CLBA Employee Overvi by ps94506


									Benefits Guide
CLBA Letter

 Dear CLBA Member:
 We are pleased to provide you with the enclosed information from the Christian Leaders
 Benefits Alliance. CLBA is a nonprofit organization which was founded in 2006 to facilitate
 collaboration among churches and affiliated nonprofit organizations with a heritage in the
 Stone Campbell movement to gain access to reasonably priced health insurance.
 As you know health insurance is not only incredibly costly, in some cases it is almost
 impossible for small churches and nonprofit organizations to attain on their own. By
 working together, we have been able to create sufficient numbers to both make health
 insurance accessible, and to make it more affordable.
 CLBA is not an insurance provider nor does it serve in any fiduciary capacity, but merely a
 nonprofit organization that facilitates the collaboration necessary for churches and
 nonprofits to aggregate their demand to help meet this critical need for health insurance
 by our ministers, church staffs, and the staff’s of affiliated nonprofit organizations.
 The Board of Directors of CLBA is comprised of Dr. Charles Siburt, Vice President of Church
 Relations at ACU, Roland Orr, Elder at Highland Church of Christ in Abilene, and Jon
 Mullican, Executive Minister at Highland Oaks Church of Christ in Dallas. We have
 contracted with Churchwide Healthcare, affiliated with the Disciples of Christ, to actually
 provide the insurance coverage through Blue Cross Blue Shield. Gallagher Benefits is our
 insurance consultant to help us make sure we make wise decisions. Ron Holifield and
 Good Stewards works with us to manage relations with participating churches and affiliated
 nonprofits to help us meet your needs.
 Thanks for your partnership in the CLBA. We hope that you find this benefit brochure
 helpful. You can find out more at our website at
 Please do not hesitate to contact any of us if we can provide additional information. May
 God bless you.
 Grace and Peace,

 Charles Siburt             Roland Orr           Jon Mullican

 If you (and/or your dependents) have Medicare or will become eligible for Medicare
 in the next 12 months, a Federal Law gives you choices about your prescription
 drug coverage. Please see page 17 for more details.


Benefits Enrollment Guide for Employees of
CLBA Benefits Program

CLBA Letter ......................................................................................................... 1

Membership Guidelines ...................................................................................... 3

Highmark BCBS Medical Program ..................................................................... 4

Summary of Medical Benefits ............................................................................ 5

Prescription Drug Program Overview ................................................................. 6

Prescription Drug Program Details ..................................................................... 7

Flexible Spending Account Overview ................................................................. 8

Flexible Spending Account FAQ .......................................................................... 9

Voluntary Dental Program ................................................................................. 10

Employer Paid Dental Program ......................................................................... 11

Vision Benefits .................................................................................................. 12

Legal Updates ................................................................................................... 13

Medicare Part D Notice ..................................................................................... 15

Medical and Prescription Drug Rates ............................................................... 17

Dental Rates ...................................................................................................... 18

Provider Reference Information ........................................................................ 19

Notes ................................................................................................................. 20

The benefit information included in this guide is summary information. It is not intended to be a complete
description of the benefit plans. That description, which contains coverage and exclusion information, is
contained in the Summary Plan Descriptions (SPD). If a discrepancy exists, the SPD will prevail.

    Membership Guidelines

Who is eligible for coverage?                                  Making enrollment changes during
In order to participate in the CLBAbenefits program, you       the year
must be a compensated staff member of an eligible              In most cases, your benefit elections remain in effect for
organization. Eligible organizations include Churches of       the entire plan year. During each annual enrollment
Christ, affiliated nonprofit organizations, and other          period, you will have the opportunity to review your
churches that share a heritage from the Stone-Campbell         benefit elections and make changes for the coming year.
movement. Eligible staff includes; ministers, church
support staff, missionaries, K-12 Christian school             Certain coverages allow limited changes to elections
personnel, non-profit Christian ministry organization          during the year. These benefits include the medical,
personnel, and Christian college and university                dental and vision plans. Under these benefits, you may
employees. Specific eligibility rules are determined by        only make changes to your elections during the year if
each individual entity/organization.                           you have a change in family status. Family status changes
If you qualify as an eligible staff member, you can also
cover your eligible dependents. Eligible dependents            •	Marriage, divorce or legal separation
include:                                                       •	Gain or loss of an eligible dependent for reasons such
                                                                 as birth, adoption, court order, disability, death,
•	Spouse
                                                                 marriage, or reaching the dependent child age limit
•	Unmarried children under 19 years of age, including:
                                                               •	Changes in your spouse’s employment affecting benefit
•	Newborn children                                               eligibility
•	Stepchildren                                                 •	Changes in your spouse’s benefit coverage with another
•	Children legally placed for adoption                           employer that affects benefit eligibility
•	Legally adopted children or children for whom the            The change to your benefit elections must be consistent
  employee or the employee’s spouse is the child’s legal       with the change in family status. For example, if you gain
  guardian                                                     a new dependent due to birth, you may only change your
•	Children awarded coverage pursuant to an order of            benefit elections to add that dependent. In this case,
  court                                                        coverage for other dependents cannot be changed.
•	Unmarried children up to the age of 25, provided they        You have 30 days from the date of a change in family
  are enrolled in and regularly attending a full-time          status to complete an enrollment change form and return
  accredited school, college or university or a licensed       it to Michael Porter. Otherwise, you must wait until the
  technical or specialized school and are dependent            next annual enrollment period to make a change to your
  solely upon you for support                                  elections. Your elections will become effective the first of
•	Unmarried children over age 19 who are not able to           the following month, with the exception of a change due
  support themselves due to mental retardation, physical       to birth or adoption.
  disability, mental illness or developmental disability

