service/Benefits Home and
   853-4900 or tie line 53-4900 .                                  print the final Confirmation Statement .

•	 Step	3	–		Access	your	Personal	Enrollment	Summary	           DEFAulT	PlAN
   which	shows	your	current	coverage,	your	options	and	         •	 Flexible	Spending	Accounts	default	to	non-participation	
   the	associated	price	tags.	Review	and	print	both	               unless you enroll each year .
   documents	and	refer	to	them	to	help	you	make	
   informed benefits choices .                                  •	The	default	package	for	full	and	part	time	employees	is	
                                                                   no	coverage.	If	you	are	enrolled	in	the	default	package,	
•	 Step	4	–		Review	your	dependent	information	and	                you	will	have	no	coverage	for	the	rest	of	the	plan	year.	
   update if necessary .                                           Also,	if	you	experience	a	life	event,	you	may	not	be	able	
                                                                   to	make	a	change	to	your	benefits	until	the	next	Open	
	 Please	note:	If	you	want	to	add	or	delete	dependents	            Enrollment period .
  to	your	medical	or	dental	plans,	you	must	make	the	
  changes on the Enroll Your Dependent panel by                 If	you	are	a	full	time	employee,	you	are	entitled	to	flex	
  checking/unchecking	the	Enroll	box	for	medical	or	            credits.	In	order	to	receive	the	flex	credits,	you	must	elect	
  dental coverage .                                             benefits . If you have other coverage and do not require
                                                                benefits	from	HFHS,	you	should	waive	or	opt	out	of	the	
	 If	your	dependent	is	between	the	ages	of	20	and	25	           HFHS provided benefits in order to receive your flex credits
  and	a	full-time	college	student,	and	you	would	like	to	       as taxable cash each pay .
  continue	their	coverage	for	dental,	you	must	go	online	
  and	verify	that	the	“Enroll”	box	on	the	Enroll	Dependent	     OPEN	ENROLLMENT	TAKES	PLACE	MONDAY,	NOV.	8	
  panel	is	checked	for	dental.	In	order	for	coverage	to	        THROUGH	MONDAY,	NOV.	22,	2010.	All	Flex	Benefits	
  continue,	this	box	must	be	checked.	Be	sure	to	submit	        changes	must	be	made	by	Monday,	Nov.	22,	2010.
  your request online and print a temporary confirmation
  statement to ensure coverage .




