HCA Health and Welfare Benefits Plan and HCA 401(k) Plan Summary Plan Descriptions As of August 1, 2010 Union Disclaimer If you are an employee at an HCA-affiliated facility where there is union representation or at a facility that mirrors the benefits of a facility with union representation, not all of the information contained here may apply to you, or it may apply to you in a modified manner. Please see your facility’s Human Resources department for details. As of Sept. 1, 2008, there are plan differences at the following facilities: Alaska Regional Hospital Good Samaritan Hospital Los Gatos Surgery Center Los Robles Hospital & Medical Center Regional Medical Center of San Jose Research Medical Center (Operating Engineers only) Riverside Community Hospital Southern Hills Hospital & Medical Center (Las Vegas) Sunrise Hospital and Medical Center West Hills Hospital & Medical Center West Hills Surgery Center Other facilities that mirror the benefits of the facilities listed above. Esta Descripción del Resumen del Plan y el folleto contienen un resumen en inglés de sus derechos y beneficios del plan bajo los planes de beneficio auspiciados por HCA. Si usted tiene dificultades en entender cualquier parte de esta Descripción del Resumen del Plan o folleto, contacte a Lifetimes al 1-800-566-4114. Las horas de oficina son de lunes a viernes, 7 a.m. a 7 p.m. #H000076045
Transcript
HCA Health and Welfare Benefits Plan and HCA 401(k) Plan Summary Plan Descriptions
As of August 1, 2010
Union Disclaimer If you are an employee at an HCA-affiliated facility where there is union representation or at a facility that mirrors the benefits of a facility with union representation, not all of the information contained here may apply to you, or it may apply to you in a modified manner. Please see your facility’s Human Resources department for details. As of Sept. 1, 2008, there are plan differences at the following facilities: Alaska Regional Hospital Good Samaritan Hospital Los Gatos Surgery Center Los Robles Hospital & Medical Center Regional Medical Center of San Jose Research Medical Center (Operating Engineers only) Riverside Community Hospital Southern Hills Hospital & Medical Center (Las Vegas) Sunrise Hospital and Medical Center West Hills Hospital & Medical Center West Hills Surgery Center Other facilities that mirror the benefits of the facilities listed above.
Esta Descripción del Resumen del Plan y el folleto contienen un resumen en inglés de sus derechos y beneficios del plan bajo los planes de beneficio auspiciados por HCA. Si usted tiene dificultades en entender cualquier parte de esta Descripción del Resumen del Plan o folleto, contacte a Lifetimes al 1-800-566-4114. Las horas de oficina son de lunes a viernes, 7 a.m. a 7 p.m.
#H000076045
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Topics
Introduction to HCA Total Rewards ....................................................................................... 1
Naming a Beneficiary .............................................................................................................. 2
If You Take a Leave of Absence ............................................................................................. 4
Health and Welfare Benefits Eligibility and Participation .................................................... 7
Retirement Program Eligibility and Participation ............................................................... 18
Medical Benefits .................................................................................................................... 21
Introduction to HCA Total Rewards Note: Plan information is updated periodically. The most accurate information is posted at HCArewards.com. The HMO Medical benefit options have separate Summary Plan Descriptions with additional information about the benefit offered under those HMOs. Please read the HMO Summary Plan Descriptions along with this SPD.
As an HCA-affiliated employee, you are part of team that puts patients first and offers best-in-class healthcare at state-of-the-art facilities. While your focus is on patient care, HCA's focus is on caring for you and your future. One of the ways HCA takes care of its affiliated employees is through the HCA Total Rewards Program. HCA has plans and programs that provide employees with financial and non-financial rewards — pay, incentives, benefits, a healthy work environment and a variety of other rewards — in an effort to create a valuable employment experience.
HCA knows that people are different. They have different needs that require different benefits. That's why the HCA Total Rewards program offers a flexible benefits program to eligible employees of its subsidiaries and affiliates. This program allows you to choose the benefits that best fit the needs of you and your family.
The HCA Total Rewards program offers the following benefit options:
Health and Welfare Benefits Plan:
Medical Dental Vision Employee Assistance Program Flexible Spending Accounts Life and AD&D Insurance and Dependent Life Insurance Long-Term Disability Voluntary Benefits
o Auto & Home Insurance (Note: Home insurance not available in all locations) o Legal Benefit o Long-Term Care o Short-Term Disability o Voluntary Permanent Life Insurance
Retirement Benefits:
401(k) Plan
Enrolling in Benefits: You'll have the opportunity to enroll in Health and Welfare benefits when you begin employment after you complete any applicable eligibility period and again each year during the annual enrollment period.
Certain default coverage elections apply if you do not enroll. Specifically, if you do not enroll by your enrollment deadline, you will receive the default coverage listed at LifeTimes Connection.
If you are a full-time employee as designated by your facility, you may receive money back in the form of Cash-Out Dollars if you waive certain benefits. Cash-Out Dollars are considered taxable income and will be taxed in the same way that your current pay is taxed.
You are automatically enrolled in the HCA 401(k) Plan when you become eligible. You can opt out of 401(k) plan participation by logging on to LifeTimes Connection at HCArewards.com. Find more information about your benefit options and the cost associated with each by logging on to LifeTimes Connection at HCArewards.com.
Making Changes:
The choices you make when you enroll for Health and Welfare benefits remain in effect throughout the plan year. You generally may not make any changes to your benefit choices until the next annual enrollment period (see page 14) — unless you experience a qualifying change in status or qualify for a “special enrollment” period. See the Making Changes During the Year section for more information.
You can change your contribution rate, investment fund or transfer money within the HCA 401(k) Plan at any time. Changes are effective per pay period.
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Benefits Information: Which benefit options are best for you? Only you can decide, but this SPD can help. It contains important information about each of your benefit options. Review the content in this SPD first for a general understanding of the available benefits. Then, when you have a question or need to use your benefits, just turn to the SPD and go to the section that applies.
Even if you don’t choose to enroll in all your benefit options now, you may decide to enroll in the future. If you do change your mind in the future — or even if you just want to reevaluate your options — you may want a copy of the Summary Plan Description (SPD).
Please Note: Benefit information is updated periodically. You should always check the SPD posted at HCArewards.com for the most up-to-date information. To receive certain benefits materials electronically instead of by mail, sign up for less paper by logging on to LifeTimes Connection at HCArewards.com.
HCArewards.com HCArewards.com is your resource for information on all of the benefits and rewards you receive as an HCA-affiliated employee. Instances in this Summary Plan Description that refer you to HCArewards.com typically require that you first login to the customized view of HCArewards.com according to the following instructions:
Go to www.HCArewards.com Click on the “Login” button Click on the “Continue to Login Screen” link Enter your LifeTimes Connection User ID and Password or follow the links to set or reset them Once you are logged on to the LifeTimes Connection site, click on the “View your HCArewards.com now” link located
on the right-hand side of the screen. This will open your customized view of HCArewards.com
You must follow the above instructions to access online Summary Plan Descriptions, benefits provider directories and other customized rewards information.
LifeTimes Connection LifeTimes Connection is your connection to benefits information. You can use LifeTimes Connection to:
Enroll in Health and Welfare benefits or the HCA 401(k) Plan when you are eligible Change your Health and Welfare benefit choices within 31 days of a qualifying change in status Add, review or change your life insurance, 401(k) and/or retirement beneficiary information View your balances and rates of return for the HCA 401(k) Plan Change your contribution rate or investments in your HCA 401(k) Plan account Change your investment fund or transfer money within the HCA 401(k) Plan Get answers to general benefits questions
You will need your PIN/password to access the system. The LifeTimes Connection Web site and voice response system allow you to use a PIN/password that can be up to 20 characters in length and use letters, numbers or a combination of both. The first time you go online or call LifeTimes Connection, you will be asked to enter your Social Security number, date of hire and home ZIP code. If these match the data about you on the system, you can then proceed to set your PIN/password.
You can obtain information about your benefits 24 hours a day through the interactive voice response system at 1-800-566-4114 or online at the LifeTimes Connection Web site through HCArewards.com. If you need to speak directly with a Benefits Center Representative, they are available Monday through Friday, from 7 a.m. to 7 p.m. (Central Time).
Naming a Beneficiary
Life and AD&D Insurance You will be asked to name a beneficiary when you enroll for Life and AD&D Insurance coverage. The beneficiary you name will receive benefits from the plan if you die. If you name more than one beneficiary, you should include how benefits should be divided among them. Otherwise, the benefit will be divided equally among the beneficiaries. If a beneficiary dies before you, his or her share will pass to any surviving beneficiaries in the order you designated.
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Changing Your Beneficiary: You may change your beneficiary designation at any time by submitting a new Beneficiary Designation Change Form. Log on to LifeTimes Connection at HCArewards.com or call 1-800-566-4114 to request a form or ask questions about naming a beneficiary. Your new designation will take effect on the date you sign the form. However, the change in beneficiary will not go into effect if the insurance company has taken any action or made any payment before LifeTimes receives the completed Beneficiary Designation Change Form.
Note: If you make a beneficiary change for Life and AD&D Insurance, it will only be changed for Life and AD&D and will not apply to the HCA 401(k) Plan. You must make changes separately for each of those benefits.
If You Do Not Name a Beneficiary If you do not have a beneficiary on file with LifeTimes, or if your beneficiary dies before you or your beneficiary is disqualified, the insurance company may pay death benefits to your estate. However, Prudential has the right to make payments to one or more of your surviving family members in the following order:
Your spouse Your child or children Your mother or father Your brothers or sisters
401(k) Plan When you enroll, you should name a beneficiary for your plan account. Your beneficiary is the person who will receive the value of your vested plan account if you die before receiving the account balance yourself. Your beneficiary designation applies only to the 401(k) Plan.* If you name more than one beneficiary, your benefits will be divided equally among all beneficiaries.
To designate a beneficiary, log onto HCArewards.com or call LifeTimes Connection. If you are married, your spouse automatically is your beneficiary. If you want to name someone other than your spouse as your beneficiary, your spouse must also sign the Beneficiary Designation Form. If your spouse is legally incompetent, a legal guardian may execute a waiver on behalf of your spouse. Your spouse’s signature must be witnessed by a notary public. All death benefits from the Plan will be paid in a lump sum.
If you are married at the time of your death and you did not name a beneficiary with appropriate spousal consent, your benefits will be paid to your spouse. For all purposes of the HCA 401(k) Plan, you are considered married only if you are married to someone of the opposite sex, according to the state law of your residence.
Upon divorce, a previous designation of your spouse as the sole beneficiary as well as any designation of a contingent beneficiary is void. If you designated more than one beneficiary and your spouse is one of the beneficiaries, your spouse’s share will be void upon divorce and the shares of the remaining beneficiaries will be proportionately increased. The same voiding and reallocation procedures apply in the event of divorce if your spouse is named as one of two or more contingent beneficiaries.
If you are single at the time of your death and you have not named a beneficiary or you named a beneficiary but no beneficiary survives you, or if you are married at the time of your death and you named a beneficiary (with spousal consent) but no beneficiary survives you, your benefits will be paid to the following entities/persons in the following order:
Surviving spouse Children (if you have no surviving spouse) Your estate (if established within six months of death)**
Under certain conditions, a named beneficiary can waive his rights to benefits.
Changing Your Beneficiary: You may change your beneficiary designation at any time by logging on to LifeTimes Connection at HCArewards.com or calling 1-800-566-4114. If you are married and want to change your beneficiary to someone other than your spouse (or in addition to your spouse), your spouse must give written consent in the presence of a notary public. Your new beneficiary designation will take effect when the information is received by LifeTimes Connection. You should review your designation from time to time to make sure it is up to date. Note: If you make a beneficiary change for Life and AD&D Insurance, it will only be changed for Life and AD&D and will not apply to HCA 401(k) Plan.
*The HCA-The Healthcare Company Stock Bonus Plan was merged into the HCA 401(k) Plan on December 31, 2000. If you submitted a Beneficiary Designation Form prior to 2001 for the Stock Bonus Plan that applied only to the Stock Bonus Plan or applied to the Stock Bonus Plan and the HCA 401(k) Plan (or the Salary Deferral Plan, which is the prior name of the 401(k)
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Plan), but did not apply to the former Retirement Plan (which was then called the Money Purchase Pension Plan), and you have not submitted a new Beneficiary Designation Form since that time, then the Beneficiary Designation Form that you submitted prior to 2001 with respect to the Stock Bonus Plan will apply to all accounts in the 401(k) Plan except your former Retirement Plan account, and any Beneficiary Designation Form that you filed with respect to your former Retirement Plan account will continue to apply to that account, until a new Beneficiary Designation Form that applies to all accounts in the Plan is properly executed and submitted. If you submitted a Beneficiary Designation Form prior to 2001 for the 401(k) Plan (or, the Salary Deferral Plan) that did not apply to the Stock Bonus Plan or the former Retirement Plan (which was then called the Money Purchase Pension Plan), and you have not submitted a new Beneficiary Designation Form since that time, then the Beneficiary Designation Form that you filed prior to 2001 for the 401(k) Plan will apply to all accounts except your former Retirement Plan account, and any Beneficiary Designation Form that you filed with respect to your former Retirement Plan account will continue to apply to that account, until a new Beneficiary Designation Form that applies to all accounts in the Plan is properly executed and submitted. If you submitted a Beneficiary Designation Form after 2000 with respect to the HCA 401(k) Plan that did not apply to the former Retirement Plan, then that Beneficiary Designation Form will apply to all accounts in the 401(k) Plan except the former Retirement Plan account, and any Beneficiary Designation Form that you filed with respect to the former Retirement Plan account will continue to apply to that account until a new Beneficiary Designation Form is properly executed and submitted that applies to all accounts in the 401(k) Plan. Other possible death benefits combinations apply. Generally, if you filed a separate designation for one plan, that designation continues to apply only to that plan. Contact LifeTimes Connection at 1-800-566-4114 to determine the payee(s) currently applicable to your benefits. The Plan Administrator may void existing forms as of a prospective date following advance notice to participants.
**The Plan Administrator may allow an estate (or state law equivalent) which is established within six months of death, but is defective under state law, to be cured and refiled with the Plan Administrator by the estate’s executor or administrator within six months following the initial six-month period that began on the date of death.
If You Take a Leave of Absence
Health and Welfare Benefits You may continue the following HCA Health and Welfare benefits elections during a leave of absence:
Medical Dental Vision Employee Assistance Program Health Care Flexible Spending Account (You may not continue participating in the Day Care Flexible Spending Account
during a leave of absence that extends beyond two weeks.) Life and Accidental Death and Dismemberment (AD&D) Long-Term Disability
If you are on a paid leave, your contributions continue (except for the Day Care Flexible Spending Account) unless you notify LifeTimes Connection otherwise. If you are on an unpaid leave of absence, you must pay the full cost of your coverage (including Basic Life and AD&D) directly to LifeTimes Connection after your paid leave ends and your unpaid leave begins. If your unpaid leave is covered under the Family and Medical Leave Act (FMLA), you will continue to pay the employee cost of coverage directly to LifeTimes Connection throughout your FMLA leave.
If your leave is due to Workers’ Compensation, you will continue to pay the employee cost of coverage directly to LifeTimes Connection for the leave period, but not more than six months.
No matter what type of leave of absence you take (including FMLA or Workers’ Compensation), the maximum amount of time you can continue benefits is six months from the date you began your leave of absence. If you are still on a leave of absence after six months, your active participation in all welfare benefits ends at the end of the month.
For Long-Term Disability, effective July 1, 2008, you must continue premium payments whether on a paid or unpaid leave — to be eligible to receive benefits at the end of the elimination period. However, you will become eligible to continue your Medical, Dental and Vision coverage and your participation in the Health Care Flexible Spending Account through COBRA.
If you elect to drop coverage during an unpaid leave of absence, according to the change in status rules, your coverage ends as of the date your unpaid leave of absence begins. If you do not elect to drop coverage, you will be required to pay the cost of your coverage. If you fail to make the required payments, your coverage ends the last day before the leave in which your unpaid leave of absence began or the last day of the month in which you paid your premiums in full, whichever is later.
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If you elected to drop coverage during an unpaid leave of absence, you may reinstate your coverage if you call LifeTimes Connection within 31 days of your return. Different rules apply for Life and AD&D Insurance.
Coverage will begin on the date you return. If you do not call within 31 days of your return to work, no coverage will be provided for the remainder of the year. At annual enrollment, you may again elect coverage; however, you may have to submit Evidence of Insurability for Life and AD&D Insurance and Long-Term Disability coverage. The insurance carrier will decide if coverage can again become effective.
For more information about a leave of absence, contact your Human Resources department or call LifeTimes Connection at 1-800-566-4114.
401(k) Plan You may be able to continue your participation during leaves of absence under this Plan under certain conditions.
Continuation of Participation on Approved Leaves of Absence: If you take an approved paid leave of absence (including short-term disability leave, but in most cases not during military leave) and the regular payroll system applies to your pay, you may continue to make Voluntary Contributions to the Plan as if you were an active employee. You may take loans and age 59½ and hardship withdrawals (subject to Plan rules) but you cannot receive a final distribution of your Plan accounts.
If you take an approved unpaid leave of absence other than a long-term disability leave, you will not be able to make contributions to the Plan and you will not receive any Matching Contributions during that time. You may take loans and age 59½ and hardship withdrawals but you cannot receive a final distribution of your Plan accounts.
If you take an approved long-term disability leave, you will not be able to make contributions to the Plan and you will not receive any Matching Contributions during that time. You may take loans and age 59½ and hardship withdrawals (subject to Plan rules) unless and until your employment is terminated. You may receive a final distribution of your Plan accounts after you terminate employment.
Continuation of Participation While on a Family and Medical Leave: Under the federal Family and Medical Leave Act (FMLA), if you meet eligible service requirements, you are entitled to take up to 12 weeks of leave for certain family and medical situations. If the FMLA is unpaid, you will receive credit for purposes of determining whether you will incur a break in service at a rate of 40 hours per week, up to 501 hours a year. You will receive up to 501 hours of service credit toward vesting, with credit granted at the rate ordinarily worked each week.
Continuation of Participation for Employees in the Uniformed Services The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) guarantees certain rights to eligible employees who enter military service. Upon reemployment, eligible employees may be entitled to the seniority, rights, and benefits associated with the position held at the time employment was interrupted, plus additional seniority, rights, and benefits that would have been attained if employment had not been interrupted. Health and Welfare Benefits: If you take a military leave in accordance with USERRA, you have the right to elect up to 24 months of continuation coverage for yourself and your covered dependents under the Medical, Dental, and Vision benefit options and the EAP. You may also continue coverage under the Health Care Flexible Spending Account through the end of the plan year in which you started your qualified military leave. Your eligible dependents who are covered by these benefit options before the date of your qualified military leave of absence are eligible to elect continuation coverage for these benefits as well.
The other welfare benefits may continue for up to six months, however, the insurance contracts may exclude benefits for death, injuries or illness incurred or aggravated during any military service.
For the first six months of your qualified military leave, the cost or your coverage will be at the active employee cost. If your leave is for a longer period of time, then after the first six months, the cost of your coverage may increase to 102% of the total cost for coverage under the Medical, Dental, and Vision benefits options and EAP.
The continuation coverage provided pursuant to USERRA runs concurrently with COBRA coverage.
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The chart below provides general guidance. Please check with LifeTimes Connection if you have any specific questions.
Coverage In General Exceptions
Life and AD&D You will receive a bill and you must make premium payments to continue coverage. Payments must be made to LifeTimes Connection
You may be required to provide evidence of insurability
Medical/Dental/Vision/EAP You will receive a bill and you must make premium payments to continue coverage. Payments must be made to LifeTimes Connection
To continue coverage for dependents under Smart Care Program and/or Dental PPO, your coverage must also be continued.
LTD You will receive a bill and you must make premium payments to continue coverage. Payments must be made to LifeTimes Connection
Flexible Spending Accounts
You will receive a bill and you must make premium payments to continue coverage. Payments must be made to LifeTimes Connection
Day Care FSA contributions end when you are no longer actively at work. Health Care FSA contributions can continue through the end of the year of in which you start your qualified military leave.
401(k) Plan: The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) guarantees certain rights to eligible employees who enter military service. Upon reemployment, eligible employees may be entitled to the seniority, rights, and benefits associated with the position held at the time employment was interrupted, plus additional seniority, rights, and benefits that would have been attained if employment had not been interrupted. These rights generally include service credit under the Plan for the period of leave and the right to make up any Voluntary Contributions that could have been made to the Plan during the leave. These make-up Voluntary Contributions may be matched by your facility.
If you think you may be eligible for these special rights under USERRA, please contact LifeTimes Connection.
Removing Dependents from Coverage ................................................................................. 17
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Eligibility
Employee Generally, you are eligible for the HCA Health and Welfare Benefits Plan if you are classified by HCA or an HCA-Affiliated Facility as an active full-time or part-time employee. Temporary employees, seasonal employees, leased employees, P.R.N.s and independent contractors are not eligible. If you are an independent contractor, you are not eligible for Health and Welfare benefits, even if you are later determined to be an employee as a result of a judicial or administrative determination. You are eligible for long-term disability coverage if you are a full-time employee and are regularly scheduled to work at least 32 hours per week. For the Life and AD&D, Long-Term Disability and Short-Term Disability benefits, you will need to be actively at work, which means you are performing all of the material and substantial duties of your occupation.
Generally, coverage begins the first of the month following two months of service. In some facilities, coverage may begin sooner. When you are eligible for benefits enrollment, view your actual Benefit Effective Date by logging on to LifeTimes Connection at HCArewards.com, calling 1-800-566-4114 or reviewing your enrollment materials.
The eligibility for the CorePlus Benefits is described under that section of the SPD.
It is important for all eligible employees to understand that if you do not elect coverage, you will be assigned default coverage.
Dependents When you become eligible to participate in the following benefit programs, you may enroll your eligible dependents in these programs:
Medical Dental Vision Dependent Life Insurance
Your eligible dependents include:
Your legal spouse, unless you and your spouse are legally separated or divorced Your common law spouse, in states that recognize those unions Your eligible domestic partner (see additional requirements below) Your unmarried eligible dependent children For the Life and AD&D Insurance benefit option, your child must be at least 14 days old Your unmarried eligible dependent children who satisfy the eligibility requirements for the insured benefit options
The dependent eligibility for the CorePlus Benefits is described under that section of the SPD.
Eligible Dependent Children Your eligible dependent children are your unmarried children, as defined below, who fall into one of the dependent categories outlined below:
Dependent Categories: Required Documentation:
Children under age 19. A birth certificate will be required when adding a dependent to coverage.
Children age 19 or over but under the age of 26 who are students regularly attending an accredited school.
A birth certificate and an official student transcript will be required each year to verify eligibility.
Children age 19 or over but under the age of 26 who meet all 3 of the following requirements: Live in your household in a parent/child relationship, Earn less than 200% of federal poverty guidelines for a single
person, and Not eligible for any other group health or life insurance coverage.
A signed affidavit regarding dependent status, a birth certificate and copy of Child’s Federal Tax Return will be required.
Children who become physically or mentally disabled while covered and remain disabled, regardless of their current age.
Call LifeTimes Connection at (800) 566-4114.
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Your Children are defined as your unmarried: Biological children Adopted children Children placed with you for adoption Children covered by a Qualified Medical Child Support Order (QMCSO). Stepchildren and children under your permanent legal guardianship who are dependent on you for more than half
their support. If they are under age 19, they must also live in your household in a parent/child relationship at least 50% of the time.
Children of eligible domestic partners (defined below). Note: If you are in the state of Florida, different dependent eligibility rules may apply to you. Call LifeTimes Connection at (800) 566-4114 for more information.
Eligible Dependent Spouse Your spouse is that one person of the opposite sex to whom you are legally married pursuant to state law.
Eligible Domestic Partner Dependents You may also enroll your domestic partner and the children of the domestic partner provided you and your domestic partner:
Both are members of the same sex in a committed relationship or both are opposite sex in a committed relationship and one or both are age 62 or older and one or both meet the criteria for Social Security benefits for old-age or aged individuals; and
Share a common residence; and Agree to be jointly responsible for each other’s basic living expenses incurred during your domestic relationship; and Neither is married to another person or a member of another domestic partner relationship; and Both are at least 18 years of age and capable of consenting to a domestic partner relationship; and Neither is related by blood that would prevent either from being married to each other; and Neither has previously filed a Declaration of Domestic Partnership that has not been revoked.
“Basic Living Expenses” means shelter, utilities and all other costs directly related to the maintenance of the common household of the shared residence of the domestic partners. It also means any other cost, such as medical care, if some or all of the cost is paid as a benefit because a person is another person’s domestic partner. “Jointly responsible” means that each partner agrees to provide for the other partner’s basic living expenses if the partner is unable to provide for him/herself. Persons to whom these expenses are owed may enforce this responsibility if, in extending credit or providing goods or services, they relied on the existence of the domestic partnership and the agreement of both partners to be jointly responsible for those specific expenses.
To enroll the domestic partner, you and your domestic partner must sign and have notarized the Declaration of Domestic Partnership affidavit (Or, for those states that recognize same sex marriage, provide a valid marriage license). You may call LifeTimes Connection at 800-566-4114 to obtain the affidavit. (For California, you may use the state affidavit.) The affidavit must be executed and notarized within 31 days of the establishment of the domestic partner relationship and fulfillment of the requirements above. You must mail the affidavit to LifeTimes Connection, P.O. Box 785012, Orlando, FL 32878-5012. You may also add your domestic partner at annual enrollment provided the affidavit is submitted during the annual enrollment period.
When the affidavit is executed, notarized and submitted to LifeTimes Connection, both of you agree:
To notify LifeTimes Connection immediately if the domestic partner relationship terminates; The value of domestic partner (including children of the domestic partner) will be treated as income to the HCA-
Affiliated Facility plan participant; Any misrepresentation may result in loss of benefits and/or termination of employment; Any person or company which suffers a loss as a result of a misrepresentation in the affidavit, or because of any
misrepresentation of eligibility for domestic partner status, may bring a legal action against both of you, jointly or separately, to recover any loss, including reasonable attorney fees and other expenses of a suit;
Proof of a domestic partner relationship will be provided when requested; and The implementation or termination of this domestic partner relationship may affect the insurance coverage and other
benefits of both parties.
If you only wish to enroll the child(ren) of the domestic partner, both of you will still need to execute, notarize and submit the Declaration of Domestic Partnership affidavit to LifeTimes Connection before such child(ren) may be added.
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The rules regarding “No Double Coverage” also apply to domestic partner relationships where both parties work for HCA-Affiliated Facilities.
Local HMO coverage provisions may apply concerning coverage for domestic partners and the child(ren) of the domestic partner; check with your local HMO to determine coverage provisions for domestic partners and their dependents.
Dependent Verification Process The purpose of the Dependent Verification Process is to make sure we provide high-quality, cost-effective healthcare coverage to eligible employees and their dependents. Documentation Required When Enrolling a New Dependent Dependents added to coverage must complete an eligibility verification process. When an employee enrolls a new dependent, they will receive a notice from LifeTimes and will be required to submit appropriate documentation. Participants have 31 days from the date they elect dependent coverage to return the appropriate documentation. If verification is not completed by the deadline, LifeTimes will retroactively drop the dependent as of the coverage effective date. Random Dependent Eligibility Audits LifeTimes conducts random checks to make sure only eligible dependents are covered. Severe penalties, including the loss of coverage and liability for repayment, could apply if you knowingly attempt to cover or continue to cover anyone who is not eligible.
During the random check process, LifeTimes will select a percentage of participants covering any type of dependent and require them to submit documentation of eligibility (including spouse, common law spouse, dependent child, student, domestic partner, domestic partner child).
If a participant was previously selected for the audit but did not provide appropriate documentation and was dropped from coverage, they must provide the documentation before adding the dependent to coverage during annual enrollment.
Participants must submit the required documentation by the deadline indicated by LifeTimes. If you do not respond by the date indicated, the dependent will be dropped from all coverages. Coverage may be reinstated once the participant submits the required documentation.
Special Note for Dependent Coverage Please be sure your dependents are eligible if you choose a Medical or Dental HMO under the rules of that organization. These additional eligibility terms can be found in the document provided by the HMO. Severe penalties, including loss of coverage, and liability for repayment, could apply if you knowingly attempt to cover or continue to cover anyone who is not eligible. HCA reserves the right to request proof of dependent status.
If you elect a Medical or Dental HMO that has different dependent eligibility rules or definitions than stated in this SPD and you later elect a medical or dental PPO option that follows the rules stated above, a dependent may lose coverage. If you are considering changing coverage options, you should pay close attention to the dependent eligibility provisions to be aware of whether your new plan election has the same dependent eligibility provisions. If you have any questions, call LifeTimes Connection at 1-800-566-4114.
Coverage for Disabled Dependents You may be eligible to cover or continue coverage under the Medical, Dental, Vision or Dependent Life Insurance benefits for your unmarried dependent child beyond the dependent eligibility age if that child is physically or mentally disabled and not capable of self-support. (A child with a learning disability is not considered physically or mentally disabled.) Call LifeTimes Connection at 1-800-566-4114 for more information.
You may continue coverage for a disabled child until one of the following events occur:
Your coverage under the plan ends; The child’s disability ends; The child marries; You fail to provide proof when requested that the disability continues; or Your disabled child fails to undergo any physical examination required as proof of continuing disability
Contact LifeTimes Connection for specific rules for the Medical, Dental and Vision benefits.
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Coverage for Seriously Injured or Ill Students Your eligible dependent child, who is participating in the Medical, Dental, Vision, or Dependent Life Insurance benefit options or the EAP as a full-time student at an accredited college or university, may take up to a one year medically necessary leave of absence (or have a reduced class schedule) and continue coverage under these benefit options, as long as he or she was enrolled in the benefit option immediately before the leave of absence (or the reduced class schedule). Your eligible dependent child’s treating physician must certify in writing that a leave of absence (or reduced class schedule) due to the child’s serious illness or injury is medically necessary and you must provide a copy of this written certification to LifeTimes Connection. Your eligible dependent child’s coverage may terminate prior to the end of the one year medically necessary leave of absence for the reasons stated in the end of coverage section.
No Double Coverage If you are eligible, you may choose coverage as an employee or as a dependent of another employee, but not both. In addition, children can be covered as dependents of only one employee. So, for example, if you and your spouse both work for HCA-Affiliated Facilities, you would have the following options: Each of you may be covered separately as employees and one of you may elect to cover any dependent children; One of you may waive coverage and be covered as a dependent, along with any eligible children, under the other
spouse’s coverage; or Each of you may waive coverage, provided you have coverage elsewhere. You cannot be eligible for coverage at more than one HCA-Affiliated Facility at the same time. If you double cover yourself or your dependents, double benefits will not be provided under any of the Health and Welfare benefits.
Qualified Medical Child Support Order The Health and Welfare benefit options will comply with the terms of a Qualified Medical Child Support Order (QMCSO). A QMCSO is a judgment, decree, order (including approval of a settlement agreement) or administrative notice issued pursuant to a state domestic relations law or a national medical support notice (as defined by ERISA) from a court or administrative body directing a health plan to cover a child of a participant under the group health plan(s). Federal law provides that a medical child support order must meet certain form and content requirements in order to be a QMCSO.
When an order is received, each affected participant and each child (or the child’s representative) covered by the order will be given notice of the receipt of the order and a copy of the plan’s procedures for determining if the order is valid. Coverage under the plan pursuant to a QMCSO will not become effective until the Plan Administrator determines that the order is a QMCSO. If you, your children or their authorized representatives have any questions or would like to receive a free copy of the written procedures for determining whether a QMCSO is valid, please contact LifeTimes Connection.
Other Coverage If you have coverage available under another health plan (for example, coverage under your spouse’s employer plan), you should consider whether you or your dependents should be covered under the HCA Medical benefit options and the other health plan. If the other health plan is the primary plan, it is unlikely that the HCA Medical benefit options will pay benefits as the secondary carrier. Refer to the Coordination of Benefits section for more information.
Participation
Enrollment
New Hire Enrollment After you begin working and become eligible for benefits, you will receive enrollment information in the mail. Access additional information about your benefits options and the cost associated with each, along with this Summary Plan Description (SPD) by logging on to LifeTimes Connection at HCArewards.com. You should keep this SPD even if you elect no coverage, so you'll have the information if you elect coverage at a later date.
To enroll in or decline coverage for yourself or your dependents by the date shown on your enrollment materials, you can access the LifeTimes Connection Web site at HCArewards.com or call LifeTimes Connection at 1-800-566-4114.
Once you enroll, you generally cannot change your choices until the next annual enrollment period — unless you have a qualifying change in status or qualify for a “special enrollment” period.
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If you do not enroll by the date shown in your enrollment materials and on the LifeTimes Connection Web site, you will automatically be enrolled in – and pay for - the default coverages shown below. The cost of this coverage will be deducted from your paycheck on a before-tax basis.
Full-Time Employees If you are a full-time employee and you do not enroll, your default coverage is the Smart Care Base Plan and employee basic Life and AD&D insurance benefits, employee-only coverage. If this default applies to you, it appears on your list of benefits options when you log on to LifeTimes Connection at HCArewards.com.
Benefits Default Coverage
Medical (including prescription drugs) Smart Care Base Plan (employee only)
Employee Life and AD&D One times base pay
Employee Assistance Program Coverage
Dental No Coverage
Vision No Coverage
Flexible Spending Accounts No Coverage
Supplemental Life No Coverage
Dependent Life No Coverage
Long-Term Disability No Coverage
CorePlus Voluntary Benefits No Coverage Part-Time Employees If you are a part-time employee and you do not enroll, your default coverage is the “no coverage” option for all benefits, except the Employee Assistance Program.
Annual Enrollment You have the opportunity to change your benefit elections each year during annual enrollment. The annual enrollment period typically occurs in the fall for coverage that will be effective the following January.
Before the annual enrollment period begins, you will receive materials to help you make your benefit choices and complete the enrollment process. During your annual enrollment period, you will need to log on to LifeTimes Connection through HCArewards.com to view your complete list of benefit plan options and the cost of each item. The portion of the information online that includes the contribution amounts for the benefits you select are considered part of this SPD.
Please review this information and contact LifeTimes Connection for answers to your questions. You must contact LifeTimes Connection, online or by phone, before the annual enrollment deadline to make any changes to your coverage for the upcoming plan year. Otherwise — except for your participation in a Flexible Spending Account — the coverage options you had in effect during the current plan year will automatically continue, including default elections, throughout the upcoming plan year (if those options are still available). Any benefit contributions from your pay (including any applicable increase in those contributions) for those benefits will continue as well. If the Medical benefit option is not available (such as a change in HMO option) and you do not make an annual enrollment election, you will default to the Smart Care Base Plan. If you want to participate in a Flexible Spending Account, you must enroll each year and specify your contributions for the upcoming year.
Your benefit choices made during the annual enrollment will take effect on January 1 and remain in effect until December 31. Once you make your choices for the upcoming plan year, you will not be able to make any changes to your coverage until the next annual enrollment period — unless you have a qualifying change in status or qualify for a “special enrollment” period. For more information, refer to the Making Changes During the Year section.
Evidence of Insurability If you decline Employee Life Insurance, Dependent Life Insurance or Long-Term Disability coverage when you are first eligible for these benefits but decide during a subsequent annual enrollment that you want to add one or more of these options or increase your level of coverage, you will be required to provide evidence of insurability. You may also be required to provide evidence of insurability if the change is due to a qualifying change in status.
To provide evidence of insurability, you’ll need to complete a form that contains questions about your or your dependent’s health and medical history. LifeTimes Connection will send the form directly to you if evidence is required. Once you complete the evidence of insurability form, send it to the carrier providing coverage in the envelope provided. If approved, your new coverage will become effective on the first of the month following the carrier’s approval or on January 1, whichever date is later.
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Special Enrollment Rights Special enrollment rights allow you and/or your dependents to enroll in or drop Medical benefits without waiting until annual enrollment, if certain events occur. Special enrollment applies only to Medical benefits. You only have a certain period of time listed below to make changes to your election by contacting LifeTimes Connection. Losing Other Medical Coverage If you declined coverage under the Medical benefits when it was first available because of other medical coverage and that coverage is later lost on account of (a) exhaustion of COBRA continuation coverage, (b) lost eligibility for other coverage, or (c) termination of employer contributions towards the other coverage, then you and your eligible dependents may enroll in the Medical benefits under the HCA Health and Welfare Benefits Plan on or before the date that is 30 days after the date you lost that other coverage.
Lost eligibility for other coverage includes:
a loss of other medical coverage as a result of your legal separation or divorce, a dependent’s loss of dependent status, death, termination of employment or reduction in number of hours of employment, meeting or exceeding a lifetime limit on medical benefits, or you no longer reside, live or work in the service area of a health maintenance organization in which you participated.
Your enrollment will take effect on the first day of the month following your loss of coverage and your timely request to enroll by contacting LifeTimes Connection.
New Eligible Dependents If you initially declined enrollment for yourself or your eligible dependents and you later have a new eligible dependent because of marriage, birth, adoption, placement for adoption, or legal guardianship, you may also enroll yourself and your new eligible dependents (including an eligible dependent spouse if you have a new eligible dependent child), if you request enrollment by contacting LifeTimes Connection on or before the date that is 30 days after the marriage, birth, adoption, placement for adoption, or legal guardianship. For example, if you and your eligible dependent spouse have a child, you may enroll yourself, your eligible dependent spouse and your new child in the Medical benefits, even if you were not previously enrolled. You will not, however, be able to enroll existing eligible dependent children for whom coverage has been waived in the past.
For birth, adoption or placement for adoption, you or your eligible dependent’s participation will start as of the date of the birth, adoption or placement for adoption, as long as you timely requested enrollment by contacting LifeTimes Connection. For marriage, your participation or your eligible dependent’s participation will start no later than the first of the month following the date of the marriage, provided you request enrollment by contacting LifeTimes Connection on or before the date that is 30 days after the marriage.
You will need to enroll your new eligible dependents on or before the date that is 30 days after the event by which they became your eligible dependent (for example, a new spouse after your marriage or your baby is born). If you do not add new eligible dependents within this 31-day period, you cannot enroll them until the next annual enrollment, special enrollment or unless a change in status event occurs.
Medicaid and CHIP Effective as of April 1, 2009, if you or your eligible dependents are eligible for, but not enrolled in, the Medical benefits and you or your eligible dependents (a) lose coverage under Medicaid or a State child health plan (CHIP), or (b) become eligible for a premium assistance subsidy for the Medical benefits through Medicaid or CHIP, then you and your eligible dependents may enroll in the Medical benefits, as long as you request enrollment by contacting LifeTimes Connection on or before the date that is 60 days after the loss of coverage or the date you or your eligible dependents became eligible for the premium subsidy.
Making Changes During the Year Generally, once you make your benefit choices, you may not change them until the next annual enrollment period. But there are some limited exceptions, described in the following sections. The general rule is that you cannot change your elections until the next annual enrollment — so choose carefully. These exceptions may or may not apply to all benefit options elections and these election changes do not apply to the CorePlus Benefits.
If you believe you may fall within one of the limited exceptions, and you need to change your election during the year, you must do so within 31 days of the event that causes the exception to occur. The HCA Health and Welfare Benefits Plan determines eligibility for any change discussed in this section.
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Contact LifeTimes Connection at 1-800-566-4114 as soon as possible to make the appropriate changes.
Family Events You may change your Health and Welfare benefit elections during the year if one of the following family events affects your, your spouse’s or your dependent child’s eligibility with respect to that coverage. Any election change must be consistent with the family event allowing the change.
Remember, it is not enough just to have an event occur. You or your eligible dependent will need to become eligible for or ineligible for coverage on account of the event, and the election change must be consistent with that event. Family events are:
Your marriage, divorce, legal separation or legal annulment, or the death of your spouse Dissolution of common law marriage through court proceeding Your dependent child’s birth, death, adoption or placement with you for adoption Your dependent child becomes eligible or ineligible for coverage due to his or her age, student status, marital status or
any similar circumstance A change in your, your spouse’s or your dependent’s residence that affects that person’s eligibility
Job Events You may change your Health and Welfare benefits elections during the year if one of the following job events affects your, your spouse’s or your dependent child’s eligibility with respect to that coverage. Any election change must be consistent with the job event allowing the change. Remember, it is not enough just to have an event occur. You or your eligible dependent will need to become eligible or ineligible for coverage on account of the event, and the election change must be consistent with that event.
Job events are:
A termination or commencement of employment A strike or lockout A commencement of or return from an unpaid leave of absence A change in worksite Any other change in employment status with the consequence that the person becomes or ceases to be eligible for a
benefit
Qualified Medical Child Support Order You may change your Medical, Dental, and Vision benefits or Health Care Flexible Spending Account if a judgment, decree, or order, resulting from a divorce, legal separation, annulment, or change in legal custody (including a Qualified Medical Child Support Order), is entered by a court of competent jurisdiction that requires accident or health coverage for your Child under the HCA Health and Welfare Benefits Plan. Coverage for a child may not be terminated unless other healthcare coverage is actually provided. Family and Medical Leave Act (FMLA) If you take FMLA leave, you may change your election with respect to Medical, Dental, Vision and Health Care Flexible Spending Account coverage. For more information, see If You Take a Leave of Absence. Day Care Flexible Spending Account Changes For your Day Care Flexible Spending Account, significant cost changes that may allow you to change your contributions include:
1. Selecting a different dependent care provider 2. Increasing the cost of your provider 3. Increasing or decreasing the hours (and thus the cost) of the provider 4. You take or return from a leave of absence that lasts longer than two weeks
The information described above does not apply to your Health Care Flexible Spending Account.
Other “Cafeteria” Plans If the employer of your spouse, former spouse or dependent child offers a “cafeteria” or “Section 125” plan that has a period of coverage different from the calendar year (for example, a different annual enrollment period) or that allows the same election changes as listed above, you may change your benefit election to correspond with an election or election change made under that other cafeteria plan. Your election change must be on account of and must correspond with that other election. Also, the
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other cafeteria plan must allow this type of change. The information described above does not apply to your Health Care Flexible Spending Account. Significant Cost or Benefit Option Changes If there is a change in the availability of benefits option o coverage (addition or removal) under the HCA Health and Welfare Benefits Plan or under your spouse’s or dependent child’s employer’s benefit plan (for example, a new HMO or PPO option is added), you may change your benefit elections consistent with the availability or removal or the benefit option. You may also change your elections if there is a significant increase or decrease in the cost of a benefit option during the plan year. The Plan Administrator determines whether there is a significant change in the cost. The information described above does not apply to your Health Care Flexible Spending Account. Automatic Changes If the cost of your underlying coverage increases or decreases, the plan may automatically change the amount of your before-tax premium contribution that is withheld. Likewise, the plan may automatically change the amount of your deduction if it is required to do so by the terms of a QMCSO or by the terms of another judgment, decree or order that requires the plan to provide coverage for your dependents. Medicare or Medicaid If you, your spouse or your dependent child is enrolled in group healthcare coverage and also becomes entitled to Medicare or Medicaid coverage (other than Medicaid coverage solely for pediatric vaccines), you may change your election to cancel or reduce group healthcare coverage of that person.
Similarly, if that person loses entitlement to Medicare or Medicaid (other than Medicaid coverage solely for pediatric vaccines), then you may change your election to begin or increase group healthcare coverage of that person.
Loss of Certain Governmental Healthcare Coverage You may change your election to add group healthcare coverage for yourself, your spouse or your dependents if you or they lose group healthcare coverage sponsored by a governmental or educational institution, including a state children’s health insurance program (CHIP) under Title XXI of the Social Security Act, certain Native American health insurance programs, a state health benefits risk pool or a foreign government group health plan. However, you may not drop group healthcare coverage during the year in favor of these governmental health programs. The information described above does not apply to your Health Care Flexible Spending Account. Special Rules for Flexible Spending Accounts You may not reduce your benefit elections for the Flexible Spending Accounts below the amount already reimbursed to you before the change in status event.
Cost of Coverage Regular deductions for your certain qualified Health and Welfare benefits occur with before-tax dollars. This means that you do not pay Social Security tax, federal income tax and most state taxes on the amount deducted for these coverages. Some benefit contributions must be made with after-tax dollars (like dependent life insurance and supplemental employee life insurance). In addition, HCA and HCA-Affiliated entities may also contribute to the cost of certain benefits.
Although the use of before-tax dollars reduces your taxable pay, benefits that are based on your pay — such as Life Insurance and Long-Term Disability (LTD) coverage — are not reduced by these regular deductions. These benefits will continue to be based on your pay as determined by these plans.
You may be required to contribute for your coverage. Log on to LifeTimes Connection at HCArewards.com for your cost information.
When Coverage Begins Generally, if you are eligible, your coverage begins on the first day of the month after you complete two calendar months of service, as long as you are actively at work on that day. (In some facilities, you may be eligible sooner. Log on to LifeTimes Connection at HCArewards.com or review your enrollment materials for your actual Benefit Effective Date.) You will be considered to be actively at work if your effective date falls on a non-scheduled weekday, weekend or holiday.
If you are away from work on your effective date because of a health status-related factor, your Medical, Dental, Vision, EAP and Health Care Flexible Spending Account (FSA) coverage will begin on the same day that it would have begun if you were actively at work. But Life Insurance and AD&D and Long-Term Disability (LTD) insurance coverage will not begin until you return to work for one full day.
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Likewise, any days you are absent from work because of your own health status, medical condition or disability will still count toward your eligibility waiting period as if you had been actively at work, but only for Medical, Dental, Vision, EAP and Health Care FSA benefits.
Generally, your dependents’ coverage begins on the same day your coverage begins. For Dependent Life Insurance, if your dependent is totally disabled on the date coverage should begin, it is delayed until the dependent is no longer totally disabled. This delayed effective date rule also applies to any increase in LTD, your Life and AD&D insurance or Dependent Life Insurance coverage due to a change in annual pay, qualified change in status event or an annual enrollment election.
If evidence of insurability is required, Life and AD&D Insurance and LTD coverage for you and your dependents will begin once the carrier approves the evidence of insurability. (Evidence of insurability may not be required when you first become eligible.)
Rehire If you terminate employment and are rehired within six months, coverage will begin on the first day you return to work subject to the eligibility periods and delayed effective date rule. If you are rehired within six months within the same calendar year, your previous elections will be reinstated and no changes are allowed except for a qualifying change in status or special enrollment rights.
However, if you are rehired in the following calendar year, your previous elections will apply (if the option is no longer available, default options apply. You will have 31 days from your rehire date to make changes, subject to evidence of insurability rules for Life and AD&D and LTD coverages.
If you are rehired after 6 months, you are treated as a new hire.
When Coverage Ends
Medical, Dental, Vision, EAP and Life and AD&D Insurance Coverage Medical, Dental and Life Insurance coverage ends as shown in the following table. In certain circumstances, Medical, Dental, Vision, EAP and Health Care Flexible Spending Account coverage may be continued under COBRA. If… Coverage ends…
You stop working for your facility or retire The last day of the month following your last day at work (not the last day you are paid)
You no longer meet the eligibility rules The last day of the month
Your dependent no longer meets the eligibility rules The date eligibility is lost. For example, your child's coverage ends on his or her 19th birthday (or 25th birthday if a student regularly attending an accredited school)
You stop coverage for yourself and/or your dependents because of a qualifying change in status
The date the qualifying change in status occurs. For example, your spouse's coverage would end at midnight on the date of the divorce
You choose to stop coverage for yourself and/or your dependents during the annual enrollment period
The last day of the current calendar year
HCA no longer provides the coverage The last day the coverage is in effect
You don't make the required contributions The end of the month in which premiums were paid
You are not at work due to disease, injury or approved paid or unpaid leave of absence and you stop making contributions
The last day before leave starts unless contributions continue. Benefits cannot continue longer than six months from the day you begin your paid or unpaid leave
You have continued coverage during a paid leave that continues beyond six months
The last day of the six months following the start of you leave of absence
You die All coverage for you ends on the date of death; however, coverage for your covered dependents terminates at the end of the month
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Flexible Spending Accounts Special participation rules apply to the Flexible Spending Accounts. You may submit claims for reimbursement from the Health Care Flexible Spending Account only for expenses or services that were incurred before the date coverage ended (unless you elect to continue coverage under COBRA). You may submit claims for reimbursement from the Day Care Flexible Spending Account for eligible expenses incurred through the end of the calendar year, even though you stop contributing when coverage ends. Expenses are treated as having been incurred when the participant is provided care that gives rise to the expense, and not when the participant is formally billed or charged, or pays for care.
Long-Term Disability Long-Term Disability (LTD) coverage follows rules that are different from other coverage options. LTD coverage will end on the day:
You actively stop working for your facility or retire You no longer meet the eligibility rules, unless you are receiving LTD benefits HCA no longer provides the coverage You no longer qualify for disability income benefits and you do not return to active work You fail to pay the required premium
Removing Dependents from Coverage It is your responsibility to call LifeTimes Connection at 1-800-566-4114 to remove ineligible dependents from coverage as soon as they become ineligible, or at least within 31 days of the date they become ineligible. Until you do so, you will continue to pay for coverage, but the HCA Health and Welfare Benefits Plan may cancel coverage for that dependent immediately upon learning of the dependent’s ineligibility. The HCA Health and Welfare Benefits Plan may make that cancellation effective to the date of ineligibility. Any amounts you pay for coverage for an ineligible dependent may not be refunded.
401(k) Plan Participation ....................................................................................................... 19
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Eligibility
401(k) Plan Eligibility As a covered employee of your facility, you are eligible to participate in the HCA 401(k) Plan on the first day of the month coincident with or immediately following two consecutive months of service, as long as you are age 18 or older.