    Highmark BCBS Medical Program

About your Churchwide healthcare                                      To find preferred providers
coverage                                                              (in-network):
Welcome to coverage through the Christian Church                      •	Visit the web site and click
Healthcare Benefit Trust (CCHCBT) for members of the                    on “Find a Physician or Facility.”
CLBA Benefits Program. CCHCBT has contracted with                     •	Call 1-800-648-4078 to find out if the provider you
Highmark BCBS to act as Third-Party Administrator of the                select is Preferred.
benefits program, which gives you access to the BCBS
                                                                      (Remember, you will reach your out-of-pocket maximum
system, one of the most widely recognized and accepted
                                                                      quicker when you use Out-of-Network Providers. Further,
throughout the United States. For decades, the nationwide
                                                                      there are separate deductibles and out of pocket limits
BCBS family of independent plan providers has offered
                                                                      for Out-Of-Network medical services.) The medical
members with innovative health coverage designed to
                                                                      summary of benefits in the booklet shows a comparison
meet their needs.
                                                                      between benefits when you use In-Network Providers
You will be covered through the CCHCBT PPO plan                       and benefits when you use Out-of-Network Providers.
administered by Highmark BCBS. No matter where you                    Also, keep in mind that your health plan pays the Allowed
live in the United States, you may take advantage of the              Price for services and supplies. In-Network Providers
expansive provider networks and discounts arranged by                 agree to accept the Allowed Price as payment in full.
the PPO plans around the country. In most cases, you                  When you use Out-of-Network Providers, you must pay
should not have to file claim forms or pay anything except            the difference between the Allowed Price and the
your co-payments, deductibles, etc., in advance. This                 provider’s charge.
guide explains your coverage with CCHBT and the PPO
                                                                      Benefits for most services require that you pay a
program. For more information, such as details about
                                                                      deductible each year for In-Network Providers’ services
how we cover a particular service or prescription drug,
                                                                      and Out-of-Network Providers’ services. Once you have
please read your contract or use one of the sources in
                                                                      met your deductible, you share the cost of your care
the list at the back of this guide.
                                                                      through coinsurance. Deductible and out-of-pocket
How does my medical plan work?                                        amounts do not cross apply.

You pay less out-of-pocket if you use the physicians,                 Once again, your coinsurance percentage amount for
hospitals, and other healthcare providers that participate            Out-of-Network Providers is higher than the one for In-
in the BCBS PPO network. While you don’t need referrals               Network Providers. You need only pay the deductible and
to visit specialists, you receive the highest level of benefits       coinsurance until you meet your out-of-pocket maximum
when you use Preferred Providers. In some instances,                  for the year.
such as hospital admissions and home healthcare
services, Highmark BCBS can require prior approval. In
other words, Highmark BCBS must approve the need for
the care before you seek it, or they may choose not to
pay for such care.

   Summary of Medical Benefits
                                            CLBA PPO Medical Plan Benefit Summaries
                       Benefit Category
                                                                          PPO1                       PPO2                     PPO HDHP
Benefit Period                                                         Calendar Year             Calendar Year               Calendar Year
Individual                                                                 $500                      $1,000                        $2,500
Family                                                                    $1,500                     $3,000                        $5,000
Payment Level/Coinsurance                                                   80% after deductible until out-of-pocket is met, then 100%
Out-of-Pocket (OOP) Maximums
Individual                                                                $2,000                     $3,500                        $5,000
Family                                                                    $4,000                     $7,000                        $10,000
Deductible Included in OOP Maximum?                                         No                         No                           Yes
Lifetime Maximum                                                                                     $2,000,000
Physician & Specialist Office Visits                                                             80% after deductible
Adult Preventive Care – Routine physical exams                                            100%, deductible does not apply
Adult Preventive Care – Routine gynecological exams, including a
                                                                                          100%, deductible does not apply
Pap Test
Adult Preventive Care – Mammograms, as required                                           100%, deductible does not apply
Pediatric Preventive Care – Routine physical exams                                        100%, deductible does not apply
Pediatric Preventive Care – Immunizations                                                 100%, deductible does not apply
Emergency Room Services                                                80% after $100 copayment and deductible            80% after deductible
Ambulance                                                                                        80% after Deductible
Hospital Expenses – Inpatient                                                                    80% after deductible
Hospital Expenses – Outpatient                                                                   80% after deductible
Hospital Expenses – Maternity                                                                    80% after deductible
Infertility Counseling, Testing and Treatment                                                    80% after deductible
Medical/Surgical Expenses (Except Office Visits)                                                 80% after deductible
                                                                                                 80% after deductible
Spinal Manipulations
                                                                                   Combined Limit: 20 visits per calendar year
Diagnostic Services (Lab, X-Ray and other tests)                                                 80% after deductible
                                                                                                 80% after deductible
Physical Medicine (Acupuncture Included)
                                                                                   Combined Limit: 20 visits per calendar year
                                                                                                 80% after deductible
Occupational/Speech Therapy
                                                                                   Combined Limit: 20 visits per calendar year
Durable Medical Equipment, Orthotics and Prosthetics                                             80% after deductible
                                                                                                 80% after deductible
Skilled Nursing Facility Care
                                                                                   Combined Limit: 120 visits per calendar year
                                                                                                 80% after deductible
Home Healthcare
                                                                                   Combined Limit: 20 visits per calendar year
Private Duty Nursing                                                                             80% after deductible
                                                                                                 80% after deductible
                                                                                        Combined Limit: 180 days per lifetime
                                                                                                 80% after deductible
Mental Health/Substance Abuse - Inpatient
                                                                                       Combined Limit: 30 days / calendar year
                                                                                                 80% after deductible
Mental Health/Substance Abuse - Outpatient
                                                                                       Combined Limit: 30 visits / calendar year
Precertification Requirements                                                                  Performed by Member *