                                                                                                                            28
H e n ry F o r d H e a lt H S y S t e m                                                               Flex Benefits



Additional Information about Flex Benefits
___________________________________________________
COVErAGE	FOr	HFHS	COuPlES                                       YOur	rIGHTS	AND	rESPONSIbIlITIES
If	both	a	husband	and	wife	are	Henry	Ford	Health	System	        •	 You	are	responsible	for	notifying	Employee	Services	or	
employees,	they	cannot	be	“double	covered”	under	Flex	             your local Human Resources department at the time a
Benefits . A	person	covered	as	an	employee	cannot	be	an	           covered	dependent	no	longer	remains	eligible	for	dental,	
eligible dependent.	However,	one	spouse	could	opt	out	of	          dependent	life	and	AD&D	coverage.	For	example:
health care coverage and be covered as a dependent by
the	other	spouse	under	two-person	or	family	coverage.	
                                                                	 ❏	 You	get	a	divorce;
Eligible dependents of a couple employed by HFHS can
be double covered under Flex Benefits . Keep in mind            	 ❏ Your child reaches 20 years of age and is not a full
that coordination of benefits rules apply for health care         	 time	student;
coverage,	so	that	not	more	than	100	percent	of	eligible	        	 ❏		Your	child	who	is	a	full	time	student	reaches	25	years		
expenses	can	be	paid.	Similarly,	an	employee	cannot	              	 of	age;
be covered as a dependent on a spouse’s life insurance          	 ❏	 Your	child	is	no	longer	a	full	time	student;
contract.	However,	an	eligible	dependent	may	be	covered	        	 ❏	 Your	child	gets	married;
under both spouse’s dependent life insurance contracts .          ❑ Your child is eligible for medical coverage through
If	that	dependent	dies,	both	spouses	could	collect	on	the	           their employer .
dependent	life	coverage	in	which	they	were	enrolled.	An	
eligible	expense	may	only	be	reimbursed	once,	even	if	both	     lEGAl	uPDATE
spouses participate in flexible spending accounts .             The	Women’s	Health	&	Cancer	Rights	Act	requires	group	
                                                                health plans that provide coverage for mastectomy to
lEAVE	OF	AbSENCE                                                provide coverage for certain re-constructive services . This
If	you	are	on	a	leave	of	absence	during	Open	Enrollment,	       law	also	requires	that	written	notice	of	the	availability	of	
changes	made	to	your	employee	or	dependent	life,	long	          the coverage be delivered to all plan participants upon
term disability or accidental death and dismemberment           enrollment and annually thereafter . This language serves
insurance	will	not	be	in	effect	until	you	have	one	active	      to fulfill that requirement for 2011 . These services include:
day	of	work	in	2011.	If	you	make	changes	made	to	your	
medical	and/or	dental	coverage	those	changes	will	be	           •	 Reconstruction	of	the	breast	upon	which	the	
effective	January	1,	2011.	                                        mastectomy	has	been	performed,
                                                                •	 Surgery/reconstruction	of	the	other	breast	to	produce	a	
TErMINATION	OF	bENEFITS                                            symmetrical	appearance,
Benefit	coverage	for	you	and	your	family	will	terminate	        •	 Prostheses,	and
on	the	last	day	of	the	month	in	which	you	terminate	            •	 Treatment	for	physical	complications	during	all	stages	
your employment or are in an ineligible benefit status .           of	mastectomy,	including	lymphedema.	
Long-term	disability	coverage	ends	on	the	date	of	
termination.	If	you	become	ineligible	for	coverage,	you	        In	addition,	the	plan	may	not:
and your eligible dependents may have continuation              •	 Interfere	with	a	woman’s	rights	under	the	plan	to	avoid	
rights	for	medical/vision,	dental	and	Health	Care	Flexible	        these	requirements,	or
Spending	Account	benefits	under	the	federal	law	known	          •	 Offer	inducements	to	the	health	provider,	or	assess	
as	COBRA.	If	you	terminate	your	employment	or	are	in	an	           penalties	against	the	health	provider,	in	an	attempt	to	
ineligible	benefit	status,	you	will	be	notified	about	your	
                                                                   interfere	with	the	requirements	of	the	law.	However,	the	
continuation	rights.	You	will	also	receive	a	Certificate	of	
                                                                   plan	may	apply	deductibles	and	co-pays	consistent	with	
Creditable Coverage according to the Health Insurance
                                                                   other coverage provided by the plan .
Portability	and	Accountability	Act	of	1996	(HIPAA).	This	
certificate	outlines	the	period	for	which	you	were	covered	
under	a	medical/vision	plan	with	Henry	Ford	Health	
System . This certificate may be used to satisfy pre-existing
limitations	in	your	new	employer’s	plans.