If you are under the age of 18, you will be eligible to participate in the Plan on the first day of the month following the date you turn age 18 and have performed at least two consecutive months of service.
The following employees are not eligible to participate:
Leased employees Temporary employees who have not completed one year of service (1,000 hours in your first 12 months of employment or
any calendar year) Employees who are members of a collective bargaining unit, unless the collective bargaining agreement provides for
participation in the Plan Employees of HCA affiliates that have not adopted the Plan Employees who have taken a vow of poverty, such as a chaplain or other clergy member
If you terminate employment with your facility after becoming eligible, but are later rehired, you can enroll again as soon as administratively possible following your rehire.
If you are rehired within 60 days of your termination, your prior contribution election should remain in effect upon rehire unless you change it. Upon rehire, you can visit HCArewards.com or call LifeTimes Connection to verify your status and make any changes.
You should review your paycheck to make sure contributions are accurate. Failure to do so may result in incorrect or no deferrals for periods not immediately reported.
You are eligible to make additional Catch-Up Contributions to the Plan in any year you are — or will be — age 50 or older by December 31 of that year.
Participants in the San Jose Market Pension Plan are not eligible for company matching contributions under the 401(k) plan.
Participation
401(k) Plan Participation
If you are a full-time, part-time or PRN status employee hired or rehired on or after January 1, 2006: You will be automatically enrolled in the HCA 401(k) Plan when you become eligible. This feature will also apply to rehired employees, unless the rehire date is within 60 days of termination of employment. However, travel nurses are not subject to automatic enrollment.
You will initially receive an enrollment kit that will contain information about automatic enrollment — along with instructions on how to opt out if you so choose. You can stop participation or elect a different deferral percentage before the date you become eligible for the Plan. No refunds will be allowed if you decide to opt out at a later date. You may opt out by logging on to LifeTimes Connection at HCArewards.com or by calling 1-800-566-4114.
When you are automatically enrolled in the Plan, your contribution rate will begin at 3% of your eligible pay, if you are eligible, and will be matched at 100% on each dollar deferred up to 3%. Contributions will be invested in the Mix B Fund unless you elect different investments. Your contribution rate will automatically increase by 1% in January of each year if you do not opt out of the automatic contribution increase feature. For this purpose, if you begin participation during the first half of a year, your contribution will automatically increase as of the beginning of the next year. If you begin participation in the latter half of a year, your first automatic contribution increase will generally occur as of the beginning of the second year following the initial year of
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participation. The automatic investment election into Mix B will remain in effect until you make a change. You can change your contribution rate and the investment election at any time by logging on to LifeTimes Connection at HCArewards.com or by calling 1-800-566-4114.
If you were hired before January 1, 2006: You may enroll in the Plan at any time after you become eligible. When you join the Plan, you will need to decide how much to contribute to the Plan and how to invest your account. If you enroll in the Plan using Quick Enrollment, the automatic contribution increase feature described above will apply and your contribution rate will automatically increase by 1% in January of each year (also described above) unless you stop this feature. Your investment election will remain in effect until you make a change. For more information, to enroll and to make elections, log on to LifeTimes Connection at HCArewards.com or call 1-800-566-4114. After you make your elections, your participation will generally begin with your next full payroll period.
The Benefits ....................................................................................................................................... 24
Smart Care Program ............................................................................................................. 24
Smart Care Program Overview Chart ................................................................................... 24
Smart Care Program Details ................................................................................................. 25
Certificate of Creditable Coverage ........................................................................................ 59
When the Plan May Recover Payment ................................................................................ 59
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Medical Highlights The Medical benefits offered under the HCA Health and Welfare Benefits Plan are designed to help you manage what you pay for medical care. The Medical benefits provide comprehensive healthcare coverage for physician’s visits, hospital care, prescription drug and behavioral health expenses.
Plan Overview:
What coverage categories are available?
You You plus one dependent You plus two dependents You plus three or more dependents
Who pays the cost? You and your facility share the cost of coverage. Your share of the cost is deducted from your paycheck on a before-tax basis. For more information on what you and your facility pay, log on to LifeTimes Connection at HCArewards.com and click on "Your Total Rewards"
Your Choices Generally, the following medical options are available:
The Smart Care Program — The Smart Care Program is a Preferred Provider Organization (PPO), which offers medical care through a network of providers. You pay less out of pocket if you use HCA-Affiliated Facilities and network providers. The options available are:
o Smart Care Value Plan o Smart Care Base Plan o Smart Care Plus Plan o Smart Care Select Plan (not available in all locations)
With each Smart Care Program option, you automatically have prescription drug coverage, but the amount of coverage depends on the plan option you choose.
Health Maintenance Organization (HMO) — HMOs are not offered in all areas, and eligibility rules for dependents vary by state. HMOs offer access to healthcare through a network of physicians and facilities. You must use an HMO provider to receive benefits — except in emergencies.
If you choose an HMO, you will receive benefit information from that organization. The materials will provide any special instructions or steps you must follow, including information regarding claim forms, network providers, copays and dollar limits. Call the Member Services telephone number on your medical ID card for more information about benefits under your plan.
No Coverage — You should choose “No Coverage” only if you have coverage elsewhere. Remember, even if you choose the “No Coverage” option, you can still contribute some of your pay to the Health Care Flexible Spending Account (FSA) and be reimbursed for eligible medical expenses that are not covered by your other medical coverage.
When You Have Other Coverage Available Generally, if your spouse has coverage under his or her employer’s plan, it does not make sense for you to also cover your spouse or dependents under these Medical benefits. If the plans pay similar benefit levels for the same covered expenses, you may receive few or no benefits under the secondary plan compared to the extra premiums you would pay. (See the Coordination of Benefits section for more information.)
Coverage Categories If you choose to enroll in the Medical benefits, you may choose coverage for:
Yourself Yourself plus one dependent Yourself plus two dependents or Yourself plus three or more dependents
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If you elect coverage for yourself plus three or more dependents, your cost for coverage will not increase if you add additional dependents. You must contact LifeTimes Connection at 1-800-566-4114 each time you add a dependent to ensure coverage under the Medical benefits option.
The Smart Care Program The Smart Care Program provides medical care through a network of physicians and providers. You receive the highest level of benefits when you and your covered dependents use a provider in the network. And, by using an HCA-Affiliated Facility for hospital expenses, you may pay little for inpatient hospital services.
When you enroll in the Smart Care Program, you are generally covered for:
Hospital and physician visit benefits Limited preventive care (when you use network providers) Behavioral health benefits Prescription drug benefits
All plans cover the same services, including office visits, in- and outpatient surgery, hospital stays, lab, x-rays, preventive care and prescription drugs – but at different levels. The Select Plan (not available in all locations) is a PPO plan that has certain HMO features like office visits copays and no deductibles. If you choose the Select Plan, all maintenance prescriptions (brand name or generic) must be for a 90-day supply and obtained from a CVS retail or mail order pharmacy.
Refer to the Smart Care Program Details chart for more information on the benefits available.
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Smart Care Program Details This chart illustrates what you will pay for various services under the Smart Care Program, but does not represent all covered services. Refer to the applicable section of this SPD for additional information.
You Pay:
Smart Care Value Plan
Smart Care Base Plan
Smart Care Plus Plan
Smart Care Select Plan (if available)
Annual Plan Deductible
Individual $1,500 $500 $300 $0
Family $3,000 $1,000 $600 $0
Out-of-Pocket Maximum
Individual $5,000 $5,000 $3,000 $3,000
Family $10,000 $10,000 $6,000 $6,000
Inpatient Hospital Services Applies to facility charges only
HCA-Affiliated Facility Requires Authorization
0%; deductibles do NOT apply
0%; deductibles do NOT apply
0%; deductibles do NOT apply
0%
Non-HCA In-Network Facility (when services are NOT available at an HCA-Affiliated facility) Requires Authorization
30%; deductibles apply
30%; deductibles apply
20%; deductibles apply
20%
Non-HCA In-Network Facility (when services are available at an HCA-affiliated facility)
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
100% (Not Covered)
Out-of-Network Facility (when services are NOT available at an HCA-Affiliated facility or network facility) Requires Authorization
30%; deductibles apply
30%; deductibles apply
20%; deductibles apply
20%
Out-of-Network Facility (when services are available at an HCA-Affiliated facility or Network facility)
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
100% (Not Covered)
Hospital-Based Physicians (Includes: radiologists, anesthesiologists, pathologists, and hospitalists)
(Inpatient /Outpatient) 30%; deductibles apply
20%; deductibles apply
20%; deductibles apply
20%
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You Pay:
Smart Care Value Plan
Smart Care Base Plan
Smart Care Plus Plan
Smart Care Select Plan (if available)
Outpatient Hospital Facility Services (Includes Outpatient Surgery and Ambulatory Surgery) Applies to facility charges only
HCA-Affiliated Facility
$75 copay; deductibles do
NOT apply
$75 copay; deductibles do
NOT apply
$50 copay; deductibles do
NOT apply
$50 copay
Non-HCA In-Network Facility (when services are NOT available at an HCA-Affiliated facility) Requires Authorization
30%; deductibles apply
30%; deductibles apply
20%; deductibles apply
20%
Non-HCA In-Network Facility (when services are available at an HCA-affiliated facility)
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
100% (Not Covered)
Out-of-Network Facility (when services are NOT available at an HCA-Affiliated facility or network facility) Requires Authorization
30%; deductibles apply
30%; deductibles apply
20%; deductibles apply
20%
Out-of-Network Facility (when services are available at an HCA-Affiliated facility or Network facility)
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
100% (Not Covered)
Outpatient Therapy Services- Facility Based (Physical, Occupational, Speech, Pulmonary, and Cardiac Rehab)Applies to facility charges only
HCA-Affiliated Facility
$25 copay; deductibles do
NOT apply
$25 copay; deductibles do
NOT apply
$25 copay; deductibles do
NOT apply
$25 copay
Non-HCA In-Network Facility (when services are NOT available at an HCA-Affiliated facility) Requires Authorization
30%; deductibles apply
30%; deductibles apply
20%; deductibles apply
20%
Non-HCA In-Network Facility (when services are available at an HCA-affiliated facility)
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
100% (Not Covered)
Out-of-Network Facility (when services are NOT available at an HCA-Affiliated facility or network facility) Requires Authorization
30%; deductibles apply
30%; deductibles apply
20%; deductibles apply
20%
Out-of-Network Facility (when services are available at an HCA-Affiliated facility or Network facility)
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
100% (Not Covered)
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You Pay:
Smart Care Value Plan
Smart Care Base Plan
Smart Care Plus Plan
Smart Care Select Plan (if available)
Physician Office Visit - Routine Services
In-Network 30%; deductibles apply
20%; deductibles apply
20%; deductibles do NOT apply
$20 copay-- PCP$30 copay--Specialist
Out-of-Network 75%; deductibles apply
75%; deductibles apply
75%; deductibles apply
100% (Not Covered)
Preventive Care (Physicals, colonoscopy, well baby, and well woman exam)
In-Network $20 copay Deductibles do
NOT apply No Maximum
$20 copay Deductibles do
NOT apply No Maximum
$20 copay Deductibles do
NOT apply No Maximum
$20 copay
Out-of-Network 100% (Not Covered)
100% (Not Covered)
100% (Not Covered)
100% (Not Covered)
Other Services (Durable medical, non-physician, surgeon services)
In-Network 30%; deductibles apply
20%; deductibles apply
20%; deductibles apply
20%
Out-of-Network 75%; deductibles apply
75%; deductibles apply
75%; deductibles apply
100% (Not Covered)
Lab Services - Facility Based Outpatient Applies to facility charges only
HCA-Affiliated Facility
0%, deductibles do NOT apply
0%, deductibles do NOT apply
0%, deductibles do NOT apply
0%
Non-HCA In-Network facility
30% deductibles apply
30%; deductibles apply
20%; deductibles apply
20%
Non-HCA \Out- of- Network facility
30% deductibles apply
30%; deductibles apply
20%; deductibles apply
20%
Lab Services -Physician Office Based
In-NetworkRoutine 30%; deductibles apply
20%; deductibles apply
20%; deductibles do NOT apply
0%
In-Network Preventive
0%; deductibles do NOT apply
0%; deductibles do NOT apply
0%; deductibles do NOT apply
0%
Out-of-Network Routine
75%; deductibles apply
75%; deductibles apply
75%; deductibles apply
100% (Not Covered)
Out-of-Network Preventive
100% (Not Covered)
100% (Not Covered)
100% (Not Covered)
100% (Not Covered)
Maternity Care (Physician charges)
In-Network 30%; deductibles apply
20%; deductibles apply
$200 maternity copay for delivering
physician charges (pre-natal,
delivery, and post natal) Includes
C-section deliveries
$200 maternity copay for delivering
physician charges (pre-natal,
delivery, and post natal) Includes
C-section deliveries
Out-of -Network 75%; deductibles apply
75%; deductibles apply
75%; deductibles apply
100% (Not Covered)
Emergency Services (if admitted, inpatient benefits apply) Applies to facility charges only
HCA-Affiliated Facility
$75 copay; deductibles do
NOT apply
$75 copay; deductibles do
NOT apply
$50 copay; deductibles do
NOT apply
$50 copay
Non-HCA, In-or Out-of Network Facility
$200 copay; deductibles do
NOT apply
$125 copay; deductibles do
NOT apply
$125 copay; deductibles do
NOT apply
$125 copay
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You Pay:
Smart Care Value Plan
Smart Care Base Plan
Smart Care Plus Plan
Smart Care Select Plan (if available)
ER Physicians 30%; deductibles do NOT apply
20%; deductibles do NOT apply
20%; deductibles do NOT apply
20%
Ambulance (Emergency)
30%; deductibles do NOT apply
20%; deductibles do NOT apply
20%; deductibles do NOT apply
20%
Behavioral Inpatient Hospital Services Applies to facility charges only unless otherwise noted
Out-of-Network Facility (when services are NOT available at an HCA-Affiliated facility or ValueOptions/New Directions network facility) Requires Authorization
30%; deductibles do NOT apply
20%; deductibles do NOT apply
20%; deductibles do NOT apply
20%
Out-of-Network Facility (when services are available at an HCA-Affiliated facility or ValueOptions/New Directions network facility)
50%; deductibles do NOT apply No penalty
50% ; deductibles do NOT apply No penalty
50%; deductibles do NOT apply No penalty
100% (Not Covered)
Behavioral Health Out-of-Pocket Maximum Applies only to Behavior Health services except copay
Individual $5,000 $5,000 $3,000 $3,000
Family $10,000 $10,000 $6,000 $6,000
Behavior Health-Outpatient (must be precertified after 20 visits)
In-Network 30%; deductibles
do NOT apply
20%; deductibles do NOT apply
20%; deductibles do NOT apply
$30 copay per session
Out-of-Network 75%; deductibles do NOT apply
75%; deductibles do NOT apply
75%; deductibles do NOT apply
100% (Not Covered)
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Prescription Drugs: You Pay:
Smart Care Value Plan
Smart Care Base Plan
Smart Care Plus Plan
Smart Care Select Plan (if available)
Retail (30-day supply)
Deductible (Individual/ Family)
$100/$200 $100/$200 $50/$100 $0/$0
Generic $5 copay; deductibles do
NOT apply
$5 copay; deductibles do
NOT apply
$2 copay; deductibles do
NOT apply
$2 copay
Brand Name 40%; deductibles apply
40%; deductibles apply
30%; deductibles apply
30%
Coinsurance Maximum
$120 per script after deductible
$120 per script after deductible
$90 per script after deductible
$90 per script
Retail (90-day supply)
Generic $12 co pay; deductibles do
NOT apply
$12 co pay deductibles do
NOT apply
$5 copay; deductibles do
NOT apply
$5 copay Must use
Maintenance Choice/ CVS
Brand Name $120 copay; deductibles do
NOT apply
$120 copay; deductibles do
NOT apply
$90 copay; deductibles do
NOT apply
$90 copay* Must use
Maintenance Choice/ CVS
Mail Order (90-day supply)
Generic $12 copay; deductibles do
NOT apply
$12 copay deductibles do
NOT apply
$5 copay; deductibles do
NOT apply
$5 copay Must use
Maintenance Choice/ CVS
Brand Name $120 copay; deductibles do
NOT apply
$120 copay; deductibles do
NOT apply
$90 copay; deductibles do
NOT apply
$90 copay* Must use
Maintenance Choice/ CVS
Specialty Drugs (30-day supply)
$40 copay; deductibles do
NOT apply
$40 copay; deductibles do
NOT apply
$30 copay; deductibles do
NOT apply
$30 copay
* In the event the cost of the medication is 30% or less than the contracted rate, the lesser amount will apply.
Prescription Drugs With each Smart Care Program option, you automatically have prescription drug coverage, but the amount of coverage depends on the plan option you choose. Prescription drug benefits are administered by Caremark. Under the prescription drug options, the amount of your copay depends on the type of prescription (generic or brand ).
Behavioral Health Services Behavioral health benefits are administered by ValueOptions, Inc. (or New Directions, for the Midwest Division). You are covered for behavioral health benefits if you choose one of the Smart Care Program plans. All plans offer the same types of services, but the amount coverage depends on the plan you choose. You must call ValueOptions at 1-800-434-5100 (or New Directions at 1-800-528-5763, for the Midwest Division only) before receiving any type of inpatient care, alternative levels of care, outpatient visits that exceed 20 visits per year (from all providers combined) or specialized services.
If you fail to contact ValueOptions (or New Directions for the Midwest Division) prior to care, limited benefits will be paid — even if you use a network provider. For emergency services, you or your family must call within 48 hours or limited benefits will be paid.
Annual Deductible The annual deductible is the amount you pay under the Smart Care Program before the plan begins to pay benefits for some covered medical expenses, such as certain hospital expenses, office visits and non-network physician services. Copays you
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may pay, such as for preventive services, do not count toward your annual deductible. Please note that there is a separate deductible for prescription benefits. The Smart Care Select Plan has no deductible.
You can reach the family deductible with any combination of covered medical expenses you and your covered dependents incur. Not everyone in your family must have medical expenses for your family to meet the family deductible. However, the expenses of one covered individual cannot count more than the individual deductible towards satisfying the family deductible.
Example: How the Annual Deductible Works for the Smart Family: Let’s say the Smart Family (Sue, Bill, Sally and Tommy) is covered under Sue’s Smart Care Base Plan, which has an individual deductible of $400 and a family deductible of $800 for any charges subject to a deductible. When Sue has over $400 of covered charges, her $400 individual deductible will be satisfied. When Bill, one of Sue’s covered dependents, also has over $400 of covered charges — or when two of her covered dependents (for example, Sally and Tommy) have $200 each of covered charges — her family deductible will be satisfied. However, if Sue has, $600 in covered charges, one or more of her dependents will still need to have a combined total of at least $400 in covered charges for the family to meet the family deductible.
Lifetime Maximum Each person covered under any Smart Care PPO option has an individual lifetime maximum of $5,000,000 for all covered expenses. A lifetime maximum is the total amount you and each covered dependent can receive under the Medical Benefits while you are covered. If you or a covered dependent reaches the lifetime maximum under any of the Medical benefit options offered under the HCA Health and Welfare Benefits Plan, then it is reached under any other Medical benefit option offered by the HCA Health and Welfare Benefits Plan. A benefit payment counted toward the individual lifetime maximum under a Medical benefit option is considered applied to the lifetime benefit maximum under each Medical benefit option.
Out-of-Pocket Maximum Your out-of-pocket maximum is the most you will pay for eligible medical care expenses during a calendar year. Once your expenses, including deductibles, reach the maximum, the plan pays 100% of the allowable amount for eligible expenses.
There is an individual and family out-of-pocket maximum for hospital and non-hospital benefits. Behavioral health expenses have a separate out-of-pocket maximum, excluding copays. There is no out-of-pocket maximum for prescription drug expenses.
The following charges do not count toward your annual out-of-pocket maximum, and they are not covered at 100% after you reach the out-of-pocket maximum:
The copay amounts you pay for certain services, such as preventive services and prescription drugs The $500 penalty incurred if you fail to precertify for care at an HCA-Affiliated Facility as required The 75% coinsurance you pay if you precertify and use a non-HCA-Affiliated Facility when services are available at
an HCA-Affiliated Facility The 75% coinsurance you pay if you fail to precertify and use a non-HCA-Affiliated Facility (network or non-network) The member coinsurance you pay for non-network physician services The coinsurance amount above the $10,000 benefit level for travel, lodging and meals associated with a transplant Non-covered services you receive and amounts above allowable amounts or reasonable and customary charges Eligible expenses with separate maximums, such as chiropractic and behavioral health Expenses related to obesity surgery The 75% coinsurance you pay if you do not use an HCA-affiliated facility or network transplant facility, even if you
have already reached your out-of-pocket maximum before the transplant. The member coinsurance you pay for using an out-of-network behavioral health facility
How to Receive the Highest Level of Benefits To receive the highest level of benefits under the Smart Care Program, you must:
Use an HCA-Affiliated Facility if one is available to you and follow precertification guidelines for hospital benefits. Non-HCA-Affiliated Facilities (network or non-network) may be used only in very limited and unusual circumstances, which must be approved by the Claims Administrator (see the Precertification section for details)
Use a network provider to receive benefits for preventive care and all other non-hospital services Choose a Caremark network pharmacy or mail-order service for maintenance medications to receive the prescription
drug benefit
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Precertify all inpatient services through ValueOptions (or New Directions for the Midwest Division) to receive behavioral health benefits. Use an HCA-Affiliated Facility to receive the highest level of benefit. Or, choose a ValueOptions (New Directions for the Midwest Division) network provider to receive the in-network level of benefits
Hospital Expenses Each time you need medical care, the Smart Care Program allows you to choose where and how to receive that care. With respect to hospital expenses, you pay nothing for the facility inpatient charges at an HCA-Affiliated Facility (this does not include physician fees) when this Medical benefit option is deemed the primary plan under the coordination of benefits provision. If you use a non-HCA-Affiliated Facility, including other network facilities, when services are available at an HCA-Affiliated Facility, you pay a significantly larger percentage of the cost. When services are not available at an HCA-Affiliated Facility, you receive higher coverage by using a network facility. Contact your Claims Administrator to determine your provider options and benefits coverage.
NOTE: Except as otherwise provided by the Newborns’ and Mothers’ Health Protection Act of 1996 (the “Newborn Act”), call your Claims Administrator as identified on your medical ID card when any hospital admittance occurs.
Non-Hospital Expenses For healthcare services outside of a hospital, the Smart Care Program pays benefits based on whether you use a network or non-network provider. When you use a network provider, the Smart Care Program pays a larger percentage of the cost of your healthcare services, because discounted rates have been negotiated for services. If you use a non-network provider, the Smart Care Program pays a certain percentage of reasonable and customary (R&C) expenses. Eligible expenses are subject to applicable deductibles on both in- and out-of-network services.
HCA-Affiliated Facilities and the Network You receive maximum benefits under the Smart Care Program when you use HCA-Affiliated Facilities. Billed charges from HCA-Affiliated Facilities (hospitals, ambulatory surgical centers, imaging centers, urgent care facilities) are discounted 65%, except for HCA-Affiliated Home Health Care billed charges, which are discounted 25%.
Under special circumstances, you may receive network-level benefits from a non-network provider (primary care providers, specialists, etc.) or non-HCA-Affiliated Facility (hospitals, other facilities, etc.). It is your responsibility to request such an upgrade for the facility, primary care providers, specialist and other non-network providers. However, please note that copays will not apply in these situations for Smart Care Program participants; the upgraded benefit payable by the plan is generally 80% or 70%, depending on the Medical benefit option selected and services rendered (subject to medical necessity and reasonable and customary amounts) after the annual deductible is satisfied. For example, you may be eligible for network-level benefits, with prior approval of the Claims Administrator, when you receive care from a non-HCA-Affiliated Facility or non-network facility, if:
You need medical services that are not available from an HCA-Affiliated or network facility; or An HCA-Affiliated Facility or network facility is not available within 30 miles of where you live for outpatient or
obstetrical treatment or within 60 miles of where you live for inpatient treatment.
However, if you choose to go to a non-HCA-Affiliated Facility that is located outside of the HCA-specified radius of where you live, i.e., 30 or 60 miles, and there is an HCA-Affiliated Facility located closer to where you live, you must go to the HCA-Affiliated Facility, or you will be penalized and pay the non-HCA-Affiliated expenses. Furthermore, if you fail to precertify your inpatient admission to a network or non-network facility, regardless of the mileage, you will pay 75% coinsurance.
A complete list of network providers and HCA-Affiliated Facilities will be available to you as a separate document free of charge. In addition, copies of this directory are available online at HCArewards.com. The network comprises a national network of providers, including but not limited to primary care providers, specialists, hospitals and other facilities.
Specific network structures will differ by your location. For further information about the composition of your local network, contact Member Services or refer to your provider directory.
Finding Network Providers Whenever possible, you should use HCA-affiliated network providers. To find out if a provider is part of the network:
Check with your provider Check your online provider directory at HCArewards.com. See login instructions in the Introduction section. Call the Claims Administrator at the number on your medical ID card
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33
Benefits at a Glance The following charts show examples of the benefits you pay for hospital services under different circumstances.
Inpatient Hospital Services
You Pay:
Smart Care Value Plan
Smart Care Base Plan
Smart Care Plus Plan
Smart Care Select Plan (if available)
Inpatient Hospital Services Applies to facility charges only
HCA-Affiliated Facility Requires Authorization
0%; deductibles do NOT apply
0%; deductibles do NOT apply
0%; deductibles do NOT apply
0%
Non-HCA In-Network Facility (when services are NOT available at an HCA-Affiliated facility) Requires Authorization
30%; deductibles apply
30%; deductibles apply
20%; deductibles apply
20%
Non-HCA In-Network Facility (when services are available at an HCA-affiliated facility)
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
100% (Not Covered)
Out-of-Network Facility (when services are NOT available at an HCA-Affiliated facility or network facility) Requires Authorization
30%; deductibles apply
30%; deductibles apply
20%; deductibles apply
20%
Out-of-Network Facility (when services are available at an HCA-Affiliated facility or Network facility)
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
100% (Not Covered)
Inpatient Hospital Services: When Services are Rendered
You Pay:
Did you precertify?
Services available at an HCA-affiliated
facility?
Smart Care Value or Smart Care
Base
Smart Care Plus Smart Care SelectPlan
(if available)
HCA-Affiliated Facility
Yes N/A 0% with no deductible 0% with no deductible 0% with no deductible
HCA-Affiliated Facility
No N/A 0% with no deductible after a $500 penalty
for failure to precertify
0% with no deductible after a $500 penalty
for failure to precertify
0% with no deductible after a $500 penalty
for failure to precertify
Network Facility Yes Yes 75% after deductible 75% after deductible 100% (not covered)
Network Facility Yes No 30% after deductible 20% after deductible 20%
Network Facility No Yes 75% after deductible 75% after deductible 100% (not covered)
Network Facility No No 75% after deductible 75% after deductible 100% (not covered)
Out-of-Network Facility
Yes Yes 75% after deductible 75% after deductible 100% (not covered)
34
Out-of-Network Facility
Yes No 30% after deductible 20% after deductible 20%
Out-of-Network Facility
No Yes 75% after deductible 75% after deductible 100% (not covered)
Out-of-Network Facility
No No 75% after deductible 75% after deductible 100% (not covered)
Emergency Hospital Services When Admitted:
You Pay:
Type of Facility Did you notify within 48 hours?
Smart Care Value or Base Plan
Smart Care Plus Plan Smart Care Select Plan (if available)
HCA-Affiliated Facility
Yes 0% with no deductible 0% with no deductible 0% with no deductible
HCA-Affiliated Facility
No 0% after a $500 penalty for failure to precertify
Dependents Living Out of the Network Area You and your covered dependents must use an HCA-Affiliated Facility or network provider to receive maximum benefits. If a covered dependent, such as a college student, is living out of the network area, contact the Claims Administrator to determine if HCA-Affiliated or network providers are available in the area.
What to Do If You Are Traveling You must use a network provider for nonemergency care while traveling in your local network area or you’ll be responsible for any charges above the negotiated rates. If you’re traveling outside your local network area, benefits are based on reasonable and customary charges. You can save money by using local PPO providers in the area where you’re traveling. You can get a list of PPO providers by calling your Claims Administrator as identified on your medical ID card directly or visiting their Web site at HCArewards.com. There is no charge to receive provider lists or directories. If you need medical care while traveling outside the network service area:
Contact the plan to locate a nearby network provider In an emergency, contact Member Services within 48 hours after you receive care to ensure network benefits
What to Do If You Are Out of the Country You and your covered dependents have coverage while traveling out of the United States. Since network provider relationships do not exist outside of the U.S., you can seek care at any qualified medical provider. All plan provisions will apply whether you are in or out of the U.S., and the Smart Care Claims Administrator must be able to determine medical necessity for any service received.
If you are in a country that has an HCA-Affiliated Facility (e.g., England or Switzerland), you should seek care at that facility to receive the highest level of benefits. HCA-Affiliated Facilities will be paid at 100%, and non-HCA-Affiliated Facilities and other medical services will be reimbursed at 80% after you meet the annual deductible.
You may be asked to pay for your care while you are still in the foreign country. You must obtain documentation and detailed information from the foreign provider, such as the name of the patient, the date of the service, the services provided and the amount of the service. You will need to send this information to your Claims Administrator, who will convert the billed amount from foreign currency to U.S. dollars and provide you with reimbursement of eligible charges.
35
Medically Necessary Services The plan pays benefits only for services that are determined by the Plan Administrator to be medically necessary. To be considered “medically necessary,” a service or supply must:
Be consistent with the diagnosis Meet quality medical practice standards Be the most appropriate level of service (for example, in the case of hospital inpatient care, care that could not be
appropriately provided on an outpatient basis) Be recognized as an accepted medical practice and have received the required federal approval Not be primarily for the comfort and convenience of the patient
Allowable Amounts The plan pays benefits based on allowable amounts for services. For in-network services, you are not responsible for the difference between the negotiated discount amount and the billed amount. For out-of-network services, you may be responsible for the difference between the reasonable and customary (R&C) amount and the billed amount. To determine this allowable amount, the Claims Administrator considers factors such as:
The complexity of the treatment The degree of skill needed to provide the treatment The provider’s specialty The range of services and supplies provided by the facility or provider The prevailing charge in the same area for that service
The allowable amount for hospital charges is based on the following:
For HCA-Affiliated Facilities and in-network facilities, discounts have been obtained. The discounted amount is the allowable amount.
For out-of-network facilities, if discounts have been negotiated by the plan or Claims Administrator, the discounted amount is the allowable amount; otherwise, the allowable amount is billed charges.
Precertification
Precertification helps to ensure that you receive the most appropriate treatment at the most appropriate facility. You must follow precertification guidelines whether you use an HCA-Affiliated Facility or non-HCA-Affiliated Facility. Precertification does not guarantee that benefits will be paid. You must be covered and the care must be a covered expense before benefits will be paid. If you do not follow precertification guidelines, a minimum $500 inpatient penalty will apply if you use an HCA-Affiliated Facility, and 75% coinsurance will apply if you use a non-HCA-Affiliated Facility. For urgent, concurrent and pre-service precertification, information may be provided by phone or in writing. An expedited process is available. Refer to the Administrative Information (Claims and Appeals) section for more details. You must call your Claims Administrator's precertification telephone number on your medical ID card:
Five days before inpatient admissions (except as otherwise provided by the Newborns’ and Mothers’ Act of 1996) Before receiving any care that is not provided at an HCA-Affiliated Facility or by a network physician Within 48 hours of emergency admission Five days before stays over 23 hours at an ambulatory surgical center To enroll in the prenatal program if you or your covered dependent is pregnant To receive inpatient and certain outpatient behavioral health services (see page 46)
Refer to the behavioral health section (see page 46) for benefit precertification details. In connection with childbirth, precertification is not required for the mother or child for the first 48 hours of a hospital stay after a normal vaginal delivery (96 hours after caesarean section), but precertification is required before receiving any care from a non-HCA-Affiliated Facility, network facility, or non-network facility (including care related to childbirth) to avoid the $500 penalty or 75% coinsurance. (See HCA-Affiliated Facilities and the Network (page 31 for details). Precertification is also required for any portion of the hospital stay that extends past the 48 hour and 96 hour time periods. (See the Newborns’ Act Notice section (page 39) for details.)
When Penalties Apply Your benefits will be reduced by $500 if you fail to follow precertification guidelines for admission to an HCA-Affiliated Facility. This reduction in benefits does not count toward your out-of-pocket limit. The Claims Administrator will confirm that the procedure or service you need is not available at an HCA-Affiliated Facility before you can use a non-HCA-Affiliated Facility.
36
You will be responsible for 75% coinsurance whether or not you precertify your treatment, if you use a non-HCA-Affiliated Facility or network facility when an HCA-Affiliated Facility could have provided the service.
Continued Stay Review You, your physician or your hospital should initiate a continued stay review by calling the precertification number on your medical ID card if it appears that your precertified inpatient hospital admission is likely to be longer than the originally authorized length of stay. Precertification ensures that plan benefits are paid for eligible expenses during these additional days. Benefits will not be paid for additional days that are not authorized. (Refer to the Case Management section for details.)
Covered Expenses The Medical benefit plan pays benefits up to the allowable amount for expenses and fees for medically necessary services or supplies to treat a non-occupational sickness or illness. The expense must be listed in this Covered Expenses section.
Private room and board, if you are using an HCA-Affiliated Facility Semi-private room and board at a non-HCA-Affiliated Facility. Charges for an optional private room are covered up to
the most common charge for a semi-private room, unless a private room is medically necessary Hospital services and supplies, including general nursing care, meals, special diets and drugs (but not including
convenience items such as televisions, cots or guest meals) Outpatient services, when billed by a hospital
Emergencies
You Pay:
Smart Care Value Plan
Smart Care Base Plan
Smart Care Plus Plan
Smart Care Select Plan (if available)
Emergency Services (if admitted, inpatient benefits apply) Applies to facility charges only
HCA-Affiliated Facility
$75 copay; deductibles do
NOT apply
$75 copay; deductibles do
NOT apply
$50 copay; deductibles do
NOT apply
$50 copay
Non-HCA, In-or Out-of Network Facility*
$200 copay; deductibles do
NOT apply
$125 copay; deductibles do
NOT apply
$125 copay; deductibles do
NOT apply
$125 copay
ER Physicians 30%; deductibles do NOT apply
20%; deductibles do NOT apply
20%; deductibles do NOT apply
20%
Ambulance (Emergency)
30%; deductibles do NOT apply
20%; deductibles do NOT apply
20%; deductibles do NOT apply
20%
*Must be an emergency situation according to the facility records. If you are admitted to the hospital, the inpatient benefit will apply based on the option and location. Once you are medically stable, the Claims Administrator may coordinate with your physician to move you to an HCA-Affiliated Facility or network facility. You must call the Claims Administrator within 48 hours of an emergency admission or the inpatient stay will be subject to $500 penalty for an HCA-Affiliated Facility or 75% coinsurance for a non-HCA-Affiliated Facility, even if the facility is a network facility.
Non-Hospital Expenses The Medical benefit option also covers non-hospital benefits for the following medically necessary supplies and services when not billed by a facility (such as a physician’s office or free-standing clinic):
Anesthesia and its administration, along with necessary supplies and equipment Birth control injections and devices Chiropractic manipulation services — up to an annual benefit maximum of $500. All expenses are subject to the
annual deductible, payable at 80%; however, the initial consultation, X-rays and modalities, such as heat and cervical stretch, are not included in the $500 annual benefit maximum.
37
Diabetic education, when medically necessary Dressings, casts and splints Drugs maintained and administered in the physician’s office Durable medical rental equipment (up to the purchase price) or purchase (in some cases) of durable medical
equipment, such as a manual wheelchair or hospital bed equal to or greater than $500 must be reviewed by the claims administrator
Emergency ambulance service: ground transportation, unless the Claims Administrator determines that air transportation is medically necessary
Emergency room physician charges One set of eyeglasses or contact lenses required as a result of, or directly related to, intraocular surgery or ocular
injury Orthopedic braces (except corrective shoes and arch supports), crutches and prosthetic appliances such as artificial
limbs, including their repair or adjustment Ostomy supplies Oxygen and rental of equipment for its administration Pain management injections (including, but not limited to trigger point injections, epidural and lumbar injections).
Services must be documented in a treatment plan that outlines the frequency and duration of the treatment and provides for ongoing reviews to determine if therapy is still necessary. Benefits will not be paid when no further improvement of functional skills can be expected.
Primary care physician or ophthalmologist charges for an eye exam, including refraction, when these services are required as a result of an accidental bodily injury or required for the diagnosis and/or treatment of a disease of the eye ("V" code with illness diagnosis) or systematic disease, such as diabetes.
Radiology and pathology services Routine foot care and custom molded orthotics for severe conditions, such as diabetes, peripheral vascular disease,
etc., as approved by the Claims Administrator Therapy services, including radiation therapy, chemotherapy and dialysis Wigs and/or artificial hairpieces purchased as part of radiation and/or chemotherapy treatment or treatment for
another disease or injury, up to a $250 annual maximum benefit X-rays and other diagnostic services, including laboratory services and CAT scans, when not billed by a facility
Physician Services The Medical benefit option covers non-hospital benefits for medically necessary services you receive from a physician. The services of an assistant surgeon are covered at 20% of the surgeon’s cost. Depending on the service(s) performed, the assistant surgeon’s allowable charges are generally calculated by taking 20% of the surgeon’s allowable amount and using that assistant surgeon’s allowable amount to apply plan benefits.
For same-day surgical services performed in the same operative session in the same vicinity or invasive area, allowable benefits for secondary operative procedures are reduced to 50% of the normal service allowable. Plan benefits are then applied to that new secondary procedure allowable. For more information, contact the Claims Administrator.
If your physician gives you a prescription for a covered injectable that the physician does not keep in the office, the cost of the injectable is covered under the Prescription Drug Benefit.
Eligible Provider For purposes of the plan, "eligible provider" means a licensed, practicing physician. The definition includes:
Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.), except an intern or resident Doctor of Dental Medicine (D.D.M.) Doctor of Dental Surgery (D.D.S.) Doctor of Ophthalmology Doctor of Surgical Chiropody (D.S.C.) Doctor of Chiropractic (D.C.) Licensed Podiatrist Licensed Midwife Physician Assistant Surgical First Assistant, including M.D.s, D.O.s, D.M.D.s, D.D.S.s, C.S.A.s, C.F.A.s, R.N.F.A.s, C.S.T.s and Physician
Assistants, provided they are licensed in the state which the surgery is performed Nurse practitioner
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Licensed Surgical Assistant (LSA) Any other provider who meets this plan’s definition of doctor as determined by the Plan Administrator and who is
operating within the scope of his or her license
Network Physician Office Visits If you elect the Smart Care Value or Base option, the deductible applies and you pay, according to the Smart Care Program Details chart, the discounted rate for routine office visit services. If you elect the Smart Care Plus option, the deductible does not apply and you pay according to the Smart Care Program Details chart the discounted rate for the routine office visit services. Non-routine office services that are typically performed in an outpatient setting, such as dialysis, chemotherapy, radiation therapy and high technical imaging (including MRI, MRA, CATs, PETs, etc.), are not subject to the deductible under the Smart Care Plus plan.
*Does not apply to out-of-pocket maximum Preventive Care Preventive care is available in the Smart Care Program. There is no annual maximum benefit. No benefit is payable for non-network providers. The following services are eligible under the preventive care benefit:
Well-baby care Routine mammograms, according to the following schedule:
o Ages 35 through 39: one baseline mammogram o Ages 40 and older: one mammogram every calendar year
Annual physical examinations, including gynecological exams, Pap smears, prostate screening and examination, stress tests, bone density test and flexible sigmoidoscopy
Flu shots and immunizations Annual hearing screening as part of a child’s annual physical exam up to age 18 when billed as preventive or
wellness by the network provider
You are reimbursed 100% of eligible preventive care expenses after the appropriate copay if you use a network provider, up to the maximum amount allowed in the Smart Care option you select. No benefit is payable for non-network providers when you have access to network providers. If you do not have access to network providers, preventive care expenses will be reimbursed at 80% after the annual deductible with prior approval from the Claims Administrator.
You Pay:
Smart Care Value Plan
Smart Care Base Plan
Smart Care Plus Plan
Smart Care Select Plan (if available)
Preventive Care (Physicals, colonoscopy, well baby, and well woman exam)
In-Network $20 copay Deductibles do
NOT apply No Maximum
$20 copay Deductibles do
NOT apply No Maximum
$20 copay Deductibles do
NOT apply No Maximum
$20 copay
Out-of-Network 100% (Not Covered)
100% (Not Covered)
100% (Not Covered)
100% (Not Covered)
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Non-Diagnostic Colonoscopy The plan will cover expenses for a routine colonoscopy every five years after the Covered Person reaches age 50. The benefit is payable as Outpatient Hospital Facility Services. The physician charge for performing the procedure is subject to the deductible, and payment is as for any other outpatient surgical procedure. These expenses are not considered part of the Preventive annual maximum. If a colonoscopy is required for medical condition indicators, it is not subject to the five-year limitation. Infertility The Medical benefit option covers eligible expenses before a determination of infertility is made. Once infertility is determined, no further benefits are covered. See the Prescription Drug section for information about infertility medications that may be covered.
Maternity Care Maternity services are covered like any illness for you or your covered spouse. If your eligible dependent child gives birth, only the birth mother’s expenses are covered. Contact your Claims Administrator to enroll the mother in the prenatal program. If you are admitted to a hospital or birthing center, call your Claims Administrator at the phone number on your medical ID card.
You Pay:
Smart Care Value Plan
Smart Care Base Plan
Smart Care Plus Plan
Smart Care Select Plan (if available)
Maternity Care (Physician charges)
In-Network 30%; deductibles apply
20%; deductibles apply
$200 maternity copay for delivering
physician charges (pre-natal,
delivery, and post natal) Includes
C-section deliveries
$200 maternity copay for delivering
physician charges (pre-natal,
delivery, and post natal) Includes
C-section deliveries
Out-of -Network 75%; deductibles apply
75%; deductibles apply
75%; deductibles apply
100% (Not Covered)
One routine ultrasound is covered under the maternity benefit. Other medically necessary ultrasounds will be paid according to plan provisions, such as Outpatient Services or physician services.
Newborns’ Act Notice In general, the plan may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth — for the mother or newborn child — to less than 48 hours following a normal, vaginal delivery, or less than 96 hours following a caesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consultation with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours, as applicable) after childbirth.
In any case, the plan may not, under federal law, require your provider to authorize a hospital stay that is less than 48 hours (or 96 hours, as applicable). The hospital or physician must call your Claims Administrator to precertify a longer hospital stay. The $500 penalty for failure to precertify will apply if a longer stay is not authorized. In addition, precertification is required before receiving any care from a non-HCA-Affiliated Facility, network facility, or non-network facility (including care related to childbirth) to avoid a $500 penalty or 75% coinsurance. (See HCA-Affiliated Facilities and the Network (page 31 for details). Use of a non-HCA-Affiliated Facility or non-network provider may result in reduced benefits.
Birthing Center Covered expenses in a birthing center are paid as hospital expenses. The plan pays benefits for the following birthing center services:
Prenatal care Delivery of child or children Care received within 48 hours after a vaginal delivery or 96 hours after a caesarean section
Precertification for is not required unless care is needed for more than 48 hours for a vaginal delivery or 96 hours for a caesarean section. However, to avoid the $500 penalty or 75% coinsurance, precertification is required before receiving any care from a non-HCA-Affiliated Facility, network facility, or non-network facility (including care related to childbirth).
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Notice of the Women’s Health and Cancer Rights Act of 1998 If you and/or your dependents are covered under an HCA medical option, you should be aware of the following information under the Women’s Health and Cancer Rights Act. Any person who is receiving benefits in connection with a mastectomy and who elects breast reconstruction will have coverage in a manner determined in consultation with her physician for:
Reconstruction of the breast on which the mastectomy was performed Surgery and reconstruction on the other breast to produce a symmetrical appearance Prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas
The normal option deductibles, copayments and coinsurance amounts apply to this coverage.
Obesity Surgery Bariatric Surgery for the treatment of obesity, i.e., banding or stomach stapling to reduce the size of the stomach, is covered, provided the surgery is:
Medically necessary Precertified and approved by your Claims Administrator Performed at an HCA-Affiliated Facility
Benefits are limited to one surgery per lifetime and covered based on the plan option you elected. No expenses related to obesity surgery count toward the out-of-pocket maximum. Refer to the Smart Care Program Details chart. If you have obesity surgery performed at a non-HCA Affiliated Facility, all related expenses, including hospital, surgeon, anesthesiologists, etc. are not eligible expenses, and you will be responsible for 100% of these expenses.
Allergy or Migraine Injections Deductible and coinsurance may apply for allergy or migraine injections that a network provider administers. You pay 20% (Smart Care Value, you pay 30%) for these services if there is no physician visit charge at the time of the injection. If there is a physician charge, the applicable coinsurance applies. For facilities with no PPO network, you pay 20% (Smart Care Value, you pay 30%) after the deductible.
Nursing Services The Medical benefit option covers benefits for care you receive from a registered professional nurse (R.N.) or nursing agency for skilled nursing care that is determined medically necessary by the Claims Administrator. Benefits are payable as a non-hospital expense. “Skilled nursing care” refers to:
Visiting nursing care by an R.N. for up to two hours to perform specific skilled nursing tasks Private duty nursing by an R.N. if the nursing services and visiting nursing care are not adequate
The services of a licensed practical nurse (L.P.N.) may be substituted if your physician orders the care of an R.N. but one is not available. Skilled nursing care does not include care that:
Does not require the skills of an R.N. Is given while the patient is an inpatient in a healthcare facility if the facility’s general nursing staff could have
provided that care All plan benefits are based on the allowable amount charged for the service or supply.
Home Healthcare If you need professional care, but can be treated at home, your physician may recommend a home healthcare program. Benefits are payable as a non-hospital expense. For you to qualify:
Your physician must provide a written plan and evidence of medical necessity for your home care You must be treated by an approved home healthcare agency
The plan pays benefits for the following non-custodial home healthcare services:
Part-time or intermittent nursing care by an R.N., L.P.N. or qualified home healthcare aide for up to four hours per day.
Physical, occupational or speech therapy that is restorative in nature
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Medical supplies, drugs, prescribed medicines and laboratory services. Services or supplies not outlined in the home healthcare plan provided by your physician will not be covered, nor will services of a social worker or transportation expenses. An approved home healthcare agency must meet the following requirements:
Be licensed, if required, by the proper authority to provide skilled nursing and therapeutic services Have policies established by a professional group associated with the agency or organization Maintain complete medical records Have a full-time administrator
Prior authorization and concurrent review are required.
Convalescent and Skilled Nursing Facility Care The Medical benefit option provides benefits for medically necessary care convalescent facility expenses as long as:
The services are recommended by the attending physician and you remain under the care of a physician; You need the skilled nursing services and physical restorative services to recover from an injury or disease; and The facility is not primarily a rest home, educational institution, custodial facility or similar institution.
The plan pays benefits for the following as non-hospital expenses:
Semi-private room and board charges, including general nursing care (if you stay in a private room, coverage is limited to the average semi-private room and board rate)
Use of special treatment rooms X-rays and laboratory examinations Physical, occupational or speech therapy Oxygen and other gas therapy Other related medical services customarily provided to patients Drugs, solutions, dressing, biologicals and casts
Benefits will not be paid for custodial care of psychiatric patients, patients with mental retardation, patients with senility or patients with drug or alcohol addictions.
Hospice Care Hospice care is designed for patients who are not expected to live beyond six months. Types of covered expenses may include:
Semi-private room and board charges (private room coverage is limited to the average semi-private room and board rate) and other services and supplies furnished for pain control and other acute and chronic symptom management
Services and supplies given to patients on an outpatient basis Up to eight hours a day of nursing care by an R.N. or an L.P.N. Medical and counseling services under the direction of a physician, including:
o The evaluation of social, emotional and medical needs o Psychological and dietary counseling o Physical and occupational therapy o Up to eight hours a day of home healthcare aide services o Medical supplies and drugs prescribed by a physician
Respite care as determined medically necessary by the Claims Administrator The patient’s care must be outlined in a written plan and developed and reviewed by the attending physician or appropriate hospice care agency personnel. The plan will not pay benefits for the following:
Care that isn’t solely related to the medical care of the patient (for example, companion service to the patient, transportation or house maintenance services)
Financial or legal counseling, including estate planning and preparation of a will Funeral arrangements
Please contact the Claims Administrator at the number on your medical ID card for more details on this benefit.
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Occupational Therapy Occupational therapy is covered when functional skills are impaired or lost as a result of an injury, disease or illness that is not job-related. Benefits are payable as a non-hospital expense. Occupational therapy must be recommended by a physician and provided by a therapist who is qualified and licensed in the jurisdiction where treatment is received. The therapy must be performed within the scope of that license. An initial evaluation of the individual’s living, transportation, work environment and work-related tasks is used to determine the effectiveness of the therapy to improve skills. After 18 visits, progress for improvement will be reviewed by the Claims Administrator. Benefits will not be paid when no further improvement of functional skills can be expected. Therapy that is part of a special educational program is considered educational training and is not covered by the plan.