  Prescription Drug Program Overview

CCHCBT Prescription Drug Program                                                     Brand Formulary-Name Drugs
Through the CCHCBT and its contractual arrangement                                   What is a brand-name drug?
with Medco Health, a Pharmaceutial Benefit Manager,                                  A prescription drug that is marketed under a proprietary,
CLBA has a tiered prescription drug program. That                                    trademark-protected name.
means that you pay the lowest co-payments when you
use tier 1 (generic) drugs. Below is the co-payment                                  What is a Tier 2 Drug?
structure at retail pharmacies for a 30-day supply:                                  A Tier 2 Drug is a “preferred” brand-name drug. The list
                                                                                     of these preferred drugs is created by Medco, your
Deductible $50 Individual/ $100 Family
                                                                                     pharmacy vendor. Many factors are taken into account
Tier 1 (Generic): $10                                                                when deriving the list, such as the utilization of the drugs,
                                                                                     the cost, and the therapeutic class to name a few.
Tier 2 (Brand Formulary): 20%
(min. $25—max. $75)                                                                  What is important to know is that Tier 2 Prescription
                                                                                     Drugs are less expensive than Tier 3 Prescription Drugs.
 Tier 3 (Brand Non-Formulary): 50%
                                                                                     Tier 3 are non-preferred and have the highest coinsurance
(min. $40—max. $120)
                                                                                     level attached to them.
When you go to in-network pharmacies, you will be
                                                                                     Where can I find the Formulary Drug
responsible for paying the copay or coinsurance –
nothing more. The pharmacy will bill Medco for the left-
over amount. As you can see, you will pay the lowest                                 The Formulary Drug List is updated quarterly to ensure
copay if you use a generic drug. Make sure to ask your                               that newer, more effective drugs are on it. Drugs
pharmacist if a generic alternative is available for the                             automatically come off the list when generic
brand-name drug you are prescribed.                                                  alternatives become available. To get the most updated
                                                                                     formulary list, go to Once there,
You must use pharmacies that are in Medco’s network to                               you can download the formulary listing or search for a
receive the benefit levels above. Over 90% of pharmacies                             medication by name.
nationwide currently belong to this network. Should you
use an out-of-network pharmacy, you will be responsible                              You may want to print off the formulary list and take it with
for the co-pay listed above plus 20% of the remaining                                you to your next doctor’s appointment. If your doctor has
cost of the drug.                                                                    the list, he or she can be sure to prescribe you a preferred
                                                                                     drug. Make sure you take the most updated list as it is
Wouldn’t you rather pay $4 for your                                                  updated quarterly.
Did you know that Wal–Mart offers over 300 different
drugs at only $4 per prescription fill or refill (up to a 30-
day supply or 60 pill maximum). The program is available
at all Wal–Mart, Sam’s Club and Neighborhood Market
pharmacies. A similar program is also offered through
Target stores.

      Please note that certain drugs are priced higher in CA, CO, HI, MN, MT, PA, TN, WI, and WY due to state laws. Program not available in
      North Dakota. You can get these prescription drug savings whether or not you have any prescription drug coverage through your company,
      under Medicare or any other plan. The list of covered drugs is subject to change. Not all prescription drugs are covered by this program.
      Only prescriptions initially filled in person at a participating pharmacy are eligible for the $4 rate; refills must also be picked up in-store, but
      may be ordered in person, online or by phone. This program is not available for prescriptions filled by mail order. See your Wal-Mart
      pharmacist for more information. Speak with your doctor if you want to try a generic alternative to a drug you are currently taking.