                                                                                                                             29
H e n ry F o r d H e a lt H S y S t e m                                                              Flex Benefits


HIPAA	rIGHTS	                                                    HFHS Lifestyle Rewards
Henry	Ford	Health	System	sponsors	a	group	health	plan.	As	
such,	the	System	has	access	to	the	individually	identifiable	
                                                                 ________________________
health	information	of	Plan	participants	(1)	on	behalf	of	        As	a	Henry	Ford	employee,	your	benefits	extend	beyond	
the	Plan	itself;	or	(2)	on	behalf	of	the	System,	for	            compensation	and	health	insurance	coverage.	Lifestyle	
administrative	functions	of	the	Plan.	                           Rewards	are	benefits	employees	receive	at	no	cost	as	valued	
                                                                 members	of	the	Health	System,	such	as	those	noted	below.	
The	Health	Insurance	Portability	and	Accountability	Act	of	      To	find	out	more	about	Lifestyle	Rewards,	log	on	to	www.
1996	(HIPAA)	and	its	regulations	restrict	the	System’s	          henryfordconnect.com,	and	follow	the	links	described	below.
ability	to	use	and	disclose	Protected	Health	Information
	(PHI).	Protected	Health	Information	means	any	                  For information about:
information	relating	to	the	past,	present	or	future	             •	 Employee	Assistance	Program	(EAP)
physical	or	mental	condition	of	an	individual	(or	payment	       •	 Helping	Hands
therefore)	that	identifies	the	individual	or	can	be	used	to	     •	 Henry	Ford	Kids	Child	Care
identify the individual .                                        •	 Employee	Health	and	Wellness
                                                                 Log	on	to	HRConnect,	click	on	the	Work	Life	icon,	and	use	
It is the Henry Ford Health System’s policy to comply fully      the right-hand navigation column .
with	HIPAA	requirements.	Consequently,	if	you	become	a	
covered	participant	under	the	group	health	plan,	you	have	       For information about:
a	right	under	HIPAA	to	receive	a	Notice	of	Privacy	              •	 Employee	Discounts	negotiated	by	the	System	such	as:
Practices	for	Protected	Health	Information.	To	request	a	        	 –	Banking	and	Credit	Union	Services
copy,	call	(313)	874-7100	or	email	ask_Ben1@hfhs.org.               – Wireless Services
                                                                    – Dining and Entertainment
                                                                 	 –	Lodging	and	Travel,	and	more
Voluntary Employee Benefits
________________________                                         Log	on	to	HRConnect,	click	on	the	Work	Life	icon,	and	
                                                                 select Employee Discounts from the right-hand navigation
                                                                 column .
Henry Ford Health System offers voluntary employee
benefits to all full time and part time benefit eligible         For information about:
employees . The benefits available include:                      •	 Tuition	Reimbursement	of	up	to	$3,000	per	year
                                                                 •	 Nurse	Tuition	Funding	Program	
•	Auto	Insurance                                                 Log	on	to	HRConnect	and	click	on	the	Learning	&	
•	Home	Owners	Insurance                                          Development icon .
•	Group	Legal	Services
•	Long	Term	Care                                                 For information about:
•	Pet	Insurance                                                  •	 Combined	Time	Off	and	Paid	Time	Off
                                                                 •	 Special	Medical	Credit
Enrollment	in	the	Auto,	Home	Owners,	Long	Term	Care	             Log	on	to	HRConnect	and	click	on	the	Benefits	icon.	
and	Pet	Insurances	can	take	place	at	any	time.	There	is	a	
designated	enrollment	period	for	the	Group	Legal	Services.       For information about:
The	enrollment	period	for	Group	Legal	Services	is	               •	 Direct	Deposit
Nov.	8	through	Nov.	22,	2010.	Newly	hired	or	newly	benefit	      Log	on	to	HRConnect	and	click	on	Your	Paycheck.
eligible employees have 30 days from their date of hire or
benefit	eligibility	to	enroll	in	the	Group	Legal	Services	and	   For information about:
90	days	for	the	Long	Term	Care	Insurance.	For	additional	        •	 Employee	Health	Clinic	services
information,	call	1-866-405-7953	or	log	onto	                    •	 Seasonal	flu	shots	and	other	health	screenings	through	
www.vbphfhs.net.                                                     Employee Health
                                                                 •	 Fitness	Works
                                                                 Log	on	to	HRConnect	and	click	on	Work	Life,	and	select	
                                                                 click	on	Employee	Health	and	Wellness	in	the	right-hand	
                                                                 navigation column .


                                                                                                                              30
H e n ry F o r d H e a lt H S y S t e m                                                                                                  Flex Benefits


                                     Events Permitting Mid-Year Election Changes Consistent with Event
IRS Qualifying Event      Explanation of Event                Medical/Vision and Dental    Health Care/Day Care        Life, Accidental Death &    Dependent Life
                                                                                           Flexible Spending           Dismemberment, Long
                                                                                           Accounts                    Term Disability
Marriage                  This event allows you to            You may:                     You may:                    You may:                    You may:
                          add your new spouse within          Enroll                       Enroll                      Enroll                      Enroll
                          30 days of your marriage.           Add spouse                   Increase Coverage           Increase overage            Increase coverage
                          Stepchildren may be added.          Change Option                Decrease Coverage           Decrease overage            Decrease coverage
                          Proof is required.                  Opt Out                      Opt Out                     Opt Out                     Opt Out