Speech Therapy Speech therapy is used to improve speech that is impaired through disease or injury. The provider must be educated and trained to plan, conduct and evaluate speech therapy programs. The plan covers benefits as non-hospital expenses for the following services performed by a speech pathologist, physician or speech therapist if the speech therapy program is prescribed and supervised by a physician:
Diagnostic services to determine the extent of the loss or impairment of the patient’s ability to speak Rehabilitative services to restore or improve the patient’s ability to speak
However, speech therapy relative to pervasive developmental disorders (PDD) is covered when it is medically necessary as determined by the Claims Administrator. Speech therapy for conditions including PDD is subject to the following exclusions. Benefits will not be paid for:
Services or supplies that a school system is legally required to provide Services to treat delays in speech development Special education, including sign language
Benefits will not be paid when no further improvement of functional skills can be expected.
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Physical Therapy The plan provides benefits for services performed by a physical therapist to provide medically necessary rehabilitative treatment that improves or prevents further deterioration of a bodily function that has been lost or impaired through a disease or injury. Physical therapy involves physical contact with the impaired area, such as massage, manipulation, heat or hydrotherapy. Services must be documented in a treatment plan that outlines the frequency and duration of the treatment and provides for ongoing reviews to determine if therapy is still necessary. After 18 visits, progress for improvement will be reviewed by the Claims Administrator. Benefits will not be paid when no further improvement of functional skills can be expected.
You Pay:
Smart Care Value Plan
Smart Care Base Plan
Smart Care Plus Plan
Smart Care Select Plan (if available)
Outpatient Therapy Services- Facility Based (Physical, Occupational, Speech, Pulmonary, and Cardiac Rehab)Applies to facility charges only
HCA-Affiliated Facility
$25 copay; deductibles do
NOT apply
$25 copay; deductibles do
NOT apply
$25 copay; deductibles do
NOT apply
$25 copay
Non-HCA In-Network Facility (when services are NOT available at an HCA-Affiliated facility) Requires Authorization
30%; deductibles apply
30%; deductibles apply
20%; deductibles apply
20%
Non-HCA In-Network Facility (when services are available at an HCA-affiliated facility)
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
100% (Not Covered)
Out-of-Network Facility (when services are NOT available at an HCA-Affiliated facility or network facility) Requires Authorization
30%; deductibles apply
30%; deductibles apply
20%; deductibles apply
20%
Out-of-Network Facility (when services are available at an HCA-Affiliated facility or Network facility)
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
75%; deductibles apply
No penalty
100% (Not Covered)
Therapy Services- Office Based (Physical, Occupational, Speech, Pulmonary, and Cardiac Rehab) *After 18 visits, progress for improvement will be reviewed by Claims Administrator.
In-Network 30%; deductibles apply
20%; deductibles apply
20%; deductibles do NOT apply
$30 copay* No referral required
Out-of-Network 75%*; deductibles apply
75%*; deductibles apply
75%*; deductibles apply
100% (Not Covered)
*Does not apply to out-of-pocket maximum
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Treatment of Mouth, Jaws and Teeth The Medical benefit option does not cover most dental treatment. However, benefits will be covered as non-hospital expenses to a physician or dentist to treat only the following conditions of the teeth, mouth, jaws, jaw joints or supporting tissues. If hospitalization is required, expenses will be covered as shown in the Smart Care Program Details chart.
Surgery necessary to correct temporomandibular joint syndrome (TMJ) Surgery necessary to treat a fracture, dislocation or wound Surgery necessary to correct severe malocclusion (faulty mouth closure) that cannot be improved by orthodontic (tooth-
moving) appliance therapy alone Non-surgical treatment of infections or diseases not related to the teeth Dental work, surgery or orthodontic treatment necessary to remove, repair, replace, restore or reposition natural teeth
damaged, lost or removed due to an injury. Other bodily tissues of the mouth that are fractured or cut due to an injury are included Teeth requiring this treatment must be free from decay or in good repair and firmly attached to the jaw at the time of the injury. All treatment must be done within 24 months following the date of the injury. If the injury necessitates crowns (caps) or dentures, bridgework or in-mouth appliances, the plan will cover:
o The first denture or fixed bridgework to replace lost teeth o The first crown needed to repair each damaged tooth o An in-mouth appliance used in the first course of orthodontic treatment after the injury
Transplants The Smart Care Program pays benefits as shown in the following table for eligible expenses related to organ and/or tissue transplants only if you obtain approval for all services before receiving care. Eligible transplants are those procedures approved by Medicare. You must contact your Claims Administrator at the number on your medical ID card as soon as you or a covered dependent is identified as a transplant candidate. If you do not contact your Claims Administrator, no coverage will be provided for transplants.
*Does not apply to out-of-pocket maximum Up to $10,000 in Special Expenses for travel, lodging and meals are eligible under the following conditions:
Maximum allowance of $50.00 per day per approved person for food, which applies to groceries and/or purchased meals. Receipts are required, and purchased meals must be itemized. Tips are reimbursable subject to the $50.00 maximum. Alcoholic beverages are not reimbursable.
Transportation, meals and lodging expenses are eligible if the transplant facility is at least 100 miles from the participant’s home. The transplant must be performed at an HCA-Affiliated Facility or Transplant Network facility.
All charges must be itemized (meals, lodging, transportation). Sales taxes are reimbursable. Medical and hospital expenses related to the donation of the organ or tissue are covered if the donor’s health plan does not provide coverage and the donor’s charges are billed under the recipient’s charges. Coverage for the donor’s transportation expenses may be covered if the $10,000 Special Expenses maximum benefit has not been exhausted and you have prior approval through your Claims Administrator. Donor search expenses are not covered.
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Expenses Not Covered Although the Smart Care Program can help pay most of the medical bills you might have, it does not cover everything. The following items are examples of expenses not covered:
General Medical Expenses Not Covered
Acupuncture therapy performed by a physician, except when used in lieu of anesthesia for surgery covered by this plan
Biofeedback as treatment for medical conditions Care covered or eligible for payment by hospital-sponsored healthcare plans (except the dental procedures covered
under the Smart Care Program), Workers’ Compensation laws (or the Employee Health and Safety Program applicable to employees working in Texas) or government programs, unless otherwise required by law
Care provided by a member of the patient’s immediate family or a person who normally lives in the patient’s home Care provided free of charge or care that would have been provided free of charge if the plan were not available Care, treatment, services or supplies that are not prescribed, recommended and approved by the attending physician
or dentist Charges over and above the reasonable and customary amount as determined by the Claims Administrator Charges that the covered individual is not legally obligated to pay Cosmetic procedures including hospitalization, surgery or other services or supplies that improve, alter or enhance
appearance — whether or not for psychological or emotional reasons — except for: o The correction of conditions resulting from accidental injuries or traumatic scars o The correction of congenital abnormalities o Reconstructive plastic surgery to correct deformities resulting from a disease or medically necessary surgery
to treat a disease or illness o Surgeries specifically mentioned as a covered expense
Counseling services: marriage, family, child, career, social adjustment, pastoral or financial Custodial care designed to help you with activities of everyday life, such as walking, dressing, bathing, feeding,
administering medication or any other services not requiring licensed and/or medically trained personnel — unless it is authorized by the Claims Administrator and will shorten the length of a hospital stay
Drugs not covered under the prescription drug plan, except drugs maintained and administered in the physician’s office
Elective abortions or abortion pills, unless medically necessary Exercise and weight-control or reduction services or treatments (except for obesity surgery and Federal Legend
weight-loss medication, if medically necessary) Feet conditions, including diagnosis and treatment of weak, strained, unstable or flat feet and any tarsalgia,
metatarsalgia or bunion, unless it involves the exposure of bones, tendons or ligaments Hospital admission kits Infertility once diagnosed, in vitro fertilization, artificial insemination, GIFT or other artificial fertilization technique
charges (and complication from these treatments). Fertility Oral Agents and fertility injectables may be covered (see Prescription Drugs section). .
Itemized hospital charges for telephone, television, cots, guest meals and other items that are not medically necessary
Mandated state service charges and taxes Massage therapy unless provided by a licensed physical therapist or physician for medically necessary treatment as
determined by the Claims Administrator Medical care received as a result of disease, defect or injury caused by declared or undeclared war Nicotine patches or nicotine chewing gum Occupational diseases or injuries Orthotics, except as covered elsewhere Physician charges for eye exams, other than charges from a primary care physician, optometrist or ophthalmologist
for services required as the result of accidental bodily injury or required for the diagnosis and/or treatment of a disease of the eye ("V" code with illness diagnosis) or systematic disease such as diabetes
Research and experimental procedures, supplies, drugs and devices (Federal Drug Administration [FDA] approval does not necessarily mean a procedure or supply has been removed from the experimental list.)
Resident physician or intern charges Services and supplies in a Veterans Administration Hospital for a covered person with a disability connected to
military service, unless otherwise required by law
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Services and supplies not medically necessary as determined by the Claims Administrator — even if they are prescribed by a physician
Services and supplies not specifically listed as a benefit Services and supplies provided primarily as a convenience, or for personal preference, even if ordered by a physician Services and supplies rendered by a provider that do not require the technical skills of that provider Services and supplies that school systems are legally required to provide Services, including hospital room and board, received after the attending physician or precertification provider
advises that no further hospitalization is necessary Services or supplies furnished in a United States government hospital not operated for the public at large, or
elsewhere at government expense, unless otherwise required by law Sex change surgery or any treatment of gender identity disorders Sterilization reversal procedures Testing or training done for educational purposes Therapy, supplies or counseling for sexual dysfunctions Transportation charges (except as specifically covered) even if prescribed by a physician Treatment needed as a result of a felony conviction, unless the injury or illness results from a medical condition
(mental or physical) or an act of domestic violence Unless medically necessary, treatment of:
o Toe nails, other than removal of the nail matrix or roots o Superficial lesions of the feet, such as corns, calluses and hyperkeratoses
Unless specifically listed in this SPD, services for or related to: o Eye surgery mainly to correct refractive errors, including radial keratotomy o Analysis or testing of vision o Biomicroscopy, field charting or aniseikonic investigation o Eyeglasses, contact lenses or hearing aids o Orthoptic or visual training
Vitamins, minerals, food supplements, dietary or nutritional counseling of any kind, unless it is specifically mentioned as covered or determined medically necessary by the Claims Administrator
Teeth, Mouth and Jaw Expenses Not Covered
Dental care, inpatient and outpatient, unless related to an accidental injury to the mouth or specifically listed as a covered procedure
Diagnosis and non-surgical treatment of temporomandibular joint syndrome (TMJ) In-mouth appliances, crowns, bridgework, dentures, tooth restorations, or any related fitting or adjustment services,
except as provided for injury, regardless of whether these services or supplies are necessary to relieve pain In-mouth scaling, planing or scraping Inpatient or outpatient services related to receiving dental care unless listed in this SPD Muscle training therapy (myofunctional therapy) or training to correct or control harmful habits Nonsurgical periodontal treatment Removal, repair, replacement, restoration or repositioning of teeth lost or damaged as a result of biting or chewing Repair, replacement or restoration of fillings, crowns, dentures or bridgework Root canal therapy or dental cleaning Routine tooth removal, except in cases of injury Services that are covered under a Dental Plan, even if you do not elect dental coverage Surgery necessary to remove:
o Impacted or partially impacted teeth in the bone of the jaw o Teeth that will not erupt through the gum o Teeth that cannot be removed without cutting into bone o The roots of a tooth without removing the entire tooth
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Behavioral Health Benefits Behavioral health benefits include benefits for mental health and substance abuse conditions. Behavioral health benefits are administered by ValueOptions, Inc. (or New Directions for the Midwest Division), not the medical claim administrator. You are covered for behavioral health benefits under the Smart Care Program according to the details provided below.
*Must be precertified with ValueOptions/New Directions **Must be precertified with ValueOptions/New Directions; out-of-pocket maximum does not apply Behavioral Health Benefits You must call ValueOptions at 1-800-434-5100 (or New Directions for the Midwest Division at 1-800-528-5763)
Treatment of Mental Disorders Covered expenses include charges made for the treatment of mental disorders by licensed behavioral health providers. In addition to meeting all other conditions for coverage, the treatment must meet the following criteria:
There is a written treatment plan prescribed and supervised by a licensed behavioral health provider; The care plan is individualized and specific to the patient’s symptoms and diagnosis; has documented follow-up
services, if indicated; services must be consistent with nationally accepted standards of clinical practice; expected to improve the patient’s condition or level of functioning; and not be a substitute for non-treatment services addressing environmental factors.
Treatment is determined to be medically necessary by ValueOptions (or New Directions) Benefits are payable for charges incurred in a hospital, psychiatric hospital, residential treatment facility, partial hospitalization program, day treatment program, intensive outpatient program, or behavioral health provider’s office. Benefits are payable only if your condition requires services that are only available in that setting. IMPORTANT: All treatment for mental health disorders must be precertified by Value Options (or New Directions for Midwest Division). See “Precertification” section for details.
Treatment of Substance Abuse Conditions Covered expenses include charges made for the treatment of substance abuse conditions by behavioral health providers. In addition to meeting all conditions for coverage, the treatment must meet the following criteria:
Care is delivered in a ValueOptions-approved (or New Directions-approved) substance abuse rehabilitation and recovery program with physician supervision
Care involves individual and group therapy, as well as attendance at meetings or organizations specializing in the therapeutic treatment of alcohol or substance abuse/dependency. The patient must attend these meetings as prescribed in the patient’s aftercare treatment plan
Care is provided by a ValueOptions-approved (or New Directions-approved) facility or provider
Medical Benefits Deductible Applies
Smart Care Value Plan
Smart Care Base Plan
Smart Care Plus Plan
Smart Care Select Plan (if available)
Behavioral Health – Inpatient
HCA-Affiliated Facility
NO 0% 0% 0% 0%
Non-HCA In-Network*
NO 30% 20% 20% 20%
Out-of-Network** NO 50% 50% 50% 100% not covered
Behavioral Health – Out-of-Pocket Annual Maximum
Applies to outpatient & inpatient services
Individual $5,000 $5,000 $3,000 $3,000
Family $10,000 $10,000 $6,000 $6,000
Behavioral Health – Outpatient (must be pre-certified after initial 20 visits from all providers)
In-Network NO 30% 20% 20% $30 copay
Out-of-Network NO 75% 75% 75% 100% not covered
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The plan will pay for detoxification claims only if treatment is certified by ValueOptions (or New Directions for the Midwest Division). Chemical dependency detoxification treatments must be followed by a completed clinically appropriate program of therapy direct toward rehabilitation that is approved by ValueOptions/New Directions.
Benefits are payable for charges incurred in a hospital, psychiatric hospital, residential treatment facility, partial hospitalization program, day treatment program, intensive outpatient program, or behavioral health provider’s office. Benefits are payable only if your condition requires services that are only available in that setting. Independent laboratory charges for other medical procedures, such as laboratory testing during inpatient hospitalization, that are primarily related to a substance abuse condition are paid at 70% under the Value option and 80% under the Base, Plus, and Select. IMPORTANT: All treatment for substance abuse conditions must be precertified by Value Options (or New Directions for Midwest Division). See “Precertification” section for details.
Types of Care
Acute Inpatient Mental Health or Substance Abuse Treatment ; represents the most intensive level of behavioral health care. Multidisciplinary assessments and multimodal interventions are provided in a 24-hour secure and protected, medically staffed and psychiatrically supervised treatment environment.
Residential Treatment Services are provided to individuals who require 24-hour treatment and supervision in a safe therapeutic environment. RTS is a 24 hour a day/7 day a week facility-based level of care. RTS provides individuals with severe and persistent behavioral health disorders therapeutic intervention and specialized programming in a controlled environment with a high degree of supervision and structure.
Partial Hospitalization is a nonresidential treatment program that may or may not be hospital-based. The program provides clinical diagnostic and treatment services on a level of intensity equal to an inpatient program, but on less than a 24-hour basis. These services include therapeutic milieu, nursing, psychiatric evaluation and medication management, group and individual/family therapy, psychological testing, vocational counseling, rehabilitation recovery counseling, substance abuse evaluation and counseling, and behavioral plans for at least 6 hours per scheduled day.
Intensive Outpatient Programs (IOP) provide time limited, multidisciplinary, multimodal structured treatment in an outpatient setting, Such programs are less intensive than a partial hospital program or day treatment (e.g., may not always include medical oversight and medication evaluation and management) but significantly more intensive than outpatient psychotherapy and medication management. This level of care is used to intervene in a complex or refractory clinical situation and should be differentiated from longer term structured day programs intended to achieve or maintain stability for individuals with severe and persistent mental illness.
Outpatient Services are those behavioral health services that are rendered in an office, clinic environment, or other locations appropriate to the provision of service for psychotherapy or counseling. Services focus on the restoration, enhancement and/or maintenance of an individual's level of functioning and the alleviation of symptoms that significantly interfere with functioning in at least one area of the individual's life (e.g., medication management, familial, social, or occupational).
Eligible Behavioral Health Providers The ValueOptions provider network (or New Directions provider network) includes licensed individual therapists, accredited treatment facilities and specialized programs. Eligible providers for behavioral health services include:
Licensed psychiatrists Licensed clinical psychologists Licensed master’s-level Clinical Social Workers Licensed master’s-level psychiatric nurse specialists or practitioners Licensed master’s-level professional counselors Certified addictionologists and anesthesiologists (may be classified as eligible providers under certain circumstances)
ValueOptions (or New Directions for the Midwest Division) will help you find a qualified provider if there is not an appropriate network provider in your area, or you can access provider information through HCArewards.com.
Precertification Precertification is required if you use a network or non-network provider for all higher levels of care and some outpatient services, including:
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Inpatient treatment (including in-hospital therapy, detoxification, and follow-up if a medical admission) Intensive outpatient treatment Residential treatment Outpatient services(Network & Out of Network Providers): The first 20 visits do not require precertification; however,
prior to the 21st visit, all treating provider(s) must submit an outpatient treatment report for authorization of additional visits and for benefits to continue to be paid
Partial hospitalization Specialized services (even if other treatment has already been preauthorized), including:
o Psychological testing o Biofeedback o Hypnotherapy o Sodium amytal interviews o Electroconvulsive therapy o Consultations by another mental health professional (except emergencies)
In case of a life-threatening situation, emergency treatment will be considered for coverage if you (or the facility) call ValueOptions (or New Directions for the Midwest Division) within 48 hours. Please note that you are responsible for notifying ValueOptions (or New Directions) within the applicable time frame. However, the facility may contact ValueOptions (or New Directions) on your behalf. Reduced benefits will be paid if you fail to contact ValueOptions (or New Directions) within this time frame.
Where services are rendered
Did You Precertify?
Services available at HCA
or Network?
Smart Care Value Plan
Smart Care Base Plan or Smart Care Plus Plan
Smart Care Select Plan (if available)
HCA-Affiliated Facility
Yes n/a 0% 0% 0%
HCA-Affiliated Facility
No n/a 0% after a $500 penalty for failure
to precertify
0% after a $500 penalty for failure
to precertify
0% after $500 penalty for failure
to precertify
Network Facility Yes n/a 30% 20% 20%
Network Facility No n/a 75% 75% No Coverage
Out-of-Network Facility
Yes Yes 50% 50% No Coverage
Out-of-Network Facility
Yes No 30% 20% 20%
Out-of-Network Facility
No Yes 75% 75% No Coverage
Out-of-Network Facility
No No 75% 75% No Coverage
ER Services if Admitted
Where services are rendered:
Did you notify within 48 hours?
Smart Care Value Plan
Smart Care Base Plan or Smart Care Plus
Plan
Smart CareSelect Plan (if available)
HCA-Affiliated Facility
Yes 0% with no deductible 0% with no deductible 0% with no deductible
HCA-Affiliated Facility
No 0% after a $500 penalty for failure to precertify
0% after a $500 penalty for failure to precertify
0% after a $500 penalty for failure to precertify
Non-HCA-Affiliated Facility
Yes 30% 20% 20%
Non-HCA-Affiliated Facility
No 30% after a $500 penalty
20% after a $500 penalty
20% after a $500 penalty
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Treatment mandated by Impaired Professional Programs must meet ValueOptions’ (or New Directions’) medical necessity criteria and be provided by a network facility (HCA-Affiliated Facility or ValueOptions — or New Directions for the Midwest Division).
Medical/Behavioral Healthcare Overlap There are some instances when medical and behavioral health disorders may overlap. For instance, if a patient attempts suicide, the patient may be admitted to a medical hospital, medically stabilized and then transferred to a psychiatric unit. In this example, the Medical Claims Administrator will process all claims prior to the patient’s transfer to the psychiatric unit, and ValueOptions (or New Directions) will process all claims after the transfer.
Behavioral Health Expenses Not Covered Services not covered under the behavioral health plan include:
Applied Behavioral Analysis (considered an investigation treatment for ASD, which is not a covered benefit) Therapy, services or treatment of autism spectrum disorders except for the initial diagnostic evaluation and assessment; or treatment of co-morbid/secondary covered conditions.
Administrative psychiatric services when these are the only services rendered Any testing, evaluation, consultation, therapy, service, supplies, or treatment that are covered as benefits under the
Medical benefits option Bioenergetics therapy Carbon dioxide therapy Chart review Chemical dependency detoxification treatments that are not followed by a completed clinically appropriate program of
therapy directed toward rehabilitation that is approved by ValueOptions (or New Directions) Confrontation therapy Consultation with a mental health professional for adjudication of marital, child support and custody cases Crystal healing treatment Cult deprogramming Durable Medical equipment for light box or photo-stimulation therapy Eating disorder and gambling programs based solely on the 12-step model Educational evaluation and therapy, testing, consultation, rehabilitation, remedial education, services, supplies or
treatment for Developmental Disabilities, Communication Disorders, or Learning Disabilities Educational treatment including reading or math clinics or special schools for the mentally retarded or behaviorally
impaired individuals. Environmental ecology treatment EST (Erhard) or similar motivational services Expressive therapies (art, poetry, movement, psychodrama) as separately billed services Group homes/halfway houses Guided imagery Hemodialysis for schizophrenia Hyperbaric or normobaric oxygen therapy L-Tryptophan and vitamins, except thiamine injections on admissions for alcoholism or with a diagnosis of nutritional
deficiency Maintenance care that provides an environment without access to alcohol or drugs, but does not include a
rehabilitative component Marathon therapy Megavitamin therapy Narcotherapy with LSD Orthomolecular therapy Prescriptions paid through prescription drug benefits Primal therapy Private duty nursing Private rooms (except when required for infection control) Psychological camps for treatment of ADHD or weight management Psychological and/or Neuropsychological Testing except when precertified and medically necessary Rolfing Sedative action electrostimulation therapy Sensitivity training
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Services and supplies listed under general exclusions of the Medical benefits option Services not deemed medically necessary Sex therapy (without DSM III-R diagnosis) Speech therapy Supervision of clinical treatment practitioners or team Training analysis (Tuitional or Orthodox) Transcendental meditation Treatment of sexual addiction, co-dependency or any other behavior that does not have a DSM III-R diagnosis Vocational assessment/school assessment Z therapy Prometa Vagus Nerve Stimulation Biofeedback except for the primary treatment of anxiety disorders Transcranial Magnetic Stimulation Testing, therapy, service, supply, or treatment which does not meet national standards for mental health professional
practice. Treatment of consolations provided via telephone, electronic transmission, or other non-in-person modalities unless
determined as medically necessary.
Prescription Drugs You will receive a Caremark prescription card that can be used at network pharmacies when you purchase prescription drugs for you and your covered spouse and/or dependents. When you use a network pharmacy, you pay the deductible, copay or coinsurance for the type of drug you select — generic or brand-name. Below are details of prescription drug coverage for the Smart Care Program:
You Pay:
Smart Care Value Plan
Smart Care Base Plan
Smart Care Plus Plan
Smart Care Select Plan (if available)
Retail (30-day supply)
Annual Deductible (Individual/ Family)
$100/$200 $100/$200 $50/$100 $0/$0
Generic $5 copay; deductibles do
NOT apply
$5 copay; deductibles do
NOT apply
$2 copay; deductibles do
NOT apply
$2 copay
Brand Name 40%; deductibles apply
40%; deductibles apply
30%; deductibles apply
30%
Coinsurance Maximum
$120 per script after deductible
$120 per script after deductible
$90 per script after deductible
$90 per script
Retail (90-day supply)
Generic $12 copay; deductibles do
NOT apply
$12 copay deductibles do
NOT apply
$5 copay; deductibles do
NOT apply
$5 copay Must use
Maintenance Choice/ CVS
Brand Name $120 copay; deductibles do
NOT apply
$120 copay; deductibles do
NOT apply
$90 copay; deductibles do
NOT apply
$90 copay* Must use
Maintenance Choice/ CVS
Mail Order (90-day supply)
Generic $12 copay; deductibles do
NOT apply
$12 copay deductibles do
NOT apply
$5 copay; deductibles do
NOT apply
$5 copay Must use
Maintenance Choice/ CVS
Brand Name $120 copay; deductibles do
NOT apply
$120 copay; deductibles do
NOT apply
$90 copay; deductibles do
NOT apply
$90 copay* Must use
Maintenance Choice/ CVS
Specialty Drugs (30-day supply)
$40 copay; deductibles do
NOT apply
$40 copay; deductibles do
NOT apply
$30 copay; deductibles do
NOT apply
$30 copay
* In the event the cost of the medication is 30% or less than the contracted rate, the lesser amount will apply.
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If your physician gives you a prescription for an injectable the physician does not keep in the office, the cost of the injectable is covered under the Prescription Drug Benefit. You may take the prescription to a network pharmacy or use the mail-order program, if available. All provisions of the Prescription Drug Program apply. Federal Legend smoking-cessation medications are covered up to a lifetime maximum of $500. Federal Legend weight-loss medications are covered if determined by Caremark to be medically necessary. If you order insulin-type drugs and supplies for treatment of a diabetic condition, One copay will apply for the insulin and supplies when they are purchased at the same time, regardless of use of retail or mail order. 90-Day Supply at Select Retail Pharmacies: You may purchase up to a 90-day supply at select retail network pharmacies. The mail-order copays will apply. You must have a prescription from your physician for a 90-day supply with three refills. Contact Caremark at 1-866-216-5767 or visit HCArewards.com for more information Call Caremark at 1-866-216-5767 or visit the Web site at HCArewards.com for a list of participating pharmacies in your area. And be sure to ask your doctor if there is a generic alternative you could try. Generic Drugs By law, generic and brand-name drugs must meet the same standards for safety, purity, strength and effectiveness.
Non-Network Pharmacy (for emergencies only) You must use a network pharmacy to receive benefits. However, if due to an emergency situation, a network pharmacy is not available, you may use a non-network pharmacy. You must pay the full cost of your prescription and then file a claim with Caremark. You will be reimbursed 100% of the cost, less the applicable deductible, copay or coinsurance. Your deductible, copay or coinsurance is based on whether or not you use a generic or brand-name drug. Drug Utilization Program (DUR): A “drug utilization program,” or DUR, evaluates prescription drug therapy for medical necessity and appropriateness. At the point of sale, before medication is dispensed, the Caremark system can access your prescription drug history and all medication acquired — including medication obtained from other pharmacies. Through this process, your pharmacist can be alerted to interactions that could be harmful to you.
Limitations on Drugs Some drugs and injectables require prior approval with Caremark (exceptions are Vitamin B12, D.H.E., Imitrex, Epi-Pen, Gulcagon, Insulin, Rhogam, Synvisc, Synagis and Depo-Provera). Prior authorization is a process where a medication is reviewed by clinicians for safety and appropriateness of use before being dispensed at a pharmacy. Medications that require prior authorization are typically drugs that are used for indications not approved by the Food and Drug Administration (FDA) or drugs that pose a significant health risk if used inappropriately. The following medications require prior authorization:
Topical Acne Agents (Age > 29) Avita, Differin, Retin-A, Tazorac (PA for all ages on Tazorac) Renova (Age > 29)
Nail Fungus Penlac
If your doctor prescribes one of these medications, you will need to have your doctor’s office: Call Caremark at 1-800-294-5979 and provide the reason the medication has been prescribed with the diagnosis and
requested clinical information.
OR
Fax a letter to 1-888-836-0730. The letter should state the reason the medication has been prescribed with the diagnosis. Caremark will normally respond within 24 hours as long as the physician replies. If the physician initiates the prior authorization and phones in the request, a response can be done at the time of the call. If you continue to need the prescription after the prior authorization expires, you will need to have your doctor’s office call Caremark again to renew the authorization. Other drugs have specific quantity limits:
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Antimigraine agents limited to 2 packages per month unless approved by Caremark. Other monthly limits include: Amerge 18 tablets; Axert-18 tablets; Frova-9 tablets; Imitrex injection kits 2 kits (4 injections); Imitrex injection vials-12 vials; Imitrex nasal spray-12 units (2 packages); Imitrex-27 tablets; Maxalt-18 tablets; Relpax-9 tablets; Zomig-18 tablets; Zomig nasal spray-6 units (1 package)
Relenza: 20 caplets/14 days Tamiflu: 10 caplets/30 days Tamiflu oral liquid: 75 ml/30 days Toradol: 20 tablets/30 days Stadol nasal spray: 3 bottles (9 ml)/30 days Erectile dysfunction agents: 6 tablets/30 days
Please note: These lists are subject to change. Contact Caremark for a complete up-to-date lists or if you have questions. You are responsible for the cost of drugs in excess of the limit. For fertility oral agents the plan pays 50% up to a lifetime maximum of $10,000 and three cycles. Benefits are limited to one cycle (7 to 10 consecutive days) per month. Contact Caremark for more information. Infertility For fertility oral agents and fertility injectables the plan pays 50% up to a lifetime maximum of $10,000 and three cycles. Benefits are limited to one cycle (7 to 10 consecutive days) per month. In addition, discounts on fertility medications may be available through Caremark. Please visit www.caremark.com/fertility or call 1-888-826-5632.
Specialty Pharmacy Services Certain chronic and/or genetic conditions require special pharmacy products, often in the form of injected or infused medicines. Caremark Connect® provides these products with a 30-day supply directly to you along with special support, including regular phone calls to answer questions about using the medicine. You are also provided with a pharmacist-led CareTeam for ongoing support and counseling. Caremark Specialty Pharmacy Services are to be used for the following conditions: Asthma Crohn’s Disease Gaucher’s Disease Hematopoietics Hemophilia, von Willebrand Disease and related bleeding disorders Hepatitis C Human Growth Hormone Immune disorders Multiple Sclerosis Myeloid Stimulant (Neutropenia) Oncology Osteoporosis Osteoarthritis Psoriasis Respiratory Syncitial Virus Rheumatoid Arthritis RSV prevention Pulmonary hypertension Please note: This list is subject to change. Contact Caremark for a complete up-to-date list or if you have questions. You must use the Caremark Specialty Pharmacy Services through Caremark Connect® for the above conditions and any others for which Caremark Connect® may advise fall under this category. You may reach Caremark Connect® at 1-800-237-2767. Any retail use of medicines under the Specialty Pharmacy Services will be denied coverage.
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Smart Care Select Plan Maintenance Choice Program
If you choose the Select Plan, maintenance prescriptions (brand name or generic) after the first two fills must be for a 90-day supply and obtained from a CVS retail pharmacy or the CVS/Caremark mail order service. The chart below indicates when you should use a network retail pharmacy, the mail service pharmacy or the Maintenance Choice Program.
Type of Pharmacy:
Network Retail Pharmacy: Mail Service Pharmacy:
Maintenance Choice Program:
When to Use: Up to a 30-day supply of immediate medicine needs or
short-term medicines
Up to a 90-day supply of maintenance or long-term
medicines
If you are a Select Plan participant, all maintenance prescriptions
(brand name or generic) must be for a 90-day supply and obtained
from the CVS/Caremark mail order service or a CVS retail
pharmacy.
You Pay: Generic: $2 Brand Name: 30%
Does not apply to
out-of-pocket maximum
Generic: $5 Brand Name: $90
Does not apply to
out-of-pocket maximum
Generic: $5 Brand Name: $90*
Does not apply to
out-of-pocket maximum
Annual Deductible: None None None
Coinsurance Maximum:
$90 $90 $90
How to Find List of Participating Providers:
www.Caremark.com www.Caremark.com For Mail Order: www.Caremark.com
For Retail:
www.CVS.com (click on Store Locator)
*In the event the cost of the medication is 30% or less than the contracted rate, the lesser amount will apply.
Maintenance drugs include drugs you take on a regular basis, such as heart, blood pressure or cholesterol medication and insulin. The Select Plan Maintenance Choice Program allows you to fill two 30-day prescriptions for the same maintenance drug (brand name or generic) at a network retail pharmacy. After that, refills for that same drug must be for a 90-day supply and obtained from the CVS/Caremark mail order service or a CVS retail pharmacy.
If you are already using the CVS/Caremark mail order service and you want to continue, there is nothing else you need to do. If you would like to switch to a CVS retail pharmacy, you can do so by visiting your local CVS pharmacy location or by calling (866) 216-5767.
If you are using a retail pharmacy, Caremark will contact you after your first 30-day fill of a maintenance drug and will help you get a 90-day prescription by contacting your doctor and arranging for your prescription to be ready when you need it through a CVS retail pharmacy.
Note: For short-term therapy prescription drugs, you can use any network retail pharmacy. For example, if your doctor prescribes an antibiotic for an infection, you can use any network retail pharmacy. Follow these steps to find a list of participating Maintenance Choice pharmacies:
Go to HCArewards.com Click on “Login” and then “Continue” Enter your LifeTimes User ID and Password” Once you are on the LifeTimes Connection main page, click on the “View Your HCArewards.com Now” link on the
right-hand side of the screen. This will open your customized view of HCArewards.com. Click on “Benefits” and “Benefits Providers” Under Prescription Drugs:
o Click on the Caremark link to learn more about your prescription benefits, locate a network pharmacy, use the mail order pharmacy and discover other cost-savings opportunities.
o Click on the Select Plan Maintenance Choice link for all 90-day retail maintenance prescriptions. Note: The Select Plan Maintenance Choice list of participating pharmacies includes all CVS locations
If you have questions about your prescription coverage, call (866) 216-5767 to speak to a Customer Care representative 24 hours a day, seven days a week.
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Mail-Order Program The mail-order program may provide a cost-effective and convenient way to purchase prescriptions for maintenance drugs. Maintenance drugs include drugs you take on a regular basis, such as heart, blood pressure or cholesterol medication and insulin. You can order refills by Internet, phone or mail. To order refills online, access Caremark through HCArewards.com and follow the directions. To order refills by phone, call the toll-free number listed on your identification card. To order refills by mail, complete the instructions on the mail-order form. In all cases, you must provide credit card information or include the exact payment. Refills will not be filled without exact payment. Mail Order Process To find out more information about this program, or to fill prescriptions through mail order, contact Caremark at the phone number listed on your identification card or link to Caremark through HCArewards.com. See the What Else You Should Know section for details.
Drug Expenses Not Covered You may check with Caremark if you have a question about whether a drug is covered. However, in general, prescription drug benefits do not cover:
Allergy serum (covered under Other Services) Anorexiants Any prescription refilled in excess of the number of refills specified by the physician, or any refill dispensed after one
year from the original order Drugs prescribed by a veterinarian Drugs that do not require a prescription even though a physician may write an order for such a drug on a prescription
form Experimental drugs Federal Legend drugs for weight control not approved by Caremark as medically necessary Growth hormones, unless specifically approved by Caremark Hair growth drugs (e.g., Rogaine®) for the sole purpose of promoting or stimulating hair growth In vitro drug treatment, except for Fertility Oral Agents and fertility injectable medications Medications administered in the hospital Medications covered by Workers’ Compensation Non-Federal Legend drugs Nutritional supplements Over-the-counter smoking deterrents Over-the-counter weight control medications Progesterone suppositories Services and supplies listed under general exclusions of the Medical benefits option Therapeutic devices or appliances Vaccines other than those covered under Preventive Care
Any exclusion above will not apply if the coverage is specifically listed in this Summary Plan Description or coverage is required under any law.
How to Use the Benefits
Filing Smart Care Program or PPO Claims The following claim filing procedures must be followed in order for your claims to be correctly filed. Incorrectly filed claims will be denied, except for certain urgent claims. All claims must be submitted in writing to the Claims Administrator. The address for your Medical Claims Administrator is on your ID card. The addresses for your behavioral health and prescription drug Claims Administrators are listed in the Administrative Information section. There are three types of PPO claims that can be filed: medical, behavioral health and prescription drugs. Within each of these types of claims, claims may be post-service or pre-service. Post-service claims are claims for which an expense has been incurred. Pre-service claims are claims for which the plan requires prior approval before the expense has been incurred. A subset of pre-service claims is urgent claims that require an expedited process. To file a pre-service claim, you must submit in writing the applicable information below plus physician proof that the service is medically necessary. If urgent care is involved, as determined by your physician, you can fax or call the Claims Administrator to submit the pre-service information. If you request, the Claims Administrator will respond orally with a written response as
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well. Please refer to the Administrative Information (Benefit Claims) section concerning specific time periods and more information.
Time Limit to File Claims All claims must be filed with the Claims Administrator as soon as reasonably possible, but you must file your claim within one year of the date of service or it will not be processed — unless you are legally incapacitated.
Filing Medical Claims
1. Ask your provider to submit your claim. When you use a network provider, your provider should submit your claim for you.
2. Send your original itemized bills and receipts to your Claims Administrator if your provider does not file your claim for you. Keep a copy of all documentation and receipts for your records. Cancelled checks and payment receipts cannot be accepted as proof of your claim. Your original bills must include:
o Your name and the participant number on your medical ID card (as the covered employee) o The name, date of birth and address of the patient o The provider’s name, address, Social Security or tax ID number and telephone number o Codes for the diagnosis and complete description of services o Charges for the services received o The date (day, month and year) the service was received
3. Submit your claim to your primary plan first and then to any secondary plan you may have. If you or your dependents
are covered by another medical plan, read the information in the Coordination of Benefits section.
Filing Behavioral Health Claims
1. Ask your behavioral health provider to submit your claim for you — or obtain a behavioral health claim form by calling ValueOptions at 1-800-434-5100 (or New Directions at 1-800-528-5763). ValueOptions (or New Directions) network providers will submit claims for you.
2. Complete all applicable sections of the claim form if you are submitting your own claim. Send your completed claim form with original bills and receipts to ValueOptions (or New Directions). Keep a copy of all documentation and receipts for your records. Your original bills must include:
o Your name and the participant number on your medical ID card (as the covered employee) o The name, date of birth and address of the patient o The provider’s name, address, Social Security or tax ID number and telephone number o Codes for the diagnosis and complete description of services o Charges for the services received o The date (day, month and year) the service was received
3. Send the claim to ValueOptions (or New Directions) at the address on the claim form.
Filing Prescription Drug Claims
Retail — Network Pharmacy
1. Go to a participating retail pharmacy. Call Caremark at 1-866-216-5767 or link to Caremark through HCArewards.com to locate a network pharmacy near you.
2. Present your prescription ID card and prescription to the pharmacist. You will receive a separate prescription ID card when you enroll in a PPO option.
3. Pay the appropriate copay, deductible or coinsurance based on your PPO option for up to a 30-day or 90-day supply.
3. File a claim form with Caremark. Call Caremark at 1-866-216-5767 or link to Caremark through HCArewards.com to request a claim form. Be sure to document the emergency situation. Keep a copy of all documentation and receipts for your records. Your reimbursement will be limited.
Mail Order
1. Ask your physician to write your prescription for up to a 90-day supply of medication, plus up to one year of refills (six months for controlled substances). The prescription should include:
o The patient’s full name o The physician’s full name, address and phone number o The physician’s DEA number, when applicable o Daily directions o The generic name and exact strength of the medication o The exact number of refills
2. Complete a mail-order form. Call Caremark at 1-866-216-5767 or link to Caremark through HCArewards.com if you
need an order form.
3. Send your order form, prescription and/or refill information and copay to the address on the form. Keep a copy of all documentation and receipts for your records.
4. Order refills by mail, phone or online. To order refills by phone, call Caremark at 1-866-216-5767 before your current supply runs out. Allow 7 to 10 business days for delivery. To order refills online, link to Caremark through HCArewards.com.
Payment of Benefits The Claims Administrator has the right to request that a physician or provider chosen by the plan examine you before approving payment of your claim. If such an examination is required, it will be performed at the plan’s expense. If you disagree with the determination regarding the payment of benefits, you have the right to appeal that decision. See the Administrative Information (Request for Review if Your Claim is Denied) section for more information about appeals.
What Else You Should Know
Case Management A case management coordinator will work with you, your family and your physician to manage and coordinate hospital and community resources if you need lengthy and complicated treatment. Your Claims Administrator will also work with you to manage the cost of care while meeting your needs and the goals of your treatment plan. Your case manager may recommend a treatment plan that includes alternative settings such as skilled nursing facilities or the patient’s home. Other services such as home health, hospice and skilled nursing services are also subject to case management. The plan may also pay for special services such as home modifications, medical equipment, nurses and caregiver training for the patient’s family within certain limitations and special provisions. When case management determines that specific services that are not usually covered under the plan will achieve the most efficient and effective use of medical resources, alternative benefits may be implemented by a separate written treatment agreement. Providing alternative benefits for one covered person does not obligate the Claims Administrator to make the same or similar determination for any other covered person. In addition, providing alternative benefits for one person is not a waiver of the plan’s provisions in accordance with the written plan documents. Deductibles, copays, coinsurance and other limitations and exclusions, including annual and lifetime maximums, still apply when alternative benefits are provided. The plan may stop providing alternative benefits when at least one of the following occurs:
The covered person no longer follows the written treatment plan The covered person uses up the maximum lifetime benefit The covered person ceases to be covered under the plan The written treatment plan ceases to provide the most efficient and effective use of medical resources under the plan
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Coordination of Benefits If you or your dependents also have coverage under another medical plan (such as your spouse’s employer’s plan), benefits are coordinated between the two plans to avoid duplication of payment. Through the coordination of benefits, you will not receive a benefit greater than the benefit you would have received in the absence of another plan. The Medical benefit option under the HCA Health and Welfare Benefits Plan will not coordinate benefits with other pharmacy benefits, school accident insurance or supplemental hospital indemnity benefit plans. It will coordinate benefits with the following types of medical and healthcare benefits:
No-fault motor vehicle plans or other types of plans required by law. This refers to a motor vehicle plan that is required by law and provides medical care payments that are made, in whole or in part, without regard to fault. A person subject to such law who has not complied with the law will be deemed to have received the benefits required by law
Group or group-type healthcare or dental plans (including other company plans) Any coverage under labor-management trusted plans, union welfare plans, employer organization plans or employee
benefit organization plans Any coverage under governmental plans, such as Medicare. This does not include a state plan under Medicaid or any
governmental plan when, by law, its benefits are secondary to those of any private insurance nongovernmental program
Any private or association policy or plan of medical or dental expense reimbursement that is rated for a group or individual
Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Dental HMOs or any combination of this type of managed care
With coordination of benefits, the primary plan pays your benefits first. Then the secondary plan considers any additional benefit that may be due. The following guidelines are used to determine which plan is primary:
A plan that does not contain a coordination of benefits provision will pay before this plan The plan covering the patient as an employee will be primary A no-fault motor vehicle plan (or another type of plan required by law) will be primary For a dependent child, if both parents have group medical plans, the parent whose month and day of birth comes first
during the calendar year will have the primary plan. This guideline is called the “birthday rule.” If both parents have the same birthday, the plan that has covered one parent for a longer period is primary
For a dependent child with parents who are divorced or separated, the plan covering the parent with custody of the dependent child usually pays benefits for the child first. If the parent with custody remarries, the stepparent’s plan pays second, and the plan of the natural parent without custody pays third. If a court decree places financial responsibility for the dependent child’s medical care on the parent, that parent’s plan always pays first
If none of the above situations applies, the plan covering the person for the longest length of time pays first, except when both plans stipulate that the plan covering a person as an employee always pays before a plan covering that person as a laid-off employee or retiree. In this case, the plan covering the active employee pays first. If the other plan does not have a provision regarding retired or laid-off employees, this exception does not apply
Medicare is always the primary plan for COBRA participants Generally, Medicare is primary for covered individuals with end-stage renal failure after 30 months
In order to administer claims, the Claims Administrator has the right to:
Provide or receive information needed to determine benefits Pay the administrator of another plan the amount that would have been paid by this plan. This amount will be
considered a benefit under this plan You must verify if you or your covered dependents are covered under another plan. Example: Coordination of Benefits: Jane's husband Bill has medical coverage through his employer and is also covered as Jane's dependent by the Medical benefits option. His medical plan pays 70% of Physician's charges. Bill's office visit costs $100. Because his plan is primary, here's how his benefits would be calculated:
Total cost: $100
Amount Medical benefits option would pay if primary: $80
Bill's plan (primary) pays: $70
Medical benefits option (secondary) pays: $10
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Eligibility for Medicare The Medical benefit option is the primary plan if one of the following applies:
You are enrolled in a medical option, you are still actively employed and you or your dependent spouse is age 65 or older
You are enrolled in a medical option and actively employed and your covered dependent is under age 65, disabled and entitled to Medicare
Other Rules If you or your dependents have other coverage not addressed above, such as retiree medical coverage, other rules apply. Call the Claims Administrator for information on these special rules.
Qualified Medical Child Support Order The Medical benefit option will comply with the provisions of a Qualified Medical Child Support Order (QMCSO).
Continuing Coverage (COBRA) Under certain circumstances you and/or your dependents may continue medical coverage under COBRA when it would otherwise end. See the COBRA section for more information.
Pre-existing Conditions The Medical benefit option has no pre-existing condition limitations.
Certificate of Creditable Coverage When your Medical coverage ends, you will receive a written certification — called a certificate of creditable coverage — of how long your coverage was in effect. This certificate is designed to lessen your new pre-existing condition exclusion period. You may also request a certificate at any time within 24 months after your active or COBRA coverage ends. Generally, if you or your dependents have been covered by any healthcare plan for the previous 12 months, your dependents will be covered under a new plan without regard to pre-existing conditions. You may be required to submit a certificate of creditable coverage when you enroll in the new health plan. As a result, you should retain any certificate of creditable coverage for future verification. However, if you had a break in coverage of at least 63 days, you or your dependents may be subject to the full pre-existing condition exclusion period of another company. You may be able to prevent a break in coverage by electing COBRA continuation coverage. See the COBRA section for more information.
When the Plan May Recover Payment In some situations, another person or entity may be legally responsible for your medical expenses. This situation might occur, for example, in an automobile accident. See the Administrative Information (HCA's Rights, Subrogation and Reimbursement) section for more information about the Medical benefits option’s right to reimbursement and subrogation.
Coordination of Benefits ........................................................................................................ 69
What Else to Know You Should Know ............................................................................................ 70
Payment of Benefits .............................................................................................................. 70
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Dental Highlights Good dental health affects more than the way you look. It affects the way you feel and your overall health. That’s why the HCA Health and Welfare Benefits Plan offers dental coverage. The plan makes it easy for you to afford preventive care such as checkups and cleanings. It also provides benefits to help you pay for other expenses such as fillings, dentures or orthodontia. Provider Directories You can obtain a provider directory by contacting the Dental PPO at 1-877-638-4422 or the appropriate Dental HMO or by going online at HCArewards.com.
Plan Overview:
What coverage categories are available? You You plus one dependent You plus two dependents You plus three or more dependents
Who pays the cost? You and your facility share the cost of coverage. Your share of the cost is deducted from your paycheck on a before-tax basis
Your Choices Depending on where you live, you may be eligible to choose one of the following options:
Dental PPO — Under this option, you may use any dentist you choose. However, you receive provider discounts only when you use a network dentist.
Dental HMO options — Dental HMOs work much like medical HMOs. They provide what is basically prepaid dental care. You must use network providers to receive benefits. You will receive information directly from the Dental HMO that provides specific instructions about how to receive benefits.
No Coverage — If you choose no dental coverage, you may receive Cash-Out Dollars to use toward the cost of other benefit choices.
Coverage Categories If you choose to enroll in the Dental PPO or in a Dental HMO, you may choose coverage for:
Yourself Yourself plus one dependent Yourself plus two dependents Yourself plus three or more dependents
You may choose dental plan coverage for dependents other than those covered under your medical plan option.
Dental HMO If you choose coverage under a Dental HMO, you will receive benefit information in a summary plan description from that organization. The Dental HMO summary plan description is considered part of this SPD. The Dental HMO materials will provide any special instructions or steps you must follow, including information regarding claim forms, network providers, copayments and dollar limits. Because state law governs Dental HMOs, the dependent eligibility rules may be different. For more information, contact the Dental HMO Member Services department.
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Dental PPO Feature: Coverage:
Preventive Treatment 100% with no annual deductible1 Includes oral exams, cleanings and X-rays (subject to limitations) as well as
emergency treatment
Basic Treatment 80% after annual deductible1 Includes basic cavity filings, root canal therapy and oral surgery Includes periodontic treatment Includes nonsurgical TMJ treatment, up to individual lifetime maximum
benefit of $2,000
Major Treatment2 50% after annual deductible1 Includes crowns, dentures and bridgework
Orthodontia2,3 50% after annual deductible, up to individual lifetime maximum benefit of $1,5001
Annual Deductible (applies to Basic, Major and Orthodontia treatment only) Individual Family
$75 $150
Annual Maximum Benefit $1,200 per person
1 Reasonable and customary limits apply to out-of-network providers. 2 You become eligible for these benefits only after you have been covered by an HCA dental plan option for a period of at least 12 months. 3 Orthodontic coverage is available to you and all covered dependents. You will be responsible for any amounts over the reasonable and customary charges when you use an out-of-network provider.