    Prescription Drug Program Details

Mandated Generics                                                 Speciality Medications: Get
For Non-Preferred drugs, including nonsedating                    Personalized Service Through
antihistamines (Allegra®, Clarinex®, Zyrtec®, etc.). If           Accredo
you purchase a brand medication when a generic is
                                                                  Specialty medications are drugs that are used to treat
available, you will pay your copay plus the difference in
                                                                  complex conditions, such as cancer, growth hormone
cost between the brand and the generic.
                                                                  deficiency, hemophilia, hepatitis C, immune deficiency,
Medco by Mail Pharmacies                                          multiple sclerosis and rheumatoid arthritis. Medco’s
                                                                  specialty pharmacy, Accredo Health Group, Inc. is
Over 6 million members enjoy the convenience and
                                                                  composed of therapy-specific teams that provides an
savings of having their long-term medications
                                                                  enhanced level of personalized service to patients with
(maintenance medications, those taken for three
                                                                  special therapy needs. By ordering your speciality
months or more) delivered to their home or office.
                                                                  medications through Accredo, you can receive:
Medco by Mail advantages include:
                                                                  •	Personalized counseling from our dedicated team of
Get up to a 90 day supply (compared with a typical 30
                                                                    registered nurses and pharmacists.
day supply at retail) of each covered medication for just
one mail order payment.                                           •	Expedited, scheduled delivery of your medications at
                                                                    no extra charge.
Order refills online, by mail or by phone—anytime day
                                                                  •	Complimentary supplies, such as needles and syringes.
or night. To order online, register at
Refills are usually delivered within three to five after we       •	Refill reminders calls
receive your order. You can also have your doctor fax             •	Safety checks to help prevent potential drug interactions.
your prescriptions. Ask your doctor to call 1-888-327-

Choose a convenient payment option—Medco offers
two safe automatic options for prescription orders. You
can use e-check to have payments automatically
deducted from your checking account. Or you can use
AutoCharge to have payments automatically charged to
the credit card of your choice For more information, visit or call member services 1-800-418-

   Flexible Spending Account Overview

What is a healthcare Flexible                                     Remember, contributions to the Healthcare FSA are
                                                                  made on a pre-tax basis, and you don’t have to wait until
Spending Account (FSA)?                                           the end of the year for reimbursement. At any time during
A healthcare flexible spending account provides you the           the year, you have access to the full amount you elected
opportunity to benefit from the tax savings available by          to deposit for the year, less any reimbursements you
setting aside money to pay for future healthcare expenses         have previously received for that year.
on a pre-tax basis. Healthcare flexible spending account
contributions are not subject to federal income tax, Social       How do I get reimbursed?
Security taxes, and most state and local income taxes.            You do not need to submit a copy of a cancelled check or
Check with your local tax advisor on your state and local         a receipt for a bill that is already paid as proof of expense.
income tax laws.                                                  An invoice or copy of an unpaid bill is acceptable since
                                                                  the program operates on an incurred date. We will look at
How does the FSA account work?                                    the date the service was received to determine if it is
The Christian Church (Disciples of Christ) Flexible               eligible for the program year.
Spending Accounts for Healthcare (“Healthcare FSA”)
allows you to prefund out-of-pocket medical and dental            Dependent Care Spending
costs and other qualified medical costs not otherwise             Account
covered through the Churchwide Healthcare. Qualified
                                                                  Day care expenses for the following dependents while
expenses may include:
                                                                  you work (and if married, while your spouse is at work, is
•	Deductibles                                                     a full-time student or is disabled):
•	Well Baby Care                                                  •	Your children under 13;
•	Co-payments                                                     •	Your dependent who is physically or mentally disabled
•	Organized Weight Loss Programs                                    and incapable of self-care, including your spouse or
•	Vision Care (including RK and LASIK                               child of any age, and;
•	Dental Care                                                     •	Claimed as dependents for income tax purposes
•	Hearing Aids and other related expenses                         •	Your dependent parent or other dependent who spends
                                                                    at least eight hours a day in your home.
•	Prescription Drugs
                                                                  Eligible dependent care expenses include those for care
•	Transportation to receive care
                                                                  in your home, in a babysitter’s home, at a licensed day
•	Certain Non-covered procedures such as experimental             care
                                                                  •	Minimum: $520.00
•	Annual Physicals
                                                                  •	Maximum: $ 5,000.00 (or $2,500.00 if you are married
•	Body scanning and Heart scoring
                                                                    and file separate income tax returns)

   Flexible Spending Account FAQ

Use it or lose it                                              When may I enroll?
It is important to accurately estimate your expenses and       You must enroll within 31 days of your hire date or along
only elect an annual contribution to cover expected            with enrollment in the Churchwide Health Care Program.
claims, because IRS rules require that any money left in       If you do, your contributions take effect as of the date you
your Health Care FSA account will be forfeited. However,       enroll. If you don’t enroll within the prescribed time
as long you are a participant you do have until March 31       frames, you must wait until the next annual enrollment to
to submit any eligible expenses you incur between              enroll.
January 1 and March 15 of the next year.
                                                               Annual enrollment takes place each year. During this
How do I submit a claim?                                       time, you can start, stop, or change the amounts you are
                                                               contributing to the flexible spending account(s). Any
When you have an eligible expense to be reimbursed
                                                               elections you make, however, take effect on January 1
from your Health Care FSA, you can file a claim by
                                                               and remain in effect through December 31 of that
completing a Flexible Spending Account Claim Form and
                                                               calendar year.
submitting it, and proof of expense, to Employee Benefit
Data Services Company, a Highmark BCBS subsidiary:             The before-tax advantage
Employee Benefit Data Services Company                         By contributing to a Healthcare FSA, you authorize your
One Gateway Center                                             congregation or church-related organization to set aside
420 North Duguesne Boulevard, Suite 1250                       certain amount from your pay before taxes. Since you are
Pittsburgh, PA 15222-1437                                      taxed only on the cash salary amount remaining in your
                                                               paycheck, this reduces your taxable wages. Lower
This form is also available on the CLBA Website:
                                                               taxable income means that you pay less in taxes.
                                                               Your Health Care FSA contributions are not subject to:
Can medical and dental premiums
                                                               •	Federal Income Taxes
be reimbursed?
                                                               •	Social Security (FICA or SECA) taxes; and
No, the IRS does not allow reimbursement of monthly
insurance premiums through a flexible spending account.        •	Most state and local (including county) income taxes.
                                                                 (Rules vary, and state and local taxes are subject to
                                                                 frequent changes.)