Divorce, legal            This event allows you to            You may:                     You may:                    You may:                    You may:
separation/annulment      remove your spouse within           Remove Spouse and            Enroll                      Enroll                      Enroll
or death of spouse        30 days of the event. Proof is      dependents                   Increase coverage           Increase coverage           Increase coverage
                          required.                           Enroll                       Decrease coverage           Decrease coverage           Decrease coverage
                                                              Change Option                Opt out                     Opt out                     Opt Out

                                                              You may not:
                                                              Opt out
Birth, Adoption,          This event allows you to add        You may:                     You may:                    You may:                    You may:
Placement for             your newborn child or newly         Enroll                       Enroll                      Enroll                      Enroll
Adoption of a child or    adopted child within 30 days        Add dependent                Increase coverage           Increase coverage
gain stepchild(ren)       of the event. Proof is required.    Change Option                                            Decrease coverage           You may not
                                                                                           You may not:                Opt out                     Increase coverage
                                                              You may not:                 Decrease coverage                                       Decrease coverage
                                                              Remove dependents            Opt out                                                 Opt Out
                                                              Opt out
Death of Dependent        This event allows you to            You may:                     You may:                    You may:                    You may:
                          remove your dependent within        Remove dependent             Decrease coverage           Enroll                      Decrease coverage
                          30 days of the event. Proof is      Change Option                Opt out                     Increase coverage           Opt Out
                          required.                                                                                    Decrease coverage
                                                              You may not:                 You may not:                Opt out                     You may not:
                                                              Enroll                       Enroll                                                  Enroll
                                                              Add dependents               Increase coverage                                       Increase coverage
                                                              Opt Out
Other eligible            This event allows you to add a      You may:                     You may:                    No changes are allowed      No changes are
dependents                sponsored dependent to your         Add your sponsor dependent   Enroll                                                  allowed
(Aged Parents)            existing medical coverage                                        Increase limit
                          only within 30 days of the          You may not:
                          event. Proof is required.           Enroll                       You may not:
                                                              Add other dependents         Decrease limit
                          A sponsored dependent must          Remove other dependents      Opt Out
                          be an IRS dependent such as         Opt Out
                          a parent or adult child who         Make any changes to dental
                          lives with you and is claimed       coverage
                          on your Federal Income Tax.


Employee changes          This event allows you to enroll     Part to Full time:           No changes are allowed      You may:                    You may:
status                    in medical/vision or dental if      You may:                                                 Increase coverage           Increase coverage
                          your status changes from part       Enroll                                                   Decrease coverage           Decrease coverage
Part time to full time    time to full time. You are now
                          eligible to receive flex credits.   You may not:                                             You may not:                You may not:
                          You have 30 days to make your       Opt out                                                  Enroll                      Enroll
                          elections.                                                                                   Opt Out                     Opt Out

Full time to part time    For status changes from full        Please see event for         Please see event for        Please see event for        Please see event
                          time to part time, please see       Significant Cost Changes     Significant Cost Changes    Significant Cost Changes    for Significant Cost
                          event for Significant Cost                                                                                               Changes
                          Changes
Employee now              You are no longer eligible for      You may:                     You may:                    You may:                    You may:
ineligible for benefits   active benefits. All benefits       Elect COBRA continuation     Elect COBRA continuation    Conversion rights are       Conversion rights
                          will be canceled and COBRA          Active coverage will be      Active coverage will be     available                   are available
                          or conversion rights will be        cancelled                    cancelled                   Active coverage will be     Active coverage
                          provided.                                                                                    cancelled                   will be cancelled
                                                              You may not:                 You may not:
                                                              Enroll in active benefits    Enroll in active benefits                               You may not:
                                                                                           Continue COBRA              You may not:                Enroll in active
                                                                                           coverage for dependent      Enroll in active benefits   benefits
                                                                                           care FSA