Annual Deductible/Maximums
Annual Deductible You must pay an annual deductible of $75 per covered person or $150 per family before the plan begins to pay benefits for covered expenses. The deductible applies to all network or out-of-network basic, major and orthodontic expenses. It does not apply to preventive or diagnostic services. Common Accident Provision If two or more members of your family are injured in the same accident, you pay only one annual deductible for all their combined dental expenses resulting from that accident. This deductible applies to the calendar year in which the accident occurs and the following calendar year. The charges used to satisfy the common accident deductible will also apply to the individual deductible of a family member who was injured if that individual has additional dental expenses not related to the accident during the same calendar year as the accident.
Maximum Benefits When you use network or out-of-network providers, the annual maximum benefit under the Dental PPO is $1,200 for each covered person. In addition, individual lifetime maximum benefits apply as shown in the following table.
Service Individual Lifetime Maximum Benefit
Orthodontia* $1,500
Nonsurgical TMJ expense $2,000
* Orthodontia expenses do not count toward the annual maximum for other dental services.
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Covered Expenses The Dental PPO pays benefits for covered services only if those services are received from one of the following providers:
Doctor who is legally licensed to practice medicine and surgery Dentist who is legally licensed to practice dentistry and surgery Denturist who is licensed to make dentures and is practicing within the scope of that license Dental hygienist who is licensed to practice dental hygiene, practicing within the scope of that license, and under the
supervision of a dentist. The following listing of services will give you an idea of what type of expense is covered under each category. Other services may also be covered. Please call the Dental Claims Administrator at 1-877-638-4422 if you are unsure if a service or supply is covered under the plan.
When Covered Services Begin Many types of dental services require multiple visits to complete. Benefit payments under the Dental PPO may start when the procedure begins or when it ends, depending on the procedure. The following table shows when payment starts for common multiple-visit procedures.
Service: When Benefit Payments Begin:
Dentures When dentures are placed
Crowns When crown is placed or sealed
Periodontal Service When service is received
Orthodontics When band or appliance is inserted
Root Canal Therapy When pulp chamber is opened and explored to the apex
When benefit payments start at the beginning of a procedure, all payments for that procedure count toward the maximum benefit for the calendar year in which the procedure begins, even if the procedure continues into the next calendar year.
Reasonable and Customary When you use an out-of-network dentist, benefits are based on the reasonable and customary charge. The Dental Claims Administrator determines what charges are reasonable and customary based on internal criteria such as the range of charges made by the majority of dentists in a given area for the same or similar courses of treatment when that treatment meets generally accepted standards of care. Reasonable and customary is the lesser of:
The dentist’s actual charge The dentist’s usual charge for the same or similar services The usual charge of most dentists in the same geographic area for the same or similar services
Preventive and Diagnostic Services The Dental PPO pays 100% of charges for preventive and diagnostic services (reasonable and customary limits apply to out-of-network providers). The annual deductible does not apply to these services. These benefits are included in the annual benefit maximum. Preventive and diagnostic services include:
Routine oral exams, limited to two visits in a calendar year Prophylaxis other than periodontal, including scaling and polishing, limited to two treatments in a calendar year Topical application of fluoride for children under age 15, limited to one treatment in a calendar year Sealants applied to pits and fissures of permanent molars after the tooth has erupted and before the tooth decays or
is filled, for patients under age 19, limited to two applications per tooth per lifetime Space maintainers to replace prematurely lost teeth for children under age 15 and adjustments to the space
maintainers within six months of insertion Emergency treatment to relieve pain, including sedatives, fillings and X-rays Dental X-rays:
o Full-mouth X-rays once in any three calendar years
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o Bitewing X-rays up to twice in a calendar year o Periapical X-rays o Intraoral X-rays o Extraoral X-rays, limited to two films per calendar year o TMJ X-rays o Posteroanterior lateral facial bone film o Sialography o Cephalometric film series
Biopsies and examinations of oral tissue
Basic Restorative Services The Dental PPO pays 80% of charges for basic restorative services to restore teeth and gums (reasonable and customary limits apply to out-of-network providers). You must satisfy the annual deductible before you receive benefits for basic restorative services. These benefits are included in the annual benefit maximum. The following services are covered when deemed appropriate by the dental claims administrator.
Oral surgery: o Simple extraction o Surgical extraction, including impactions o Root recovery (surgical removal of residual root) o Removal of dentigerous or odontulous cyst o Incision and drainage of an abscess o General anesthesia (subject to approval of Dental Claims Administrator) o Surgical exposure of impacted tooth to aid eruption o Surgical preparation of ridge for dentures (alveoplasty) o Stomatoplasty o Removal of exostosis (growth on bone) o Frenulectomy (fold that aids movement of the tongue) o Removal of hyperplastic (enlarged) or redundant tissue o Oral anterior fistula (abnormal passage) closure o Removal of dental cysts, tumors or other diseased tissues
Periodontics o First diagnostic consultation limited to one in any calendar year o One of these procedures per area of the mouth in any calendar year:
Gingivectomy, per quadrant Gingival curettage, per quadrant Gingival flap procedure, per quadrant Mucogingival surgery, per quadrant Osseous (bone) surgery, per quadrant Osseous grafts, single site
o Pedicle grafts o Free soft tissue grafts o Vestibuloplasty o Provisional splinting o Periodontal occlusal adjustment, if done with periodontal surgery o Periodontal appliance limited to one appliance in any three calendar years o Periodontal scaling and root planing, full mouth o Periodontal prophylaxis, including scaling and root replaning, limited to a total of two periodontal prophylaxis
treatments in any calendar year o Horizontal pin splinting
Endodontics: o Pulpotomy o Root canal therapy o Apicoectomy (removal of part of the tooth root) and retrograde filling o Root resection o Hemisection o Apical curettage o Apexification
Restorative dentistry: o Fillings of amalgam (permanent and baby teeth) o Fillings of silicate, acrylic, plastic, resin or gold foil o Acid etch is included with the restoration
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o Pin retention, if done in conjunction with an amalgam or composite restoration o Recementing of crowns, inlays, bridgework or space maintainers o Crown build-up (If done for endodontically treated teeth that require crowns, the build-up is included with the
crown allowance) o Repair of crowns to replace a broken facing with other facing o Repairs (other than relining) and adjustments to dentures, limited to repairs or adjustments done more than
12 months after initial insertion o Other repairs include repairing broken complete or partial dentures and replacing broken teeth or clasps
Treatment of temporomandibular joint (TMJ) dysfunction/pain syndrome (Nonsurgical TMJ treatment benefits are limited to an individual lifetime maximum benefit of $2,000 and are subject to the maximum dental benefit per calendar year):
o Initial diagnostic consultation and examination o Temporomandibular repositioning appliance and adjustments o Injections
Major Restorative Services After you’ve been covered under an HCA dental plan option for 12 months, the Dental PPO pays 50% of the reasonable and customary charges for major restorative services. You must also satisfy the annual deductible before receiving benefits for major restorative services. These benefits are included in the annual benefit maximum. The following metals are defined as materials that contain, in any combination:
Precious metal — more than 50% of gold, platinum or palladium Semi-precious metal — 10% to 50% of gold, platinum or palladium Non-precious metal — less than 10% of gold, platinum or palladium
Temporary restorations and appliances and one year of follow-up care for all major restorative services will be considered part of the final service rather than a separate service. Major restorative services include:
Restorations (crowns, inlays and onlays): o Precious metal inlays and onlays, if tooth can’t be restored by amalgam or composite fillings o Crowns and abutments, if tooth can’t be restored by a filling (limited to plastic or stainless steel crowns for
children under age 16): Plastic: acrylic, prefabricated or processed to metal Precious (full or 3/4 cast), semi-precious or non-precious (full cast) metal Porcelain or porcelain fused to metal, for the second bicuspid or anterior teeth only Stainless steel Gold thimble Post and cores, if tooth has had root canal therapy Veneers
Initial installation of fixed bridges or full or partial removable dentures (a bridge or denture is considered to be installed for the first time if it doesn’t replace any existing bridge or denture) if proof is given that:
o The service is necessary due to the extraction of an injured or diseased tooth, and it is received within 12 months after the tooth is extracted
o You are covered under the plan at the time of the extraction o The service includes replacing the extracted tooth
Bridges and dentures: o Full dentures, complete or immediate, upper or lower o Partial dentures, including two clasps and rests:
Acrylic base, upper or lower Precious metal palatal/lingual bar, acrylic base, upper or lower Removable Add tooth, with or without clasp Additional clasps and rests
o Dentures relined: At least one year after initial insertion No more than once in any two calendar years
o Fixed bridges: Cast gold, cast semi-precious, and cast non-precious pontic
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Slotted facing steels and slotted pontic Tru-pontic Pin facing Porcelain fused to metal pontic (replacing the second bicuspid or an anterior tooth) Plastic processed to metal pontic Maryland bridge Stress breakers
Replacements of, or additions to, partial dentures or fixed bridgework if proof is given that: o The service is necessary due to the extraction of an injured or diseased natural tooth that occurs while
covered under this plan and the service is completed within 18 months after the tooth was extracted or o Your existing denture or bridgework can’t be repaired and the replacement is made after the later of:
Ten years after the existing appliance was installed and Two years after you became covered under this plan
Replacements of full dentures if proof is given that your existing denture or bridgework can’t be repaired, and the replacement is made after the later of:
o Ten years after the existing appliance was installed and o Two years after you became covered under this plan
Implants
Orthodontia You must be covered by an HCA dental plan option for 12 months before you and your dependents become eligible for orthodontic benefits. Benefits are subject to the annual deductible and are limited to an individual lifetime maximum benefit of $1,500. The Dental PPO will pay 50% of reasonable and customary charges for covered orthodontic services you receive while you are eligible for orthodontic benefits. Orthodontic services include:
Diagnostic, evaluation and pre-care procedures Fixed or removable appliances Full-banded treatment
Pre-treatment Estimate of Benefits To get a general idea of what the plan will pay (and what you must pay), you may want to request a pre-treatment estimate of benefits for procedures expected to cost $300 or more. To do so, ask your dentist to prepare a written treatment plan outlining the diagnosis, suggested treatment and estimated costs. Then submit this treatment plan, along with appropriate X-rays, on a standard claim form. The Dental Claims Administrator will review the treatment plan, consider possible alternate procedures and provide you with a pre-treatment estimate of benefits. The estimate is not a guarantee of payment. The actual amount paid will depend on how much of your deductible has been met and on your maximum benefit limits.
Alternate Procedures If your dental problem can be treated in more than one way, the plan will pay benefits based on the reasonable and customary charge for the least expensive services and supplies recognized by the dental profession as adequate and appropriate in accordance with accepted standards of dental practice. You and your dentist always have the freedom to choose your treatment. You may use the benefit you receive from the plan toward payment for the treatment of your choice.
Expenses Not Covered The Dental PPO does not cover the following services and supplies:
Amounts over and above reasonable and customary charges, as determined by the Dental Claims Administrator, when you use an out-of-network provider
Services not dentally necessary Dental services with benefits paid or eligible under the Medical benefits option (such as accidental dental injury) Services not ordered by a doctor or dentist Services provided by anyone other than a dentist (D.M.D. or D.D.S.) or dental hygienist who, under the supervision of
a dentist, cleans or applies fluoride to your teeth Cosmetic services and supplies, including bleaching procedures and personalization of dentures Duplication of bridges, appliances or dentures if lost or stolen Replacement, repair or duplication of an orthodontic appliance
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Appliances for bruxism and harmful habits, such as occlusal appliances (which protect the teeth from harmful effects of grinding/bruxism and clenching) and night guards (also referred to as occlusal guards and bruxism appliances)
Duplication of prosthetic appliances Orthodontic appliances and treatment that began before the patient's coverage started, unless specifically covered
above Appliances, restorations or procedures, except those specifically mentioned as covered, that:
o Splint teeth o Alter vertical dimension o Restore occlusion
Services provided by a resident doctor, an intern or a person in training Services and supplies that don’t meet generally accepted standards of dental care as they apply to diagnosis or
treatment, even if ordered by a doctor or a dentist Repeated tests, even if ordered by a doctor or dentist Dental services and supplies received before you or your dependents were covered by the plan or after coverage
ended, except orthodontic treatment and services and supplies covered under COBRA, if elected Dental care covered by an employer-sponsored health plan, Workers’ Compensation law or government program Services or supplies furnished in a United States government hospital not operated for the public at large, or
elsewhere at government expense, unless required by federal law Dental care provided free, or that would have been provided free if coverage weren’t available Dental care received as a result of disease, defect or injury caused by war, declared or undeclared Dental care received from a health department maintained by an employer, a union, a trustee or similar type of entity Treatment needed as a result of an illegal act, unless the injury or sickness results from a medical condition (mental
or physical) or an act of domestic violence Dental care for major and restorative services and supplies received during the first 12 months of coverage (the
waiting period) Services and supplies for an injury or sickness due to employment with any employer or self-employment
How to Use the Benefits
Dental PPO Network If you choose the Dental PPO option, you will have access to a network of dentists who have agreed to provide certain services at discounted rates. You may use any dentist you wish, but you receive provider discounts when you use a network dentist. To use the Dental PPO, follow these steps.
1. Call your dentist to make an appointment. You may consult a provider directory to find a participating dentist in your area or use an out-of-network dentist if you choose. Call the Dental Claims Administrator at 1-877-638-4422 if you need a provider directory or go online to HCArewards.com.
2. If your dentist does not file the claim form, you may request a claim form from the Dental Claims Administrator by calling 1-877-638-4422, or you may download a claim form from HCArewards.com. If you expect the cost of your services to be $300 or more, you may also want to ask your dentist to submit a written treatment plan to receive a pre-treatment estimate of benefits stating how much you can expect the Dental PPO to pay.
3. Receive your dental care.
4. Pay the full cost of the visit if your dentist does not file your claim.
5. File a claim form with the Dental Claims Administrator. Follow the directions on the form and attach original copies of itemized bills as proof of the claim. Your itemized provider’s bill must include all the following information:
a. Your name and the name of the patient (if different) b. The provider’s name, address, Social Security or tax identification number and telephone number c. Codes for the diagnosis and complete description of services d. Charges for the services received
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e. The day, month and year the service was received
6. Receive your benefits. Benefits are generally paid to you, but you may request that benefits be paid to your provider directly. You must make such a request in writing on your claim form when you provide proof of the claim.
7. If your claim is denied, in whole or in part, you will receive written notice of the denial. See the Administrative Information section for information regarding claim denials and appeals.
Orthodontic Treatment Plan After you and/or your eligible dependents have been covered under an HCA dental benefit option for 12 months, the Dental PPO will pay 50% of reasonable and customary charges for covered orthodontic services you receive while you are eligible for orthodontic benefits, up to an individual lifetime maximum of $1,500.
To receive orthodontic benefits, follow these steps:
1. Ask your orthodontist to submit a treatment plan. The Dental Claims Administrator will review the plan and provide you with a pre-treatment estimate of benefits that will give you an idea of how much the Dental PPO will pay. While this step is not required, it is recommended.
2. Submit a claim form if your provider does not file the claim for you.
3. Receive your benefits on a monthly basis. Benefits will be paid only for those months during which the individual (you or your dependent) is covered, eligible for orthodontic benefits and receiving orthodontic services. The first benefit payment will be based on 25% of the total covered charges. (This portion of the benefit will not be paid if orthodontic treatment begins during your 12-month waiting period.) You will then receive monthly benefit payments based on the remaining balance of the total covered charges divided by the number of months needed to complete the course of treatment.
4. If your claim is denied, in whole or in part, you will receive written notice of the denial. See the Administrative Information section for information regarding claim denials and appeals.
Example: Jane's course of orthodontic treatment is expected to last 24 months, with covered charges of $3,000. The plan will pay benefits as follows:
First, the plan considers 25% of the total to be the initial fee and pays 50% of that amount:
25% of $3,000 = $750 initial fee
50% of $750 = $375 first benefit payment
Then, the plan pays a monthly benefit equal to 50% of the remaining charges, spread equally over the course of the treatment:
$3,000 – $750 = $2,250, remaining charges
50% of $2,250 = $1,125, total remaining benefit
$1,125 ÷ 24 months = $47.00, monthly benefit (payment is rounded to the next highest dollar)
The total benefit paid under either payment plan will be $1,500
Orthodontic Expenses After You Terminate Employment Benefits for some orthodontic expenses may be paid even after your coverage under the plan ends. If your course of treatment began when you were eligible for coverage, the plan will continue to pay benefits up to three months after the date your coverage ends unless:
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Coverage ends because the group plan ceases to provide orthodontia, the Dental PPO ceases in its entirety or the class you belong to is no longer eligible
You become covered under another group plan that covers orthodontia, whether the plan is insured or not
Filing Claims You should file a Dental PPO claim within three months after you receive the service or supply. If, through no fault of your own, you are unable to file within three months, your claim will be accepted if you file as soon as reasonably possible, but not later than one year after the date of service, unless you are legally incapacitated.
Coordination of Benefits If you or your dependents also have coverage under another dental plan (such as your spouse’s), benefits are coordinated between the two plans to avoid duplication of payment. Through the coordination of benefits, you will not receive a benefit greater than the benefit you would have received in the absence of another plan. The Dental PPO will not coordinate benefits with school accident insurance or supplemental hospital indemnity benefit plans. It will coordinate benefits with the following types of medical, dental and healthcare benefits:
No-fault motor vehicle plans or other type of plan required by law. This refers to a motor vehicle plan that is required by law and provides medical or dental care payments that are made, in whole or in part, without regard to fault. A person subject to such law who has not complied with the law will be deemed to have received the benefits required by law
Group or group-type healthcare or dental plans (including other company plans) Any coverage under labor-management trusted plans, union welfare plans, employer organization plans or employee
benefit organization plans Any coverage under governmental plans, such as Medicare. This does not include a state plan under Medicaid or any
governmental plan when, by law, its benefits are secondary to those of any private insurance non-governmental program
Any private or association policy or plan of medical or dental expense reimbursement that is rated for group or individual
Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Dental HMO or any combination of this type of managed care
With coordination of benefits, the primary plan pays your benefits first. Then the secondary plan may pay any additional benefit that may be due. The following guidelines are used to determine which plan is primary:
A plan that does not contain a coordination of benefits provision will be primary to this plan The plan covering the patient as an employee will be primary A no-fault motor vehicle plan (or another type of plan required by law) will be primary to this plan For a dependent child, if both parents have group dental plans, the parent whose month and day of birth comes first
during the calendar year will have the primary plan. This is called the “birthday rule.” If both parents have the same birthday, the plan that has covered one parent for a longer period will be primary
For a dependent child of parents who are divorced or separated, the plan of the parent with custody of the dependent child usually pays benefits for the child first. If the parent with custody remarries, the stepparent’s plan pays second, and the plan of the biological parent without custody pays third. If a court decree places financial responsibility for the dependent child’s dental care on one parent, that parent’s plan always pays first
If none of the above situations applies, the plan that has covered the person the longer time pays first, except when both plans provide that the plan covering a person as an employee always pays before a plan covering that person as a laid-off employee or retiree. In this case, the plan covering the active employee pays first. If the other plan does not have a provision regarding retired or laid-off employees, this exception does not apply
In order to administer claims, the Dental PPO has the right to:
Provide or receive information needed to determine benefits Recover money paid above that was not required under the coordination of benefits rules Pay the administrator of another plan the amount that would have been paid by this plan. This amount will be
considered a benefit under this plan Example: Jane’s husband Bill has dental coverage through his employer and is also covered as Jane’s dependent by the Dental PPO option. He gets a crown that costs $600. His dental plan pays $240 (40% of the cost). If it were the primary plan, the Dental PPO option would pay $300 (50%), but in this case, Bill’s plan is primary. Since his plan pays $240, the Dental PPO option, which is secondary, will pay $60 ($300 – $240).
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What Else You Should Know
Payment of Benefits
Examination Right The Dental Claims Administrator has the right to request that you be examined by a doctor or dentist chosen by the plan before approving payment of your claim. If such an examination is required, it will be done at the plan’s expense. Appeal Right If you disagree with the Dental Claims Administrator’s decision, you have the right to appeal that decision. See the Administrative Information section for information regarding claim denials and appeals. Payment to Minor/Legally Incapacitated If you are a minor or legally unable to give a valid release for payment of benefits, the plan may pay up to $1,000 of any benefit directly to any of your relatives the plan believes is fairly entitled to receive them.
The Benefits ....................................................................................................................................... 73
Limitations and Exclusions .................................................................................................... 73
How to Use the Benefits ................................................................................................................... 74
Using your Vision Benefit ...................................................................................................... 74
Contact Lenses by Mail ......................................................................................................... 75
Additional Purchases and Out-of-Pocket Discounts .............................................................. 75
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Vision Highlights
The Vision benefit option under the HCA Health and Welfare Benefits Plan is designed to encourage you to maintain your vision through regular exams and to help cover expenses for lenses, frames and contacts when you use an EyeMed Vision Care (Eye Med) provider. You can also see a non-EyeMed provider and receive reduced benefits.
Plan Overview:
What coverage categories are available? See the Your Choices section (see below) for details.
Who pays the cost? You pay the cost of coverage, which is deducted from your paycheck on a before-tax basis. See the Your Choices section (see below) for more details.
Your Choices
Plan Options Generally, the following vision options are available:
Vision Plan — Vision coverage is provided by EyeMed Vision Care. The Vision option offers you a network of EyeMed providers from which to choose. You are free to use any EyeMed provider you like. Each time you need services, you can decide whether to use an EyeMed provider or go to a non- EyeMed provider. Either way, the Vision option provides coverage for many basic services, including eye exams, lenses, frames and contact lenses, but you pay less when you use an EyeMed provider.
No coverage — You should choose “No Coverage” only if you have coverage elsewhere. Remember, even if you choose the “No Coverage” option, you can still contribute some of your pay to the Health Care Flexible Spending Account and be reimbursed for eligible vision expenses that are not covered by your other vision coverage.
Coverage Categories If you choose to enroll in the Vision option, you may choose coverage for:
You Yourself plus one dependent Yourself plus two dependents or Yourself plus three or more dependents
If you elect coverage for yourself plus three or more dependents, your cost for coverage will not increase if you add additional dependents. You must contact LifeTimes Connection at 1-800-566-4114 each time you add a dependent to ensure coverage under the Vision option. If a dependent is not listed, no coverage will be provided.
The Benefits Vision coverage is provided through an insurance contract using EyeMed Vision Care. To receive vision coverage, you must elect this coverage for yourself and your dependents. Once enrolled in the plan, you will receive an EyeMed Vision Care ID card to be used at an in-network provider. When you use an in-network provider, you pay the copay or receive the allowance for the type of service you select. Members are responsible for balances over and above the covered benefit. If you use an out-of-network provider, you must pay in advance and file a claim with EyeMed to receive reimbursement up to the plan limits. An out-of-network claim form is available at HCArewards.com.
Your vision benefit provides you with up to 40% savings on your eyewear needs. Additional discounts include 20% off items not covered by the plan and continued savings on additional eyewear purchases. After your initial benefit has been used, you are eligible for a 40% discount on additional complete eyewear purchases and 15% off conventional contact lenses at EyeMed provider locations.
The following chart provides details on the benefits:
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*Standard Contact Lens Fitting - spherical clear contact lenses in conventional wear and planned replacement (Examples include but not limited to disposable, frequent replacement, etc.). **Premium Contact Lens Fitting - all lens designs, materials, and specialty fittings other than Standard Contact Lenses (Examples include toric, multifocal, etc.) ***Standard Progressive Lenses include, but are not limited to the following trade names; Access®, Adaptar®, AF Mini®, Continuous®, Vue®, Freedom®, Sola VIP®, Sola XL® and True Vision®.
Note: Discounts do not apply for benefits provided by other group benefit plans. Allowances are one-time use benefits, no remaining balance. Lost or broken materials are not covered.
Limitations and Exclusions: Benefits are not provided for services or materials arising from:
Orthoptic or vision training; Subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; Medical and/or surgical treatment of the eyes; Corrective eyewear required by an employer as a condition of employment, and safety eyewear;
Vision Care Service: You Pay: Out-of-Network Reimbursement:
Exam with Dilation as Necessary $10 copay Up to $35
Contact Lens Fit and Follow-up (Contact lens fit and two follow-up visits are available once comprehensive eye exam has been completed)
Standard*: $0 copay, paid-in-full fit and up to two follow-up visits
Premium**: $0 copay, 10% off retail price, then apply $55 allowance
Up to $40
Frames $130 allowance, 80% of balance over $130
Up to $65
Standard Plastic Lenses $20 copay Single Vision: Up to $25 Bifocal: Up to $40 Trifocal: Up to $55
Lens Options (Paid by the participant and added to the base price of the lens)
Tint (solid and gradient): $15 UV Coating: $15 Standard Scratch-Resistance: $15 Glass Lenses: $0 Oversize Lenses: $0 Standard Polycarbonate: $40 Standard Anti-Reflective: $45 Standard Progressive (Add-on to
Bifocal)***: $65 Other Add-Ons and Services: 20% off
retail price
N/A
Contact Lenses (Allowance covers materials only; in lieu of Standard Plastic Lenses)
Conventional: $85 allowance, 15% off balance over $85
Disposables: $85 allowance, balance over $85
Medically Necessary: Paid in Full
Conventional: Up to $68 Disposables: Up to $68 Medically Necessary: Up to
$200
LASIK and PRK Vision Correction Procedures
15% off retail price or 5% off promotional pricing
N/A
Frequency Exams: Once every 12 months Frames: Once every 24 months Standard Plastic Lenses or Contact
Lenses: Once every 12 months
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Services provided as a result of Workers’ Compensation law; Plano non-prescription lenses and nonprescription sunglasses (except for the 20% EyeMed discount); Two pairs of glasses in lieu of bifocals (does not apply to You but does apply for your dependents); Services or materials provided by any other group benefit providing for vision care; Lost or broken lenses, frames, glasses or contact lenses until the next frequency period listed under Vision Care Services.
Benefit allowances provide no remaining balance for future use within same benefit period. For example, if you purchase frames for $100, the amount between the actual price and the allowance of $130 may not be used for future purchases within the same frequency period. Also, discounts do not apply for benefits provided by other group benefit plans.
How to Use the Benefits
Using Your Vision Benefit
1. Locate an EyeMed provider. For the most up-to-date listing, log on to the EyeMed Web site at HCArewards.com. 2. Schedule an appointment and inform the doctor you are an EyeMed member. When you arrive for your appointment,
show the receptionist or sales associate your EyeMed Identification Card. If you forget to take your card, be sure to say that you are participating in the EyeMed vision care plan so that eligibility can be verified.
3. EyeMed Vision Care Customer Service can be reached seven days a week, Monday through Saturday, 8 a.m. to 11 p.m., and Sunday, 11 a.m. to 8 p.m. (Eastern time) at 1-866-723-0513.
Filing Claims
Network Provider When you receive services at a participating EyeMed Provider location, you will not have to file a claim form. At the time services are rendered, you will have to pay the cost of any services or eyewear that exceeds any allowances, and any applicable co-payments under Vision Care Service chart. You will also owe state tax, if applicable, and the cost of non-covered expenses (for example, vision perception training). Out-of-Network Provider For out-of-network services, you will need to pay for all services in full and then submit a claim form and receipt to EyeMed for eligible reimbursement. You can download a claim form at HCArewards.com.
Member Grievance Procedure If you are dissatisfied with the services provided by an EyeMed Vision Care Provider, the member should either write to EyeMed at the address indicated above or call the EyeMed Vision Care Member Services at 1-866-723-0513. The EyeMed Vision Care Member Services representative will log the telephone call and attempt to reach a resolution to the issues raised. If a resolution cannot be reached during the telephone call, the EyeMed Vision Care Member Services representative will document all of the issues or questions raised. EyeMed Vision Care will use its best efforts to communicate back to you within four (4) business days with a decision or resolution to the issues or questions raised. If you are not satisfied with the resolution, you may file a formal appeal related to a denial of benefits. See the appeals portion in Administrative Information section for more information.
What Else You Should Know
Laser Vision Benefit You are entitled to a 15% discount or a 5% discount on promotional pricing on LASIK and PRK treatments through the U.S. Laser Network, including pre-operative and post-operative care. However, if the treatment is performed at a LasikPlus Center, which is part of the U.S. Laser Network, and you elect to obtain pre-operative and post-operative care not from the LasikPlus Center provider, the other provider may charge additional fees for the pre-operative and post-operative care and you will be responsible for those fees. These fees are not subject to the 15% discount or the 5% discount on promotional pricing.
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Using the Laser Vision Benefit :
1. To locate the nearest U.S. Laser Network provider, call 1-877-5LASER6. 2. Contact the U.S. Laser Network provider and identify yourself as an EyeMed Member. You should schedule a
consultation with a U.S. Laser Network provider to determine if you are a good candidate for laser vision correction. 3. If it is determined that you are a good candidate for laser vision correction, you should schedule a treatment date with
a U.S. Laser Network provider. 4. To activate the benefit, call the U.S. Laser Network again at 1-877-5LASER6 with your scheduled treatment date. 5. At the time the treatment is scheduled, you will be responsible to remit an initial refundable deposit to U.S. Laser
Network. (If you decide not to have the treatment, the deposit will be returned. Otherwise, the deposit will be applied to the total cost of the treatment.)
6. At the time you remit the deposit, U.S. Laser Network will issue you an authorization number confirming the EyeMed discount. This authorization number will be sent to your U.S. Laser Network provider prior to treatment.
7. On the day of the treatment, it is your responsibility to pay or arrange to pay the balance of the fee. 8. After the treatment, you should follow all post-operative instructions carefully. In addition, you are responsible to
schedule any required follow-up visits with a U.S. Laser Network provider to ensure the best results from the laser vision correction.
Contact Lenses by Mail The EyeMed program allows you to order replacement contact lenses at competitive prices online and have them mailed directly to your home. For more information and to order, log on to the EyeMed Web site at HCArewards.com. Your plan allowance and discounts do not apply to this service.
Additional Purchases and Out-of-Pocket Discount: You will receive a 20% discount on remaining balance at Participating Providers beyond plan coverage, which may not be combined with any other discounts or promotional offers, and the discount does not apply to EyeMed’s Providers’ professional services or disposable contact lenses.
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Flexible Spending Accounts (FSA)
Health Care FSA ............................................................................................................................... 77
For More Information on the FSAs ........................................................................................ 86
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Flexible Spending Accounts (FSA)
FSAs allow you to set aside money from each paycheck — before most taxes are deducted — to reimburse yourself for eligible healthcare and day care expenses. You save money because the taxable portion of your income is reduced. The HCA Health and Welfare Benefits Plan offers two FSAs:
Health Care FSA Day Care FSA
You can check your account balance and claims status anytime online at HCArewards.com. Also, you have the option to sign up for direct deposit so your Health Care and Day Care FSA reimbursements can be deposited directly into your banking account.
Health Care FSA — Highlights HCA offers the Health Care FSA through the HCA Health and Welfare Benefits Plan to allow you to pay for certain healthcare expenses on a before-tax basis — and that saves you money.
Plan Overview:
How much can I contribute? You may deposit up to $5,000 each year in the Health Care FSA.
Who pays the cost? You contribute to the account on a before-tax basis.
Your Choices You may use the Health Care FSA to reimburse yourself for eligible healthcare expenses for you and your eligible dependents (except domestic partner or children of domestic partner) that are not paid by a healthcare plan. You and your dependents are not required to participate in a Medical benefit option to enroll in the Health Care FSA.
The Benefits Contributions you make to the Health Care FSA are taken from your pay before federal income taxes or Social Security and Medicare taxes are deducted. That means the taxes on your remaining pay are lower. In some areas, you also pay no state or local taxes on your contributions. You then use these before-tax dollars to reimburse yourself for eligible healthcare expenses during the year. You may contribute up to $5,000 to reimburse yourself for eligible medical, dental or vision care expenses for you or an eligible dependent not paid or payable by any healthcare plan. This includes deductibles, copays and certain non-covered expenses. You are only eligible to receive reimbursement for expenses you incurred during the plan year while you were participating in the plan. Expenses are treated as having been incurred when the participant is provided medical care that gives rise to the medical expenses, and not when the participant is formally billed or charged, or pays for the care.
Use It or Lose It Under IRS regulations, if your eligible expenses for the year are less than the amount of your annual contributions, you will lose any unused balance in your account. Generally, service must be rendered during the plan year to be eligible for reimbursement for that year. And, if you terminate employment during the year, the Health Care FSA will reimburse only those expenses incurred while you were an active participant in the Health Care FSA (either the last day of the month that your employment terminates or your COBRA coverage ceases). However, under special IRS rules, if you remain an active participant in the Health Care FSA as of December 31 of the plan year, you have an extra 2½ months to use your Health Care FSA balance. For example, if you contribute $1,200 to the Health Care FSA for 2011 and only have $1,000 in eligible expenses for that year, a special “grace period” may apply. Under this grace period, if you incur another $200 of eligible expenses between January 1, 2012 and March 15, 2012, you can use your leftover $200 from 2011 for these 2012 expenses. However, in all cases, you must file claims for expenses incurred for a plan year by no later than March 31 of the following year. So, all claims for 2011 — even those incurred during the 2½-month grace period ending March 15, 2012 — must be submitted no later than March 31, 2012. To avoid losing any unused money, be sure to carefully estimate your Health Care FSA contributions and file your reimbursements in a timely manner. You may not transfer money from your Health Care FSA to your Day Care FSA or vice versa.
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Contributions You choose the amount you contribute each year — up to a maximum of $5,000. Your before-tax contributions are deducted from your paychecks in equal amounts during the year and deposited into your account. If a before-tax contribution is missed, the missed contribution may be made from future contributions. Changing Your Health Care FSA Contributions Once you choose to participate in the Health Care FSA, your contributions will be in effect for the rest of the calendar year, unless you experience a qualifying change in status. In this case, you may start or stop contributing, but you may not change the amount of your contribution. If you stop participating in the Health Care FSA, you may not be allowed to re-enroll until the next annual enrollment period, with contributions beginning again the following January.
Special Distribution Provisions When Called to Active Duty Active FSA participants who are called to active duty have the option to receive a one-time distribution in any plan year of the amount that they have contributed to (less any expenses reimbursed from) their Health Care FSA so contributions are not forfeited. The reservist must be called to duty for at least 180 days or for an indefinite period, provide a copy of orders, and receive the distribution during the current FSA plan year (or before the end of the grace period) which coincides with the date of call. Activated reservists should contact PBS to process a distribution or get additional information.
Covered Expenses The Health Care FSA may be used for eligible expenses that are not covered by any medical, dental or vision plan in which you or your spouse participates. The Health Care FSA uses “IRS Publication 502: Medical and Dental Expenses” only as a guide for eligible expenses. Examples of covered expenses* include:
Acupuncture Alcoholism or drug dependency treatment Ambulance Braille books and magazines (limited to the part of the cost that is more than the price for non-Braille books and
magazines) Car controls for the handicapped Chiropractors Cost and repair of special telephone equipment that allows a deaf person to communicate over a regular telephone Deductibles, coinsurance and copays for medical, dental and vision plans Dental treatment Doctor’s bills Guide dog for the blind or deaf Hearing examinations, hearing aids and hearing aid batteries Healthcare equipment Home healthcare Hospital bills In-vivo fertilization, in-vitro fertilization and embryo placement Laboratory fees Laser eye surgery Non-prescription nicotine gum or patches Over-the-counter drugs and products used to treat illnesses or injuries as determined eligible by the Claims
Administrator Oxygen Physical therapy Prescription drugs, except prescription drugs for cosmetic purposes Prescription smoking cessation aids and programs Psychologist and psychotherapy Reversal of sterilization operations Routine physical examination and related charges Services for work-related accident or illness (portion not covered by Workers’ Compensation) Syringes, needles or injections Transplants TV closed-captioning equipment Vaccinations and immunizations
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Vasectomy or tubal ligation Vision examinations, eyeglasses, contact lenses, contact lens solution or radial keratotomy
* Certain expenses may require proof that the expense is eligible. Whom to Call for More Information on Eligible Expenses You may call the Flexible Spending Account Claims Administrator at 1-877-888-3539 to determine if an expense is eligible for reimbursement under your Health Care FSA. For a copy of any Internal Revenue Service Publication, call the IRS at 1-800-829-1040 or visit their Web site at www.irs.gov.
Expenses Not Covered Following are some of the expenses that are generally not reimbursable under the Health Care FSA:
Premiums paid for healthcare insurance, including premiums paid for plans maintained by the employer of an employee’s spouse or dependent
Expenses not recognized as legitimate deductions by the Internal Revenue Service, as detailed in Publication 502 Expenses for general health purposes, and not for the prevention or correction of a specific ailment Any expense incurred in connection with an illegal operation or treatment Automobile insurance premiums, including premiums for medical coverage Bottled water or food supplements or alternatives Cosmetic surgery, including facelifts, hair transplants, etc. Cosmetic procedures, such as bleaching of teeth Doctor’s visits associated with weight control, unless for treatment of a specific disease Funeral and burial expenses Health club dues, YMCA or YWCA dues, steam baths, etc. Household and domestic help (even if recommended by a qualified physician due to an employee’s or dependent’s
inability to perform physical housework) Marriage counseling Maternity clothes, diaper services, etc. Prescription drugs prescribed for cosmetic purposes Social activities, such as dance lessons or classes (even if recommended by a qualified physician for general health
improvement) Transportation expenses to and from work, even though a physical condition may require special means of
transportation Uniforms Vacation or travel taken for general health purposes Vitamins taken for general health purposes
Coordinating FSA Savings and Income Tax Deductions When you receive reimbursement from your Health Care FSA for an expense, you cannot claim that same expense as a deduction or tax credit on your federal income tax return.
How to Use the Benefits
Health Care FSA Debit Card If you elect to participate in the Health Care FSA program, you will receive a Health Care FSA benefits card that works similar to a debit card to pay for certain eligible healthcare services. In situations where you pay a copay or purchase an eligible product, you can swipe the card with a provider who accepts MasterCard® to have the amount automatically deducted from your Health Care FSA account. In some situations, you may have to wait for you or your spouse’s healthcare plan to process your claim to find out how much you owe. When this happens, you will receive an Explanation of Benefits form from the healthcare plan with the amount you owe. If your healthcare provider agrees, you can then charge your Health Care FSA benefits card for the amount you owe. If your provider does not accept MasterCard®, you have to pay for the expense and submit a claim to the Health Care FSA for reimbursement. Finally, you may request an additional Health Care FSA benefits card for your spouse. Contact the FSA Claims Administrator at 1-877-888-3539.
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Keep All Receipts IRS regulations require that you keep all receipts in case the Health Care FSA Claims Administrator needs to verify that expenses are eligible. In some situations, the FSA Claims Administrator may send you a preprinted claim form and require you to return it with the appropriate receipt. The receipt must include the name and address of the provider, date and description of service, amount paid and the name of the person receiving the service. If you are not able to provide a receipt when it is requested, you will be required to reimburse the Flexible Spending Account Plan for the expense. If you do not reimburse the plan, this expense will become taxable income to you. If you purchase both eligible items and non-eligible items at the same time, make sure you pay for them separately so you have a separate receipt that includes only eligible items. Eligible Expenses Eligible Expenses are described in the Covered Expenses section. Expenses or persons not eligible under the Health Care FSA and expenses that exceed the annual election amount will be denied. You will be required to repay the Flexible Spending Account Plan for any ineligible expenses or persons deducted from your benefits card or Health Care FSA account. Health Care FSA Benefits Card Expiration Once you receive a Health Care FSA benefit card, you will need to keep it until the expiration date listed on the card. The card you receive will be refreshed with your new Health Care FSA election amount each year until the expiration date. When your card expires, you will receive a new one provided you continue participation in the plan.
Filing a Health Care FSA Claim You may receive reimbursement for the total amount you elect to deposit in the Health Care FSA for the year, regardless of how much you have contributed to date. For example, suppose you elect to deposit $2,400 to this account. Once you have made your first contribution, you may be reimbursed up to $2,400 at any time during the year for any eligible healthcare expenses you may have incurred while a plan participant.
There is no minimum amount for a claim processed using the Health Care FSA benefits card, or for direct deposit for reimbursement. However, if you submit a claim form and have not signed up for direct deposit, the minimum amount for your reimbursement check is $25. There is no minimum amount for expenses filed after December 31 for that year.
Follow these steps to file a Health Care FSA claim.
1. Obtain a bill or receipt for the qualifying expense. Eligible healthcare expenses may not be reimbursed by any other plan (for example, your spouse’s) and must qualify as a deduction on your federal income tax return. The bill must be on the provider’s letterhead or billing form and must also include:
Name of the patient, Dates of service, Description of an amount charged for the service.
Bills for prescription drugs and eligible equipment, appliances or supplies must also include:
Description of the item (including drug name) Provider of service Name of the prescribing doctor Date of purchase or rental
2. Submit the expense to your healthcare plan. You will receive an Explanation of Benefits that you will need to
submit with your claim form. If you are covered by another medical or dental plan (such as your spouse’s), you must submit your healthcare expenses to both plans before you can request FSA reimbursement.
3. Complete and submit a claim form. You must complete a claim form and mail, fax or submit online the completed form to the address on the claim form. Claim forms are available online through HCArewards.com or from your Human Resources department. Be sure to keep a copy of all documentation for your records. Cancelled checks are not acceptable proof of an expense. You will need to attach the Explanation of Benefits from your insurer or an itemized bill from your provider indicating that the eligible expense is not covered.
4. Receive a reimbursement check from your account. Reimbursement checks will be processed daily.
5. File all claims for eligible expenses by the deadline. Claims for each calendar year must be postmarked by March 31 of the following year or you’ll forfeit the money left in your account for that year. For example, you have until March 31, 2011, to submit your 2010 expenses for reimbursement.
6. If your claim is denied (in whole or in part), you will receive a notice to that effect. See the Administrative Information section for information regarding claim denials and appeals.
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Submitting Claims After Participation Ends When your Health Care FSA participation ends, you may submit claims only for expenses incurred up to the date your participation in the Health Care FSA ended. For example, if your Health Care FSA participation ended July 31, you may receive reimbursements you had for eligible expenses you had through July 31. Generally, your participation in the Health Care FSA ceases on the first to occur of either (a) the last day of month that your employment terminates, or (b) the day your COBRA coverage ceases. You may not be reimbursed for an eligible expense incurred after the date your participation ends, even if you have money remaining in the account. You have until March 31 of the following year to submit claim forms for eligible expenses incurred before the date your participation ended.
Statements Twice a year, you will receive a statement showing:
Your account contribution totals Reimbursements made from each account (year-to-date claims paid) Your ending balance
These statements help you track your account for the year and avoid any forfeitures. They can also help you plan your contributions for the next year. Your account information is also available online at HCArewards.com.
Continued Health Care FSA Coverage You may be eligible to continue making contributions to the Health Care FSA when your employment ends if you qualify for COBRA. However, COBRA only applies to the Health Care FSA for the plan year in which the qualifying event occurred, and then only if the maximum benefit available for the rest of the year under the Health Care FSA is greater than the COBRA premiums for the Health Care FSA for the remainder of that year.
For example, suppose you choose to contribute $1,200 ($100 per month) to your Health Care FSA for the year, but on May 31 your employment is terminated (a qualifying event). As of May 31, you had submitted $300 of claims to your Health Care FSA, leaving $900 as the maximum benefit available for the rest of the year. Your COBRA premiums for the Health Care FSA would be up to 102%, or $102/month, or $714 for the rest of the year. Because the maximum benefit will be greater than the COBRA premiums, you would be allowed to elect COBRA continuation coverage of your Health Care FSA for the rest of the plan year.
COBRA premium payments for the Health Care FSA are on an after-tax basis, unlike regular premium payments for the Health Care FSA, which are deducted from your paycheck before taxes.
Day Care FSA — Highlights
HCA offers the Day Care FSA through the Health and Welfare Benefits Plan to help you save money by paying for certain dependent care expenses on a before-tax basis.
Plan Overview:
How much can I contribute? You may deposit up to $5,000 each year in the Day Care FSA.
Who pays the cost? You contribute to the account on a before-tax basis.
Your Choices You may use the Day Care FSA to reimburse yourself for eligible expenses for your eligible dependents (except domestic partner or children of domestic partner) while you (and your spouse, if you are married) work outside the home, look for work or attend school full time.
The Benefits Contributions you make to your Day Care FSA are taken from your pay before federal income taxes or Social Security and Medicare taxes are deducted. That means the taxes on your remaining pay are lower. In some areas, you also pay no state or local taxes on your contributions. You then use these before-tax dollars to reimburse yourself for your eligible dependent day care expenses during the year.
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Generally, you may contribute up to $5,000 a year to reimburse yourself for eligible dependent day care expenses you incur while you (and your spouse, if you are married) work outside the home, look for work or attend school full-time. You may also contribute to this account if you are married and your spouse is a full-time student or is mentally or physically unable to care for himself or herself. However, the amount you may contribute is reduced.
Expenses are treated as having been incurred when the participant’s dependent is provided care that gives rise to the expense, and not when the participant is formally billed or charged, or pays for the care.
Use It or Lose It Under IRS regulations, if your eligible expenses for the year are less than the amount of your annual contribution, you will lose any unused balance in your account. However, under special IRS rules, if you still have a balance in the Day Care FSA as of December 31 of a plan year, you have an extra 2½ months to use your Day Care FSA balance. For example, if you contribute $2,400 to the Day Care FSA for 2011 and only have $2,000 in eligible expenses for that year, a special “grace period” may apply. Under this grace period, if you incur another $400 of eligible expenses between January 1, 2012 and March 15, 2012, you can use your leftover $400 from 2011 for these 2012 expenses. This grace period applies whether or not you are actively employed by an HCA-affiliated facility on December 31, 2011—as long as you still have an unused balance in your Day Care FSA on that date. However, in all cases you must file claims for expenses incurred for a calendar year no later than March 31 of the following year. So, all claims for 2011—even those incurred during the 2½-month grace period ending March 15, 2012—must be submitted no later than March 31, 2012.
Contributions If you elect to participate in the Day Care FSA, your before-tax contributions are deducted from your paychecks in equal amounts during the year. Special Limits The IRS limits how much you may contribute to the Day Care FSA.
Your total contributions cannot be more than your earned income or your spouse’s earned income — whichever is less. For example, if you earn $30,000 and your spouse earns $4,500, you are only allowed to contribute up to $4,500 to the account. Special provisions described below apply if your spouse is a full-time student or is physically or mentally unable to care for himself or herself. In determining your spouse’s income for purposes of this limit, special rules apply if your spouse is physically or mentally incapable of caring for himself or herself, or is a full-time student during at least part of five calendar months during the calendar year. If you have such a spouse, then his or her earned income is deemed to be not less than $250 per month if one dependent is in day care, and $500 per month if two or more dependents are in day care. If such a spouse has earned income in excess of these minimums in any month, then the spouse’s actual earned income is used for that month.
If you and your spouse file separate federal income tax returns, the maximum amount you may contribute to the account is $2,500. Your spouse is also limited to $2,500 if he or she contributes to a dependent care reimbursement account at his or her workplace.
If you and your spouse file a joint federal income tax return, your combined total contributions for any or all dependent care programs may not be more than $5,000.
Changing Your Day Care FSA Contributions When you enroll in the Day Care FSA, your contribution election is effective for the rest of the calendar year, so plan your expenses carefully. You may change your participation only if you have a qualifying change in status. If you have a qualifying change in status, you may stop, start or change the amount of your contributions to your Day Care FSA.
Eligible Dependents The use of the Day Care FSA is limited to your eligible expenses for the care of your eligible dependents. Eligible dependents must depend on you for more than 50% of their support and may include:
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Your children under the age of 13 Your children who are physically or mentally incapable of caring for themselves, regardless of their age Your spouse who is physically or mentally incapable of caring for himself or herself Any other person who resides in your home for at least 8 hours each day, is related to you by blood or marriage and is
physically or mentally incapable of caring for himself or herself
If you receive reimbursement for expenses from your Day Care FSA, you cannot claim those same expenses as a credit on your federal income tax. For some people, the tax savings will be greater using the federal income tax credit instead of the Day Care FSA. For others, the savings will be greater using the Day Care FSA. You should consult a tax advisor to help you determine which option is best for you. If you are married and filing separate income tax returns, you may not be eligible for the tax credit. In that case, the Day Care FSA may be your only option.
Choosing the Day Care FSA or a Federal Tax Credit Under current law, if you pay dependent care expenses with after-tax dollars, you may be able to take part of these expenses as a credit on your federal income tax, as shown below:
For one dependent receiving care, you can take up to $3,000 in annual expenses as a tax credit For two or more dependents receiving care, you can take up to $6,000 Any expenses beyond those amounts don’t qualify for a federal income tax credit
If you receive reimbursement for expenses from your Day Care FSA, you cannot claim those same expenses as a credit on your federal income tax. For some people, the tax savings will be greater using the federal income tax credit instead of the Day Care FSA. For others, the savings will be greater using the Day Care FSA. You should consult a tax advisor to help you determine which option is best for you or you may refer to IRS Publication 503 Child and Dependent Care Expenses at www.irs.gov. If you are married and filing separate income tax returns, you may not be eligible for the tax credit. In that case, the Day Care FSA may be your only option.