    Voluntary Dental Program

Dental PPO plan – Delta Dental (voluntary)
We are excited to announce that this year your Dental             You will receive your new Dental ID card in the mail within
PPO coverage will move to Delta Dental. Delta Dental has          three weeks of your enrollment.
one of largest network of dentists in the country
                                                                  To locate participating dentists, go to www.deltadental.
through DeltaPremier USA, so there should be no
                                                                  com or call 1-800-524-0149.
disruption with your current dental provider. With the PPO
dental plan, you may see any dentist that you choose.
However, you have access to discounted charges by
utilizing network providers.

                 PLAN FEATURES                                                             INDEMNITY
                 Single                                                                         $50
                 Family                                                                   $50 per person
                 ANNUAL MAXIMUM BENEFIT – TYPE A, B AND C SERVICES                            $1,000

                 •	Oral Exams & Evaluations – 1 per 6 months
                 •	Cleaning – 1 per 6 months
                 •	Fluoride Treatment – 1 per 12 months for dependents under age 19            100%
                 •	Bitewing Series – 1 per 6 months for dependents under age 19 and
                   1 per 12 months for all other covered persons
                 •	Full mouth X-ray – 1 every 5 years

                 TYPE B - BASIC RESTORATIVE
                 •	Oral Surgery
                 •	First installation of space maintainers
                 •	Fillings
                 •	Extractions
                 •	Relining and rebasing of existing removable dentures
                 •	Endodontic treatment (including root canal treatment)
                 •	Periodontal services and surgery

                 TYPE C - MAJOR RESTORATIVE
                 Inlays and Crowns
                 Crown Repair
                 Bridgework installation – fixed and removable
                 Replacement of existing removable denture or fixed bridgework

                 TYPE D - ORTHODONTIA (Adult & Child)                                          50%

                 Lifetime Maximum                                                              $500

   Employer Paid Dental Program

Dental PPO plan – Delta Dental (employer paid)
What is DeltaPremier USA?                                       participating dentist. That is because participating dentist
DeltaPremier USA is a carefully managed fee-for-service         agree to accept their fee or Delta Dental’s UCR fee,
program administered by De;ta Dental. “Fee-for-service”         whichever is less, as full payment for covered services.
means that the dentist charges a fee for each service           More than 108,000 dentist throughout the United States
performed, then sends a claim to Delta Dental. Delta            and its territories participate in DeltaPremier USA.
Dental then pays a certain percentage for each covered
service. With DeltaPremier USA, you are likely to lower
your out-of-pocket costs by going to a DeltaPremier

                PLAN FEATURES                                                              INDEMNITY
                Single                                                                         $50
                Family                                                                         $150
                ANNUAL MAXIMUM BENEFIT – TYPE A, B AND C SERVICES                             $1,000
                •	Oral Exams & Evaluations – 1 per 6 months
                •	Cleaning – 1 per 6 months
                •	Fluoride Treatment – 1 per 12 months for dependents under age 19            100%
                •	Bitewing Series – 1 per 6 months for dependents under age 19 and
                  1 per 12 months for all other covered persons
                •	Full mouth X-ray – 1 every 5 years

                TYPE B - BASIC RESTORATIVE
                •	Oral Surgery
                •	First installation of space maintainers
                •	Fillings
                •	Extractions
                •	Relining and rebasing of existing removable dentures
                •	Endodontic treatment (including root canal treatment)
                •	Periodontal services and surgery

                TYPE C - MAJOR RESTORATIVE
                Inlays and crowns
                Crown repair
                Bridgework installation – fixed and removable
                Replacement of existing removable denture or fixed bridgework

                TYPE D - ORTHODONTIA (Adult & Child)                                           50%

                Lifetime Maximum                                                              $1,000

    Vision Benefits

Vision – Vision Service Plan (VSP)
We are pleased to announce that this year your vision             Effortless Benefits
coverage will be provided by Vision Service Plan (VSP)            Choose a VSP doctor at or call
with national and local network access. With VSP doctors,         1-800-877-7195.
you’ll enjoy quality, personalized care. Your VSP doctors
will get to know you and your eyes, helping you keep              Make an appointment and tell the doctor you are a VSP
them health year after year. Besides helping you see              member.
better, routine eye exams can detect symptoms of serious
                                                                  That’s it! No ID cards or filling out claim forms.
conditions such as glaucoma, cataracts, and diabetes,
even tumors.