                                                                                                                                                                       31
H e n ry F o r d H e a lt H S y S t e m                                                                                                 Flex Benefits


                            Events Permitting Mid-Year Election Changes Consistent with Event (continued)
IRS Qualifying Event     Explanation of Event               Medical/Vision and Dental       Health Care/Day Care        Life, Accidental Death &    Dependent Life
                                                                                            Flexible Spending           Dismemberment, Long
                                                                                            Accounts                    Term Disability
Employee rehires         This event allows you to           You may:                        You may:                    You may:                    You may:
within 30 days           be reinstated in your prior        Have your prior elections       Have your prior elections   Have your prior elections   Have your prior
                         elections within 30 days of        reinstated                      reinstated                  reinstated                  elections reinstated
                         your rehire.
                                                            You may not:                    You may not:                You may not:                You may not:
                                                            Make changes to prior           Make changes to prior       Make changes to prior       Make changes to
                                                            elections                       elections                   elections                   prior elections

Employee rehires         This event allows you to enroll    You may:                        You may:                    You may:                    You may:
after 30 days            in all of your benefits as a new   Enroll                          Enroll                      Enroll                      Enroll
                         hire within 30 days of your
                         rehire.
Spouse/Dependent         This event allows you to           You may:                        You may:                    You may:                    No changes are
now eligible for their   change some of your options        Remove dependents who now       Decrease coverage           Increase coverage           allowed
employer’s plan          within 30 days of being            have other coverage             Opt Out                     Decrease coverage
                         covered under your spouse/         Opt out if covered by spouse/
                         dependent employer’s plan.         dependent’s plan                You may not:                You may not:
                         Proof is required.                                                 Enroll                      Enroll
                                                            You may not:                    Increase limit              Opt out
                                                            Enroll
                                                            Add dependents
Spouse/Dependent or      This event allows you to           You may:                        You may:                    You may:                    You may:
HFHS employee* lose      change some of your options        Enroll                          Enroll                      Increase coverage           Increase coverage
eligibility for their    within 30 days, due to your        Add dependents who lost         Increase limit              Decrease coverage           Decrease coverage
employer’s plan          spouse/dependent losing            coverage
                         coverage through their                                             You may not:                You may not:                You may not:
                         employer’s plan. Losing            You may not:                    Decrease limit              Enroll                      Enroll
                         coverage does not mean             Remove dependents               Opt Out                     Opt out                     Opt out
                         voluntarily opting out of          Opt Out
                         coverage. Proof is required.

                         In rare situations, an HFHS
                         employee may waive
                         coverage because they are
                         employed and have full time
                         benefits elsewhere. If the
                         employee loses their eligibility
                         through that employer, they
                         would be entitled to enroll in
                         all of the HFHS benefits listed
                         in this chart. Proof is required

Change in Residence      This event allows you to           You may:                        No changes are allowed      No changes are allowed      No changes are
or Worksite of           change your medical/vision         Change option                                                                           allowed
employee, spouse or      or dental coverage, within
dependent that causes    30 days, because you or a          You may not:
eligibility or loss of   dependent moved out of the         Enroll
eligibility              service area (as defined by        Add dependents
                         the insurance contract.)           Remove Dependents
                                                            Opt Out
Significant cost         This event allows you to           You may:                        No changes are allowed      You may:                    You may:
changes                  change certain benefits,           Switch to less costly option                                Enroll                      Enroll
For HFHS Employee        within 30 days, due to your        Remove dependents                                           Increase coverage           Increase coverage
                         status change from full time                                                                   Decrease coverage           Decrease coverage
                         to part time. The loss of          You may not:                                                Opt Out                     Opt Out
                         flex credits results in a cost     Enroll
                         change to you.                     Add dependents
                                                            Opt Out
Employee begins          This event allows you to           You may:                        You may:                    You may:                    You may:
FMLA Leave               change certain benefits within     Change Option                   Enroll                      Enroll                      Enroll
                         30 days as a result of your        Opt Out                         Increase limit              Increase coverage           Increase coverage
                         FMLA leave.                                                        Decrease limit              Decrease coverage           Decrease coverage
                                                            You may not:                    Opt Out                     Opt Out                     Opt Out
                                                            Enroll
                                                            Add dependents
                                                            Remove dependents