The Working Families Tax Relief Act of 2004 made changes in the definition of a dependent that may affect the Earned Income Tax Credit and the Dependent Care Tax Credit. You should consult a tax advisor concerning your specific situation.
Covered Expenses A listing of current eligible expenses can be found in “IRS Publication 503: Child and Dependent Care Expenses”. Examples of eligible expenses include:
Expenses for the care of a dependent under the age of 13 while you and your spouse are both working, are full-time students or are seeking employment
Expenses you could otherwise claim as a dependent care deduction or credit on your federal income tax return Expenses for the care of a mentally or physically handicapped dependent who regularly spends at least eight hours a
day in your home (24-hour-a-day care in a nursing home for a dependent parent does not qualify) Fees for a day care center if it meets all state and local laws, provides care for more than six persons and is paid for
the services it provides Fees for an individual or private sitter who is not an immediate family member under age 19 or any person you claim
as a dependent on your federal income tax return Costs for a nursery school or summer program for a child (not including overnight camps) Expenses that qualify as IRS deductible dependent care expenses
Whom to Call for More Information on Eligible Expenses You may call the Flexible Spending Account Claims Administrator at 1-877-888-3539 to determine if an expense is eligible for reimbursement under your Day Care FSA. For a copy of any Internal Revenue Service Publication, call the IRS at 1-800-829-1040 or visit their Web site at www.irs.gov.
Expenses Not Covered Following are some of the expenses that are not reimbursable under the Day Care FSA:
Any amounts you pay to an immediate family member under the age of 19 or to any person you claim as a dependent on your federal income tax return
Cost for any person caring for a child (or children) when you or your spouse are not working, are not considered full-time students or are not incapacitated
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Transportation expenses, including chauffeur services Charges for a convalescent nursing home for a parent Education, camp expenses or kindergarten programs Costs for child care that enables you or your spouse to do volunteer work Amounts you pay for child care for any period you or your spouse is off work due to sickness unless you or your
spouse is physically or mentally incapable of caring for oneself. Incapable of caring for oneself means the person cannot dress, clean or feed themselves because of a physical or mental problem or must have constant attention to prevent them from injuring themselves or others
Activity fees, field trips, clothing and meals that can be separated from the cost of the actual child care
How to Use the Benefits
Filing a Day Care FSA Claim Unlike the Health Care FSA, the Day Care FSA reimburses you only up to the actual amount you have deposited to that account. For example, if you elect to deposit $4,800 for the year, $400 is deducted from your paychecks each month. If you have $600 in eligible expenses and only $400 in your account, you are reimbursed $400. When you have an additional $200 in your account, you will automatically be reimbursed for the balance of your claim. Reimbursement If you receive reimbursement for expenses from your Day Care FSA, you cannot claim those same expenses as deductions or tax credit on your federal income tax. For some people, the tax savings will be greater using the federal income tax credit instead of the Day Care FSA. For others, the savings will be greater using the Day Care FSA. You should consult a tax advisor to help you determine which option is best for you. If you are married and filing separate income tax returns, you may not be eligible for the tax credit. In that case, the Day Care FSA may be your only option.
Follow these steps to file a Day Care FSA claim:
1. Obtain a bill or receipt for the qualifying expense. The itemized bill should include: a. Dates of service b. Name and address of the provider of the service c. Signature of the provider (if an individual) d. The provider’s Social Security number (if an individual) or federal taxpayer identification number (if an
organization) e. The expenses charged (not just the expenses paid) f. A brief explanation of the service that was received (for example, in-home care of a child under 13 years of
age) No bill or receipt is needed if the child care provider completes and signs the appropriate information on the claim form.
2. Complete and submit a claim form. You must complete a claim form and mail, fax or submit online the completed form to the address on the claim form. Claim forms are available online through HCArewards.com or from your Human Resources department. Be sure to keep a copy of all documentation for your records. Cancelled checks are not acceptable proof of an expense.
3. Receive a reimbursement check from your account. Reimbursement checks will be processed daily.
4. File all claims for eligible expenses by the deadline. Claims for each calendar year must be postmarked by March 31 of the following year or you’ll forfeit the money left in your account from that year. For example, you have until March 31, 2011, to submit your eligible 2010 expenses for reimbursement.
5. If your claim is denied (in whole or in part), you will receive a notice to that effect. See the Administrative Information section for information regarding claim denials and appeals.
In addition to the above, you are required to supply the provider’s taxpayer identification number to the IRS with your tax return.
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Submitting Claims After Participation Ends Contributions cannot be continued after plan participation ends. However, participants may continue to submit claims for services incurred after the date plan participation ends as long as there is a Day Care FSA balance greater than $0. Generally, claims must be incurred no later than December 31 of the year that you end plan participation. But, if a balance remains on December 31, expenses incurred through March 15 of the following year are eligible for reimbursement due to the FSA grace period. The grace period allows you an extra 2½ months to incur eligible expenses as long as you have a Day Care FSA balance greater than $0. Claims for reimbursement must be postmarked and sent to the FSA claims administrator by March 31 of the year following the end to your plan participation. Reimbursements cannot exceed the balance in your Day Care FSA at the time your participation ended.
Statements Each calendar quarter, you’ll receive a statement showing:
Your account contribution totals Reimbursements made from each account (year-to-date claims paid) Remaining unpaid requests Your ending balance
These statements help you track your account for the year and avoid any forfeitures. They can also help you plan your contributions for the next year.
What Else You Need to Know
Claims Administrator Call the Flexible Spending Account Claims Administrator at 877-888-FLEX (3539) for information about your FSA claims and reimbursements. LifeTimes Connection can only provide information about your eligibility and pay-period deductions for these plans.
Transfers You are not allowed to transfer money between the Health Care FSA and the Day Care FSA.
Forfeitures IRS regulations require that any money left in your account after the filing deadline be forfeited. You have until March 31 of the following year to submit claims for any eligible expenses incurred either during the current year or during the special 2½-month grace period.
To avoid losing any unused money, be sure to estimate your contributions carefully and file your claims in a timely manner. Use your accounts only for predictable expenses that you will have during the year.
Forfeitures will be used to help pay the cost of administering both FSAs.
If You Are Rehired
Health Care FSA If you had elected to participate in the Health Care FSA and you terminate employment and are rehired as a full-time employee within 6 months, your original Health Care FSA election is reinstated as it was before you left minus any claims paid before termination and contributions adjusted accordingly, if your return is within the same plan (calendar) year. If you are rehired within 6 months and the rehire date crosses plan (calendar) years, you will have an opportunity to elect Health Care FSA upon your return.
However, if you are rehired after 6 months, you are treated as a new hire and subject to any eligibility waiting periods.
Claims for expenses during the time of your termination will not be paid unless you continued your Health care FSA through COBRA.
Day Care FSA If you terminate employment and are rehired within 6 months, your original Day Care FSA election is reinstated as it was before you left, if your return is within the same plan (calendar) year. If you are rehired within 6 months and the rehire date
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crosses plan (calendar) years, you will have the opportunity to elect Day Care FSA upon your return. However, if you are rehired after 6 months, you are treated as a new hire and subject to any eligibility waiting periods.
If You Take a Leave of Absence
Health Care FSA If you take an unpaid leave of absence, you may continue making after-tax contributions to your Health Care FSA up to the amount of your elected annual contribution. You will be billed for this amount by LifeTimes Connection on a monthly basis. This allows you to continue submitting claim forms for eligible expenses you have during a leave of absence — as long as you continue making contributions. For more information, call LifeTimes Connection at 1-800-566-4114. Day Care FSA If you take a leave of absence that extends beyond two weeks, you may not continue contributions to the Day Care FSA.
If You Stop Participation in a Plan Year If you stop participating in the Health Care FSA plan at any time during the plan year, you may not be able to re-enroll in the plan until the following annual enrollment.
IRS Regulations Health Care and Day Care FSAs are subject to legislation that could affect how the account is administered or used. For example, contribution maximums may be adjusted to comply with regulations. You’ll be notified if changes in the law or IRS interpretation affect the plan.
For More Information on the FSAs You can find additional information about the FSAs in the Administrative Information section. It includes information about the plan sponsor, your rights under ERISA (Health Care FSA only), claim appeal procedures and HCA’s rights to change or terminate the plan.
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Life and AD&D Insurance
Life and AD&D Highlights ................................................................................................................. 88
Your Choices ..................................................................................................................................... 88
Basic Life and AD&D ............................................................................................................ 88
Supplemental Employee Life and AD&D .............................................................................. 88
Evidence of Insurability ......................................................................................................... 89
Dependent Life ...................................................................................................................... 90
Cost of Coverage .................................................................................................................. 91
— Supplemental Employee Life and AD&D ................................................................... 91
Prudential Privacy Information .............................................................................................. 99
What Else You Need to Know .......................................................................................................... 99
Receiving Accelerated Payments – Living Benefits ............................................................. 99
Right to Recover Payment .................................................................................................... 100
Attachment of Benefits .......................................................................................................... 100
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Life and AD&D Highlights
The HCA Health and Welfare Benefits Plan offers Life and Accident Death & Dismemberment (AD&D) Insurance coverage to help provide financial security for you and your family in case of death or serious injury. If you are a full-time employee, your facility provides Basic Life and AD&D coverage (see below) at no cost to you. You may also elect Supplemental Life and AD&D (see below).
If you are eligible and elect Employee Life and AD&D coverage for yourself, you may also elect Dependent Life coverage for your spouse only, eligible children only, or both. The HCA Health and Welfare Benefits Plan allows you to choose the coverage that best meets your needs.
Every effort has been made to accurately describe the Life and AD&D benefit option in this SPD; however, these benefits are offered and controlled by a group insurance contract with The Prudential Insurance Company of America. The insurance contract is the plan document for the Life and AD&D insurance benefit option and if there is a discrepancy between this SPD and the insurance contract, the terms of the insurance contract will control. A certificate of insurance is available upon written request to HCA Inc., Corporate Benefits, One Park Plaza, P.O. Box 550, Nashville, TN 37203.
Plan Overview:
What coverage categories are available? Basic Life and AD&D (full-time employees only) Supplemental Employee Life and AD&D Dependent Life
See the Your Choices section (see below) for more details
Who pays the cost? Your facility pays the cost of Basic Life and AD&D coverage. You pay the cost of Supplemental Employee Life and AD&D and Dependent Life coverage through after-tax payroll deductions. See the Your Choices section (see below) for more details.
Your Choices
Basic Life and AD&D There are two basic insurance coverages:
Basic Life Insurance Basic AD&D Insurance
Basic Life and AD&D cover all full-time employees. Full-time employees receive Basic Life and AD&D coverage equal to one times annual pay rounded to the next higher $1,000 — up to a combined maximum of $6,000,000 with Basic and Supplemental Life.
Your facility provides this coverage at no cost to you. If you choose no Basic Life coverage, you will receive Cash-Out Dollars to use toward the cost of other benefit choices.
Supplemental Employee Life and AD&D Full-time employees may buy Supplemental Employee Life and AD&D coverage equal to a multiple of their annual pay rounded to the next higher $1,000.
You may choose one of the following coverage levels if you are an eligible full-time employee:
1 x annual pay 2 x annual pay 3 x annual pay 4 x annual pay 5 x annual pay No coverage
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The maximum amount of coverage you may purchase is $6,000,000, which is a combined maximum of Basic and Supplemental coverage.
Part-time employees may buy a flat coverage amount of $15,000 of Supplemental Life and AD&D.
Evidence of Insurability Evidence of Insurability (EOI) applies to Employee Basic and Supplemental Life and AD&D and Dependent Life. EOI applies to you and your spouse, not your child(ren) if coverage:
Is elected as a new hire for amounts above one times Basic and two times Supplemental For your spouse if elected at annual enrollment after initially declining coverage or if the amount is increased at
annual enrollment or was previously required EOI and EOI was not approved Was previously required EOI and EOI was not approved Is elected at annual enrollment after initially declining Is increased at annual enrollment
There is no AD&D benefit for Dependent Life. EOI means you must complete a questionnaire and possibly have a physical examination in order for Prudential to determine if coverage will become effective. Submission of EOI does not guarantee coverage; Prudential has the right to refuse coverage. You must provide all information requested by Prudential or your EOI will not be reviewed. Prudential will send you applicable EOI forms. You will be notified of Prudential’s determination of acceptance or rejection of your EOI. If approved, coverage will begin on January 1 of the new coverage period or on the first day of the month after Prudential approves EOI, whichever comes later. New Hires You may generally elect the following coverages without EOI. All other elections require EOI. (You can have up to three times annual pay — Basic plus Supplemental — without EOI.)
Basic Life and AD&D: 1 x annual pay Supplemental Life and AD&D: Up to 2 x annual pay Dependent Life: Option 1, Option 2 or Option 3. If you elect Option 4, only your spouse will be subject to EOI
Exception: If you at any time declined life insurance coverage under this plan because you could not satisfy EOI, you will not have coverage until you can now satisfy EOI even if you elect such coverage and pay the premiums. Any premiums paid will be returned to you. Change in Status If you have a change in status and if a change to life insurance coverage is allowed, you may elect the following coverages. All other elections require EOI.
Basic Life and AD&D: 1 x annual pay Supplemental Life and AD&D: You may elect up one level. For example, if you had Supplemental 2x annual pay, you
may elect Supplemental 3x annual pay. If you had no coverage, you may elect Basic and Supplemental 1x annual pay
EOI is required at annual enrollment if you increase your coverage if you elect coverage for the first time after initially declining it.
Annual Pay Annual pay is your base pay determined by your employer; however, base pay excludes commissions, bonuses, overtime pay or any other extra compensation or income received from your employer. It is not your W-2 wages. If you are a commissioned salesperson, annual pay includes your base pay plus commissions but excludes renewal commissions. Commissions will be averaged for the 12-full calendar month period of your employment just before the date of loss or the period you actually worked for your facility, whichever is less. If you are a pieceworker, annual pay is based on your average monthly piecework earnings for the three months just prior to the date of loss.
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Dependent Life You must have elected coverage for yourself to be eligible to elect Dependent Life coverage. If eligible, you may purchase coverage for your spouse and/or eligible dependent children. You have the following Dependent Life coverage options:
The amount of Dependent Life coverage you elect cannot exceed 50% of your own Basic and Supplement Life Insurance coverage. Evidence of Insurability (EOI) for the spouse under Dependent Life is required if:
New Hires — You elect Option 4 Change in Status — You elect more than one option increase or if you elect Option 4 under any conditions Annual Enrollment — You elect an option increase or if you elect Option 4 under any conditions
You can elect coverage of up to $25,000 for a new spouse without providing evidence of insurability. Eligible Dependents Refer to the Eligibility section for details. If your eligible dependent is totally disabled, your dependent’s coverage will begin on the date your dependent is no longer totally disabled. Totally disabled means that, as a result of an injury, a sickness or a disorder, you dependent:
Is confined in a hospital or similar institution Is unable to perform two or more activities of daily living due to a physical or mental incapacity. Activities of daily
living include bathing, toileting, transferring (moving in and out of bed without a can or crutches), continence and eating
Is cognitively impaired Has a life-threatening condition
If you enroll ineligible or disabled dependents, even if you pay the premium for such a child, the claim will be denied and any premiums paid will be returned to you. Dependent Extension of Coverage Coverage will continue for a child age 19 or over who becomes totally disabled while covered under the plan, provided:
The child is unmarried The disability was acquired before the child’s coverage would have ended The child is incapable of self-support and remains so incapable and You are the main source of support and maintenance
If a child meets the requirements above to continue coverage beyond age 19 (or age 26 if he/she meets eligibility requirements) and the child becomes ineligible, such as marries, becomes self-supporting or has someone else provide the main support, the child may not be added again because the child later becomes eligible, such as divorces, becomes no longer self-supporting or has you again provide the main support. Prudential must receive proof of eligibility within 31 days of the date the child attains age 19 and as required during the first two years. After the first two years, Prudential will ask for proof when needed, but not more than once a year.
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Cost of Coverage
Supplemental Employee Life and AD&D The cost for Supplemental Employee Life and AD&D coverage options are shown on the LifeTimes Connection Web site during enrollment. Generally, your costs are based on:
Your current annual pay Your age as of your last birthday The amount of coverage you elect
Taxation Under present tax law, the cost for Employee Life Insurance coverage over $50,000 is included in your taxable income. This taxable, or “imputed,” income is reported on your form W-2. The value of your AD&D coverage is not taxable even if it exceeds $50,000.
Dependent Life The cost of your Dependent Life Insurance depends on the amount of coverage you choose. The number of eligible dependent children you cover does not affect the price you pay for coverage.
The Benefits
Basic Life and AD&D If you have elected Basic Life Insurance at the time of death, coverage will provide a benefit to your beneficiary equal to one times your annual pay — up to a combined Basic and Supplemental maximum of $6,000,000. The benefit payable is rounded to the next higher $1,000 after your pay is multiplied by your level of coverage.
The amount of coverage may increase or decrease during the year with any adjustments to your pay.
If you die as a result of an accident, the plan will pay your beneficiary a Basic AD&D benefit equal to your Basic Life benefit. These benefits are payable if your accidental injuries result in death within 365 days of the accident, and are in addition to your Basic Life benefit.
For dismemberment benefits, see the Benefit for Injuries section.
Supplemental Employee Life and AD&D If you die while covered under the Supplemental Employee Life and AD&D plan, your beneficiary will receive a benefit based on the multiple of your annual pay that you elected. The benefit payable is rounded to the next higher $1,000 after your pay is multiplied by your level of coverage.
If you are a part-time employee and have elected Supplemental Employee Life and AD&D, your beneficiary will receive a flat amount of $15,000.
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Benefits for Accidental Death If you die as a result of an accident, the plan will pay your beneficiary a Supplemental AD&D benefit amount equal to your Supplemental Employee Life benefit. These benefits are payable if your accidental injuries result in death within 365 days of the accident, and they are in addition to your Supplemental Employee Life benefit.
Benefits for Injuries The AD&D plan pays benefits for certain accidental injuries. The level of benefit payable is shown in the following table and is a percentage of your Supplemental Employee Life benefit amount.
Type of Loss Benefit Amount Percentage
Both hands or both feet or sight in both eyes 100%
One hand and one foot 100%
One hand and sight of one eye 100%
One foot and sight of one eye 100%
One hand or one foot 50%
Sight of one eye 50%
The full amount of AD&D insurance is payable only once for all losses, including death, resulting from one accident. If 50% of the insurance is paid for a covered loss, only the other 50% is payable for a later loss caused by the same accident. Once 100% of the insurance amount has been paid for losses caused by an accident, no later injuries caused by that same accident are covered.
Expenses Not Covered AD&D insurance does not cover any accidental losses caused by, contributed to by, or resulting from:
Intentional self-inflected injuries, suicide or any suicide attempt, while sane or insane Active participation in a riot Attempt to commit or commission of a crime under state or federal law Operating a motorized vehicle while intoxicated Voluntary use of prescription or non-prescription drugs (except according to the prescription or direction of your or
your dependent’s physician), poison, fumes or other chemical substance. This exclusion will not apply if the chemical substance is ethanol.
Disease or diagnostic, medical or surgical treatment or mental disorder as set forth in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders
War, or any act of war, whether declared or undeclared
Benefit Reductions As you get older, your Supplemental Employee Life and AD&D benefits are reduced. This reduction takes place on the January 1 following the year you reach age 65, 70, 75 and 80, according to the following table:
When You Reach Age... Your Coverage Is Reduced By...
65 35% of your benefit amount
70 60% of your benefit amount
75 75% of your benefit amount
80 80% of your benefit amount
Although benefit coverage under this plan is reduced when you turn age 65, you may convert this coverage to an individual policy.
Example: Life and AD&D Benefit Reductions If you have $120,000 of life insurance when you reach age 65, your coverage is reduced by 35% to $78,000. When you reach age 70, your coverage is reduced to $48,000 — your original $120,000 of coverage reduced by 60%.
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Seat Belt and Air Bag Benefit Prudential will provide a seat belt benefit — up to a maximum of $25,000 — to you or your authorized representative if you (or your dependent) sustain accidental bodily injury that causes your (or your dependent’s) death while driving or riding in a private passenger car, provided:
The car is equipped with seat belts, and the seat belts were in actual use and properly fastened at the time of the covered accident
The position of the seat belts is certified in the official report of the covered accident or by the investigating officer. A copy of the police accident report must be submitted with the claim. If such certification is not available, and it is clear that you (or your dependent) were properly wearing seat belts, then Prudential will pay a fixed benefit of $1,000.
Prudential will provide an air bag benefit — up to a maximum of $5,000 in addition to any eligible seat belt benefit — to you or your authorized representative if you (or your dependent) are the driver, provided:
The private passenger car is equipped with an air bag for both the driver and front seat passenger, and you (or your dependent) occupy one of those seats
The private passenger car is equipped with an air bag for the driver, front and rear seat passengers, and you (or your dependent) occupy one of those seats
The seat belt is in actual use and properly fastened at the time of the covered accident
No seat belt or air bag benefit is payable if:
You (or your dependent) are the driver and do not hold a current and valid driver’s license or You (or your dependent) are not covered under the plan when the accident causing death occurs
Accelerated Payment — Living Benefits If you become terminally ill, the living benefit feature gives you the option to accelerate benefits payment and receive part of your life insurance benefit before you die.
If you are eligible, you may choose to receive an accelerated benefit, but you are not required to do so. The living benefit maximum is 50% of the coverage amount for you — up to $300,000 for combined Basic and Supplemental coverage.
You are eligible to receive an accelerated payment if:
You request this election, in writing, on a form acceptable to Prudential You are terminally ill at the time of the accelerated payment Your doctor certifies, in writing, that you are terminally ill and your life expectancy is less than 12 months Prudential deems the doctor’s certification satisfactory
You will not be eligible to receive an accelerated benefit if:
You are required by law to use this benefit to meet the claims of creditors, whether in bankruptcy or otherwise You are required by a government agency to use this benefit in order to apply for, get or otherwise keep a
government benefit or entitlement
You must continue to pay premiums on the full amount of life insurance coverage.
This feature is also available to your spouse if you purchase Dependent Life Insurance for your spouse.
Benefits may be taxable. Prudential is not responsible for any tax or other effects of any benefit paid. As with all tax matters, you or your spouse should consult your personal tax advisor to assess the impact of this benefit.
Method of Payment If the life insurance claim is at least $10,000, the beneficiary will have access to a Prudential Security Account. This interest-bearing account will be established by an intermediary bank in the name of you or your beneficiary as owner. The owner of the account may write a draft in a single sum or drafts in smaller sums. The funds are fully guaranteed by Prudential.
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If the life insurance claim is less than $10,000, Prudential will pay the benefit in one lump sum to you or your beneficiary.
You or your beneficiary may request to receive benefits according to one of Prudential’s other settlement options. This request must be made in writing.
If the beneficiary is a minor, or, in Prudential’s opinion, legally unable to give a valid release for payment of benefits, Prudential has the option to:
Pay up to $2,000 from the total death benefit to the person or institution that appears to have assumed custody and main support of the beneficiary
Pay up to $1,000 from the total death benefit to the person or persons, in Prudential’s opinion, who have incurred expenses for your last sickness and death
Dependent Life Insurance If your spouse or child dies, you will receive a benefit in the amount of coverage you have chosen. If more than one of your dependents dies, you receive benefits for each deceased dependent.
Benefit Reductions As your dependents get older, benefits are reduced according to the following table:
On... Coverage Is Reduced To...
The date your child dependent reaches age 19 (age 26 if he/she meets eligibility requirements)
0% of the benefit amount
January 1 following the date your spouse reaches age 70
$10,000
You may convert your Dependent Life coverage to an individual policy. See the Converting Coverage section for more information.
Seat Belt and Air Bag Benefit If your covered spouse or child dies in a motor vehicle accident while wearing a seat belt, the beneficiary may receive an additional $25,000 plus $5,000 for use of an air bag.
Accelerated Payment — Living Benefits If your covered spouse becomes terminally ill, you may be eligible to receive a portion of your spouse’s Dependent Life coverage before your spouse dies. The living benefit maximum is 50% of the coverage amount for your spouse.
Method of Payment You are automatically the beneficiary for Dependent Life and AD&D. If the life insurance claim is at least $10,000, the beneficiary will have access to a Prudential Security Account.
If the life insurance claim is less than $10,000, Prudential will pay the benefit in one lump sum to the beneficiary.
You or the beneficiary may request to receive benefits according to one of Prudential’s other settlement options. This request must be made in writing.
How to Use the Benefits
Benefit Extension Before Converting Coverage A life insurance benefit (excluding AD&D) will be paid to the beneficiary if you or one or more of your covered dependents dies within the 45-day conversion application period. Prudential will pay the beneficiary(ies) the amount of insurance that could have been converted. This coverage is available whether or not you have applied for an individual life policy under the conversion privilege.
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How to File a Claim
Life Insurance
1. Contact LifeTimes Connection at 1-800-566-4114 if your spouse or child dies. If you die, a family member should call LifeTimes Connection. LifeTimes Connection will contact Prudential, who will send you a claim form and request a certified copy of the death certificate.
2. Mail the claim form and a certified death certificate to Prudential within 90 days of the death, to: Prudential, Group Life Claim Division P.O. Box 8517 Philadelphia, PA 19176 Keep a copy of all documents for your records. If you or an authorized representative is unable to meet the 90-day deadline, the claim will be accepted if it is filed as soon as reasonably possible. However, the claim must be filed within a year after the deadline, unless you or your representative is legally incapacitated. In some cases, Prudential may require authorization to obtain additional medical and non-medical information as part of the proof of claim. Prudential will have the right and opportunity to request an autopsy where not forbidden by law.
3. Prudential will send you or your beneficiary a benefit payment upon approval of your claim. You or your beneficiary may appeal Prudential’s decision if the claim is denied. See the Administrative Information section for information regarding claim denials and appeals.
Accelerated Payment Benefits (Living Benefit) Contact LifeTimes Connection at 1-800-566-4114 and ask for a Request for Accelerated Death Benefit Form. LifeTimes will forward the request to Prudential.
Complete the Request for Accelerated Death Benefit Form. State the benefit amount that you want to receive (up to the maximum amount) and attach appropriate medical documentation. Mail the claim to:
Prudential, Group Life Claim Division P.O. Box 8517 Philadelphia, PA 19176
Prudential will send you or your legal representative a benefit payment upon approval of your claim. You may be required to undergo an independent medical examination by a physician chosen by Prudential in order to receive approval. You or your legal representative may appeal Prudential’s decision if the claim is denied. See the Administrative Information section for information regarding claim denials and appeals.
AD&D Insurance
1. Notify LifeTimes Connection at 1-800-566-4114 if you suffer a covered injury. A family member should notify LifeTimes Connection if you are killed in a covered accident.
2. LifeTimes Connection will forward your request for an AD&D claim filing packet to Prudential.
3. File your claim with Prudential within 90 days of the injury or death. Mail the completed claim form, along with proof of the injury or death to:
Prudential, Group Life Claim Division P.O. Box 8517 Philadelphia, PA 19176
Keep a copy of all documents for your records. If you or an authorized representative is unable to meet the 90-day deadline, the claim will be accepted if it is filed as soon as reasonably possible. However, the claim must be filed within a year after the deadline, unless you or your representative is legally incapacitated.
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In some cases, Prudential may require authorization to obtain additional medical and non-medical information as part of the proof of claim. Prudential will have the right and opportunity to request an autopsy where not forbidden by law.
4. Prudential will send you or your beneficiary a benefit payment upon approval of your claim. You or your beneficiary may appeal Prudential’s decision if the claim is denied. See the Administrative Information section for information regarding claim denials and appeals.
Proof of Claim for AD&D Benefits You must submit the following proof of claim for a covered loss or death, provided at your or your authorized representative’s expense:
The cause of death or covered loss The extent of the covered loss The date of the covered loss The name and address of any hospital or institution where treatment was received, including all attending doctors A certified death certificate, if applicable
In some cases, Prudential may require authorization to obtain additional medical and non-medical information as part of the proof of claim. In the case of death, Prudential will have the right and opportunity to request an autopsy where not forbidden by law.
Assignment of Benefits You may assign Life and AD&D Insurance benefits by submitting a signed or certified copy of the written assignment to Prudential’s home office. Prudential will only recognize an assignee as the owner of the rights after it has received and registered the written assignment request.
Prudential will not be responsible for the legal, tax or other effects of any assignment, or for any action taken under the plan’s provisions before receiving and registering an assignment. Call LifeTimes Connection at 1-800-566-4114 if you wish to request an assignment form or receive more information about assigning benefits.
Coverage If You Become Sick, Injured or Take a Leave of Absence If you cannot work due to sickness, injury or a leave of absence, and you continue to pay your premiums, you may continue your life insurance coverage up to six months.
Disabled Dependent If your eligible dependent is totally disabled, your dependent’s coverage will begin on the date your dependent is no longer totally disabled.
Totally disabled means that, as a result of an injury, a sickness or a disorder, your dependent:
Is confined in a hospital or similar institution Is unable to perform two or more activities of daily living due to a physical or mental incapacity. Activities include bathing,
toileting, transferring (moving in and out of a bed without cane or crutches), continence or eating Is cognitively impaired Has a life-threatening condition
Portability of Coverage If your benefits end because your employment ends, you retire or you are no longer eligible for your coverage amount, you may elect portable Life Insurance coverage for yourself and your dependents. In addition, you may elect portable AD&D coverage for yourself, but not for your eligible dependents.
In case of your death, your insured dependents may also elect portable coverage for themselves. However, children cannot become insured for portable coverage unless your spouse (including your domestic partner) also becomes insured for portable coverage. You must apply and pay premiums within 45 days.
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The portable insurance coverage will be the current coverage and amounts that you and your dependents are insured for under the plan. In a case where the employee dies and there is no spouse, the only option available to the dependents is to convert coverage.
However, the amount of portable coverage for you will be the lesser of:
The amount of Supplemental Life and AD&D Insurance you had Five times your annual pay, or $750,000 from Supplemental Life and AD&D combined; however, the amount of AD&D cannot exceed the amount of
Life portable coverage
The amount of portable coverage for your spouse will be the lesser of:
The amount of Dependent Life you had, or 50% of your amount of portable coverage
The amount of portable coverage for your child(ren) will be the lesser of:
The amount of Dependent Life you had, or 50% of your ported amount
The minimum amount that can be ported for you is $5,000 and $1,000 for your dependents.
Your or your dependent’s amount of Life Insurance will reduce or cease at any time it would have reduced or ceased if you had continued in active employment with your facility.
Applying for Portable Coverage
You have the responsibility to request a portability application from Prudential to apply for portability of your supplemental life benefits. To request an application, contact Prudential, Group Life Claim Division, PO Box 8517, Philadelphia, PA 19176 or call 1-800-778-3827.
You must apply for portable coverage for yourself and your dependents and pay the first premium within 45 days after the date:
Your coverage ends or you retire from your facility, or You are no longer eligible for your coverage amount. If you die, your dependents must apply and pay the premium within 45 days after you die.
Portable coverage does not apply to you or your dependents if:
The policy is cancelled, or You fail to pay any required premiums
Furthermore, the following rules apply to dependents:
If you do not port coverage, your dependents cannot port; however, if you port, child(ren) can port If your surviving spouse (or domestic partner) does not port coverage, child(ren) cannot port If your surviving spouse (or domestic partner) is not covered, no child(ren) can port
Applying for Increases or Decreases in Portable Coverage You or your dependents may increase or decrease the amount of Life Insurance coverage based on the minimum and maximum amounts described above. All increases are subject to evidence of insurability. Portable coverage will reduce at the ages and amounts shown above.
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Adding Portable Coverage for Your Dependents
If you chose not to enroll your dependents when your dependents were first eligible for portable coverage, you may enroll your dependents at any time for the amounts allowed under the plan. You may enroll newly acquired dependents at any time for the amounts allowed under the plan. Evidence of insurability is required in both cases.
When Portable Coverage Ends
Portable coverage for you will end on:
The date you fail to pay the required premium The date the policy is cancelled
Portable coverage for your spouse (or domestic partner) will end on:
The date you fail to pay the required premium The date your spouse (or domestic partner) fails to pay the required premium The date the policy is cancelled
Portable coverage for your child will end on:
The date you fail to pay the required premium The date your spouse (or domestic partner) fails to pay the required premium The date the policy is cancelled The date your child no longer qualifies as a dependent The date your surviving spouse (or domestic partner) dies
If portable coverage ends due to failure to pay the required premium, portable coverage cannot be reinstated.
Converting Coverage If you or your dependent is not eligible for portable coverage, if portable coverage ends or if you lose Basic Life Insurance coverage, you or your dependents may qualify for conversion coverage. You can convert your life insurance coverages to individual policies without evidence of insurability if your life insurance terminates or reduces because you:
End active employment Become ineligible due to a change of job status Retire Reach a specified age Change classes
You can convert your dependents’ coverages to individual policies if your dependent no longer meets the eligibility requirements or you terminate your life insurance.
The maximum life insurance amounts that you can convert are the amounts you and your dependents are insured for under the plan. You may convert a lower amount of life insurance.
You must request a Conversion Application from Prudential to apply for a conversion of your group life insurance policy to an individual insurance policy. To request an application, contact:
Prudential, Group Life Claim Division P.O. Box 8517 Philadelphia, PA 19176 Or call 1-800-778-3827
You must apply and pay the policy premium within 45 days of your or your dependent’s loss of eligibility to participate in coverage.
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If you convert to an individual life policy, then return to work and again become insured under the plan, you are not eligible to convert to an individual life policy again. However, you do not need to surrender that individual life policy when you return to work.
If the Group Plan Ends If HCA terminates the plan or changes the plan for all participants so that you are no longer eligible, you and your dependents may convert a limited amount of Life Insurance coverage.
The individual policy maximum for you and each of your covered dependents will be the lesser of:
$10,000 Your or your dependent’s coverage amount under the plan, less any amounts of any group life insurance plan your
facility offers within 45 days of the date your coverage ends
AD&D insurance cannot be converted. For additional information, contact Prudential at 1-800-778-3827.
Premiums You pay the full cost of coverage for converted insurance. Premiums for the converted insurance will be based on:
The insured person’s age on the effective date of the individual life policy The type and amount of insurance to be converted Prudential’s customary rates at the time The class of risk to which the insured belongs
Prudential Privacy Information This notice applies to your Prudential Employee Life and AD&D and Dependent Life Insurance plans. It outlines rights you have as a plan participant.
Prudential has adopted a comprehensive insurance privacy policy based on the recommendations of the Federal Privacy Protection Study Commission.
This notice describes certain aspects of the policy that apply to you as a covered person in a plan of group insurance issued by Prudential. The policy does not apply when law requires a different approach.
Information That Can Be Collected In providing insurance services to you Prudential relies mainly on information that you provide when you enroll for coverage and when you file claims.
Prudential may also collect information about you from other sources. The information collected is necessary for Prudential to perform its function with regard to the insurance transaction in question. For example, if the amount or type of coverage to which you are entitled depends on your earnings or job class, Prudential will obtain that information from your facility.
What Else You Need to Know
Receiving Accelerated Payments – Living Benefits After a living benefit is paid, the beneficiary of the Life Insurance policy will receive the remainder of the policy amount when the covered individual dies. Any life insurance benefit that may be continued as a result of injury or sickness or that may be available under the conversion privilege will be reduced by the amount of the accelerated payment.
The living benefit feature was designed to help pay the large medical bills frequently associated with a terminal illness, but there are no restrictions on how a living benefit can be used. You should consult a professional tax advisor for information on the tax treatment of living benefits. The amount of your living benefit may be subject to income tax upon receipt.
You may request a living benefit from this plan only one time. If you have assigned ownership of the policy’s benefits to someone other than yourself, the assignee or irrevocable beneficiary must agree, in writing in a form acceptable to Prudential, to the accelerated payment.
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If you or your spouse receives a living benefit, premium payments must continue to be paid on the full amount of life insurance (yours and your spouse’s). For more information on your living benefit, see the Accelerated Payment section.
Right to Recover Payment Prudential has the right to recover any claim overpayments due to:
Fraud Any error Prudential makes in processing a claim
You or your beneficiary must reimburse Prudential in full for any overpayment. Prudential will determine the method for repayment, but it cannot recover more than the actual amount of overpayment.
Attachment of Benefits To the extent permitted by law, all rights and benefits under this plan are exempt from execution, attachment, garnishment or other legal process for your debts or liabilities or your beneficiary’s debts or liabilities.
Your Choices .................................................................................................................................... 102
Cost of Coverage .................................................................................................................. 102
Evidence of Insurability ......................................................................................................... 102
The Benefits ...................................................................................................................................... 103
When Benefits Are Paid ....................................................................................................... 103
How Benefits Are Paid ......................................................................................................... 103
How Benefits Are Calculated ............................................................................................... 103
Attachment of Benefits .......................................................................................................... 109
Conversion of Coverage ....................................................................................................... 109
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Long-Term Disability Highlights
A disability can affect much more than your health. It can change practically every part of your life — including your personal finances. As part of the HCA Health and Welfare Benefits Plan, long-term disability (LTD) coverage through The Prudential Life Insurance Company of America can help protect you from the financial consequences of a disability. You can purchase LTD coverage to replace part of your income if a serious accident or illness leaves you unable to work.
Every effort has been made to accurately describe the LTD benefit option in this SPD; however, these benefits are offered and controlled by a group insurance contract with The Prudential Insurance Company of America. The insurance contract is the plan document for the LTD insurance benefit option and if there is a discrepancy between this SPD and the insurance contract, the terms of the insurance contract will control. A certificate of insurance is available upon written request to HCA Inc., Corporate Benefits, One Park Plaza, P.O. Box 550, Nashville, TN 37203.
Plan Overview:
What options are available? 60% of pre-disability pay 50% of pre-disability pay No coverage
Who pays the cost? Your facility may share the cost. Your contributions are deducted on a before-tax basis. Log on to LifeTimes Connection at HCArewards.com for your actual cost.
When do LTD benefits begin? After a five-month waiting period
Your Choices You may choose to purchase one of two long-term disability options or no coverage.
60% of Pre-Disability Pay — Pays a benefit equal to 60% of your pre-disability pay if you become disabled, up to $10,000 per month
50% of Pre-Disability Pay — Pays a benefit equal to 50% of your pre-disability pay if you become disabled, up to $10,000 per month
No Coverage
Cost of Coverage Your price for LTD coverage depends on:
Your age (as of January 1 of the year the coverage is in effect) and Your current pay
The older you are and the higher your pay, the more your coverage costs. If your pay changes during the year, your LTD cost will also change.
If you become disabled, you must still pay contributions during the five-month waiting period before benefits begin. Once benefits begin, you will not be required to make additional contributions.
Evidence of Insurability Evidence of Insurability (EOI) means you must complete a questionnaire and possibly have a physical examination in order for Prudential to determine if coverage will become effective. Submission of EOI does not guarantee coverage; Prudential has the right to refuse coverage. If EOI is approved, coverage will begin on January 1 of the new coverage period or on the first day of the month after Prudential approves EOI, whichever comes later. EOI applies if coverage:
Is increased at annual enrollment (from 50% to 60%) Is elected at annual enrollment after you initially declined it
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EOI is not required if you elect coverage (50% or 60%) within 31 days of first becoming eligible or within 31 days of a change-in-status event. Also, if you have the 50% option, you may increase to the 60% option if you make the election to increase within 31 days of a change-in-status event.
The Benefits If you are eligible for LTD benefits, you may receive 50% or 60% of your pre-disability pay — depending on the level of coverage you choose during enrollment — after you have been partially or totally disabled for at least five months. The minimum monthly benefit you may receive is $50, and the maximum monthly benefit is $10,000. While you are disabled, your monthly benefit will be reduced by any other income you are entitled to receive on the date you became disabled, such as Workers’ Compensation or Social Security benefits. This does not include private disability insurance policies or the LifeTimes Retirement Program. You are considered to be partially or totally disabled if Prudential determines:
You have an illness or injury that limits you from performing the material and substantial duties of your regular occupation during the first 24 months of disability, and after the first 24-month period, you are unable to perform the material and substantial duties of any gainful occupation for which you are reasonably fitted by education, training or experience, and
Your current monthly income is at least 30% lower than your indexed pre-disability earnings, due to that same illness or injury.
Indexed pre-disability earnings means your monthly earnings adjusted yearly by 10% or the current annual percentage increase in the Consumer Price Index, whichever is less. Your indexed earnings may increase or remain the same, but will never decrease. Indexing is used only to determine your percentage of lost earnings while you are disabled and working.
When Benefits Are Paid LTD benefits are paid when Prudential determines that you are — and continue to be — partially or totally disabled for a period of five months. A period of disability starts on the first day you are totally disabled. You must be under the care of a doctor during this period. In addition, as proof of your continuing disability, you may be asked to have a medical examination from time to time by a doctor selected and paid for by Prudential.
How Benefits Are Paid LTD benefits are paid at the end of each calendar month and mailed directly to you by Prudential. If a monthly benefit is payable for less than a month, the plan will pay 1/30th of the monthly benefit for each day you were disabled. If your LTD benefit is overpaid, your future benefits will either be reduced to recover the overpayment or you will be asked to repay the overpayment in a lump-sum payment.
How Benefits Are Calculated Your LTD benefits are based on your pre-disability pay, and they are reduced by any other disability income you may receive from Social Security (individual and family), Workers’ Compensation, state disability or any other company- or government-sponsored plan. For more information, refer to the Disability Income section. Before your benefit is reduced by any other disability income you are eligible to receive, the amount of your LTD benefit will be 50% or 60% of your pre-disability pay, depending on the option you chose when you enrolled. Pre-disability pay is your monthly benefit pay for the last full pay period before the period of total disability begins. It does not include bonuses, overtime and any other extra compensation, nor does it include income received from sources other than HCA. If you’re a commissioned salesperson, your pre-disability pay includes income you actually receive from commissions, but it does not include renewal commissions, bonuses, overtime pay and any other extra compensation, nor does it include income received from sources other than HCA. If you’re a pieceworker, pay is calculated based on your average monthly piecework earnings for the three months prior to the period your disability begins. LTD Payment Example: Suppose your monthly pay just before your disability is $3,000. Suppose you file a claim for Social Security disability payments and your claim is approved. If you begin receiving $750 in monthly Social Security disability payments, here's how your LTD payment is figured under the 60% option.
$3,000 Monthly benefit pay before disability
x 60% LTD plan replacement percentage
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$1,800 Total amount to be replaced
- $750 Social Security disability payment
$1,050 Monthly LTD payment
In this example, the LTD Plan works with Social Security disability payments to bring your monthly income to 60% of your pre-disability pay. This is only an example. Your disability may or may not qualify for Social Security payments.
Taxes are not withheld from the monthly LTD payment unless you request withholding, but the benefit is taxable. Benefits for Partial Disability If your disability does not prevent you from working in another job or part-time in your regular job, you are considered partially disabled. Your monthly benefit will not be reduced if your monthly disability earnings are less than 30% of your indexed pre-disability earnings. If your monthly disability earnings are between 30% and 70% of your indexed pre-disability earnings, your monthly disability benefit will be calculated as follows:
During the first 12 months of partial disability, your monthly benefit will not be reduced as long as the sum of your disability earnings and your monthly benefit is not more than 100% of your indexed pre-disability earnings.
After the first 12 months of partial disability, if you continue to be partially disabled, the following calculation is used to determine your monthly benefit:
Monthly benefit = (A – B) x C A
A = Your pre-disability earnings
B = Your disability earnings
C = The monthly taxable benefit payable if you were totally disabled
Your monthly benefit will not be less than the minimum monthly benefit of $50, or more than the maximum monthly benefit of $10,000.
If a monthly benefit is payable for less than a month, the plan will pay 1/30th of the monthly benefit for each day you were disabled.
Disability Earnings Your disability earnings are the monthly earnings you receive from any employer or for any work while you are disabled and eligible for partial disability under the LTD Plan.
Cost-of-Living Increases Once the amount of your disability benefit has been determined, it will not be adjusted for cost-of-living increases. Similarly, Prudential will not reduce the amount of your benefit if disability benefits you are receiving from another source are adjusted for cost-of-living increases. For more information, see the Other Disability Income section.
Taxes on Benefits Because premiums are paid on a before-tax basis, the IRS considers LTD benefits to be taxable income. However, Prudential generally does not withhold taxes from your monthly benefit, unless you request otherwise. As a result, you will need to pay taxes on the benefits when you file your federal income tax return. You may request Prudential to withhold taxes as you receive your LTD payments. You can make this request on the last page of your claim form.
Other Disability Income If you become disabled, you may be entitled to benefits from other company- and government-sponsored plans. Your LTD income benefits will be reduced by disability benefits that you are eligible to receive from other plans. Sources of other benefits payments include:
Social Security or disability benefits payable to you because of disability Social Security retirement benefits Workers’ Compensation, occupational disease laws or other disability legislation No-fault wage replacement benefits or other group insurance coverage Payments provided by the Veterans Administration
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Any portion of a settlement or judgment, minus associated costs, of a lawsuit or claim that represents or compensates for your loss of earnings
Half of any pay you receive while participating in an approved rehabilitation program
It is your responsibility to contact Prudential if there is any change in your disability income from other sources of if your dependent's benefits change. If you receive other income benefits in a lump-sum payment, the amount you receive will be prorated on a monthly basis over a reasonable period of time. This monthly amount will reduce the amount you receive as monthly LTD benefits. If you receive any retroactive benefits, you must notify Prudential. You will be required to repay the amount you received from the LTD Plan that was more than the maximum benefit you should have received. Prudential will notify you of the amount you will be required to repay. Workers’ Compensation If you are disabled because of a job-related illness or injury, you may be entitled to receive Workers’ Compensation. Your LTD benefit from Prudential will be reduced by any cash benefits you receive from Workers’ Compensation for the disability. Social Security Benefits You become eligible for Social Security disability income benefits after five full months of disability. You must apply for Social Security disability income benefits with your local office of the Social Security Administration and appeal any denial of these claims. If your appeal is denied, you must request a hearing before an Administrative Law Judge of the Office of Hearing and Appeals.
Any income you or your eligible dependents receive from Social Security as a result of your disability reduces the amount of your LTD benefit. If you become eligible for and begin receiving retirement benefits from Social Security after you become disabled, the amount you receive from Social Security will reduce your LTD benefits. If you receive retroactive Social Security disability income benefits, you are required to notify Prudential and repay the amount you received that exceeded the maximum benefit to which you were entitled. Prudential will notify you of the amount you will be required to repay.
Rehabilitation and Return to Work Assistance Program Prudential has a vocational Rehabilitation and Return to Work Assistance Program available to assist you in returning to work. Prudential, at its sole discretion, will determine whether you are eligible for this program. To be eligible for rehabilitation services and benefits, you must be medically able to engage in a return-to-work program.
One of Prudential’s rehabilitation professionals will review your claim file to determine if the program might help you return to gainful employment. As your file is reviewed, medical and vocation information will be analyzed to determine an appropriate return-to-work program.
If Prudential determines you are eligible to participate in the program, you must participate in order to receive disability benefits. Prudential will provide you with a written Rehabilitation and Return to Work Assistance plan developed specifically for you, and you must comply with the terms of the plan to receive benefits.
The program may include, but is not limited to, the following services and benefits:
Coordination with your facility to assist you to return to work Adaptive equipment or job accommodations to allow you to work Vocational evaluation to determine how your disability may impact your employment options Job placement services Resume preparation Job seeking skills training Education and retraining for a new occupation
Additional benefits if you participate in the program include:
Additional 10% of your gross disability benefit, up to $1,000 per month (This benefit is not subject to the provision that would otherwise reduce your benefit amount as another source of income. However, the total benefit maximum will apply)
Additional three months of disability benefits — paid in a lump sum — after the date your disability ends if you are unable to find employment
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Monthly child care expenses of $250 per child, up to a maximum of $1,000 per month for all eligible child care combined
The child care expense benefit is provided to reimburse expenses incurred for providing care for your dependent children who:
Are under the age of 15 or Are incapable of providing their own care on a daily basis due to their own physical or mental disability
You must provide proof that payment has been made to the child care provider and that you are incurring these expenses while participating in the rehabilitation program.
When Rehabilitation Benefits End Child care expense benefits will end on the earliest of the following dates:
The date the dependent child attains the age of 15 The date that a mentally or physically disabled dependent no longer requires daily care or is no longer incapacitated The date that a charge is no longer made by the child care provider The date that you no longer participate in the program Any other date on which payments would stop under this plan
Benefits under this program end on the earliest of the following dates:
The date Prudential determines that you are no longer eligible to participate in the program, or Any other date on which monthly payments would stop under this plan
When Benefits End LTD benefits will end on the earliest date that one of the following events occurs:
During the first 24 months of payments, you are able to work in your regular occupation on a part-time basis, but you choose not to do so
After 24 months of payments, you are able to work in any gainful occupation on a part-time basis, but choose not to do so
The date you refuse to participate in the Rehabilitation and Return to Work Assistance Program If you are working, the date your monthly disability earnings exceed 70% of your indexed pre-disability earnings The date you are no longer disabled under the terms of the plan The date you fail to submit proof of continuing disability Twelve months of payments have been made, if you reside outside the United States or Canada, for a total period of
six months or more during any 12 consecutive months of benefits You die You reach the age limitations shown below:
If your disability begins at age: Benefits continue:
Before age 62 To the end of the month in which you reach age 65
62 48 months
63 42 months
64 36 months
65 30 months
66 27 months
67 24 months
68 21 months
69 and over 18 months
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Disabilities Not Covered LTD benefits will not be paid for disabilities caused by, contributed to by or resulting from your:
Intentionally self-inflicted injuries Active participation in a riot Commission of a crime for which you have been convicted under state or federal law Pre-existing condition
In addition, no benefits will be paid for:
A disability due to war, declared or undeclared, or any act of war Any period of disability during which you are incarcerated Any disability caused by, contributed to by, or resulting from your loss of a professional license, occupational license
or certification
How to Use the Benefits
How to File a Claim
1. Notify your supervisor that you are unable to work as the result of a disability.
2. File a claim with Prudential Insurance within 30 days after the beginning of your disability. (Request a claim form from your local Human Resources Department.) If you want Prudential to withhold income taxes from your LTD benefit, you should note your request on the last page of the claim form.