                                          Your Coverage From a VSP Doctor
               Exam covered in
                               Every plan year
               Prescription Eyewear Discounts

               Lens                  20% discount when a complete pair of glasses are purchased.

               Frame                 20% discount when a complete pair of glasses are purchased.
                                     15% discount off the contact lens fitting and evaluation exam. This
               Contact Lens Care
                                     exam is in addition to your vision exam to ensure proper fit of contacts.
               Extra Discounts and Savings

               Vision Correction Discounts
                                     20% off additional complete pairs of prescription glasses.
               Contacts*             15% off cost of contact lens exam (fitting and evaluation).
                                     20% off additional complete pairs of prescription glasses
               Glasses               *Available from the same VSP doctor who provided your eye exam
                                     within the last 12 months.
                                     15% off cost of contact lens exam (fitting and evaluation)
               Contacts*             *Available from the same VSP doctor who provided your eye exam
                                     within the last 12 months.
               Your Copays           Exam $20

    Legal Updates

The Women’s Health and Cancer                                         HIPAA Special Enrollment Rights
Rights Act                                                            If you are declining or have declined enrollment for
The Women’s Health and Cancer Rights Act requires                     yourself or your dependents (including your spouse)
group health plans that provide coverage for mastectomy               because of other health insurance coverage, you may in
to provide coverage for certain reconstructive services.              the future be able to enroll yourself or your dependents in
This law also requires that written notice of the availability        this plan, provided that you request enrollment within 30
of the coverage be delivered to all plan participants upon            days after your other coverage ends.
enrollment and annually thereafter. This language serves              You may also be able to enroll yourself or your dependents
to fulfill that requirement for this year. These services             in the future if you or your dependents lose health
include:                                                              coverage under Medicaid or your state’s Children’s
Reconstruction of the breast upon which the mastectomy                Health Insurance Program, or become eligible for state
has been performed;                                                   premium assistance for purchasing coverage under a
                                                                      group health plan, provided that you request enrollment
Surgery/reconstruction of the other breast to produce a               within 60 days after that coverage ends or after you
symmetrical appearance;                                               become eligible for premium assistance.
Prostheses; and                                                       In addition, if you have a new dependent as a result of
                                                                      marriage, birth, adoption, or placement for adoption, you
Treatment for physical complications during all stages of
                                                                      may be able to enroll yourself and your dependents,
mastectomy, including lymphedemas.
                                                                      provided that you request enrollment within 30 days after
In addition, the plan may not:                                        the marriage, birth, adoption, or placement for adoption.
Interfere with a participant’s rights under the plan to avoid
these requirements; or

Offer inducements to the healthcare provider, or assess
penalties against the provider, in an attempt to interfere
with the requirements of the law.

However, the plan may apply deductibles, coinsurance,
and copays consistent with other coverage provided by
the Plan.

    Legal Updates

HIPAA Privacy Notice                                               Continuation Required by Federal
Contact Michael Porter for further details or questions.           Law for You and Your Dependents
Churchwide Healthcare follows all legal requirements in            Federal Law enables You or Your Dependent to continue
regard to protecting your Protected Health Information             health insurance if coverage would cease due to a
(PHI).                                                             reduction of your work hours or your termination of
                                                                   employment (other than for gross misconduct). Federal
Newborn’s and Mother’s Health                                      law also enables Your Dependent(s) to continue health
Protection Act                                                     insurance if their coverage ceases due to your death,
Federal Law (Newborns’ and Mothers’ Health Protection              divorce, legal separation, or with respect to a Dependent
Act of 1996) prohibits the plan from limiting a mother’s or        Child(ren), failure to continue to qualify as a Dependent.
newborn’s length of hospital stay to less than 48 hours            Continuation must be elected in accordance with the
for a normal delivery or 96 hours for a cesarean delivery          rules of Your Employer’s group health plan(s) and is
or from requiring the provider to obtain pre-authorization         subject to Federal Law, regulations and interpretations.
for a stay of 48 hours or 96 hours, as appropriate.
However, Federal Law generally does not prohibit the               Children’s Health Insurance
attending provider, after consultation with the mother,            Program (CHIP) Coverage
from discharging the mother or her newborn earlier than            Under the Churchwide Healthcare group health plans,
48 hours for normal delivery or 96 hours for cesarean              employees and their eligible dependents may enroll for
delivery.                                                          coverage when they first become eligible for coverage
                                                                   and annually during Open Enrollment. In addition,
Mental Health Parity Act                                           employees and/or their eligible dependents are allowed
According to the Mental Health Parity Act of 1996, the             to enroll in the group health plan if they experience a
lifetime maximum and annual maximum dollar limits for              special enrollment event under the Health Insurance
mental health benefits under the Churchwide Healthcare             Portability and Accountability Act (HIPAA). Effective April
Group Medical Plan are equal to the lifetime maximum               1, 2009, the plan rules have changed to allow you and/or
and annual maximum dollar limits for medical and                   your eligible dependents to enroll for coverage under a
surgical benefits under this plan. However, mental health          new HIPAA special enrollment opportunity. If you have
benefits may be limited to a maximum number of                     any questions about the attached notice or want more
treatment days per year or series per lifetime.                    information, please contact Michael Porter, Director of
                                                                   Health Services 866-495-7322.