                                                                                                                                                                      32
H e n ry F o r d H e a lt H S y S t e m                                                                                                  Flex Benefits


                            Events Permitting Mid-Year Election Changes Consistent with Event (continued)
IRS Qualifying Event     Explanation of Event                Medical/Vision and Dental       Health Care/Day Care         Life, Accidental Death &   Dependent Life
                                                                                             Flexible Spending            Dismemberment, Long
                                                                                             Accounts                     Term Disability
Employee returns from    This event allows you to            You may:                        You may:                     You may:                   You may:
FMLA Leave               change certain benefits within      Enroll if coverage was          Enroll if coverage was       Enroll if coverage was     Enroll if coverage
                         30 days that were terminated        terminated while on FMLA        terminated while on FMLA     terminated while on FMLA was terminated
                         as a result of your FMLA leave.     Change option                                                                           while on FMLA
                                                                                             You may not:                 You may not:
                                                             You may not:                    Enroll if coverage was not   Enroll if coverage was not You may not:
                                                             Enroll if coverage was not      terminated while on FMLA     terminated while on FMLA Enroll if coverage
                                                             terminated while on FMLA                                                                was not terminated
                                                             Add dependents                                                                          while on FMLA
                                                             Remove dependents
                                                             Opt Out
Special Enrollment       This event allows you to enroll     You may:                        No changes are allowed       No changes are allowed     No changes are
Rights Under HIPAA       in medical coverage, within         Enroll in medical/vision only                                                           allowed
Loss of other coverage   30 days, even though you            Add dependent(s)
or acquisition of new    previously opted out. Eligibility
dependent                to enroll is contingent on          You may not:
                         adding a newborn or adding          Enroll in dental
                         a dependent that recently lost      Opt out of dental
                         coverage. Losing coverage
                         does not mean voluntarily
                         opting out of coverage. Proof
                         is required.

Judgment, Divorce or     This event allows you to            You may:                        You may:                     No changes are allowed     No changes are
Medical Child Support    enroll your dependent, within       Add dependent as a result of    Elect if Order requires                                 allowed
Order                    30 days, as a result of a           the Order                       Increase limit if Order
Require coverage         Judgment, Divorce or Medical                                        requires
for child(ren) under     Child Support Order. Proof is       You may not:
employee’s plan          required.                           Add dependents not part of      You may not:
                                                             the Order                       Decrease limit
                                                             Remove dependents               Opt Out
                                                             Change option
                                                             Opt out
Coverage required        This event allows you to            You may:                        You may:                     No changes are allowed     No changes are
under spouse’s plan      remove your dependent               Remove dependent                Decrease limit                                          allowed
                         within 30 days because your                                         Opt out
                         dependent is now enrolled           You may not:
                         under your spouse’s plan.           Enroll                          You may not:
                         Proof is required.                  Add dependent                   Enroll
                                                             Change option                   Increase limit
                                                             Opt out
Entitlement to           This event allows you to            You may:                        You may:                     No changes are allowed     No changes are
Medicare/Medicaid        remove your dependent that          Remove dependent                Decrease limit                                          allowed
                         is now eligible for Medicare                                        Opt out
                         or Medicaid within 30 days of       You may not:
                         becoming eligible. Proof is         Enroll                          You may not:
                         required                            Add dependent                   Enroll
                                                             Change option                   Increase limit
                                                             Opt out
Loss of Medicare/        This event allows you to enroll     You may:                        You may:                     No changes are allowed     No changes are
Medicaid eligibility     your dependent that is no           Enroll in medical/vision only   Enroll                                                  allowed
                         longer eligible for Medicare        Add dependent to medical/       Increase limit
                         or Medicaid within 30 days          vision only
                         of losing eligibility. Proof is                                     You may not:
                         required                            You may not:                    Decrease limit
                                                             Change option                   Opt Out
                                                             Remove dependents
                                                             Opt Out




                                                                                                                                                                      33