3. Submit medical proof of the disability before benefits start. You may be required to show proof of your continuing disability from time to time.
4. Apply for Social Security disability income benefits if you have not already done so. You will receive a notice from Prudential instructing you to apply for Social Security disability income benefits. You can get the necessary forms by contacting the Social Security Administration. You must apply for these benefits and promptly appeal any denial of these benefits to remain eligible for benefits through the LTD Plan. If your appeal is denied, you must request a hearing before an Administrative Law Judge of the Office of Hearing and Appeals.
5. Notify Prudential if you, your spouse or your dependents have been approved for Social Security disability benefits, Workers’ Compensation, occupational disease awards or any other federal or state disability benefits.
6. If applicable, provide Prudential with any documents that would help Prudential to recover payment from a third party. Prudential has the right to recover LTD payments when a third party is found to be responsible for your disability. For example, you could be in an automobile accident caused by another person, and the courts could find that person responsible for your disability.
7. Notify Prudential immediately when you return to work in any capacity.
8. If you have questions about your claim or LTD benefit check, contact Prudential Life Insurance toll-free at 1-800-842-1718. You may also write to Prudential. The address is: Prudential Insurance Company of America 751 Broad Street, Newark, NJ 07102
Delay of Benefits The following situations could result in a delay of your benefits:
You fail to apply for benefits within 90 days of becoming disabled or fail to provide the information required on claim forms
You change your address while receiving benefits and fail to provide Prudential with your new address You fail to inform Prudential that you were approved (or not approved) for Social Security benefits
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When Prudential May Recover Payment In some situations, a third party, such as another person or insurance company, may be legally responsible for your disability. This may happen, for example, in an automobile accident.
When this occurs, Prudential is entitled to be reimbursed for all LTD benefits that have been paid under the program. Prudential may take any actions necessary to enforce its rights to be reimbursed. When you accept payment from the LTD program, you agree to provide any documents that would help Prudential recover payments it has made on your behalf. The legal term for this right of recovery is subrogation.
In situations where your program has a subrogation interest, you may be asked to sign certain documents acknowledging Prudential’s rights. Prudential is entitled to subrogation even if you fail to sign the requested documents.
Proof of Disability Prudential may require you to provide proof that your disability continues and that you are receiving regular medical treatment from a doctor. In addition, Prudential may require you to have an independent medical examination, from time to time, to verify a continuing disability. Failure to appear for an independent medical examination may cause you to lose your benefits.
If You Become Disabled Again You may return to work up to 30 days during your five-month waiting period without interrupting the waiting period. If you are able to return to work on a temporary basis during the five-month waiting period but then must stop working because of the same disability, you will not be required to begin a new five-month waiting period — as long as your earnings do not exceed 30% of your pre-disability pay.
You will not be required to begin a new five-month waiting period if you recover and return to work after the five-month waiting period but then the same or a related disability occurs within three months of your return to work.
If a new disability occurs after you recover from your disability and return to work, or if the same or a related disability occurs more than three months after you return to work, this disability will be considered separately. You will be required to satisfy a new five-month waiting period before your LTD benefits begin.
The rules for more than one period of disability do not apply beyond 24 months for disabilities due to mental or emotional disease. For more information, see the Mental Health Limitations section (see below).
Appealing a Claim Denial If your disability claim is denied or your benefit payments are terminated, you will receive a written explanation of the reason for the denial or termination. You have the right to have your claim reviewed and reconsidered. All claims and appeals are handled by Prudential. Prudential has absolute discretion in deciding claims and appeals. HCA does not decide claims or appeals. See the Administrative Information section for information regarding claim denials and appeals.
Limitations and Pre-Existing Conditions
Mental Health Limitations If your disability is due to mental illness, alcoholism or drug abuse, benefits will generally be paid only for a period of up to 24 months. However, you may continue to receive benefits after 24 months under one or both of the following conditions:
If you are confined to a hospital or institution at the end of the 24-month period, you will continue to receive your benefit payments during your confinement. You may continue to receive payments during a 90-day recovery period if you are still disabled when you are discharged. If you must be confined again during that recovery period and your new confinement lasts at least 14 consecutive days, you may receive benefit payments during the new confinement and for one additional 90-day recovery period
If you continue to be disabled after receiving payments for a period of 24 months and become confined to a hospital or institution for at least 14 consecutive days, you will receive benefit payments during your confinement
The mental illness limitation will not apply to dementia that is a result of:
Stroke Trauma
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Viral infection Alzheimer’s disease Other conditions that are usually treated by a mental health provider or other qualified provider using psychotherapy,
psychotropic drugs or other similar methods of treatment
Pre-existing Conditions You have a pre-existing condition when you first become eligible or when you request an increase in coverage if:
You had symptoms for which an ordinarily prudent person would have consulted a health provider in the three months just prior to the effective date of your coverage
You received medical treatment, consultation, care or services (including diagnostic measures) or took prescribed drugs or medicines for that condition in the three months just prior to the date of your coverage or increase in coverage
The disability begins in the first 12 months after your coverage or increase in coverage begins
If you stop working for an HCA-Affiliated Facility and are rehired more than six months later, a new pre-existing condition limitation will apply.
Pre-existing conditions are covered after you have had LTD coverage for 12 consecutive months.
What Else You Should Know
Survivor Benefit If you die, a single lump-sum benefit equal to three months of your gross disability benefit may be payable to your eligible survivor if, on the date of your death:
You had been disabled for 180 or more consecutive days and You were receiving or were entitled to benefits under the plan
If you have no eligible survivors, payment will be made to your estate. However, the plan will first apply the survivor benefit to any overpayment that may exist.
Attachment of Benefits To the extent permitted by law, your LTD benefits may not be attached, garnished or subject to other legal processes for your debts or liabilities.
Conversion of Coverage LTD cannot be converted to an individual policy when your coverage ends.
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HCA 401(k) Plan
HCA 401(k) Plan Highlights .............................................................................................................. 112
The HCA 401(k) Plan gives you a convenient way to save money for retirement — by putting money aside each payroll period. To help you save, each payroll period, your facility makes a matching contribution to your account. For most employees, the contribution is a 100% match on your contributions up to a certain level (from 3% to 9% of eligible pay) based on your years of vesting service and subject to contribution limits. The longer you work for your facility, the more you will receive in Matching Contributions.
Plan Overview The HCA 401(k) Plan allows you to save money on a before-tax basis, reducing the amount of federal income tax you pay each year. You choose how to invest the money in your account. You may be eligible to access your money before retirement — through loans and, in cases of financial hardship, through withdrawals from the Plan. And with the phased retirement distribution feature, you can continue to work for your HCA-affiliated facility while having access to your money when:
You reach age 59½ withdraw all or part of your vested 401(k) Plan balance (except for your former Retirement Plan account, and any earnings thereon) for any reason
You reach age 62 withdraw up to 50% of your former Retirement Plan account, and any earnings thereon.
In combination with your personal saving and your Social Security benefits, the HCA 401(k) Plan plays an important role in helping you meet your financial goals for retirement.
Note: As of 1/1/09, the Regional Medical Center of San Jose 401(k) Plan and the Los Robles Surgi-Center 401(k) Plan were merged into the HCA 401(k) Plan. On December 30, 2009, the Value Health Retirement Savings Plan was merged into the HCA 401(k) Plan. Participant accounts in the previous plans have been converted to HCA 401(k) Plan accounts.
For most employees, the HCA 401(k) Plan encourages you to save for retirement by matching your savings.
Contributions
Contributions to Your Account The Plan allows you to save for your future — and benefit from tax reductions today. The sooner you begin contributing to the Plan, the more you can accumulate for your future.
Your account generally contains two types of contributions:
Voluntary Contributions are contributions you make to your account on a before-tax basis. Your Voluntary Contributions and their investment earnings are always 100% vested.
Matching Contributions are contributions your facility makes to your account. Matching Contributions and their investment earnings are subject to a vesting schedule.
Your total account balance may also include separate accounts with contributions from other plans which may have been merged with the Plan. For example, accounts under the HCA Retirement Plan were merged into the HCA 401(k) Plan in 2008 – these accounts are referred to in this summary as the Retirement Plan account. Also, if you rolled over assets into the Plan, you will have a rollover account.
You decide how much to contribute to the Plan and how to invest your account. Your account value depends on the amount of Voluntary Contributions you make, your facility’s Matching Contributions, any other contributions, and investment results based on your investment elections.
Employee Retirement Assistance Contribution (ERAC) At the annual discretion of the employer, certain employees who have relatively low income from their HCA-affiliated facility may be eligible to receive a supplemental employer contribution known as ERAC. To be eligible to receive this contribution, you generally must: (a) be employed on the first and last day of the year; (b) perform at least 1,600 hours of service during the year; (c) make no more than twice the U.S. Department of Health and Human Services (HHS) single person poverty income amount, and (d) not participate in the San Jose Market Pension Plan or the Alaska Regional Hospital Pension Plan portion of the HCA Retirement Plan for Certain Facilities. If an ERAC is made, the amount of the contribution will generally equal the maximum matching contribution that could have been received by the eligible employee and will not depend on the participant’s contributions.
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Voluntary Contributions If you are automatically enrolled in the plan, your initial contribution rate will be 3% of your pay and your rate will automatically increase by 1% in January of each year unless you actively elect another rate. If you are automatically enrolled after June of the current plan year, the automatic escalator will become effective after the next full year in January. For example, if you are enrolled in July 2010, your automatic escalator will take effect in January 2010. In general, you can contribute from 1% to 50% of eligible pay each payroll period to the Plan through automatic payroll deductions. For most employees, each payroll period, your facility will provide a 100% match on your contributions up to a certain level (from 3% to 9% of pay) based on your years of vesting service. However, if you are a highly compensated employee (as defined in the Internal Revenue Code), your contributions may be limited if HCA determines that a reduction or restriction is necessary in order for the Plan to meet IRS regulations. For purposes of the Plan, your eligible pay generally includes all wages reported on your W-2 form, including your contributions to the Plan and any before-tax dollars you use to pay for additional benefits through the LifeTimes Connection Benefit Choices Program. Pay also includes any retention bonuses you receive. If your eligible pay increases during the year because of a raise or promotion, your contributions for the balance of the year are based on the increased amount. There are some exceptions to eligible pay. Examples of pay that is not eligible:
Pay that you received while a member of a union (unless the collective bargaining agreement provides for participation)
Pay that you received while you were not an active participant in the Plan Discretionary bonuses Reimbursements, allowances, or compensation associated with a geographic transfer or relocation Income from the exercise of a stock option or nonqualified plan Cash-Out Dollars taken as cash instead of benefits Sales commissions Back pay or compensation received as a result of a legal settlement or otherwise Fringe benefits in the form of cell phones, country club dues, airplane use, spouse travel, personal auto use, etc. All amounts paid through manually issued checks or otherwise paid outside your facility’s ordinary payroll system,
including: o Compensation payable in a form other than cash or that is taxable without a cash payment, and any
associated tax gross-up o Stock dividends
Severance pay Pay received while on military leave Income from discharge of debt owed to HCA and its affiliates Life insurance coverage Foreign tax gross ups for expatriates Taxable non-cash compensation such as group life imputed income, reward prizes or gifts received Taxable domestic partner benefits
Compensation that is eligible may include childcare, meals reimbursement and adoption reimbursement.
Contributions may also be made to the HCA 401(k) Plan in accordance with the Thurman vs. HCA Inc. lawsuit settlement, which was completed in 2009.
Advantages of Saving Through the Plan Saving through the HCA 401(k) Plan can offer you some significant tax breaks. The reason is the difference between before-tax savings (in the Plan) and after-tax savings (in a bank, for example).
Let's assume your eligible annual pay is $30,000, you are single, take the standard deduction, and have one personal exemption. Here's an example of how your tax savings might be calculated using 2008 tax laws.
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After-Tax Contributions Before-Tax Contributions
Annual pay $30,000 $30,000
Before-tax contributions (6%) – 0 – $1,800
Taxable Income $30,000 $28,200
Estimated federal income taxes* – 2,763 – 2,493
After-tax savings (6%) – 1,800 – 0
Your remaining pay $25,437 $25,707
Tax savings $270 * Estimated federal income taxes based on 2008 tax tables and exemption amounts. State income taxes have not been included but could represent additional savings if you would have otherwise paid state tax on the money you contribute to your Plan account. Deferral rate is assumed to be consistent throughout the year. FICA taxes are not reduced by contributions to the Plan. And, don’t forget that, if you are eligible, your facility makes dollar-for-dollar matching contributions each pay period, subject to the savings you contribute and the limits described below. Your savings and current taxes will depend on your own tax status and financial information. In this example, that could add an additional $1,800 to your account if you have 10-14 years of vesting service with HCA. Remember, this is only an example. Your savings and current taxes will depend on your own years of service, tax status and financial situation. You should consult a personal tax advisor for more information.
Contribution Limits Federal law limits the total amount of Voluntary Contributions you can make each year. This limit is subject to change periodically. The limit for 2010 is $16,500. In addition, if you will be age 50 or older by the last day of the calendar year, you can make Catch-Up Contributions (see page 123) as well. For 2010, you can contribute up to an additional $5,500.
Year Limit on Voluntary Contributions Limit on Catch-Up Contributions (if eligible)
2004 $13,000 $3,000
2005 $14,000 $4,000
2006 $15,000 $5,000
2007 $15,500 $5,000
2008 $15,500 $5,000
2009 $16,500 $5,500
2010 $16,500 $5,500
These limits to Voluntary and Catch-Up Contributions apply to all contributions you make to this Plan and to the 401(k) and/or 403(b) plans of any other employer in the same calendar year. Your employer will monitor your contributions so that you will not exceed the limit under the Plan. However, if you contribute to a 401(k) or 403(b) plan of any other employer, it is your responsibility to monitor compliance with these limits. If you exceed the limit with your Voluntary or Catch-Up Contributions to the HCA 401(k) Plan and any other 401(k) and/or 403(b) plans, you should contact LifeTimes Connection before March 1 of the following year to request a refund. This will allow enough time for LifeTimes Connection to issue you a refund before the April 15 deadline. If you contact LifeTimes Connection after March 1 (but before April 15), LifeTimes Connection may or may not be able to issue you a refund before April 15. A refund check will not be issued after April 15. In this case, the excess amount will be considered income in the prior year, which means you will receive no tax benefit for that income when you ultimately receive your distribution. As a result, you will pay taxes on the excess contribution twice — once in the year you contributed the money and again when you actually receive the money from the Plan. If a distribution check is issued to you, any earnings on the excess contributions will be taxable in the year of the refund. Income Tax Credit The Internal Revenue Code allows certain individuals to receive an income tax credit of up to $1,000 for contributing to before-tax retirement plans, such as the HCA 401(k) Plan. These credits are limited to individuals whose adjusted gross income (AGI) is less than the following amounts for 2009:
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$55,000 for couples filing income taxes jointly $41,625 for individuals who file as heads of household $27,750 for single taxpayers.
For information, please contact your personal financial or tax advisor.
Tax Regulation Limits Tax law requires that the rate of contributions by highly compensated not exceed the non-highly compensated employees’ rate of contribution by more than a certain amount. The IRS has procedures to determine this maximum. If the Plan cannot pass the legal test for a balanced proportion of participation, contributions for highly compensated employees may be limited or refunded. You will be notified if this affects you.
Highly Compensated Employees For 2010, a highly compensated employee is someone who has W-2 adjusted wages from HCA in 2009 of more than $110,000. (W-2 adjusted wages generally means W-2 wages plus 401(k) contributions and most other before-tax contributions.) This limit is set by the government and is adjusted from time to time. In addition, the Internal Revenue Code limits the amount of annual pay that can be taken into account for Plan purposes. The amount is $245,000 for 2010, and is subject to change periodically.
There are also IRS limits on the combined total annual additions that can be made to your accounts in the tax-qualified plans of HCA Inc. and its affiliates. Under certain circumstances, this overall limit may reduce the maximum contribution you are allowed to make to the Plan.
If you exceed these limits, you may receive a distribution of the exceeded amount following the end of the Plan year or other action may be taken according to Plan terms.
HCEs may elect to make before-tax contributions in flat dollar amounts or whole percentages. Flat dollar amounts cannot exceed 50% of eligible pay each pay period. For Highly Compensated Employees who elect a whole dollar amount, LifeTimes will estimate the eligible pay and ensure the year-to-date contribution amount does not exceed 10% of eligible pay.
Electing a deferral percentage works best when the IRS maximum deferral ($16,500 for 2010) is more than 10% of pay. This means that if expected pay in 2010 is less than or equal to $165,000, the participant may simply elect the maximum HCE deferral percentage.
Electing a flat dollar amount works best when the IRS maximum deferral ($16,500 for 2010) is less than or equal to 10% of pay. This means that if expected pay in 2010 is more than $165,000, the participant should elect a flat dollar amount. To determine the appropriate flat dollar amount, follow these steps:
Subtract the amount of your year-to-date deferrals from $16,500 Divide the difference by the number of pay periods remaining in the year
Contribution Elections as Flat Dollar Amount or Percentage You may elect before-tax contributions in whole dollar amounts or whole percentages at any time. If you designate a whole dollar amount, it cannot exceed 50% of your eligible pay each pay period. For Highly Compensated employees who elect a whole dollar amount, LifeTimes will estimate the eligible pay and ensure the year-to-date contribution amount does not exceed 10% of eligible pay.
Matching Contributions To help you build your savings, your facility provides a Matching Contribution to the Plan. You are immediately eligible for this Matching Contribution when you begin contributing to the plan. Your facility will provide a 100% match on your contributions up to a certain level (from 3% to 9% of pay) based on your years of vesting service as of the end of the payroll period.
Years of Vesting Service as of End of Payroll Period Plan Match
0-4 3%
5-9 4%
10-14 6%
15-19 7%
20-24 8%
25 or more 9% Service for determining your matching rate in the above chart is generally the same as your vesting service, which is described below, except that past service credit may not apply.
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There is no match for any additional contributions you make, for Catch-Up Contributions or for Rollover Contributions. Matching Contributions are made based on compensation for each payroll period. Therefore, to maximize matching contributions, you need to contribute the maximum matched percentage of eligible pay each payroll period.
You invest your facility’s matching contributions the same way as you invest your voluntary contributions: in one or more of the 401(k) Plan investment funds. While your Voluntary Contributions and their earnings, if any, are always 100% vested, your matching contributions and their earnings are subject to a vesting schedule.
Low Income Contributions For employees earning less than 200% of U.S. poverty guidelines for an individual, HCA may make an additional graded contribution referred to as ERAC. You will be notified if you qualify for this special benefit.
Rollover Contributions If you participated in a tax-qualified retirement plan through another employer — such as another 401(k) plan — you generally can roll that money into the HCA 401(k) Plan anytime after you become a Plan participant. The Plan Administrator must receive sufficient information showing that the other plan is tax-qualified before the money is eligible for a rollover.
Rollover Contributions are not matched by your facility, but they can be invested in any of the current investment options.
The Plan does not accept Rollover Contributions in stock or property. If you have questions concerning rollover accounts, please call LifeTimes Connection.
Making a Rollover Contribution
1. Call LifeTimes Connection to request a Rollover Contribution Form. You must be eligible to participate in the 401(k) Plan to make a Rollover Contribution.
2. Complete and return the form to the LifeTimes Connection Benefit Center. Be sure to include sufficient information showing that the amount is coming from a tax-qualified plan and is eligible for a rollover. You must also elect how you would like your Rollover Contribution invested in the Plan.
3. Enclose a check from the distributing plan or individual retirement account (IRA), money order, certified check, or cashier’s check for the rollover amount. The HCA 401(k) Plan does not accept share certificates as part of a Rollover Contribution. Checks should be made payable to the Plan and mailed to LifeTimes Connection Benefits Center – C1515, 2300 Discovery Drive, P.O. Box 785012, Orlando, FL 32878-5012.
4. Make a copy of the Rollover Contribution Form and your check or money order for your records.
5. If you were not already enrolled in the Plan, you must designate a beneficiary. A beneficiary is the person who will receive the value of your Plan account if you die before receiving the account balance yourself. You can designate a beneficiary online at HCArewards.com or by calling LifeTimes Connection at 1-800-566-4114.
6. For any rollover that is not a direct rollover (for example, a payment to you from your IRA), the check must be deposited within 60 days of receipt.
Catch-up Contributions Generally, you are eligible to make additional Catch-Up Contributions to the Plan in any year you are — or will be — age 50 or older by December 31. Simply go to HCArewards.com or call LifeTimes Connection at 1-800-566-4114 to enroll for a Catch-Up Contribution.
If you make Catch-Up Contributions to another employer’s savings plan during the same year, be sure your total contributions to the 401(k) Plan and other employer’s plans do not exceed the Catch-Up Contribution limit ($5,500 for 2010) for the Plan year.
Note: You cannot make a catch-up contribution until you have contributed the maximum amount of $16,500 (or 10% of eligible pay for Highly Compensated Employees). Catch-up Contributions are flat dollar elections per pay period.
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Changing or Stopping Your Contributions You can increase, decrease, or stop your contributions at any time by visiting HCArewards.com or by calling LifeTimes Connection at 1-800-566-4114. Changes or suspension of contributions are generally effective beginning the next full payroll period.
If your eligible pay increases during the year because of a raise or promotion, your contributions for the remainder of the year are based on the increased amount.
Account information on HCArewards.com is updated daily and is available 24 hours a day, Monday through Saturday and after noon (Central Time) on Sunday. You can also make contribution changes by calling the LifeTimes Connection automated phone system at 1-800-566-4114. Representatives are available to answer your questions from 7:00 a.m. to 7:00 p.m. (Central Time), Monday through Friday.
Other Plan Accounts In some cases, your total 401(k) account balance may also include separate accounts with contributions from former employers’ plans, or plans merged into the Plan. All contributions to these accounts and their associated earnings are fully vested, with the exception of the former Stock Bonus Plan Accounts and former Retirement Plan Accounts.
Any investment direction you make with respect to the Plan shall apply equally to the accounts transferred to the Plan via merger or otherwise. If your prior plan accounts were transferred to the Plan, the investments were then converted to Plan funds that generally resembled your old funds in terms of risk and return. It is your responsibility to choose and confirm how your account balance is invested.
Service and Vesting You earn ownership rights to the Matching Contributions in your account through your years of vesting service with your facility. You receive one year of vesting service for each calendar year that you perform at least 1,000 hours of service if you are age 18 or older.
Hours of Service In general, “service” means the length of time you work for an HCA affiliate. However, service under the Plan is counted in a special way. Hours of service are used to determine whether you have worked the 1,000 hours required to earn a year of vesting service. You earn one hour of service:
For each hour you work for pay, including hours for which you receive back pay. You ordinarily will not receive hours of service for a period during which you are “on call,” but not actually performing services. (If you received pay for a period you were unable to work due to Hurricane Katrina in 2005, you received credit for those hours of service.)
For each hour you receive pay while away from work for vacation, holidays, jury duty, sick leave, and similar periods of paid time off. You can receive up to 501 hours for any single period away from work. (If you received pay for a period you were unable to work due to Hurricane Katrina in 2005, you received credit for those hours of service).
For each normally scheduled work hour (ordinarily at a rate of 40 hours per work week for full-time employees) while you are in the U.S. military service, as long as you are reemployed within the period required under veterans’ reemployment laws.
Hours of service and pay will generally be credited to the Plan year in which they are paid. For example, if a pay period begins in December and ends the first week of January of a new year, all hours for that pay period will apply for determining whether a year of service has been performed in the new plan year.
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Vesting in Matching Contributions and Former Retirement Plan Contributions You are always 100% vested in your own before-tax Voluntary Contributions, any Rollover Contributions and any investment earnings on those contributions. You become vested in your Matching Contributions, former Retirement Plan contributions and any investment earnings on those contributions according to the following: If you were employed by your facility and became eligible for the new benefits structure (greater matching contributions) in
late March or early April of 2008, and you had three or more years of vesting service at that time, then you are now fully vested in your HCA 401(k) Plan account and your former HCA Retirement Plan account. If you became eligible for the new benefits structure after early April of 2008, and you: (a) were employed by your facility on both April 1, 2008, and the date your facility became eligible for the new benefits structure, and (b) had three or more years of vesting service on April 1, 2008, then you are fully vested in your HCA 401(k) Plan account and your former HCA Retirement Plan account.
If you had less than 3 years of vesting service as of April 1, 2008, or were not employed by an HCA-affiliated facility on April 1, 2008, the six-year graded vesting schedule below applies to your former HCA Retirement Plan account. Your matching contributions will be 0% vested until you perform 3 years of vesting service and will be 100% vested thereafter.
Years of Vesting Service Percent Vested
0-1 0%
2 20%
3 40%
4 60%
5 80%
6 100%
If your facility was acquired by HCA, you may be entitled to credit for service with your prior facility, depending on the terms of the acquisition agreement. For more information, call LifeTimes Connection.
You also become 100% vested in your account regardless of your years of vesting service if, while actively employed on your facility’s payroll, you:
Reach 65 Become disabled, or Die.
You are considered disabled if your physical or mental condition qualifies as a total and permanent disability for benefits from the Social Security Administration and your disability occurred while you were employed by an HCA affiliate. You must provide proof of your disability by supplying the letter from the Social Security Administration approving your eligibility for disability benefits to LifeTimes Connection.
If you were not actively employed after 2001, your account is subject to the 3- to 7-year vesting schedule that applied before 2002.
Vesting Under Prior Plans
Stock Bonus Plan The Stock Bonus Plan was merged into the HCA 401(k) Plan on December 31, 2000. If you were a participant in the Stock Bonus Plan, your accounts are subject to a seven-year vesting schedule. A different schedule applies to certain participants who had three or more years of Vesting Service on December 31, 1994. Call LifeTimes Connection for more information. Galen Plan or Columbia Hospital Corporation Plan If you were a participant in either the Galen Plan or the Columbia Hospital Corporation Plan, and were employed on June 30, 1994, your account(s) from either or both of those plans became 100% vested as of June 30, 1994. HealthTrust and/or the EPIC Plan If you were a participant in the HealthTrust and/or the EPIC plans, and were employed on January 1, 1995, and June 30, 1995, your account(s) in those plans became 100% vested as of June 30, 1995. MCA 401(k) Plan and Colorado Healthcare Plan Accounts in the MCA 401(k) Plan and Colorado Healthcare Plan were fully vested and merged into the HCA 401(k) Plan Oct.
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1, 2005. Vesting with respect to former HCA Retirement Plan accounts is discussed above in the Vesting in Matching Contributions and Former Retirement Plan Contributions section. San Jose 401(k) Plan The San Jose 401(k) Plan vesting schedule applies to matching contribution accounts added to the HCA 401(k) Plan via the plan merger. Los Robles 401(k) Plan The 6-year graded vesting schedule described below (which is the same Los Robles 401(k) Plan vesting schedule) applies to the former Los Robles matching contribution accounts and the new HCA 401(k) Plan matching contribution accounts.
Completed Years of Service Vested Percent
0-1 0%
2 20%
3 40%
4 60%
5 80%
6 or more 100%
Value Health Retirement Savings Plan The accounts transferred from the Value Health Retirement Savings Plan are 100% vested.
Breaks in Service If you terminate employment with your facility for any reason, you stop earning service. If you earn less than 501 hours of service in any calendar year, you experience a one-year break in service.
For purposes of determining a one-year break in service, you will ordinarily receive credit for:
Hours while on an unpaid leave according to the Family and Medical Leave Act of 1993 at a rate of 40 hours per week, and Leave taken due to pregnancy or birth or adoption of a child, or to care for a child immediately following birth or adoption, with
hours credited at the rate they would have been worked, provided that no more than 501 hours will be credited for such leave.
If you earn more than 500 hours but less than 1,000 hours of service during a Plan year, you will not have a one-year break in service for that year. However, you will not receive a year of vesting service. (You must work at least 1,000 hours during a Plan year to receive a year of vesting service.)
The vesting breaks in service rules and buy-back rules have been changed due to the addition of the former Retirement Plan accounts to the 401(k) Plan. The last two rows of the chart below will apply separately to (a) your accounts in the 401(k) Plan other than your former Retirement Plan account and (b) your former Retirement Plan account:
Consecutive One-Year Breaks
Any Vested Benefit Prior to Break?
Will Forfeitures BeRestored?
Will Vesting Service Be Restored?
5 or more
Yes No Yes, for future contributions
No No No, for service performed after Aug. 11, 2008. Otherwise, yes.
Any Vested Benefit
Prior to Break?
Did You Receivea “Cash-Out”?
Will ForfeituresBe Restored?
Will Vesting ServiceBe Restored?
Less than 5
Yes Yes Only if you repay your prior “Cash-Out”
Yes
No Yes (never forfeited) Yes
No Yes* Yes Yes
*Your benefit was deemed to have been cashed out upon termination of employment.
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If You Return to Work If you return to work before you have had five consecutive one-year breaks in service, your vesting service earned before the break will be restored upon your reemployment. If you experience five or more consecutive one-year breaks in service and you had a vested right (excluding prior plan accounts) to all or part of your account, your prior service will be restored when you return, but only with respect to employer contributions made to your account after your return.
What Happens to Nonvested Amounts (Forfeitures) The nonvested portion of your account will be forfeited if:
You receive a cash-out You have five consecutive one-year breaks in service (see above), or You are not vested in any portion of your account at the time you terminate employment.
In some cases, the forfeited nonvested portion of your account may be restored. The forfeited nonvested portion of your account will not be restored if you have five or more consecutive one-year breaks in service.
Receiving a Cash-Out A cash-out is a lump-sum payment of your vested account balance. It can occur after you terminate employment. If your total vested account (including your former Retirement Plan account) does not exceed $5,000 and your employment terminates, then, subject to your ability to elect a direct rollover of benefits, your benefit will be cashed out through an automatic rollover as described below. If your total vested account exceeds $5,000, then you must consent to a distribution. In addition, if you are married and you have a vested former Retirement Plan account that exceeds $5,000, your spouse must sign a consent to the distribution in the presence of a notary public in order for you to be eligible to receive a lump-sum distribution of your former Retirement Plan account. If your vested former Retirement Plan account exceeds $5,000 and you consent to a distribution but your spouse does not properly consent, then all accounts except for your former Retirement Plan account will be distributed to you. If you are married, the ordinary payment method with respect to your vested former Retirement Plan account (if it exceeds $5,000) is a qualified joint and 50% survivor annuity. If you are married and you die before receiving a distribution of your account, the normal form of payment with respect to a former Retirement Plan account (if it exceeds $5,000) is a qualified preretirement survivor annuity. With appropriate spousal consent, these forms of benefit can be waived. Single participants can receive either a life annuity or a lump-sum distribution with respect to their former Retirement Plan accounts if the vested balance of that account exceeds $5,000. If you received a cash-out of the vested portion of your account and you are rehired by an HCA affiliate before five consecutive one-year breaks in service, the forfeited nonvested portion of your account will be restored to you if you repay all distributions you previously received. These distributions must be repaid in one lump-sum payment within five years of your rehire (or five consecutive one-year breaks after distribution, if earlier). If you did not have any vested right to your account when you terminated employment with your facility and you are rehired by your facility or an HCA affiliate before incurring five consecutive one-year breaks in service, the forfeited nonvested amount will be restored automatically as soon as you are rehired. Benefit Payment Notice When you are eligible for payment, you will receive a benefit payment notice explaining your distribution options. The notification gives you instructions on making a benefit payment choice, as well as information and services offered by RolloverSystems. HCA has partnered with RolloverSystems to help with the different distributions choices when you retire or leave. If you do not make a benefit payment choice and your vested balance is $5,000 or less, your account will be automatically rolled over to an IRA. Automatic rollovers for balances of $5,000 or less to IRAs avoids potential tax penalties sometimes associated with cash disbursements. The automatic IRA meets IRS requirements and is provided by Bancorp Bank, a RolloverSystems affiliate. Balances of $5,000 or less can also be:
Rolled over to a new or existing IRA of your choice, Rolled over to an IRA provider offered by RolloverSystems, Transferred to another employer’s qualified plan (if that plan accepts rollovers), Cashed out.
For balances greater than $5,000, you can:
Elect a distribution from among the payment options available to you.
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Leave it in the plan and continue tax-free growth. You can also choose to rollover to a financial institution to which you wish to have your benefits transferred. You may also wish to elect a direct rollover to an IRA provider of your choice. Due to a law change, if certain personal income limitations and tax filing requirements are met, following termination of employment, you can roll over your benefits to a Roth IRA. If you do so, the full benefit amount must be included in income, but no penalties apply. Distributions from a Roth IRA during retirement ordinarily are tax-free. All former employees have the opportunity to use the services offered by RolloverSystems regardless of the size of your account. To request a distribution call RolloverSystems at 1-866-340-3252 or log on to http://lifetimes.rolloversystems.com/.
Investing in the Plan
Your Investment Options You choose how to invest your future Voluntary Contributions and the Matching Contributions to your 401(k) account, as well as your rollover and transfer contributions, and any other amounts credited to your account. Each fund offers a different investment strategy and its own degree of financial risk and earnings potential. You may allocate your savings among the funds any way you like. Your investment election applies to all assets in your Plan account. As of January 1, 2010, the investment options are (arranged according to investment risk):
Pre-Mix Funds:
Mix A
Mix B
Mix C
Eight Core Funds:
Interest Income Fund
Bond Fund
Large Company Value Fund
S&P 500 Index Fund
Large Company Growth Fund
Small Company Value Fund
Small Company Growth Fund
International Stock Fund
In addition to these funds, if you had a former Retirement Plan account it remains invested in the Retirement Plan Fund, unless you choose to transfer all or a portion of that account into one or more of the other funds available in the HCA 401(k) Plan. However, once money is transferred out of the Retirement Plan Fund, you cannot transfer any of your account back into that fund.
Pre-Mixed Funds The pre-mixed funds are a convenient approach to choosing your investment elections. They range in risk/return expectations from conservative to moderate to relatively aggressive. Once you have selected your risk tolerance and investment objectives, all you need to do is choose the mix that best suits you. The funds are automatically rebalanced quarterly for you. If your objectives change, you can simply switch to another investment mix.
Core Funds The eight core funds each focus on one particular asset class, allowing you to mix and match the funds to design your own investment strategy. See the investment objective and risk/return expectations associated with each option. You may invest in one or more of these funds. Each of the funds is professionally managed by independent investment managers selected by the HCA Treasury Department and overseen and periodically reviewed by the HCA Plan Administration Committee. Each manager specializes in a particular segment of investments (e.g., U.S. or international stocks, small company stocks, long-term or short-term fixed income securities, international bonds, real estate).
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Each fund’s performance is continually tracked and monitored to see that the fund’s objectives are being met over the long term. Periodically, investment managers may be replaced for reasons such as continued failure to meet investment performance goals or a change in investment philosophy. Funds may be changed or eliminated in the future. New funds may be added. Visit LifeTimes Connection at HCArewards.com for information on fund options, fund performance, and investment managers. The intent is to provide information only and does not constitute investment advice. You may wish to consult an investment advisor before making any investment decision.
How to Get Detailed Fund Information 1. Go to HCArewards.com. 2. Click on the “Login” button and then click on the “Continue to Login Screen” link. 3. Log on using your User ID and password. 4. From your personal 401(k) Plan menu, click on Portfolio Performance. 5. Click on any fund name to view fund performance, investment objective, Top 10 holdings (where applicable),
investment manager information, and growth history.
Investing in Your Account You may invest your account in 1% increments in one or more of the Plan’s investment options — as long as your total election equals 100%. For example, you could invest 50% of your account in the Bond Fund, 20% in the Interest Income Fund, 19% in the Large Company Growth Fund, 10% in the Small Company Value Fund and 1% in the International Stock Fund. Your contribution election remains in effect until you change it. However, the allocation — or distribution — of the total value of your account may change over time as a result of gains and/or losses experienced by the funds to which you contribute. You can also direct the investment of future contributions to your account differently than you direct investment of your existing account. You can change the investment of your existing account balance and how your future savings will be invested at any time. If the change is requested before 3:00 p.m. Central Time (on a day that the New York Stock Exchange is open), the change will be effective the same day. Additionally, if you make a transfer to invest in the International Stock Fund, you may not make another change for seven days with respect to the amount that was transferred in. All investments carry risk — some more than others. Generally, funds with the lowest potential for risk (i.e., investment losses) also have the lowest potential for return (i.e., investment gains). Funds with the greatest potential risk generally have the greatest potential for return. You need to understand the potential risks and rewards associated with each fund before investing. A complete summary of the investment options and the risk and reward features for each option is available at HCArewards.com. You can also request a summary by contacting LifeTimes Connection at 1-800-566-4114.
Prior Plan Accounts If you have any balances in a prior plan account, any investment direction you make with respect to the Plan will apply equally to your prior plan accounts.
Example of Investment Allocation:
Allocation may change over time due to gain/losses in individual investment funds.
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Investment and Administrative Expenses Asset management fees are charged to the assets in the trust of the Plan. The Plan’s fiduciary, the Plan Administration Committee, oversees the Plan’s asset managers and ensures that expenses paid to them are reasonable.
Administrative expenses including those related to maintaining the Plan’s tax-qualified status and otherwise carrying out the Plan’s terms in accordance with applicable laws and regulations, charged to participants’ accounts in the Plan.
While most of these expenses are charged to accounts pro rata based on account values, some charges are directly allocated to the participant who receives the benefit of a service.
For example, the loan administrative fee is charged directly to the participant requesting the loan. Under the terms of the Plan, the Plan Administrator may charge any expenses that relate solely to a subset of accounts to those accounts on a pro rata or per capita basis.
For more information on fees, log on to LifeTimes Connection at HCArewards.com or refer to the fund performance report included with your quarterly statement.
Questions to Ask Before You Invest There are many issues to consider before you invest. Here are just a few questions you may want to ask:
How much do I need? Figuring how much you need may be your first step in developing your investment strategy. What is my risk tolerance? How you invest generally determines how your money will grow. So, are you a
conservative, moderate, or aggressive investor? The “Risk Spectrum” for each fund may be helpful to you. How long before I’ll need my money? Start counting from today — until the day you begin withdrawing from the
Plan. Remember, you’ll need money as long as you live. And you may live longer than you think! What is diversification and why should I do it? For many people, diversification can help manage risk. Basically,
diversification involves spreading money across different types of investments, which can help an investor weather the ups and downs of the market. The 401(k) Plan makes it easy to diversify – by offering three pre-mixed funds and eight core funds.
Each of these funds has its own investment strategy, level of volatility, risk, and potential return. By comparing the differences, you can find the investment options that best meet your needs. However, diversification is not a guarantee against a loss. For details on your investment options, visit HCArewards.com. Be sure to read investment fund descriptions and the fund’s prospectus before investing.
Pre-Mixed Investment Options: Fund Name Investment Objective Risk Spectrum*
Mix A This fund targets conservative growth with a diversification strategy. Its general strategy is a mix of 70% bonds and 30% stocks. This is the most conservative of the three mixed investment funds. It has both the lowest risk of short-term loss and the lowest expected long-term return. As a result, this mix provides less protection against inflation than do the other two (Mix B and Mix C).
Mix B Mix B targets moderate growth with a diversification strategy. This mix has an even split between stock and bonds. In its stock holdings, it is weighted toward stocks of large U.S. companies. This mix offers some growth opportunity and inflation protection.
Mix C This fund targets aggressive growth with a diversification strategy. Its general strategy is a mix of 30% bonds and 70% stocks. This is the most aggressive mix of the three funds. The earnings on this mix vary considerably over the short term, but it has potential for higher returns.
* The Risk Spectrum was derived using 10 years of monthly performance data ending September 2009
Lower HigherLower Higher
Lower HigherLower Higher
Lower HigherLower Higher
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Retirement Plan Fund: In addition to these funds, if you had a former Retirement Plan account, it remains invested in the Retirement Plan Fund, unless you choose to transfer all or a portion of that account into one or more of the other funds available in the HCA 401(k) Plan. However, once money is transferred out of the Retirement Plan Fund, you cannot transfer any of your account back into this fund. Fund Name Investment Objective Risk Spectrum*
Retirement Plan The Retirement Plan fund is invested in diversified investment vehicles, such as domestic and international stocks, fixed income securities (i.e. bonds), real estate, and short-term securities.
Core Investment Options:
Fund Name Investment Objective Risk Spectrum*
Interest Income Fund
Provides a reasonably stable return with reduced risk to principal. Generally, the long-term objective of the Interest Income Fund is to outperform the yield of a one-year U.S. Treasury Bill while limiting the risk to principal associated with other investments (i.e. stocks and bonds).
Bond Fund Provides high current income through investing in fixed income securities (i.e., bonds). Bonds are issued by governments, government agencies, cites, states, municipalities and corporations.
S&P 500 Index Fund
Replicate of Standard & Poor's 500 Index, a capitalization weight index of 500 companies that represent various industries in the United States. The S&P 500 Index is considered by many investors to represent a broad-based measure of the U.S. stock market that reflects the performance of the 500 most widely-held common stocks.
Large Company Value Fund
Produces returns through equity investments in value stocks. Generally, the long-term objective of the Large Company Value Fund is to outperform the Russell 1000 Value Index. The Russell 1000 Value Index is a measure of the largest U.S. publicly-traded stocks with lower price-to-book ratios and lower forecasted growth values.
International Stock Fund
Produces returns through investments in stocks of foreign (i.e., non-U.S.) companies. Generally, the long-term objective for the International Stock Fund is to outperform the Morgan Stanley EAFE Index. The Morgan Stanley EAFE Index is based on the performance of approximately 1,600 companies listed on the stock exchanges of 22 countries primarily in Europe, Australia, and the Far East (EAFE).
Small Company Value Fund
Produces returns through equity investments in small, promising companies in the U.S. stock markets. Generally, the long-term objective of the Small Company Value Fund is to outperform the Russell 2000 Value Index. The Russell 2000 Value Index is a measure of the next grouping of U.S. publicly-traded stocks (smaller capitalization companies than those in the Russell 1000) with lower price-to-book ratios and lower forecasted growth values.
Lower HigherLower Higher
Lower HigherLower Higher
Lower HigherLower Higher
Lower HigherLower Higher
Lower HigherLower Higher
Lower HigherLower Higher
Lower HigherLower Higher
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Large Company Growth Fund
Produces returns through equity investments in growth stocks. Generally, the long-term objective of the Large Company Growth Fund is to outperform the Russell 1000 Growth Index. The Russell 1000 Growth Index is a measure of the largest U.S. publicly-traded stocks with higher price-to-book ratios and higher forecasted growth values.
Small Company Growth Fund
Produces returns through equity investments in small, promising companies in the U.S. stock markets. Generally, the long-term objective of the Small Company Growth Fund is to outperform the Russell 2000 Growth Index. The Russell 2000 Growth Index is a measure of the next grouping of U.S. publicly-traded stocks (smaller capitalization than those in the Russell 1000) with higher price-to-book ratios and higher forecasted growth values.
* The Risk Spectrum was derived using 10 years of monthly performance data ending September 2009
Loans Borrowing from your account gives you access to your money while preserving your savings for retirement. Although you withdraw money from your investments to provide the loan, your account balance is restored as you repay the loan. When you borrow rather than withdraw money from your account, the money you receive as a loan is not subject to income taxes — as long as you repay the loan within the approved period. Plus, the interest you pay on the loan goes back into your own account.
You may request a loan for any reason; however, all loans are subject to the approval of the Plan Administrator and are subject to the following conditions:
You may have only one loan outstanding at any time. Former HCA Retirement Plan accounts are not eligible for a loan. Loans may be made only from your Voluntary Contributions account and your Rollover account, and your prior
employer contributions account, if any. Your loan will be secured by the vested balance of your account. An administrative fee of $75 will be charged per loan against your loan proceeds (Florida residents will also be
subject to a charge against the loan proceeds for the Florida stamp tax). Loans must be repaid within 5 years, except in the case of taking a loan to purchase a home, in which case the loan
may be repaid within 10 years. Your loan must be repaid before you can receive a final distribution or it will reduce the amount distributed to you. If
you fail to repay the loan prior to receiving a distribution, the full amount (i.e., the actual distribution and the unpaid loan amount) will be subject to tax and possibly penalties.
Failure to make timely payments generally results in a loan default — which is a taxable event. (A “grace period” applies to correct certain late payments.)
The amount of your loan will be reduced by the amount of any loan outstanding against your account. The amount you can borrow is limited under the plan. Details will be available if and when you attempt to take a loan.
If you file personal bankruptcy and have an outstanding loan from the Plan, you should contact LifeTimes Connection at 1-800-566-4114 to find out what effect the bankruptcy will have on your account. If you file a Chapter 13 bankruptcy, you could be prohibited from taking a loan or refinancing a loan.
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When you can receive payment:
If… Then…
You want to access your before-tax money before retirement You can apply for a loan for any reason or for a financial hardship withdrawal if you meet certain requirements
You want to access your after-tax or rollover money before retirement
You can withdraw all or part of your after-tax or rollover account balances at any time and for any reason
You reach age 59½, even if you continue working at your facility
You can withdraw all or part of your vested account balance at any time and for any reason (except for your former Retirement Plan account balance)
You reach Age 62, even if you continue working at your facility
You can withdraw up to 50% of your former Retirement Plan account balance
You become disabled while employed You can withdrawal all or part of your vested account balance attributable to elective deferral contributions or roll-ins following termination of employment
You die Your beneficiary can (and should) apply for payment immediately after LifeTimes Connection has received verification of your death
You terminate employment for any other reason You will be eligible to receive your vested account balance subject to any required tax withholding
Amount Available for Loans
Minimum Maximum
$1,000 50% of your vested account balance, up to $50,000 (less your highest outstanding loan balance in the last 12 months)
The minimum amount you may borrow is $1,000. If 50% of your vested account balance is less than $1,000, you are not eligible for a loan. The maximum amount you may borrow is the lesser of:
50% of your vested account balance, excluding your prior HealthTrust ESOP account, your Stock Bonus Plan account, your San Jose 401(k) Plan matching account and your former HCA Retirement Plan account (if applicable).
The amount of before-tax contributions (not including earnings credited after Dec. 31, 1988), plus your vested account balance attributable to sources other than your Matching Contributions, HealthTrust ESOP, prior Stock Bonus Plan, San Jose 401(k) Plan matching account and former HCA Retirement Plan accounts (if applicable), or
$50,000, less your highest outstanding loan balance in the last 12 months.
When you refinance, you must pay off your original loan. If you are refinancing and you request additional amounts available, your actual amount available may be decreased by any outstanding loan amounts.
You are only allowed to have one loan outstanding at a time. If you currently have a loan outstanding, you can refinance your current loan. To process a loan refinance, you will need to request a new loan amount that is at least enough to pay off your current outstanding loan balance plus any new loan fees. Once you initiate a loan refinance, your new loan will be processed in approximately two weeks. This timing is required to completely discharge your existing loan before the new loan is issued. At that time, LifeTimes will use the new loan amount to pay off the current loan balance and send you a check for any remaining amount minus fees.
The Plan specifies the 401(k) Plan and prior plan accounts from which loans can be made and any limits on these accounts. Also, special rules and limits apply in the event of a loan refinancing. For more information, or to find out how much money you can borrow from your account, visit HCArewards.com or call LifeTimes Connection at 1-800-566-4114.
Loans are withdrawn from each investment fund in the Plan in the same proportion as the funds are invested within each category.
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Applying for a Loan To apply for a loan, visit HCArewards.com or call LifeTimes Connection at 1-800-566-4114. Be prepared to answer the following questions:
The type of loan you want — a general-purpose or primary residence loan The loan amount, and The number of years you wish to take to repay the loan.
Based on this information, you will receive the current interest rate and the per-pay-period loan payment amount. You will then have the option to request the loan under those terms. If you request the loan, you will ordinarily receive your loan check within two to three weeks, minus the applicable administrative fee and less the amount of any loan outstanding against your account.
Your signature on the loan check is your approval of the terms of the loan promissory note, which should arrive before the actual loan check. It is imperative that you know your legal rights and obligations with respect to a Plan loan.
If you do not receive your promissory note or if you have any questions regarding the terms set forth in the promissory note, contact LifeTimes Connection before you cash the loan check. Once you accept the loan by cashing the loan check, you are legally bound by the terms of the loan promissory note.
As you repay a loan from your 401(k) account, the interest you pay goes back into your retirement savings account. Interest Rate on Your Loan The interest rate charged for your loan is a market rate that is determined monthly and based on rates charged by the Northern Trust Company in Chicago. The rate on your loan will be fixed at the time the loan is made, and will remain unchanged for the life of the loan. To find out the current interest rate on loans, visit HCArewards.com or call LifeTimes Connection at 1-800-566-4114. The interest rate on your loan may be reduced if you take a military leave of absence, but only for the period of the leave.