    Medicare Part D Notice

Important notice from Churchwide                                   participants, expected to pay out as much as standard
                                                                   Medicare prescription drug coverage pays and is
Healthcare about your prescription                                 therefore considered Creditable Coverage. Because your
drug coverage and Medicare                                         existing coverage is Creditable Coverage, you can keep
Please read this notice carefully and keep it where you            this coverage and not pay a higher premium (a penalty) if
can find it. This notice has information about your current        you later decide to join a Medicare drug plan.
prescription drug coverage with Churchwide Healthcare
                                                                   When can you join a Medicare drug plan?
and about your options under Medicare’s prescription
drug coverage. This information can help you decide                You can join a Medicare drug plan when you first become
whether or not you want to join a Medicare drug plan. If           eligible for Medicare and each year from November 15th
you are considering joining, you should compare your               through December 31st.
current coverage, including which drugs are covered at             However, if you lose your current creditable prescription
what cost, with the coverage and costs of the plans                drug coverage, through no fault of your own, you will also
offering Medicare prescription drug coverage in your               be eligible for a two (2) month Special Enrollment Period
area. Information about where you can get help to make             (SEP) to join a Medicare drug plan.
decisions about your prescription drug coverage is at the
end of this notice.                                                What happens to your current coverage if you
                                                                   decide to join a Medicare drug plan?
There are two important things you need to know about
                                                                   If you decide to join a Medicare drug plan, your current
your current coverage and Medicare’s prescription drug
                                                                   Churchwide Healthcare coverage will not be affected.
                                                                   Your current coverage pays for other expenses in addition
Medicare prescription drug coverage became available               to prescription drugs. If you enroll in a Medicare
in 2006 to everyone with Medicare. You can get this                prescription drug plan, you and your eligible dependents
coverage if you join a Medicare Prescription Drug Plan or          will still be eligible to receive all of your current health and
join a Medicare Advantage Plan (like an HMO or PPO)                prescription drug benefits. If you drop your current
that offers prescription drug coverage. All Medicare drug          coverage and enroll in Medicare prescription drug
plans provide at least a standard level of coverage set by         coverage, you may enroll back into Churchwide
Medicare. Some plans may also offer more coverage for              Healthcare’s benefit plan during the annual enrollment
a higher monthly premium.                                          period under Churchwide Healthcare’s Health Benefit
Churchwide Healthcare has determined that the
prescription drug coverage offered by the Churchwide
Healthcare Health Plan is, on average for all plan

    Medicare Part D Notice

When will you pay a higher                                           For more information about Medicare
                                                                     prescription drug coverage:
premium (penalty) to join a
Medicare drug plan?
You should also know that if you drop or lose your current           Call your State Health Insurance Assistance Program
coverage with Churchwide Healthcare and don’t join a                 (see the inside back cover of your copy of the “Medicare
Medicare drug plan within 63 continuous days after your              & You” handbook for their telephone number) for
current coverage ends, you may pay a higher premium                  personalized help
(a penalty) to join a Medicare drug plan later.                      Call 1-800-MEDICARE (1-800-633-4227). TTY users
If you go 63 continuous days or longer without creditable            should call 1-877-486-2048.
prescription drug coverage, your monthly premium may                 If you have limited income and resources, extra help
go up by at least 1% of the Medicare base beneficiary                paying for Medicare prescription drug coverage is
premium per month for every month that you did not                   available. For information about this extra help, visit
have that coverage. For example, if you go nineteen                  Social Security on the web at, or
months without creditable coverage, your premium may                 call them at 1-800-772-1213 (TTY 1-800-325-0778).
consistently be at least 19% higher than the Medicare
base beneficiary premium. You may have to pay this                                       Date: 01/01/2009
higher premium (a penalty) as long as you have Medicare
                                                                      Name of Entity/Sender: Christian Church Health
prescription drug coverage. In addition, you may have to
                                                                                             Care Benefit Trust / Michael
wait until the following November to join.
For more information about this notice or your
                                                                     Contact–Position/Office: Director of Health Services
current prescription drug coverage…
Contact the person listed below for further information                              Address: 130 East Washington Street
Michael Porter at 866-495-7322 NOTE: You’ll get this                                          Indianapolis, IN 46204
notice each year. You will also get it before the next period                 Phone Number: 866-495-7322
you can join a Medicare drug plan, and if this coverage
through Churchwide Healthcare changes. You also may
request a copy of this notice at any time.

For more information about your options under
medicare prescription drug coverage…
More detailed information about Medicare plans that offer
prescription drug coverage is in the “Medicare & You”
handbook. You’ll get a copy of the handbook in the mail
every year from Medicare. You may also be contacted
directly by Medicare drug plans.

  Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare
  drug plans, you may be required to provide a copy of this notice when you join to show
  whether or not you have maintained creditable coverage and, therefore, whether or not you
  are required to pay a higher premium (a penalty).