Things to Consider Before Taking a Loan
You can borrow for any reason, with your account serving as collateral. You will pay a $75 loan administration fee for each new loan. You cannot have more than one outstanding loan at any time. A loan is not a withdrawal, so it isn’t taxable. However, if you default on your loan (or fail to repay all necessary
payments on a timely basis), your outstanding balance is subject to taxation. The interest you pay on your loan is paid back to your account. You will repay the loan amount and interest with after-tax dollars. Money that you borrow does not share in your investment earnings (or losses). You must follow your repayment schedule – even if a payroll deduction is not taken for any reason. If you leave employment before you repay your loan, the outstanding balance (plus accrued interest) becomes due
immediately.
Repaying Your Loan You will repay your loan in equal installments through after-tax payroll deductions based on the repayment schedule you selected when you applied for the loan. You must repay your loans according to the following rules:
The loan repayment period is a minimum of one year and a maximum of five years. However, if you are using the loan to purchase your primary residence, you may take up to ten years to repay the loan. You may be asked to provide documentation of your primary residence purchase to qualify for the longer repayment period.
Loan repayments will be invested according to your contribution investment choices. For example, if you are investing 50% of your current contributions in the Interest Income Fund and 50% in the Bond Fund, your loan repayments will be divided equally between these funds.
If you terminate employment while you have a loan balance, you may pay the balance back in full. If you repay the balance, you may include that amount in any direct rollover you elect to make. You will have until the end of the calendar quarter following the quarter in which the first loan payment is missed to repay the balance. Otherwise, the amount of the remaining balance of your loan will be considered a distribution to you from the Plan and taxable income to you.
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Payments can be suspended up to a year if you take a leave of absence, and up to five years if your leave is due to military service.
You can repay the entire balance of your loan at any time. However, partial repayments are not permitted. To find out the outstanding balance of your loan, visit HCArewards.com or call LifeTimes Connection at 1-800-566-4114.
Defaulting on Your Loan If you miss a payment on your loan, your loan may be placed in default. HCA will allow you to make up missed payments, provided any missed payment is paid by the end of the quarter following the quarter in which the payment is missed. If you do not pay the missed payment before the end of the calendar quarter following the quarter in which the loan payment is missed, the remaining balance of your loan is considered a distribution to you and it will be taxed as ordinary income to you. As a taxable distribution, the outstanding loan amount may also be subject to IRS penalties on premature distributions from retirement plans. For more information on these consequences, please contact a tax advisor.
Withdrawals The primary purpose of the 401(k) Plan is to save for your future. In return for the tax advantages of the Plan, federal law restricts your ability to take withdrawals from your accounts. You (or your beneficiary, in the event of your death) may take withdrawals from your accounts at any time after:
Your employment with your HCA affiliate ends, You reach age 59½, You reach age 62, You become disabled, or You die.
Also, a reservist who was called to duty before 2008 for a period in excess of 179 days or for an indefinite period of time may request and receive all or a portion of his elective deferrals account before the end of the active duty period.
Former HCA Retirement Plan accounts are not eligible for hardship withdrawals or age 59½ distributions.
Generally, if you are under age 59½, you cannot withdraw funds from your 401(k) account during employment unless you have a financial hardship.
Generally, withdrawals are processed and checks are issued within two to three weeks after your properly completed forms and supporting documents are received by LifeTimes Connection. For details or to initiate a withdrawal, visit HCArewards.com or call Lifetimes Connection at 1-800-566-4114.
Hardship Withdrawals If you do not meet one of the requirements for a withdrawal (see above) as described above, you may only take a withdrawal for a financial hardship, which is defined by federal income tax regulations as:
Uninsured and unreimbursed medical expenses or expenses necessary to obtain medical care for yourself, your spouse, your dependents or your designated beneficiary, or
Payment of tuition, related educational fees, and room and board expenses for the next twelve months of post-secondary education for you, your spouse, or your dependent children, or your designated beneficiary, or
Costs directly related to the purchase (but not renovation, repair, or mortgage repayments) of your primary residence, or
The prevention of foreclosure on or eviction from your primary residence, or Payment of funeral expenses of parent, spouse, child, legal dependent or designated beneficiary, or Payment of repairs of damage to your primary residence as a result of a natural disaster.
If you experience one of the above financial hardships, you can apply for a hardship withdrawal of your account, including Voluntary and Catch-Up Contributions (but excluding any investment earnings on those contributions earned after December 31, 1988), rollover contributions and direct transfers from other plans except the Retirement Account. No other contributions to the Plan (or earnings thereon) are available for hardship withdrawals. You will be required to provide evidence of the financial need.
If you experience one of the above financial hardships, you can apply for a hardship withdrawal of your account, including Voluntary and Catch-Up Contributions (but excluding any investment earnings on those contributions earned after December
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31, 1988). No other contributions to the Plan (or earnings thereon) are available for hardship withdrawals. You will be required to provide evidence of the financial need.
In addition, you must be employed and:
Have already attempted to satisfy your financial need by borrowing the maximum loan amount available from your account or, if less, the amount necessary to pay for the hardship (if you do not already have an outstanding loan) and
Have used other readily available financial resources (such as a savings account, marketable securities, a discontinuation of contributions to the Plan, or a loan from a commercial lender) or those resources are not available.
The amount of your financial hardship withdrawal may not exceed the amount required to satisfy the immediate need created by the financial hardship (increased by the amount of income taxes). There is no minimum financial hardship withdrawal amount. However, withdrawal amounts are limited to, and will be distributed only from, certain accounts in the Plan. For details, visit HCArewards.com or call LifeTimes Connection at 1-800-566-4114.
Financial Hardship Withdrawal Penalties If you take a financial hardship withdrawal from your Voluntary Contributions account, you will not be able to make any contributions to your Plan account for six months following the hardship withdrawal. For example, during 2008, let’s say you were contributing 6% of your pay to the Plan. In June 2008, you requested a hardship withdrawal that became effective on June 30, 2008. As a result, you may not contribute to the Plan again until January 1, 2009. Taxes on Your Financial Hardship Withdrawal Generally, hardship withdrawals are considered taxable income and are subject to ordinary income taxes for the year in which you receive them. Before requesting any withdrawal from the Plan, you should consult with a tax advisor about tax consequences that may result.
If you are younger than age 59½, you will owe an additional 10% penalty on the tax-deferred amounts withdrawn, unless the money is used to pay certain unreimbursed medical expenses or is paid to you because of your total and permanent disability. Hardship withdrawals may not be rolled over. A repayment option exists for some reservists which prevents the 10% penalty.
When you take a hardship withdrawal, you are responsible for paying all taxes on the amount you receive when you file your federal, state, and local income tax returns for that year. You may elect to have an additional amount withheld from your distribution to help pay this tax liability.
Receiving Your Financial Hardship Withdrawal You may begin the withdrawal process online at HCArewards.com or you can request a Financial Hardship Withdrawal Form from LifeTimes Connection at 1-800-566-4114. A representative also can give you information about the necessary supporting documentation. Supporting documents providing proof of your need for a financial hardship withdrawal (for example, a copy of the notice of intent to foreclose and the dollar amount of the financial need) will be required to complete your withdrawal request.
If your financial hardship is approved, the hardship withdrawal payment will generally be made approximately two to three weeks after your properly completed forms and supporting documentation are received by LifeTimes Connection.
Withdrawals After Attaining Age 59½ and Age 62 At age 59½, you can elect to receive all or any portion of your vested account balance, other than your former HCA Retirement Plan account balance. (Some union employees are not entitled to take an age 59½ withdrawal of matching and certain other employer contributions.) Upon attaining age 62 and thereafter (an “age 62 distribution”), you can elect to receive up to 50% of your vested former HCA Retirement Plan account. (If you are married, spousal consent in the presence of a notary public is necessary for a lump-sum distribution of your former Retirement Plan account after you reach age 62.) If you elect to receive an age 62 distribution, thereafter, subject to Plan limits, one or more additional in-service distributions may be permitted. Call LifeTimes Connection at 1-800-566-4114 for more details.
The Plan specifies the order in which distributions will be taken from the Plan and prior plan accounts. For details, visit HCArewards.com or call LifeTimes Connection at 1-800-566-4114.
The amount available for withdrawal will be reduced by the amount of any loan outstanding against your account. For more details, visit HCArewards.com or call LifeTimes Connection at 1-800-566-4114. You will ordinarily receive your check approximately two to three weeks after LifeTimes receives your request.
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The IRS requires the Plan Administrator to automatically withhold federal income tax equal to 20% of your withdrawal (State income tax withholding may also apply). You can avoid this automatic withholding if you roll over your withdrawal directly into an individual retirement account (IRA) or another employer’s qualified retirement plan. Call LifeTimes Connection for more information before you request your withdrawal.
The additional 10% excise tax does not apply to withdrawals made after you reach age 59½.
Withdrawal of After-Tax Contributions If you made prior after-tax (or thrift) contributions, you may withdraw all or part of these accounts at any time for any reason. Your withdrawal will be prorated among after-tax/thrift accounts according to Plan terms.
If you withdraw after-tax (or thrift) contributions from your account, the IRS requires you to withdraw a portion of the tax-deferred investment earnings associated with your after-tax contributions. The tax-deferred investment earnings will be subject to ordinary income taxes as well as any applicable penalty tax if you are under age 59½. However, the after-tax contributions will not be subject to either tax.
What Happens to Your Account While You’re Waiting for Your Money? You will continue to receive any investment gains or losses between the time you end employment with your facility and the time your distribution request is processed. However, you are no longer eligible to make Voluntary Contributions or receive Matching Contributions during that time.
You can continue to monitor your account by visiting HCArewards.com or by calling LifeTimes Connection at 1-800-566-4114, 24 hours a day, Monday through Saturday, and after noon (Central Time) on Sunday. In addition, trained benefits representatives are available if you have questions, from 7:00 a.m. to 7:00 p.m. (Central Time), Monday through Friday.
Receiving Benefits from the Plan You or your beneficiary are entitled to withdraw your vested account balance if you:
Take normal retirement (see below) Become disabled while employed Die, or Terminate employment for any other reason.
IRS rules require that certain minimum distributions be made annually to certain retired participants.
If you are rehired by your facility (or an HCA affiliate that has adopted the Plan) when your benefits would otherwise be payable, payment will be deferred and paid (based on previous rules) following your next termination of employment.
Normal Retirement You can take normal retirement at or after age 65. You may choose to delay payment of your account to a later date, but not beyond April 1 of the year following the year in which you turn 70½. Benefit Payment Notice When you are eligible for payment, you will receive a benefit payment notice explaining your distribution options. The notification gives you instructions on making a benefit payment choice, as well as information and services offered by RolloverSystems. HCA has partnered with RolloverSystems to help with the different distributions choices when you retire or leave.
If you do not make a benefit payment choice and your vested balance is $5,000 or less, your account will be automatically rolled over to an IRA. Automatic rollovers for balances of $5,000 or less to IRAs avoids potential tax penalties sometimes associated with cash disbursements. The automatic IRA meets IRS requirements and is provided by Bancorp Bank, a RolloverSystems affiliate. Balances of $5,000 or less can also be:
Rolled over to a new or existing IRA of your choice, Rolled over to an IRA provider offered by RolloverSystems, Transferred to another employer’s qualified plan (if that plan accepts rollovers), or Cashed out
For balances greater than $5,000, you can:
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Elect a distribution, Leave it in the plan and continue tax-free growth.
All former employees have the opportunity to use the services offered by RolloverSystems regardless of the size of your account. To request a distribution call RolloverSystems at 1-866-340-3252 or log on to http://lifetimes.rolloversystems.com.
If You Become Disabled If you become totally and permanently disabled while you are actively employed by an HCA affiliate, you will become 100% vested in the value of your account balance, regardless of your actual years of service. You will also be eligible to request a lump-sum distribution of your Plan benefits after you terminate employment.
For purposes of the Plan, you are considered disabled if your physical or mental condition qualifies as a total and permanent disability for benefits from the Social Security Administration and your disability occurred while you were employed by an HCA affiliate. You must prove your disability by supplying the letter from the Social Security Administration approving your eligibility for disability benefits to LifeTimes Connection.
If You Die If you die while you are actively employed by an HCA affiliate, you will become 100% vested in the value of your account balance, regardless of your actual years of service. To receive payment after your death, your beneficiary must contact LifeTimes Connection and provide verification of your death. Minimum Distributions Under current laws, if you are no longer actively at work, you must begin to receive payment of your account balance no later than April 1 following the year in which you reach age 70½. If this “minimum distribution” provision applies to you, you will be notified. You cannot roll over a minimum distribution.
Forms of Payment After you leave an HCA affiliate for any reason, if your vested account balance exceeds $5,000, you (or your beneficiary, if you die) may take a distribution from the Plan or defer payment to a later date. With respect to all accounts except your former Retirement Plan account, the payment form is a lump-sum distribution. The ordinary payment form with respect to your former Retirement Plan account is:
If you are married, a joint and 50% survivor annuity; and If you are single, a life annuity.
These payment forms and means of waiving them to receive a lump-sum distribution are described below.
The IRS requires the Plan Administrator to withhold 20% of the taxable portion of any lump-sum distribution made to you. State income taxes and a 10% penalty might also apply. You should report the distribution and pay any penalty (if applicable) on your personal income tax return.
The only way you can bypass this withholding is to arrange a direct rollover of your distribution from the Plan to an individual retirement account (IRA) or another employer’s qualified retirement plan. Once you are eligible for this distribution, you will receive a notice stating your vested balance and explaining your distribution options.
Former HCA Retirement Plan Account: Payment Options With respect to your former HCA Retirement Plan account (if applicable), you should choose one of the payment options offered within the 180-day period before payments are scheduled to begin. You will receive notice when the 180-day period begins. Depending on your circumstances, the vested portion of your former Retirement Plan account will be paid to you in one of these forms:
A qualified joint and 50% survivor annuity or a joint and 75% survivor annuity (applicable only to married participants) A single life annuity (applicable only to single participants), or If proper waiver is made, a lump-sum distribution.
If you are married when you become eligible to receive your former Retirement Plan account and the vested balance of that account is greater than $5,000, your standard payment form is the qualified joint and survivor annuity, unless you and your spouse waive this form in writing within 180 days before payments would otherwise start. If your spouse is legally incompetent, a legal guardian may execute a waiver on behalf of your spouse.
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If you are single when you become eligible to receive your former Retirement Plan account and your vested account balance is greater than $5,000, the standard payment form is a single life annuity, unless you waive this method in writing within 180 days before payments would otherwise start. If you die before receiving a distribution from your former Retirement Plan account and the amount your spouse is entitled to receive is greater than $5,000, your spouse will receive a qualified preretirement survivor annuity, unless you and your spouse waived the qualified preretirement survivor annuity prior to your death. If your spouse is legally incompetent, a legal guardian may execute a waiver on behalf of your spouse. In the event of a proper waiver, your beneficiary will receive a lump-sum distribution. Also, even if you and your spouse have not waived the qualified preretirement survivor annuity prior to your death, your spouse may waive this form of benefit after your death and elect to receive a lump sum. If you die before receiving a distribution from your former Retirement Plan account and are single at the time of your death, your beneficiary will receive a lump-sum distribution.
Marital Status:
Former Retirement Plan Account Balance:
When You Become Eligible to Receive Your Account:
If You Die:
Married $5,000 or less Lump-Sum Distribution Lump-Sum Distribution
More than $5,000 Qualified Joint and Survivor Annuity1 Qualified Preretirement Survivor Annuity2
Single $5,000 or less Lump-Sum Distribution Lump-Sum Distribution
More than $5,000 Single Life Annuity1 Lump-Sum Distribution
1 Unless you (and your spouse, if married) waive this form of payment in writing within 180 days before payment would otherwise begin. 2 Subject to possible waiver. Former HCA Retirement Plan Account: Qualified Joint and Survivor Annuity This method pays a monthly benefit for the “joint” life of you and your spouse, and provides the survivor with a benefit for the remainder of his or her life. If you are single, this payment option is not applicable to you. The amount of the monthly benefit is based, among other things, on your account balance, your age, and the age of your spouse when you retire. After your death, 50% of your benefit will be paid each month for the lifetime of your spouse. If your spouse dies before you do, your benefit payments continue to you in the same amount as before your spouse died and payments stop at your death. In lieu of a joint and 50% survivor annuity, a joint and 75% survivor annuity can be elected. You and your spouse may waive the qualified joint and survivor annuity within 180 days before payments would begin and choose a lump-sum distribution; however, your spouse’s signature must be witnessed by a notary public. Before your payments would begin, you will receive more information on the terms and conditions of this payment method and your and your spouse’s rights to waive and revoke your rejection of the qualified joint and survivor annuity. Former HCA Retirement Plan Account: Single Life Annuity This method pays you a monthly benefit during your lifetime, with payments stopping at your death. The amount of the monthly benefit is based, among other things, on your account balance and your age. You may waive the single life annuity within 180 days before payments would begin and request in writing to receive a lump-sum distribution. Former HCA Retirement Plan Account: Qualified Preretirement Survivor Annuity A qualified preretirement survivor annuity is a monthly benefit paid to your spouse for the rest of his or her life following your death. If you are married, and you die prior to retirement, your vested account balance will be used to purchase the annuity for your spouse, unless you and your spouse have properly waived the qualified preretirement survivor annuity prior to your retirement. Your spouse will be eligible for a qualified preretirement survivor annuity if: You die while married before the date payments with respect to your former Retirement Plan account would begin You were vested in any portion of your former Retirement Plan account or die while actively employed by your facility The amount your spouse is entitled to receive is greater than $5,000, and You have not waived the qualified preretirement survivor annuity (with spousal consent if a nonspouse beneficiary is
named).* However, if you should die and your surviving spouse becomes entitled to the qualified preretirement survivor annuity, your spouse may reject the annuity form and elect a lump-sum distribution.
* The Plan Administrator will send you notices explaining how and when the qualified preretirement survivor annuity can be waived, and explaining how your vested former Retirement Plan account may be paid to someone other than your surviving
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spouse. In the event of a desire to waive the qualified preretirement survivor annuity and pay your former Retirement Plan account to another person(s) following your deaths, see the Your Beneficiary section.
What Else You Need to Know
How You Could Lose Benefits under the Plan Certain circumstances may reduce or eliminate the benefits you would otherwise receive from the Plan. These include:
You will not be permitted to contribute to the Plan if you do not meet the eligibility requirements for participation, your eligible compensation ends, you elect to stop contributing to the Plan, you reach any Plan or legal limits, you transfer to an affiliate that does not participate in the Plan, or you die.
If you are eligible to participate but do not contribute to the Plan, or if you participate in the San Jose Market Pension Plan, you will not receive any Matching Contributions.
If you are not vested when you leave an HCA affiliate, you will not be entitled to the value of unvested employer contributions made on your behalf.
The amount paid out from the Plan may be less than you anticipated, depending on the market value of your account in each investment fund at the time your account is paid out.
Your account cannot be used to satisfy taxes owed to the IRS, and may be assigned if a court order concerning child support, alimony, or material property rights so decrees. Then, money in your Plan account may be payable to someone other than you or your designated beneficiary.
Federal tax law requires that participation in the Plan by participants at all pay levels must be balanced. If you are considered to be “highly compensated,” according to IRS guidelines, and there is an imbalance in Plan participation during the year between highly compensated employees and other (non-highly compensated) employees, your contributions may be reduced and/or refunded. If you are affected, you will be notified.
If the Plan does not pass required nondiscrimination tests, a portion of the contributions made on behalf of highly compensated employees may be reduced and/or refunded. Nondiscrimination tests are required by law to ensure that there is sufficient Plan participation by non-highly compensated employees. If you are affected by these limits, you will be notified.
If you take a military leave of absence, you may have the right to make up Voluntary Contributions that you could have made while on leave and to receive Matching Contributions on that amount when you return from leave. For more information call LifeTimes Connection.
For any other leave of absence, you should contact LifeTimes Connection for information on how your leave may affect your Plan participation and benefits.
Important Tax Information Please note that the IRS requires the Plan Administrator to withhold 20% of the taxable portion of your cash payment if you receive a lump-sum payment. Withholding is required even if you later decide to roll over part of all of your distribution. The only way you can bypass this withholding is to arrange a “direct rollover” of your distribution from the Plan to an IRA or another employer’s qualified retirement plan.
If it is not rolled over, your distribution may be subject to a 10% early payment penalty tax in addition to regular income taxes, unless:
You are at least age 55 at the time you terminate employment You are at least age 59½ at the time payment is made to you, or Another exception applies as described in more detail below.
For more information on the additional 10% tax, please see IRS Form 5329.
You are responsible for complying with applicable federal, state, and local tax laws and regulations when you receive the distribution. You will receive more information about the applicable rules when you request a distribution.
Tax Treatments Generally, you pay regular income taxes on the taxable portion of your payment in the year you receive it.
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10% Early Payment Penalty Tax If you receive a payment from the HCA 401(k) Plan before age 59½, you may also have to pay a 10% penalty tax which the IRS imposes on early withdrawals from retirement plans. The tax will not apply if payment is made under one of these conditions:
Because of your disability or death Because your employment ends after you reach age 55 Through a life annuity over your lifetime To pay eligible tax-deductible medical expenses, or To comply with a qualified domestic relations order.
The 10% penalty discussed above (if applicable) will not be withheld from your payment — you will be responsible for paying this additional tax when you file your tax return. A repayment option exists for some reservists which prevents the 10% penalty.
Special Tax Treatment If you were born before January 1, 1936, you may be eligible for a special tax treatment that reduces the taxes you pay on your benefit. You should contact your tax professional to see if you are eligible for any special tax treatments. Paying Your Taxes When you receive Plan payments, the IRS requires withholding as follows:
If you receive a cash payment other than an annuity payment or a hardship withdrawal, the Plan Administrator must withhold 20%, unless you elect a “direct rollover” as explained later in this section. Any death beneficiary of your benefits can roll over such benefits. If you are in a tax bracket that is higher than 20%, you may owe more taxes on the payment when you file that year’s tax return. If you are in a tax bracket that is lower than 20%, part or all of the amount withheld may be refunded.
When you receive other taxable payments from the Plan in the form of annuity payments made over a period of 10 years or more or required distributions when you reach age 70½ or retire (whichever is later), withholding generally will be made based on wage withholding tables unless you elect no withholding. If you elect no withholding or if the amount withheld is not enough to cover the actual taxes due, you will be required to pay taxes when you file your tax return for that year. You may also be required to file estimated taxes.
Deferring Taxes You can defer taxes on part of all of most payments by making a rollover. Amounts eligible for rollover are amounts that would be subject to 20% withholding if they were not rolled over. There are two types of rollovers: direct and participant. Direct Rollover You can ask RolloverSystems to roll over all or part of your taxable payment directly into an IRA or another employer’s eligible retirement plan. The other employers’ plan must permit rollovers to it. To make a direct rollover, you must give RolloverSystems specific information about the receiving plan or IRA before the Plan Administrator makes any payment from the Plan.
With a direct rollover, you will not pay any taxes until you actually receive payment from the IRA or other employer’s plan.
If you die and your spouse is your designated beneficiary, then your spouse is eligible to make a direct rollover of your vested Plan benefits to his or her IRA or other eligible retirement plan and thereby avoid 20% withholding and defer taxation. A death beneficiary who is not the surviving spouse can roll over death benefits to an IRA via a direct transfer.
Your spouse or your death beneficiary can elect a direct rollover by calling RolloverSystems.
Indirect Rollover You can receive your taxable payment and then roll all or part of it over into an IRA or other employer’s eligible retirement plan yourself. You must make the rollover within 60 days following your receipt of the distribution. Of course, an amount eligible for rollover that is distributed to you will be subject to 20% federal income tax withholding. To avoid taxation on the distribution altogether, you must add the amount withheld (obtained from other personal resources) to your net distribution payment and contribute the entire amount to your IRA or your employer’s eligible plan within 60 days following your receipt of the distribution. If you roll over the net amount received (for example, 80%) then only the 20% (which was withheld) would be subject to tax.
The 10% early withdrawal penalty also may apply.
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Any contributions paid to you as part of a hardship withdrawal are not eligible for either type of rollover. Special rules apply to rollovers of after-tax contributions. Contact Lifetimes Connection for details.
Consult a Tax Expert No attempt has been made here to outline all of the rules that may apply in your circumstances. Because tax laws are quite complex and change often, you may wish to consult with a qualified tax advisor about the tax situation of any payment you receive from your account.
Plan Trust and Trustee Assets of the Plan are held in a trust. Once a contribution is made to your Plan account, the money is paid to the trust fund, where it is invested and held by the trustee.
Account Statement The value of your account is determined and updated each business day (generally, each day that the New York Stock Exchange is open). You can visit HCArewards.com or call LifeTimes Connection at 1-800-566-4114 for the most up-to-date information on your account, including the current value of your account, recent transactions, and how your account is invested in the various Plan investment options. You should review your account from time to time to ensure that your investment choices continue to reflect your personal financial objectives and risk tolerance.
Receiving Advice HCA will not advise you regarding tax, investment, or legal considerations relating to the Plan. Therefore, if you have questions regarding benefit planning, you should seek advice from a personal advisor.
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What to Do If You…
What to Do If You Change Your Address ........................................................................................ 137
What to Do If You Get Married ......................................................................................................... 137
What to Do If Your Name Changes ................................................................................................. 138
What to Do If You Get Divorced or Legally Separated .................................................................. 138
What to Do If You Adopt or Have a Baby ....................................................................................... 138
What to Do If Your Dependent Child’s Eligibility Changes ........................................................... 139
What to Do If You Become Totally Disabled .................................................................................. 139
What to Do If You Terminate Employment ..................................................................................... 140
What to Do If You Die or Lose Family Member .............................................................................. 142
If you die, a family member should: ...................................................................................... 142
If your spouse or child dies, you should: ............................................................................... 142
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What to Do If You…
Many life events require you to make changes to your benefit records. You may need to change your name or address, or designate a new beneficiary. This section outlines steps to consider when you have a life event and want to change your benefit records. If you have any questions, call LifeTimes Connection at 1-800-566-4114. You can also obtain information about your benefits online at the LifeTimes Connection Web site through HCArewards.com. LifeTimes Connection is HCA’s benefits information system that allows you to access automated information about your benefits through the Web site or interactive voice response system, or to speak to a Benefits Center Representative. You can access the Web site or voice response system from noon Sunday through midnight Saturday (Central Time) or speak with a Benefits Center Representative Monday through Friday, from 7 a.m. to 7 p.m. (Central Time).
What to Do If You Change Your Address
1. Notify Human Resources.
2. Complete a new beneficiary change form for Life Insurance or HCA 401(k) Plan if your address change also affects your beneficiaries’ addresses by logging on to HCArewards.com or calling LifeTimes Connection at 1-800-566-4114.
What to Do If You Get Married
1. Notify Human Resources and contact LifeTimes Connection at 1-800-566-4114 or through HCArewards.com if your marital status changes.
2. Make any benefit changes as soon as possible, but no later than 31 days after your marriage. You may want to consider:
o Enrolling your spouse (and/or dependent stepchildren) in the Medical and/or Dental benefit options — even if you do not currently participate in these plans
o Enrolling in the Health Care Flexible Spending Account o Enrolling in, stopping or changing contributions to the Day Care Flexible Spending Account o Enrolling in or changing your Employee Life and Accidental Death and Dismemberment (AD&D) Insurance o Enrolling your new spouse (and/or dependent stepchildren) in Dependent Life Insurance if you currently
participate in Employee Life coverage o Updating your beneficiary designation for your Life Insurance and 401(k) Plan
3. Complete an Employee’s Withholding Allowance Certificate (W-4 form) if you want to change your income tax withholding amount. Forms are available from your payroll department.
4. Review your current contributions to the HCA 401(k) Plan. Adjust them, as appropriate, by logging on to LifeTimes Connection at HCArewards.com.
When You Get Married: Within 31 days of your marriage, you must contact LifeTimes Connection at 1-800-566-4114 or through HCArewards.com to make any benefit changes, such as to enroll your new spouse and any other new eligible dependents. If you don’t, you must wait until the next annual enrollment period before you can make changes or enroll them, unless you experience another change in status. However, you can make changes to your 401(k) Plan account contribution and investment elections at any time by contacting LifeTimes Connection.
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What to Do If Your Name Changes
1. Notify Human Resources. You may need to provide proof of your name change.
2. Contact the local Social Security Administration office. Request a form to change your name on your Social Security card and records.
What to Do If You Get Divorced or Legally Separated
1. Notify Human Resources and contact LifeTimes Connection at 1-800-566-4114 or through HCArewards.com if your marital status changes.
2. Make any benefit changes within 31 days of your divorce, legal annulment, legal separation or legal dissolution of common-law marriage. If you participate in the following benefits, you should:
o Delete your spouse and/or dependents from your Medical and/or Dental coverage and arrange to offer them continued coverage through COBRA
o Consider enrolling in, or stopping contributions to the Health Care Flexible Spending Account o Consider enrolling in, stopping or changing contributions to the Day Care Flexible Spending Account o Consider enrolling in, stopping or changing your Employee Life and AD&D coverage o Delete Dependent Life Insurance for your spouse and/or children and consider updating your beneficiary
designation for your Life Insurance and 401(k) Plan
3. Complete an Employee’s Withholding Allowance Certificate (W-4 form) if you want to change your income tax withholding amount. Forms are available from your payroll department.
4. If necessary, follow Steps 1 and 2 in If Your Name Changes (see above).
5. Review your current contributions to the HCA 401(k) Plan. Adjust them, as appropriate, by logging on to LifeTimes Connection at HCArewards.com.
6. Obtain information, if appropriate on Qualified Domestic Relations Orders (QDROs) by contacting LifeTimes Connection at 1-800-566-4114. A QDRO is a legal judgment, decree, or order that recognizes the rights of an alternate payee with respect to a former spouse, child, or other dependent for support, alimony, or marital property rights. The company is legally required to recognize QDROs.
What to Do If You Adopt or Have a Baby
1. Talk to your supervisor and/or Human Resources if you would like to arrange a leave of absence.
2. Contact the Medical Claims Administrator to enroll in any available prenatal program if you or an eligible dependent is pregnant.
3. Contact a Benefits Center Representative at LifeTimes Connection at 1-800-566-4114 for information on the appropriate forms to complete — including beneficiary change forms.
4. Make any benefit changes as soon as possible within 31 days of the birth, adoption or placement for adoption. You may want to consider:
o Adding your child to your Medical and/or Dental coverage o Enrolling in the Health Care Flexible Spending Account o Enrolling in or changing contributions to the Day Care Flexible Spending Account o Enrolling in or changing your Employee Life and AD&D Insurance o Updating your beneficiary designation for your Life Insurance and 401(k) Plan
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o Adding Dependent Life Insurance, if you currently participate in Employee Life coverage
5. Complete an Employee’s Withholding Allowance Certificate (W-4 form) if you want to change your income tax withholding amount. Forms are available from your payroll department.
6. If adopting a child, contact your local Human Resources representative for information on Adoption Assistance benefits that may be available to you. Refer to the Adoption Assistance section for more information. Go to HCArewards.com to print forms.
7. Review your current contributions to the HCA 401(k) Plan. Adjust them, as appropriate, by contacting LifeTimes Connection at 1-800-566-4114.
Note: When you add a dependent, you will be required to provide proof of eligibility. Refer to the Dependent Eligibility section for more information.
What to Do If Your Dependent Child’s Eligibility Changes
Insurance coverage for dependent children generally stops when the dependent reaches age 19, or age 26 if he/she meets eligibility requirements. See the Dependent Eligibility section for more information.
When your dependent reaches the age limit for coverage:
1. Call LifeTimes Connection at 1-800-566-4114 to end coverage for the dependent child.
2. Make any benefit changes before your dependent reaches the age limit for coverage. o If LifeTimes Connection receives notice of the change before the covered dependent’s 19th birthday,
coverage will end on that birthday. o If LifeTimes Connection receives notice of the dependent's 19th birthday, coverage will end unless the
dependent meets eligibility requirements.
3. Consider continuing healthcare coverage for your dependent through COBRA.
4. Complete an Employee’s Withholding Allowance Certificate (W-4 form) if you want to change your income tax withholding amount. Forms are available from your payroll department.
5. For more information about porting/converting coverage, refer to the Dependent Life Insurance section.
What to Do If You Become Totally Disabled
1. Notify your supervisor and/or Human Resources as soon as possible.
2. Call LifeTimes Connection at 1-800-566-4114 if you have questions about ongoing participation in the benefit programs.
3. Check with your local Human Resources representative regarding any paid time off you may have.
4. Apply for other disability income benefits that may be payable. o Social Security o Workers’ Compensation o State disability benefits o Other disability benefits
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5. Review your current HCA 401(k) Plan contribution to determine whether you should change your contribution percentage, or request a loan or hardship withdrawal.
6. Log onto HCArewards.com or contact LifeTimes Connection at 1-800-566-4114 to request a cash-out of your vested retirement benefits if you’re on long-term disability and your employment has been terminated. Refer to the vesting information in the retirement section for more information.
7. Refer to the Long-Term Disability section for claim information.
8. Refer to the Life Insurance section for information about porting/converting coverage.
What to Do If You Terminate Employment
Health and Welfare Benefits Plan
Medical, Dental and Vision Benefits and EAP coverage as an active employee will end on the last day of the month in which you terminate employment. Please file claims immediately with the appropriate claims administrator for expenses incurred prior to termination of your benefits. You will receive a letter from Planned Benefit Systems explaining your right to COBRA continuation coverage. If you elect coverage and pay the required premiums within the time limit stated in the letter, your COBRA coverage will be retroactive to the first day after you lost active employee coverage.
Your Medical benefits and/or your Dental benefits, if an insured HMO or DMO, may have a conversion feature that allows you to convert your group policy into an individual policy. To find out if this is an option for you, please call the member services number located on your medical and/or dental ID card.
Group Life and AD&D Insurance and Dependent Life Insurance coverage as an active employee will end on the last day of the month in which you terminate employment. You may be able to convert to a whole life policy all or part of the basic life insurance you had in force at the time your employment terminated. In addition, you may be able to port (maintain coverage as term life insurance) all or part of the in-force amounts of Supplemental Life Insurance for both you and your dependents. Although it is ultimately your responsibility to request this option, Prudential will be notified by LifeTimes of your termination, and Prudential upon receipt of the termination from LifeTimes, will mail you a Port/Convert packet with filing instructions at the address they have on file. For further information or if you wish to request the port/convert kit, refer to the Life Insurance section or call Prudential at 1-800-778-3827.
No medical exams will be required, but applications along with premium must be returned to Prudential within 45 days from the date your Life benefits terminated.
Long-Term Disability coverage as an active employee will end at midnight on the date you terminate. This plan does not have a conversion feature. Employees already receiving disability benefits will continue to receive benefits according to the plan.
Flexible Spending Accounts coverage as an active employee will end on the last day of the month in which you terminate employment.
Day Care FSA — Contributions CANNOT be continued after termination. However, participants MAY continue to submit claims for services incurred after the benefits termination date, but no later than December 31. Claims for reimbursement incurred in the current plan year must be postmarked by March 31 of the next plan year. Reimbursements will not exceed the balance in your day care flexible spending account at the time of benefit termination.
Medical FSA — Employees may, following termination, elect to continue contributions to the account (on an after-tax basis) for the rest of the calendar year through COBRA elections. If continuation is not elected, expenses incurred after your termination date will not be reimbursed and any remaining balance may be forfeited.
By electing to continue coverage through COBRA, participants can submit claim forms for services rendered/incurred through the date COBRA coverage is continued. For example, if you continue Medical FSA COBRA through October 31, only expenses incurred through the end of October are eligible. Expenses incurred in November or December are not eligible. However, if you continue Medical FSA COBRA through December 31, expenses incurred through March 15 of
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the next plan year are eligible for reimbursement due to the FSA plan adoption of the Grace Period. The Grace Period allows you an additional 2-1/2 months to incur eligible expenses as long as you have paid all COBRA premiums through the end of the plan year. Medical FSA COBRA monthly checks should be sent to Planned Benefit Systems, HCA’s COBRA Administrator. Whether you elect Medical FSA COBRA or not, you can submit claims for services rendered/incurred only during your period of coverage in the current plan year, as long as such claims are postmarked by March 31 of the next plan year and sent to the Flexible Spending Account Administrator. However, you are urged to submit claims as soon as possible.
All other benefits will end on the last day of the month in which you terminate employment. These “other” benefits include post-termination loan applications with Wells Fargo student loans, and post-termination reimbursement through the Adoption Program.
For general health benefits concerns/questions, call LifeTimes Connection at 1-800-566-4114.
CorePlus Benefits If you have elected any of the CorePlus Benefits, coverage as an active employee will end at midnight on the date you terminate. With the exception of the Short-Term Disability benefit option, the applicable carrier(s) will notify you to setup direct billing procedures to continue your benefits after payroll deductions cease. The Short Term Disability benefit option does not have a conversion privilege or portability option. Employees already receiving benefits from the Short Term Disability benefit option will continue to receive benefits according to the terms of the plan.
If you prefer, you may contact the carrier(s) directly at the numbers listed below:
Texas Life Voluntary Permanent Life: 1-866-892-2345 MetLife Long Term Care: 1-800-438-6388 Legal Access Plan: 1-800-421-4340 Choice Auto and Home Insurance Plan: 1-866-795-9342 Former CorePlus Benefits (Guardian Legal or TransAmerica Universal Life): 1-877-650-4251
HCA 401(k) Plan
For retirement benefits purposes, your ending date of benefits from the HCA plans will be midnight on your date of termination. If you have a vested balance in either the HCA 401(k) Plan, a notice will be mailed to you at the time you become eligible to receive a distribution from the plan. Distribution notices will be mailed to the last known address of each eligible participant as reported to the Plan Administrator.
HCA has partnered with RolloverSystems to make it easier for you to determine how to manage your 401(k) Plan account when you to leave HCA. You will receive a notification from LifeTimes within two to four weeks after your last day of work at your HCA-affiliated facility and you will need to review your distribution options.
Benefit Payment Notice When you are eligible for payment, you will receive a benefit payment notice explaining your distribution options. The notification gives you instructions on making a benefit payment choice, as well as information and services offered by RolloverSystems. HCA has partnered with RolloverSystems to help with the different distributions choices when you retire or leave.
If you do not make a benefit payment choice and your vested balance is $5,000 or less, your account will be automatically rolled over to an IRA. Automatic rollovers for balances of $5,000 or less to IRAs avoids potential tax penalties sometimes associated with cash disbursements. The automatic IRA meets IRS requirements and is provided by Bancorp Bank, a RolloverSystems affiliate. Balances of $5,000 or less can also be:
Rolled over to an IRA of your choice, Rolled over to an IRA provider offered by RolloverSystems, Transferred to another employer’s qualified plan (if that plan accepts rollovers), Cashed out, or Rolled over to existing IRA.
For balances greater than $5,000, you can:
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Elect a direct rollover, or Leave it in the plan and continue tax-free growth.
You can also choose to rollover to a financial institution to which you wish to have your benefits transferred. You may also wish to elect a direct rollover to an IRA provider of your choice.
All former employees have the opportunity to use the services offered by RolloverSystems regardless of the size of your account. To request a distribution call RolloverSystems at 1-866-340-3252 or log on to http://lifetimes.rolloversystems.com.
Your vesting in the HCA 401(k) Plan will be based on your years of service through your termination date. If you worked at least 1,000 hours for HCA in the current plan year, you will be credited with a year of service for that year.
HCA 401(k) Plan vested balances, if any, will be available for distribution once the termination date has been properly processed through payroll. If your balance is $5,000 or greater, you will have the opportunity to take a distribution of your account balance in a lump sum or you may roll it over to another employer's plan (that accepts rollovers) or IRA account. Balances less than $5,000 will automatically roll over to an IRA designed to meet IRS requirements. Loans from the 401(k) that are outstanding on your termination date will become immediately due in full. You will have until the end of the calendar quarter following the quarter in which your termination date occurred (and a payment was missed) to repay the entire outstanding loan balance. For example, if your termination date is October 2009 (and you miss a payment in October because the payroll deductions stop), the loan will need to be repaid by March 31, 2010. If you have not repaid your loan in full by this date, the outstanding balance of your loan will be treated as a taxable distribution to you. As a taxable distribution, the outstanding loan amount may also be subject to IRS penalties on premature distributions from retirement plans. If you take a distribution while the loan remains outstanding, you will receive the net amount, but you will be taxed on the amount received plus the unpaid loan balance.
Who to Call for Questions You may contact LifeTimes Connection at 1-800-566-4114 with any questions you may have about your accounts.
What to Do If You Die or Lose Family Member
If you die, a family member should: 1. Notify LifeTimes Connection at 1-800-566-4114. Submit a certified death certificate if Life Insurance or AD&D benefits
are payable.
2. Talk with a Benefits Center Representative about: o Completing any necessary benefit claim forms o Continuing healthcare coverage for eligible dependents o Processing any Life Insurance or AD&D benefits that are payable
3. To receive a distribution of your retirement benefits, your beneficiary must contact LifeTimes Connection at 1-800-
566-4114 and provide verification of your death. To receive Life and AD&D benefits, if applicable, your beneficiary will also receive a request from Prudential for a certified death certificate.
If your spouse or child dies, you should: 1. Notify LifeTimes Connection at 1-800-566-4114. Submit a certified death certificate if Dependent Life Insurance
benefits are payable.
2. Talk with a Benefits Center Representative about: o Completing any necessary benefit claim forms o Changing your benefit coverage elections within 31 days of the death, if appropriate o Processing any Dependent Life Insurance benefits that are payable o Updating your beneficiary designation for Life Insurance and 401(k) Plans, if appropriate
3. Complete an Employee’s Withholding Allowance Certificate (W-4 form) if you want to change your income tax
withholding amount. Forms are available from your payroll department.
Eligibility and Participation .............................................................................................................. 144
Your Choices ..................................................................................................................................... 146
The Benefits ....................................................................................................................................... 146
Auto and Home Insurance .................................................................................................... 146
Long-Term Care .................................................................................................................... 150
Voluntary Permanent Life Insurance ..................................................................................... 153
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CorePlus Benefits Highlights CorePlus Benefits is a package of voluntary benefit plans that offer choices and convenience for employees and their eligible dependents. Employees who choose one or more of the CorePlus Benefits plans will have premiums paid through payroll deduction on an after-tax basis. You pay the full cost of any coverage you elect. When you enroll, you will receive individual policies that describe the benefits and procedures to access benefits. All benefits are provided according to the terms of the insurance contracts. Every effort has been made to accurately describe the CorePlus Benefits in this SPD; however, these benefits are offered and controlled by the individual insurance contract. The insurance contract is the plan document for the CorePlus Benefits and if there is a discrepancy between this SPD and the insurance contract, the terms of the insurance contract will control. Important Note for California Residents: As a resident of California, you are eligible for the California State Disability Income Plan (SDI). Because you are eligible for the state-sponsored SDI Plan, the Short-Term Disability (STD) Plan described in this SPD may not be of any value to you. This does not affect your ability to participate in the STD Plan, but you may wish to confirm that the STD Plan will offer value as you consider enrollment. To learn more about California SDI benefits, go to www.edd.ca.gov and click on Disability Insurance. You may also call the Customer Service Department of the California Employment Development Department at 1-800-480-3287.
Plan Overview:
Who is eligible? Generally, you are eligible for CorePlus Benefits if you are an active full-time or part-time employee as designated by your facility. Also, if you enroll in Short-Term Disability, you must have an annual benefits salary or $6,000 or more to be eligible. See the CorePlus Benefits Eligibility section for more details.
When are you eligible? Generally, coverage begins the first of the month following two months of service. In some facilities, coverage may begin sooner. Log on to LifeTimes Connection at HCArewards.com or review your enrollment materials for your actual Benefit Effective Date. See The Benefits section for each CorePlus Benefits program for more details.
When do you need to enroll? Generally, you enroll for coverage when you are hired and again each year during annual enrollment. However, certain plans allow for enrollment throughout the year. See the CorePlus Benefits Enrollment section for more details.
What coverage categories are available?
See the Benefits section for each CorePlus Benefits program for details.
Who pays the cost? You pay the cost of coverage, which is deducted from your paycheck on an after-tax basis. See the Your Choices section for more details.
Eligibility & Participation
Eligibility Generally, you are eligible for CorePlus Benefits if you are an active full-time or part-time employee as designated by your facility. Also, if you enroll in Short-Term Disability, you must have an annual benefits salary or $6,000 or more to be eligible. Temporary employees, seasonal employees, leased employees, P.R.N.s and independent contractors are not eligible. Generally coverage begins the first of the month following two months of service. In some facilities coverage may begin sooner. Short-Term Disability: If you do not elect coverage when first eligible, you may be required to submit evidence of insurability if you later elect coverage. If you elect coverage after the date you are first eligible for coverage, coverage is generally effective the first of the month following the date the carrier approves you for coverage. Other CorePlus Benefits Plans: You may need to provide evidence of insurability.
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Dependents Your spouse and dependent children are eligible for the Auto and Home Insurance (if available at your location), Legal Benefit, Long-Term Care and Voluntary Permanent Life Insurance. Other dependents may be eligible, as defined by the insurance carrier. Refer to your certificates or policies for more information.
Enrollment You may enroll in any of the CorePlus Benefits when you are first eligible and during annual enrollment. Log on to LifeTimes Connection at HCArewards.com or call LifeTimes Connection at 1-800-566-4114 to enroll in, change or decline coverage. Short-Term Disability and Legal Plans: You can drop your coverage at any time, but Annual Enrollment is the only time when other changes to coverage are allowed. If you do not enroll when first eligible, you must wait until the next annual enrollment. At that time, you may have to provide evidence of insurability for Short-Term Disability. If you enroll in the Legal Benefit program, you will receive a welcome kit from Legal Access. If you enroll in the Short-Term Disability program, this SPD contains a summary of the certificate of coverage. You can obtain the complete certificate of coverage at HCArewards.com or by making a request in writing to Voluntary Employees Benefit Advisors (VEBA), One American Center, 3100 West End Avenue, Suite 905, Nashville, TN 37203. Other CorePlus Benefits Plans: Once eligible, you can enroll in these plans at any time through HCArewards.com. You may need to provide evidence of insurability. If you enroll in the Auto and Home insurance program, you will receive information from the carrier. If you enroll in the Long-Term Care program or Voluntary Permanent Life Insurance program, you will receive a policy/certificate of coverage from the carrier.
Cost of Coverage You pay the entire cost of this coverage with after-tax payroll deductions. For Short-Term Disability or the Legal Plan, if you wish to terminate coverage for you and/or your dependents, you must contact LifeTimes Connection at 1-800-566-4114. For all other plans, you must call the plan carrier directly.
When Coverage Ends Coverage for you and your covered dependents ends on the date you terminate employment or the date your covered dependents are no longer eligible. Contact the insurance carrier to determine if you can continue coverage directly with that carrier. Coverage can also end if you request that the coverage end. For Short-Term Disability or the Legal Plan, if you wish coverage to terminate coverage for you and/or your dependents, you must contact LifeTimes Connection at 1-800-566-4114. For all other plans, you must call the plan carrier directly.
If You Take a Leave of Absence
Short-Term Disability Depending on the type of leave of absence, you may be allowed to continue your coverage during your approved leave. Continuing your Short-Term Disability coverage does not guarantee the payment of benefits under the Plan, as a claim eligibility determination must be made by the carrier.
However, by continuing your coverage during your leave, you will be able to maintain continuous enrollment in the plan, therefore preventing a break in coverage. Breaks in coverage will result in new coverage effective dates and new 12-month requirements for pre-existing conditions. New coverage elections may also be subject to Evidence of Insurability requirements.
If you are on a paid leave of absence, your contributions will continue unless you contact LifeTimes Connection to stop the contributions. If you are on an unpaid leave of absence, your contributions will be billed to you by LifeTimes Connection.
Please note if you voluntarily drop your contributions, you will not be allowed to begin coverage again until the next annual enrollment. At that time, you will be subject to Evidence of Insurability and if approved, you will have a new effective date of coverage and a new 12-month required for pre-existing conditions.
Legal Benefit If you are on a paid leave of absence, your contributions will continue unless you contact LifeTimes Connection to stop the contributions. If you are on an unpaid leave of absence, your contributions will be billed to you by LifeTimes Connection. If you voluntarily stop your contributions, you will not be allowed to begin coverage again until the first day of January following the next annual enrollment. Long-Term Care, Voluntary Permanent Life and Auto and Home If you are on a paid leave of absence, your contributions will continue unless you notify the carrier directly. If you are on an unpaid leave of absence, you may either receive a direct bill from the carrier or the missed premiums may be added to your
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payroll deduction once you return from LOA. If missed premiums are not paid, your policy may be terminated. The carrier will notify you directly if premiums are missed or if your policy is at risk of being terminated.
Your Choices
The CorePlus Benefit plans available are:
Auto and Home Insurance (Note: Home insurance is not available in all locations) Legal Benefit Long-Term Care Insurance Short-Term Disability Voluntary Permanent Life
The programs offer discounted group rates and are portable so that most benefits (excluding the Short-Term Disability Plan) go with you if you change jobs, retire or are no longer eligible.
The Benefits
Auto and Home Insurance The Choice Auto and Home Program allows benefits-eligible employees to compare their current auto and home insurance with the coverage and competitive premiums offered through the Choice program. This program is designed to help you get a better value on your insurance. It offers rates brought to you by three of the most respected providers in the nation. You don’t have to wait until your current policy expires – you can sign up at any time during the year through HCArewards.com. The program offers several advantages, including:
Group rates typically not available to the general public, in some cases up to 15% off current premiums. Payroll deduction as a payment method option. Free, no-obligation quotes by phone or online.