 Medical and Prescription Drug Rates

    PPO 1
                                                        Employee +
$500 Deductible     Employee Only   Employee + Spouse                 Employee + Family
      <25              $224.82           $494.59          $540.34          $810.13
     25-29             $290.24           $638.55          $605.78          $954.07
     30-34             $304.29           $669.45          $619.83          $984.97
     35-39             $331.60           $729.51          $647.14         $1,045.04
     40-44             $370.58           $815.25          $686.11         $1,130.79
     45-49             $426.62           $938.53          $742.14         $1,254.06
     50-54             $517.57          $1,138.65         $833.10         $1,454.19
     55-59             $685.61          $1,508.34        $1,001.14        $1,823.87
     60-64             $850.44          $1,870.98        $1,150.94        $2,171.49
      65+             $1,151.70         $2,533.77        $1,452.21        $2,834.27
     PPO 2
                                                        Employee +
$1,000 Deductible   Employee Only   Employee + Spouse                 Employee + Family
      <25              $203.37           $447.43          $489.64          $733.69
     25-29             $262.57           $577.66          $548.84          $863.92
     30-34             $275.28           $605.62          $561.54          $891.88
     35-39             $299.99           $659.95          $586.25          $946.22
     40-44             $335.23           $737.53          $621.51         $1,023.80
     45-49             $385.93           $849.06          $672.19         $1,135.32
     50-54             $468.22          $1,030.10         $754.49         $1,316.36
     55-59             $620.25          $1,364.54         $906.51         $1,650.80
     60-64             $769.36          $1,692.60        $1,041.99        $1,965.24
      65+             $1,041.90         $2,292.18        $1,314.53        $2,564.81
PPO HDHP (HSA                                           Employee +
                    Employee Only   Employee + Spouse                 Employee + Family
   Eligible)                                             Child(ren)
      <25              $171.91           $378.20          $415.59          $621.88
     25-29             $220.95           $462.96          $464.65          $729.79
     30-34             $227.13           $499.66          $470.81          $743.36
     35-39             $244.09           $537.00          $487.78          $780.69
     40-44             $274.88           $604.73          $518.57          $848.42
     45-49             $335.63           $738.37          $579.31          $982.07
     50-54             $413.77           $910.29          $657.46         $1,153.97
     55-59             $553.70          $1,218.17         $797.40         $1,461.84
     60-64             $692.01          $1,522.41         $924.08         $1,754.48
      65+              $954.52          $2,099.93        $1,228.87        $2,374.29

Dental Rates

                                                                 Employee +
Region          Employee Only        Employee + Spouse                                  Employee + Family
Region I            $29.35                  $57.61                  $67.98                     $110.19

Region II           $27.32                  $53.63                  $63.29                     $102.58

Region III          $24.33                  $47.77                  $56.37                     $91.37

Region IV           $21.27                  $41.75                  $49.27                     $79.86

                                                                 Employee +
Region          Employee Only        Employee + Spouse                                  Employee + Family
Region I            $41.95                  $82.64                  $88.91                     $146.69

Region II           $36.56                  $72.34                  $77.83                     $131.03

Region III          $31.94                  $63.18                  $67.98                     $114.46

Region IV           $29.65                  $58.67                  $63.12                     $106.27

                                    Regional Rates - Based on Participants Residence
             Alaska, California, Colorado, Connecticut, Delaware, Minnesota, New Jersey, New Mexico, Oklahoma,
Region I
             Oregon, Washington
             Arizona, Florida, Guam, Hawaii, Idaho, Illinois, Maine, Massachusetts, Michigan, Nebraska, Nevada,
Region II
             New Hampshire, New York, Rhode Island, Utah, Vermont, Virgin Islands, Washington D.C., or Wyoming
             Alabama, Georgia, Kansas, Louisiana, Missouri, Montana, North Dakota, South Carolina, South
Region III
             Dakota, Texas, Virginia, or Wisconsin
             Arkansas, Indiana, Iowa, Kentucky, Maryland, Mississippi, North Carolina, Ohio, Pennsylvania, Puerto
Region IV
             Rico, Tennessee, or West Virginia

 Provider Reference Information

                                     Policy No.             Member
Coverage              Carrier                                                 Website Address
                                      Contact             Services No.

Medical           Highmark BCBS         13145         1.800.648.4078

                   Medco Health        121842         1.800.818.0093

Dental              Delta Dental         9823         1.800.524.0149

Vision                  VSP              N/A          1.800.877.7195  

                  Employee Benefit
Spending                                              1.800.860.EBDS 
                   Data Services

Enrollment         Businessolver     Thad Phillips    1.866.502.3468

Billing/Claims/                        Michael
                    Churchwide                        1.866.495.7322
Eligibility                            Porter

The information contained in this guide should in no way be construed as a promise or guarantee
of employment. The company reserves the right to modify, amend, suspend or terminate any plan
at any time for any reason. If there is a conflict between the information in this brochure and the
actual plan documents or policies, the document or policies will always prevail. Complete details
about the benefits can be obtained by reviewing current plan descriptions, contracts, certificates,
policies and plan documents available from Churchwide Healthcare attention Michael Porter.



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