The Choice Auto and Home Program can even insure your boat, motorcycle or personal property, like jewelry and artwork. Multi-policy discounts can save you money. Customer Service Representatives will provide you free, no-obligation quotes at (866) 795-9342, Monday through Friday, 7 a.m. to 5 p.m. Central Time. Visit HCArewards.com or www.personal-plans.com/hca to learn more. Important Notes: Due to state regulations, only the Choice Auto Program is available to Florida employees. Due to increased risk associated in some other coastal areas, the availability of home insurance may be limited.
Legal Benefits The Legal Benefits program is administered by Legal Access Plans, L.L.C. and provides access to professional legal providers for consultations and representation at special coverages and group rates within the Legal Access network of providers. Who Is Covered When you elect this coverage, your spouse, domestic partner, unmarried legal dependent children (including children of a domestic partner) who live in your household up to age 19, and between ages 19 and 25 if enrolled in an accredited school or college may use these services. Also, your or your spouse’s elder parents (domestic partner), even if they do not live with you, may use benefits. Portability This benefit plan is portable, which means you can elect to continue coverage at the same rate even if you change jobs or retire. Just contact Legal Access directly to discuss your portability options. How the Plan Works Once you are enrolled in your Legal Plan and a legal need arises, simply contact Legal Access. It’s that easy. A Specialist will guide you through the process and necessary steps and will assist you for the life of your matter. Whether you have used the plan in the past or you are not sure where to start, Legal Access can help. Legal Access understands that when you have a legal need, it can be the most important event in your life. Legal Access also knows that finding an attorney on your own can be stressful and take many hours or days. The plan is designed to help you save time by locating an attorney for you, and the plan provides you a personal contact within the Legal Access offices to help you.
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When you have the need for an attorney, you can save time and worry with Legal Access. The plan locates or Matches you to the most applicable attorney in your area with availability. The attorneys in the network must meet the most rigorous credentials on the market today. In many cases, benefits offer a substantial savings over standard costs for legal assistance.
Benefits include:
Initial Legal Consultations – You can discuss any non-excluded legal problem with network attorney for up to half an hour per matter.
o No charge for each consultation with a network attorney. o Unlimited number of new legal matter consultations. o The consultation can be conducted with a network attorney in person, by phone or online, where available.
Discounted Flat Rates for eight covered services, including traffic tickets, bankruptcy and divorce. Special Attorney Hourly Rates – If legal representation is needed, you can receive the discounted rate of $75 per hour.
o Special network hourly rate for all covered services that may not have a special rate or no cost attached to them as outlined in this summary.
o $75 per hour special low hourly rate. o Covers all non-excluded matters that do not have a special rate.
Free Document Preparation – Includes simple wills, living wills, annual updates and letters to resolve consumer, neighbor and other disputes.
Review of Legal Documents o No charge for each document review, up to three documents (six pages per document) per year. o Review can be in person or online, where available, with a network attorney or by comparing to documents in the
online library. Small Claims Court Preparation
o Consultation at no additional charge by phone with attorney on small claims lawsuits. o Each problem can be assessed (at network rate) in person or online, where available, with a network attorney.
You can also access the online library to learn more about legal issues and legal disputes involving small claims court cases, including credit issues, injuries, emergencies, liability and related issues.
Guaranteed Discounted Contingency Fees – Contingency rate discounts apply in those cases where attorneys customarily take a case on a contingency fee (an agreed upon portion of any recovery to you), depending on what happens when the case ends.
o When state laws set contingency fees: Lesser of 10% less than state law minimum fee or the attorney’s usual fee.
o When state laws do not set contingency fee: Maximum of 29% if settled before trial, 36% if trial is conducted or 40% after an appellate brief is filed.
o Ask your attorney if your case merits a contingency fee. Guaranteed Special Low Rates – These have specific definitions and this summary defines each service*:
o Traffic Ticket Defense: $89 o Bankruptcy (Chapter 7): $250 o Name Change: $155 o Will with Minor Trust: $170 o Collection of Support (Spouse/Child): $239 o Divorce (Simple): $210 o Corporation (Regular): $239 o Non-Commercial Real Estate: $175
*If your matter does not fit into these specific definitions, the special network hourly rate for these services will apply.
Living Trust Center – Unlimited online access to learn about trust issues or disputes. Trust preparation requires an additional charge.
Access for Dependent Children in College – Unlimited online access to learn about legal issues and legal disputes that students face, including accidents, DWI/DUI, credit issues, injuries and emergencies.
Property Damage Disputes – Unlimited online access to legal analysis of how to handle a property damage legal problem.
Lawsuit/Litigation Procedural Guide – Unlimited online access to legal analysis of the typical steps involved in lawsuits and litigation.
Complete Online Legal Research System – Unlimited online access for researching legal issues in all types of legal problems.
Financial Counseling o Unlimited Telephone Consultations – One half hour per new topic, personal financial tune up. o Financial Services with Counselors – Review goals/objectives, reduced rates for continuing sessions.
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o Access to Financial Web Site – Available 24 hours a day, interactive calculators, online discussion of financial concepts, legal library of credit and collection information
o Personal Budget Preparation and Assistance – Provides assistance in preparing your personal budget and understanding solutions to credit problems
Exclusions No coverage is provided for the following types of legal matters:
Preparing, completing or filing of federal, state or local tax returns. Any employment-related matter. Duplication of services previously claimed and in relation to the same matter. Filing fees, court costs, reporter’s fees and other miscellaneous costs in any proceeding. Any legal proceeding in which you or a family member is entitled to legal representation or reimbursement for the
costs from any source other than this coverage. Frivolous matters. Frivolous matters include a matter with no merit, is brought for the sole purpose of harassing,
vexing or annoying another party, or as defined by the professional code of your state. Any action against Legal Access or its network attorneys for the provision of services under this coverage. Any service on behalf of your family member against your interests. Any action which the network attorney feels may be a conflict of interest. Any legal matters or questions involving antitrust, immigration, business matters, securities law, environmental torts,
trademarks, copyrights, patents and related matters.
Filing a Claim There are no claim forms since you receive the benefit or discounted fee. If you have any issues with a network attorney, please contact Legal Access Member Services Center at 1-800-421-4340. Legal Benefit Note: This benefit summary is intended only to highlight your benefits and should not be relied upon to fully determine coverage. More complete descriptions of benefits and the terms under which they are provided are contained in the plan documents that you receive upon enrolling in the Plan. If this benefit summary conflicts in any way with the Policy issued to your employer/association, the policy shall prevail.
Short-Term Disability Short-Term Disability (STD) coverage is administered by Prudential and pays benefits to you if you are absent from work due to a non-work-related illness, injury or pregnancy. After a 14-day waiting (or elimination) period, your benefits will begin on the 15th calendar day of your absence and will continue for up to six months within a 365-day period. (Certain exclusions may apply.) Elimination period means a period of continuous disability which must be satisfied before you are eligible to receive benefits from Prudential. Every effort has been made to accurately describe the Short-Term Disability benefit option in this SPD. However, these benefits are offered and controlled by an insurance contract with The Prudential Insurance Company of America. The insurance contract is the plan document for the Short-Term Disability benefit option and if there is a discrepancy between this SPD and the insurance contract, the terms of the insurance contract will control. A certificate of insurance is available upon written request to HCA Inc., Corporate Benefits, One Park Plaza, P.O. Box 550, Nashville, TN 37203. Plan Benefits If you are eligible for benefits, the plan pays up to 60% of your annual benefits salary. These tax-free benefits are paid on a bi-weekly basis (with after-tax deductions) based on the coverage amount you choose when you enroll. Coverage amounts are available from $300 to $2,500 per month, in $100 increments.
Your monthly STD benefits will be the increment of $100 that you have chosen, up to the maximum amount, less deductible sources of income and disability earnings.
For Employees Whose Compensation is Based Solely on Commissioned Sales, Bonuses or Overtime – Monthly earnings means 1/12 of your gross income from your Employer in effect for the 12 months prior to your date of disability.
For all other Employees – Monthly earnings means your gross monthly income from your employer in effect just prior to your date of disability. Monthly earnings includes the average commissions, bonuses and overtime pay earned per month during the shorter of (i) the 12 month period just prior to your date of disability; or (ii) your period of employment. It does not include, any other extra compensation, or income received from sources other than your Employer.
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Deductible sources of income include benefits from statutory plans, Disability Social Security, payments to you or your dependents, Retirement Social Security payments to you, other group insurance plans, retirement, any salary continuation paid through accumulated sick leave and other sources. Call Prudential at 1-800-842-1718 for more details. If your disability is deemed to be partial, you will receive payments based on the percentage of income you are losing due to your disability. The sum of the partial disability payment, salary earned while on partial disability, and income from other sources cannot exceed 80% of your pre-disability salary. If you are totally disabled and receiving regular treatment due to a covered mental illness, monthly disability benefits will be paid for up to three months. Work-related disabilities are covered by workers’ compensation. Payment of Benefits You will begin to receive payments when Prudential approves your claim, providing the elimination period has been met. Prudential will send you a payment every two weeks for any period for which Prudential is liable. Evidence of Insurability (EOI) In any of these situations, you must provide Evidence of Insurability:
You enroll for coverage more than 31 days after the date you are eligible for it. You re-enroll for coverage after you voluntarily cancelled it. You enroll after any coverage ends because you did not pay a required contribution. You have not met a previous evidence requirement to become covered under any plan provided by Prudential.
If you are required to provide EOI, you will receive a form from Prudential. You must provide all information requested by Prudential. You will be notified of Prudential’s acceptance or rejection of your EOI. If approved, your coverage will begin January 1 of the new coverage period or on the first day of the month after Prudential approved EOI, whichever comes later. Pre-Existing Conditions You are considered to have a pre-existing condition if you have received treatment, consultation, care or services, including diagnostic measures, or took prescribed drugs or medicines, or followed treatment recommendations in the 12 months prior to your coverage effective date. Should a pre-existing condition apply, you must be covered under the plan for 12 months before you are eligible to receive benefits related to this condition. Definition of Disability You are considered disabled when, because of injury, sickness or pregnancy, you are unable to perform the material and substantial duties of your regular occupation and your disability results in a loss of income of at least 20%. Returning to Work Part-Time If you are still disabled and attempt to return to work part-time, you will remain eligible for benefits. Your monthly benefits may be reduced by a portion of your disability earnings. Waiver of Premium After the first day of the month following 90 days of disability, you do not have to pay premiums. Until that time, premiums are required to be paid by you. Limitations and Exclusions Disabilities due to mental illness have a limited pay period during your disability. Examples of mental illness include schizophrenia, depression, manic depressive or bipolar illness, anxiety, adjustment disorders, personality disorders or other conditions. The limited pay period for mental illness is 3 months during your disability. You are not covered for a disability caused by war or any act of war, an intentionally self-inflicted injury while sane or insane, occupational sickness or injury, active participation in a riot, and commission of a crime for which you have been convicted. Benefits are not payable for any period of incarceration as a result of a conviction. During the first 12 months of coverage, no STD benefits will be paid for a disability that is due to a pre-existing condition. A pre-existing condition is an injury or sickness for which you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines, or for which you followed treatment recommendations during the 12 months prior to your effective date of coverage. Filing a Claim You should notify Prudential of your claim as soon as possible so a claim decision can be made in a timely manner. You should call Prudential or provide written notice of a claim within 30 days after the date of your disability begins. However, you must notify Prudential by phone or written notice of your proof of claim no later than 90 days after your elimination period ends. If it is not possible to give proof within 90 days, it must be given no later than one year after the time proof is otherwise required except in the absence of legal capacity.
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Your proof of claim, provided at your expense, must show that you are under the regular care of a doctor, the appropriate documentation of your monthly earnings, the date your disability began, appropriate documentation of the disabling disorder, the extent of your disability, including restrictions and limitations preventing you from performing your regular occupation, the name and address of any hospital or doctor you have seen. Prudential may request that you send proof of continuing disability indicating that you are under the regular care of a doctor.
Telephone Claim Submission – Claim submission by phone will speed the collection of claim information from you, your doctor and your employer. Call 1-800-842-1718 and speak to a Prudential Customer Service Representative.
What you need to do if you are out of work – If you are absent from work due to an injury, illness or pregnancy for more than 14 days, or up to 2 weeks in advance of a planned disability absence (such as child birth or prescheduled surgery) you need to:
o Notify your supervisor. o Call Prudential at 1-800-842-1718, 24 hours/day 7 days a week and follow the prompt for submitting a disability
claim. Provide the Customer Service Representative with your company name and control number which is HCA Management Services #44028.
o You and your employer must fill out your own section of the claim form and then provide it to your attending doctor. Your doctor should complete his/her section and send it directly to Prudential
Gathering Important Information – Please take a moment to make sure that you have the required information before you call 1-800-842-1718. During the live claim interview process the following information will be requested:
o Company’s name: HCA-Affiliated Facilities o Policy number: 44028 o Name and Social Security number o Complete address and phone number o Date of birth o Job title o Doctor’s name and telephone number o A brief description of your medical condition o Your last day worked and your first day out due to this condition o Is the absence work-related o The date you expect to return to work
How to contact Prudential: o You can obtain claim and payment status 24 hours per day by calling 1-800-842-1718. o You can also obtain claim and payment status online at www.Prudential.com/inst/gldi. o For more information, call 1-800-842-1718. English- and Spanish-speaking customer service representatives are
available Monday through Friday, 8 a.m. to 8 p.m. (Eastern time). Your Claim Will Be Considered Filed When – In order for a claim for benefits to be considered filed, Prudential requires
an employee's statement, employer's statement and attending physician's statement to be submitted. o If you have STD coverage with Prudential, your claim will be considered filed the later of (1) when Prudential
receives your employee's statement (which you submit by calling the 800 Number), the employer's statement (or information received from HCA electronically) and the attending physician's statement, (or information received from your doctor by way of telephone call) and (2) the start of your STD elimination period.
Long-Term Care Long-Term Care insurance coverage is administered by MetLife and provides benefits for long-term care expenses up to a specific dollar amount per day. You can purchase benefits through payroll deduction for yourself and your spouse as well as your natural or adopted adult child or stepchild who is age 18 or older. You may also purchase coverage for a parent, in-law parent, step parent, grandparent, step grandparent, in-law grandparent or a surviving spouse. Coverage is also available for domestic partners, but coverage is not available for domestic partners in Louisiana. Coverage is also not available for children of a domestic partner.
You decide how large your total benefit amount will be and how long you want the policy to cover you or your eligible family members, based on the plan you select. The plan lets you choose where to receive your care – nursing home facility, assisted living facility or home care setting. You also have the option to choose an automatic inflation protection feature.
Every effort has been made to accurately describe the Long-Term Care coverage. However, these benefits are offered and controlled by an insurance contract with MetLife. A certificate of insurance is mailed directly to your home. If you need a duplicate certificate, contact MetLife at 1-800-438-6388. Some provisions are based on the state in which you live. For more information, log on to the MetLife Web site located in the CorePlus Benefits section at HCArewards.com or call 1-800-438-6388.
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Your rates are based on your age on the effective date of coverage. This plan is portable, which means you can keep coverage even if you change jobs or retire. You will need to contact the plan directly to discuss your portability options.
Note: If your application for Long-Term Care coverage has been accepted, there may be a delay between when the policy becomes effective and when payroll deductions begin. Should this occur, the premium required to cover the period of time in which the policy has been active, will be recovered by increasing your first one or two payroll deductions. Once the missed premium is recovered, your payroll reduction will be adjusted to the normal premium amount. Please also note that if an on-going payroll deduction is missed, the missed deduction will be recovered by increasing a future deduction.
Every effort has been made to accurately describe the Long-Term Care coverage. However, these benefits are offered and controlled by an insurance contract with MetLife. The insurance contract is the plan document for the Long-Term Care benefit option and if there is a discrepancy between this SPD and the insurance contract, the terms of the insurance contract will control. A certificate of insurance is available upon request by calling MetLife at 1-800-438-6388.
Coverage Options When you enroll in the CorePlus Benefits Long-Term Care coverage, you will have three options: Coverage Features: Plan A Plan B Plan C
Daily Benefit Amount: Maximum amount the plan will reimburse for covered services you receive in a single day.
$100 $150 $150
Benefit Period (Total Lifetime Maximum): Length of time your insurance will last if you receive care every day at a cost equal to your daily benefit amount.
3 years 3 years 5 years
Total Lifetime Benefit (Amount): Total dollar amount of benefits that your insurance coverage could pay for covered services.
$109,500 $164,250 $273,750
Cost of Coverage Your premium payment is based on your age on your effective date of coverage. The longer you wait, the more it will cost. Your premium will also be determined by the level of coverage you purchase (Daily Benefit Amount, Total Lifetime Maximum, etc.). The total lifetime benefit amount is determined by the daily benefit amount you choose multiplied by how long you want coverage (benefit period).
For example, if you elected the $200 daily benefit amount and the five-year benefit period (1,825 days), then your total lifetime benefit amount would be $365,000.
Premiums do not increase each year simply because you get older. Premium rates are designed to remain constant (unless you have voluntarily selected an increase in your coverage at an additional cost). MetLife reserves the right to raise rates on a class-wide basis.
There are several factors to consider when determining the appropriate amount of coverage for you and your family. A good benchmark is to be familiar with is the costs of long-term care in your area. You will also want to consider the following: how much of your savings you're willing to spend, where you'd like to receive long-term care, how much long-term care you think you'll need and how long you'll need it.
To calculate a premium for your coverage level, log on to the MetLife Web site at HCArewards.com or call 1-800-438-6388.
Covered Services
Home Care by a Licensed Caregiver: Cost of services up to 60% of daily benefit. Nursing Home Care: Cost of services up to 100% of daily benefit. Assisted Living Facility: Cost of services up to 100% of daily benefit. Adult Day Care: Cost of services up to 60% of daily benefit. Respite Care: Cost of services up to 100% of daily benefit.
Under the Alternate Plan of Services provision, a MetLife care manager can authorize benefits for qualified long-term care services not specifically covered under the plan. Services must be qualified, must meet the needs of the covered person, and may be a cost-effective alternative.
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Expenses Not Covered The policy may not cover all expenses associated with your long-term care needs. This plan does not provide benefits for the following:
Care specifically provided for detoxification of or rehabilitation for alcohol or drug abuse (chemical dependency), except drug abuse sustained at the hands of or while being treated by a physician for an injury or sickness.
Any service or supply received outside the United States or its territories. Illness, treatment or medical condition arising out of:
o war or act of war (whether declared or undeclared) o participation in a felony, riot or insurrection o service in the armed forces or auxiliary units o attempted suicide (while sane or insane) or intentionally self-inflicted injury
Treatment in a government facility, unless otherwise required by law Any care provided while in a hospital, except for confinement in a distinct part of a hospital which is licensed as a
nursing home or hospice. Any service provided by your immediate family, unless provided by an informal care provider. Any service or supply to the extent that such expenses are reimbursable under Medicare, or would be so
reimbursable but for the application of a deductible or coinsurance or copayment amount. This exclusion will not apply in those instances where Medicare is determined to be secondary payor under applicable law.
Services for which no charge is normally made in the absence of insurance. If you are outside the United States, the group policy does not provide benefits for any of the following: Any services or supplies you receive; Illness, treatment or medical condition arising out of:
o War, whether declared or undeclared, or act of war; o Your participation in a felony, riot or insurrection; o Your service in the armed forces or auxiliary units of any country; or o Your attempted suicide, while sane or insane, or intentionally self inflicted injury.
Additional Plan Features
Periodic Inflation Protection: This feature gives you the option to purchase an increase in your benefits at an additional cost, without proof of good health as long as the option has been selected once in every two offerings. Premiums for the additional coverage are based on your age at the time it is purchased.
Waiting Period: You must wait 90 days (once per lifetime) from the date MetLife determines you are first disabled until the date benefits for covered services can begin to be payable, assuming you have been certified as chronically ill. You do not have to receive covered services to fulfill the waiting period.
Care Advisory Services: Independent care advisors are available to meet with you and your family to help assess your need for various types of LTC services, and to help develop care options with you.
Transition Benefit: Will help pay for items needed for specific long-term care such as an emergency response system, a wheelchair ramp or durable medical equipment. The plan provides for up to five times the daily benefit to help pay for these items.
International Coverage: If you are eligible for benefits outside of the United States, a reduced daily benefit will be available.
Waiver of Premium: You stop paying premiums once you qualify for benefits and have satisfied your waiting period. Pre-Existing Conditions: This plan does not include limitations for pre-existing conditions.
Payment of Benefits You are eligible to receive benefits when a licensed healthcare practitioner certifies, and MetLife agrees to, your inability to perform two of the six activities of daily living (ADLs) listed below for a period expected to last at least 90 days:
Bathing Continence Dressing Eating Using the bathroom (toileting) Moving into or out of a bed, chair or wheelchair (transferring)
You will also be eligible if the licensed healthcare practitioner determines that you have a severe cognitive impairment such as Alzheimer's disease. A cognitive impairment is a deterioration or loss in intellectual capacity that results in impairment in some or all of the following: short- and long-term memory, orientation to people, place, and time, deductive or abstract reasoning (including judgment) and the ability to perform activities of daily living.
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Coordination of Benefits MetLife will reduce your benefits by the dollar amount payable by any of the following, to the extent that the combination of your benefit and amounts payable or which would be payable by any of the following exceed 100% of the actual charge for the covered expenses:
any federal, state or other governmental health care plan or law (except Medicaid or Medicare); any state or federal workers’ compensation law; any employer’s liability or occupational disease law; any motor vehicle no-fault law; or any other plan which any employer contributes to or sponsors.
Note: These provisions vary by state.
Filing a Claim To start the process, you or someone acting on your behalf must call our toll-free number to inform us of your request for a determination of eligibility for benefits and the reasons for it. This number is shown on your identification card.
You will be certified as chronically ill only if MetLife is provided with proof satisfactory to the licensed healthcare practitioner employed or retained by us that you are chronically ill. If MetLife requires more information:
MetLife or a person designated by MetLife may contact you, your representative, your physician or other persons familiar with your condition; and
MetLife or a person designated by MetLife may need to access your medical records to obtain information about your condition (MetLife cannot certify you as Chronically Ill if it is denied access to your medical records); and
MetLife has the right to have you examined, at MetLife’s expense, by a healthcare provider and to conduct an on-site assessment.
For more information, call MetLife at 1-800-438-6388 or log on to the MetLife Web site at HCArewards.com.
Voluntary Permanent Life Insurance The CorePlus Benefits Voluntary Permanent Life Insurance benefit option is administered by Texas Life Insurance Company and is offered to complement your group term life insurance. Subject to plan and age limits, you may apply for coverage for you, your spouse, your dependent children and your grandchildren. Every effort has been made to accurately describe the Voluntary Permanent Life Insurance coverage. However, these benefits are offered and controlled by an insurance contract with Texas Life. The insurance contract is the plan document for the Voluntary Permanent Life Insurance benefit option and if there is a discrepancy between this SPD and the insurance contract, the terms of the insurance contract will control. Plan Features
The plan provides a death benefit guaranteed to age 121 upon payment of the required premium. After the guaranteed period, your premium may stay the same, go down or go up.
Premiums are based on the insured’s age when the policy is issued. The plan provides a unique right to a refund of five years of the initial premium if the required premium increases
(conditions apply). During your initial period of eligibility, you may apply for Express Issue coverage by answering just three health- and
work-related questions (additional information may be required). All individual policies will automatically include an Accelerated Death Benefit Due to Terminal Illness rider for no
additional premium; some restrictions and limitations apply. This plan is portable, which means you can keep coverage even if you change jobs or retire. You will need to contact
Texas Life directly to discuss your portability options. See PureLife brochure for details. Policy form number PRFNG-NI-07 or ICC-07-PRFNG-NI-07. Texas Life is licensed
to do business in the District of Columbia and every state but New York.
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Other Benefits
This section outlines other benefits that may be available to you. Check with your Human Resources representative about the benefits available at your location.
Adoption Assistance Adopting a child can be a lengthy and emotional process. It can also be expensive. Adoption Assistance can help you with eligible expenses for each child you adopt, with a yearly maximum. This assistance with adoption expenses is made on an after-tax basis. In other words, when you receive your reimbursement, taxes will be withheld.
If you adopt a child under the age of 18 who is not your relative or stepchild, Adoption Assistance will reimburse you for the following expenses:
Adoption agency fees Placement fees Attorney and court fees Travel expenses to pick up the child
Adoption Assistance will not reimburse you for:
Expenses for a child age 18 or older at the time of adoption (unless the child is physically or mentally incapable of self-care)
Expenses for the adoption of a stepchild Donations to an adoption agency Legal guardianship fees
If an employee and his or her spouse both work at HCA, only one employee can utilize the benefit.
For more information on Adoption Assistance, see your local Human Resources representative or go online to HCArewards.com.
Federal Income Tax For federal income tax purposes, you may include an adoption tax credit up to $10,000 per child for adoption expenses you paid which have not been reimbursed. This tax credit is decreased for adjusted gross incomes above $150,000, and it is not available if your adjusted gross income is greater than $190,000. You should consult with a tax advisor on combining Adoption Assistance and the tax credit.
Employee Assistance Program (EAP) All HCA-affiliated employees have access to an Employee Assistance Program, a confidential counseling and referral service providing personal, legal and financial services. For more information, contact your facility’s Human Resources office. If your facility uses the ValueOptions EAP, call 1-800-434-5100.
Eye Services HCA-affiliated employees and their immediate family members can save 15% on the usual and customary global fee for laser vision correction to correct nearsightedness, farsightedness and/or astigmatism when the procedure is performed at a designated provider location. For more information, log on to HCArewards.com.
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Sittercity HCA has partnered with Sittercity.com to provide a resource for employees looking to find a local caregiver. Sittercity.com is America’s leading Web site for connecting families with in-home care providers, babysitters, nannies, elder care providers, dog walkers, housekeepers and more. HCA-affiliated employees have access to a paid membership to Sittercity.com – valued at up to $150. You can access a nationwide network of more than a million caregiver profiles. This benefit can help you continue to be productive at work and feel secure knowing that things are taken care of at home. To register, visit Sittercity.com/HCA and follow the links to conduct a caregiver search or post a job to let caregivers find you. You can use Sittercity’s four-step screening process to read reviews, conduct interviews, check references and review background checks.
Wells Fargo Student Loan Program Have you been thinking about completing a degree, or do you have a child who is about to start college? Wells Fargo can help you (or anyone who is related to you) pay for all education-related expenses, even for a previous semester or year. This includes tuition, room and board, books or even a computer. You can apply any time during the year and be pre-approved to borrow up to $25,000, which you can repay over a period as long as 15 years. Anyone who is related to you — spouse, children, aunts, brothers, cousins — can take advantage of this benefit. For more information, contact Wells Fargo toll-free at 1-800-SOS-LOAN or visit HCArewards.com.
Qualifying Events ............................................................................................................................. 157
Your Choices .................................................................................................................................... 158
The Benefits ...................................................................................................................................... 159
Steps to Follow ................................................................................................................................. 160
What Else You Should Know ........................................................................................................... 161
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COBRA Highlights When you and/or your covered dependents would otherwise lose health coverage, a federal law known as “COBRA” (which stands for the Consolidated Omnibus Budget Reconciliation Act of 1985) may allow you to pay for continuation of that coverage. COBRA applies to medical, vision, dental and employee assistance coverage, and — in some circumstances — to coverage under the Health Care Flexible Spending Account (collectively, “healthcare benefits” or “healthcare benefit options”). This section summarizes your options for COBRA continuation of health coverage. COBRA applies if a “qualifying event” occurs that would otherwise cause you or a covered dependent to lose coverage. COBRA calls each person who would lose coverage a “qualified beneficiary.” A child born to you or placed for adoption with you during your COBRA coverage period is also a qualified beneficiary and is entitled to the same COBRA rights as your other dependents. Each qualified beneficiary has an independent right to elect COBRA coverage. For medical, vision, dental and employee assistance benefits, COBRA coverage can last up to 18 or 36 months, depending on the qualifying event. The 18 months can be extended to 29 months if a disability is involved. For the Flexible Spending Account (Health Care FSA), COBRA coverage can last until the end of the plan year in which the qualifying event occurred. COBRA coverage can be expensive. COBRA premiums can be as much as 102% of the actual cost of providing coverage (150% for disability extensions). Remember that your facility subsidizes part of the cost of non-COBRA medical and dental coverage for active employees and their families. COBRA does not include this employer subsidy, so your COBRA premiums may be quite a bit higher than what you paid as an active employee. COBRA continuation applies only to the healthcare benefits and not to any other benefits offered under the HCA Health and Welfare Benefits Plan, such as life insurance, disability, accidental death or dismemberment benefits or CorePlus Voluntary programs. The Plans provide no greater COBRA continuation rights than what COBRA requires — nothing in this Summary Plan Description (SPD) is intended to expand your rights beyond COBRA’s requirements. Only qualified beneficiaries have independent COBRA continuation rights. A domestic partner or children of a domestic partner are not qualified beneficiaries. Domestic partners and children of domestic partners are not eligible for COBRA continuation coverage.
Qualifying Events A “qualifying event” is any of the following events that cause you or another qualified beneficiary to lose coverage under the healthcare benefits. Qualifying events for which you or a qualified beneficiary may elect to continue healthcare coverage for you or your qualified beneficiaries under COBRA are:
Your employment with an HCA-Affiliated Facility ends for a reason other than your gross misconduct A reduction in your hours worked that causes a loss of coverage.
Qualifying events for which your covered spouse and/or covered dependents may elect to continue their healthcare benefits under COBRA are:
You become divorced or legally separated You become entitled to Medicare Your child is no longer eligible for dependent coverage You die
Remember, for COBRA to apply, the event must cause a loss of coverage.
Newborn or Adopted Children If, during the period of COBRA coverage, you or your eligible spouse gives birth to a child — or if a child is placed with you for adoption — you may elect COBRA continuation coverage for that child. Coverage for the newborn or adopted child will continue for the same period of time that coverage for any other dependent children is or could have been provided. Special Enrollment Rules for Qualified Beneficiaries As a qualified beneficiary, you will have the same right to enroll family members under Special Enrollment Rights as if you were an employee or participant within the meaning of those rules. Losing Coverage A “loss of coverage” means that, because of the qualifying event, you, your covered spouse and/or your covered dependents cease to be covered on the same terms and conditions as those in effect immediately before the qualifying event. This includes the loss of eligibility for coverage as well as an increase in the cost of coverage caused by the qualifying event. A loss of COBRA coverage itself does not count, however.
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Qualified Beneficiaries A “qualified beneficiary” is each person who, on the day before a qualifying event, is covered under a healthcare benefits option (other than COBRA continuation coverage) and would lose that coverage because of the qualifying event. For example, in the case of a terminated employee with family coverage, this would be the employee and each covered member of his or her family. Qualified beneficiaries also include children who are born to you or placed for adoption with you during your COBRA continuation coverage. Each qualified beneficiary has an independent right to elect COBRA continuation coverage. This means that qualified beneficiaries may elect COBRA coverage for themselves, regardless of whether other family members who are also qualified beneficiaries elect or decline coverage. As a qualified beneficiary, you may change healthcare benefits or add/drop eligible dependents at annual enrollment. However, dependents who are not themselves qualified beneficiaries do not become qualified beneficiaries if they are added or dropped at annual enrollment. Special Enrollment Rights may allow a qualified beneficiary to add coverage for new dependents or dependents who lose other coverage, although such added persons do not themselves become qualified beneficiaries (except in the case of your newborn or adopted child or a child placed for adoption with you). Divorce or Legal Separation If the employee reduced or eliminated spousal group health coverage in anticipation of a divorce or legal separation, and the divorce or legal separation later occurs, then the divorce or legal separation may be considered a qualifying event for the spouse even though the spouse’s coverage was reduced or eliminated, such as at annual enrollment, before the divorce or separation. Notification of Qualifying Event The healthcare benefits option will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, or the employee’s becoming entitled to Medicare benefits (under Part A, Part B or both), your affiliated facility must notify the Plan Administrator of the qualifying event. For other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify LifeTimes Connection acting for the Plan Administrator within 60 days after the later of (a) the date of the qualifying event; or (b) the date on which the qualified beneficiary loses (or would lose) coverage under the terms of the healthcare benefits option as a result of the qualifying event. You must provide notice within 60 days to LifeTimes at 1-800-566-4114. If you do not timely notify LifeTimes Connection, YOU WILL LOSE YOUR RIGHT TO ELECT COBRA.
Your Choices COBRA applies only to the Medical (including vision) benefits, Dental benefits, Employee Assistance Program, and in some cases to the Health Care FSA. The right to elect COBRA continuation applies only if the person had the corresponding coverage when the qualifying event occurred. For example, if you had medical and dental coverage but no Health Care FSA, then you would be offered COBRA coverage of medical and dental, but not COBRA coverage of the Health Care FSA. Each qualified beneficiary has an independent right to elect COBRA continuation for healthcare benefits he or she would lose. For example, if you had family healthcare and participated in a Health Care FSA, then you and each covered family member could elect COBRA continuation of medical, dental, vision and/or the Health Care FSA. A parent may elect continuation with respect to any dependent child who is a qualified beneficiary. However, you cannot decline COBRA coverage for your spouse. Your spouse must decline coverage. COBRA coverage is the same group healthcare coverage that is offered to similarly situated non-COBRA active participants and dependents. Ordinarily, this would be the same coverage the qualified beneficiary had on the day before the qualifying event occurred. A Few Words About the Health Care Flexible Spending Account: COBRA applies to the Health Care FSA only for the plan year in which the qualifying event occurred, and then only if the maximum benefit available for the rest of the year under the Health Care FSA is greater than the COBRA premiums for the Health Care FSA for the remainder of that year. You will receive a COBRA election form if you are eligible to continue participation in the Health Care FSA. Note that COBRA contributions for the Health Care FSA are on an after-tax basis, unlike regular premium payments for the Health Care FSA, which are deducted from your paycheck before taxes.
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The Benefits The 18-, 29- and 36-month COBRA continuation periods described here are the maximum times COBRA coverage may last. COBRA coverage ends at midnight on the date any one of the following events occurs:
The applicable COBRA continuation period ends. This may be 18, 29 or 36 months for the Medical (including vision) benefits, Dental benefits and Employee Assistance Program. For the Health Care FSA, it is the end of the plan year in which the qualifying event occurred
Premium payments are not made within a 30-day grace period (or 45 days for initial payment). Termination is retroactive to the last day for which payment was made
Any requirement premium is not paid in full on time HCA no longer offers any healthcare coverage to HCA-affiliated employees After the date COBRA is elected, the covered person first becomes covered by another group healthcare plan (not
sponsored by HCA) but not before any pre-existing conditions exclusions of the other plan for a pre-existing condition of the covered person have been exhausted or satisfied
After the date COBRA is elected, the covered person first becomes entitled to Medicare. For this purpose, “entitled” means the effective date of enrollment in either Medicare Part A or B, whichever occurs earlier. It does not mean mere eligibility to enroll
In the case of a disability extension (namely from 18 to 29 months), there has been a final determination under the Social Security Act that the person is no longer disabled. In this case, COBRA ends on the first day of the month that is more than 30 days after the final determination is issued. This termination provision does not apply, however, if a second qualifying event occurred during the first 18 months of COBRA coverage
For any reason the plans would terminate coverage of a participant not receiving COBRA coverage, such as fraud
When counting the 18-, 29- or 36-month periods, the periods are measured from the date you lost coverage according to When Coverage Ends.
Up to 18 Months COBRA coverage allows qualified beneficiaries to elect to continue their healthcare benefits for up to 18 months if you or they otherwise would lose coverage because of the following qualifying events:
Your employment with an HCA-Affiliated Facility ends (unless because of your gross misconduct) A reduction in your hours worked causes a loss of coverage
In addition, certain events may extend the 18-month COBRA continuation by another 18 months, to a total of up to 36 months from the original qualifying event:
Second Qualifying Event: If your spouse or dependents experience a second qualifying event within the original 18-month period, they (but not you) may extend the COBRA continuation period for up to an additional 18 months (for a total of up to 36 months from the original qualifying event). This extension may be available to the spouse and any dependent children receiving COBRA coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both) or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. This extension due to a second qualifying event is available only if you notify Planned Benefit Systems at 1-877-20-COBRA (26272) within 60 days after the later of (a) the date of the second qualifying event; and (b) the date on which the qualified beneficiary would lose coverage under the terms of the Plan. If you do not call PBS during the 60-day notice period, THEN THERE WILL BE NO EXTENSION OF COBRA COVERAGE DUE TO A SECOND QUALIFYING EVENT.
Medicare Entitlement: If you became entitled to Medicare while employed (even if it was not a qualifying event for your covered dependents because their coverage was not lost or reduced) and then a second qualifying event (for example, your termination of employment or reduction in hours of work) happens within 18 months, your spouse and/or dependents may elect COBRA continuation for up to 36 months from the date you became entitled to Medicare. For example, if a covered employee becomes entitled to Medicare eight months before the date on which termination of employment occurs, COBRA continuation for the spouse and children can last up to 36 months after the date of Medicare entitlement which is equal to 28 months after the date of the qualifying event (36 months minus eight months). Otherwise,
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when the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage generally can last for only up to a total of 18 months.
Up to 29 Months If you or anyone in your family covered under the healthcare benefits options is determined by the Social Security Administration (SSA) to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a maximum total of 29 months. The disability would have to have started at least at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage.
You must mail or fax a copy of the SSA determination to Planned Benefit Systems within 60 days of the SSA determination but before the end of the 18 months of COBRA coverage. If proof is not timely provided within the first 18 months of COBRA coverage, or if these procedures are not followed, or if the notice is not provided in writing to PBS within 60 days of receiving the SSA determination and within 18 month after the covered employee’s termination of employment or reduction of hours, THEN THERE WILL BE NO DISABILITY EXTENSION OF COBRA COVERAGE. The disability extension is available only if you notify PBS of the SSA’s determination of disability (and provide a copy of the SSA determination) within 60 days after the latest of:
1. The date of the SSA’s disability determination; 2. The date of the covered employee’s termination of employment or reduction of hours; and 3. The date on which the qualified beneficiary loses (or would lose) coverage under the terms of the Plan as a result of
the covered employee’s termination of employment or reduction of hours.
You must also provide this notice within 18 months after the covered employee’s termination of employment or reduction of hours in order to be entitled to a disability extension. Also, if SSA determines that the qualified beneficiary is no longer disabled, you are required to notify the Plan Administrator within 30 days after this determination.
Up to 36 Months COBRA allows qualified beneficiaries to elect to continue their healthcare coverage (except the Health Care FSA) for up to 36 months if they otherwise would lose coverage because one of the following qualifying events:
You become divorced or legally separated You become entitled to Medicare. For this purpose, “entitled” means the effective date of enrollment in either
Medicare Part A or B, whichever occurs earlier. It does not mean mere eligibility to enroll Your child is no longer eligible for dependent coverage You die
Steps to Follow
Electing COBRA Coverage To elect COBRA coverage, you must complete the Election Form that is part of the COBRA election notice and mail or fax it to Planned Benefit Systems.. (An election notice will be provided to qualified beneficiaries at the time of a qualifying event.) You may also obtain a copy of the Election Form from Planned Benefit Systems at 1-877-20-COBRA (26272).
If mailed, your election must be postmarked, or if sent via facsimile, your election must be received no later than 60 days after the date of the COBRA election notice provided to you at the time of your qualifying event or within 60 days of the date coverage is lost because of a qualifying event. IF YOU DO NOT TIMELY ELECT COBRA COVERAGE, YOU WILL LOSE YOUR RIGHT TO ELECT COBRA. Any qualified beneficiary for whom COBRA is not elected within the 60-day election period specified in the COBRA election notice WILL LOSE HIS/HER RIGHT TO ELECT COBRA COVERAGE.
Special Consideration Concerning COBRA Election In considering whether to elect COBRA, you should take into account that a failure to elect COBRA will affect your future rights under federal law. First, you can lose the right to avoid having preexisting conditions exclusions applied to you by other group health plans if you have more than a 63-day gap in health coverage, and election of COBRA may help you not to have such a gap. Second, you will lose the guaranteed right to purchase individual health insurance policies that do not impose such preexisting condition exclusions if you do not get COBRA coverage for the maximum time available to you. Finally, you should take into account that you have Special Enrollment Rights under federal law. You have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your spouse’s employer) within 30 days after your healthcare benefits end because of one of the qualifying events listed above. You will also have the same special enrollment right at the end of COBRA coverage if you get COBRA coverage for the maximum time available to you.
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Divorce or Separation or Child's Becoming Ineligible
If you divorce or become legally separated, or your child reaches the maximum age for coverage (19 or 25) or marries, and you have healthcare coverage for any of these persons, then you must notify LifeTimes Connection of these events by calling 1-800-566-4114. You must call within 60 days from the date of the event or, if later, from the date your spouse or dependent would lose coverage because of the qualifying event. The representative will notify the COBRA Administrator — PBS — of the qualifying event. PBS will then send any qualified beneficiaries a COBRA notice at their last known address describing their continuation options and premiums, along with a form for electing continuation coverage. If you or your dependent is already continuing coverage through COBRA, contact PBS directly.
All Other Initial Qualifying Events
For all other initial qualifying events, the COBRA Administrator will notify any qualified beneficiaries — at their last known address — of the right to continue healthcare coverage under COBRA. The notice will describe the continuation options and premiums, and it will contain a form for electing continuation coverage.
Returning the Election Form and Payment
To elect COBRA coverage, return the election form to the COBRA Administrator within 60 days and pay the initial premium within 45 days of the election. Any qualified beneficiaries who wish to continue healthcare coverage must return the election form to the COBRA Administrator within 60 days from the date notice is provided or coverage is lost because of the qualifying event, whichever is later. Each qualified beneficiary has an independent right to elect COBRA coverage. However, if an employee or spouse elects coverage but does not specify that it is only for himself or herself, then that election is deemed to include an election of coverage on behalf of all other qualified beneficiaries with respect to that qualifying event. If no response is made by the deadline, then the right to continue coverage is lost.
Disability Extension
To extend coverage to 29 months because of a qualified beneficiary’s disability, a qualified beneficiary must notify the COBRA Administrator of the disability. If the qualified beneficiary is approved by the Social Security Administration for disability income within 18 months of the COBRA qualifying event and the disability income is retroactive so that the disability existed on the date of the qualifying event or within the first 60 days of COBRA coverage, a qualified beneficiary must notify the COBRA Administrator within 60 days of the determination and within the 18-month period in order to qualify for the disability extension by forwarding a copy of the letter from the Social Security Administration.
Contacting the COBRA Administrator
If you have questions about COBRA eligibility or coverage, call the COBRA Administrator and speak to a COBRA Representative, or write to:
Planned Benefit Systems ATTN: COBRA Administrator P.O. Box 4594 Greenwood Village, CO 80155-4594 1-877-20-COBRA or 1-877-202-6272
What Else You Should Know
Cost As noted earlier, COBRA coverage can be expensive. COBRA premiums can be as much as 102% of the actual cost of providing coverage (150% for certain disability extensions). This may be quite a bit higher than what you pay as an active employee, because your facility subsidizes part of the cost of non-COBRA medical and dental coverage and all of the employee assistance coverage for active employees and their families, but COBRA payments do not include your facility’s subsidy.
When a qualified beneficiary becomes entitled to COBRA continuation coverage, he or she will receive a notice explaining the continuation options and how to elect them. That notice will state the premium costs associated with those options.
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You must pay premiums at the times specified. Your initial payment (including all unpaid premiums retroactive to the date coverage otherwise would have ended) is due within 45 days after the date you elect COBRA. All other premium payments have a 30-day grace period.
Special rules apply to the cost of disability extensions. For disability extensions (months 19 – 29), the COBRA premiums may be up to 150% of the actual cost of providing coverage. (For months 1 – 18, the premiums remain at 102%, even if the person is disabled.) The premiums for the 19th through 29th months of coverage under the disability extension are 150% of the full cost of coverage for all family members participating in the same coverage option as the disabled individual, but are 102% for any family members participating in a different coverage option than the disabled individual. However, if a second qualifying event occurs during the first 18 months of coverage, the 102% rate applies to the full 36 months even if the individual is disabled.
If a second qualifying event occurs during the disability extension period (that is, during the 19th through 29th months), then the rate for the 19th through 36th months is 150% for all family members participating in the same coverage option as the disabled individual, but still 102% for any family members in a different coverage option from the disabled individual.
The amount of your COBRA premiums may change from time to time during your period of COBRA coverage and will most likely increase over time. You will be notified of COBRA premium changes by Planned Benefit Systems. If you have any questions concerning the amount of COBRA premiums, call Planned Benefit Systems at 1-877-20-COBRA (26272).
Payment for COBRA Coverage All COBRA premiums must be paid by check or money order. Your first payment and all monthly payments for COBRA coverage must be mailed to:
Planned Benefit Systems P.O. Box 4594 Greenwood Village, CO 80155-4594
Your payment is considered to have been made on the date that it is postmarked. You will not be considered to have made any payment if your check is returned due to insufficient funds or otherwise.
If you timely elect COBRA, you do not have to send any payment initially. However, you must make your first payment for COBRA coverage not later than 45 days after the date of your election and the amount must include all payments through the end of the month in which you make your first payment. For example, Sue’s employment terminates September 15 and she loses coverage on September 30. Sue elects COBRA on November 15. Her initial premium payment equals the premiums for October, November and December and is due on or before December 30, the 45th day after the date of her COBRA election.
You are responsible for making sure that the amount of your first payment is correct. You may contact Planned Benefit Systems at 1-877-20-COBRA (26272) to confirm the correct amount of your first payment.
Claims for reimbursement will not be processed and paid until you have elected COBRA and made the first payment for it.
After you make your first payment for COBRA coverage, you will be required to make monthly payments for each subsequent month of COBRA coverage. The amount due for each month for each qualified beneficiary will be disclosed in the election notice provided to you at the time of your qualifying event. Each of these monthly payments for COBRA coverage is due on the first day of the month for that month’s coverage. If you make a monthly payment or before the first day of the month to which it applies, your COBRA coverage will continue for that month without any break. Planned Benefit Systems will not send periodic notices of payments due for these coverage period (that is, you will not be sent a bill for your COBRA coverage — it is your responsibility to pay your COBRA premiums on time).
Although monthly payments are due on the first day of each month of COBRA coverage, you will be given a grace period of 30 days after the first day of the month to make each monthly payment. For example, the April payment is due April 1 and the grace period ends April 30. If you pay a monthly payment later than the first day of the month to which it applies, but before the end of the grace period for the month, your coverage will be suspended as of the first day of the month and then retroactively reinstated (going back to the first day of the month) when the monthly payment is received. This means that any claim you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated.
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Your Right to a Certificate of Creditable Coverage When your active coverage ends, LifeTimes Connection will provide a written certification — called a “certificate of creditable coverage” — of how long your coverage was in effect. You may also request this certification from the COBRA Administrator at any time within the 24-month period after your coverage ends. The purpose of this coverage certification is to help satisfy another plan’s pre-existing condition limitation. If you become covered by a plan that has a pre-existing condition exclusion, you may use the certificate to show your new plan how long you had coverage under your old plan. If you do not have a certificate, you can prove your prior coverage by producing documentation or other evidence. The new plan must notify you of any length of time that a pre-existing condition exclusion may apply to you after counting your previous coverage. Other Group Health Coverage If any qualified beneficiary becomes covered under another group healthcare plan after COBRA continuation coverage has been elected, you or that beneficiary must notify the COBRA Administrator immediately. COBRA coverage for that qualified beneficiary may be terminated if the other coverage does not contain a pre-existing condition limitation that applies to the qualified beneficiary. COBRA and the Family and Medical Leave Act (FMLA) The taking of an FMLA leave is not a qualifying event. However, if you fail to return to employment with an HCA-Affiliated Facility at the end of your FMLA leave, then you and any of your dependents who had healthcare coverage when the leave began — and who otherwise would lose that coverage because of your failure to return — would experience a qualifying event on the last day of the FMLA leave or, if later, the day coverage is lost. COBRA notices and election forms would be sent accordingly to any qualified beneficiaries at that time. You do not have to continue healthcare coverage during your FMLA leave to be eligible for COBRA, and your right to COBRA continuation coverage cannot be conditioned upon repayment of any premiums your facility may have paid on your behalf during FMLA leave. Qualified Medical Child Support Orders A child of the covered employee who is receiving benefits pursuant to a qualified medical child support order received by LifeTimes Connection during the covered employee’s period of employment is entitled to the same rights to elect COBRA as an eligible dependent child of the covered employee. Trade Act of 2002 The Trade Act of 2002 created a new tax credit for certain individuals who become eligible for trade adjustment assistance and for certain retired employees who are receiving pension payments from the Pension Benefit Guaranty Corporation (PBGC) (eligible individual). Under the tax provisions, eligible individuals can either take a tax credit or get advance payment of 65% (or 80 percent before January 1, 2011) of premiums paid for qualified health insurance, including continuation coverage. In accordance with the American Recovery and Reinvestment Act of 2009, you may also be eligible for a temporary extension of the applicable maximum period of COBRA continuation coverage. If you have questions about these tax provisions, you may call the Health Care Tax Credit Customer Contact Center toll free at 1-866-628-4282. TTD/TTY callers may call toll free at 1-866-626-4282. More information about the Trade Act is also available at www.doleta.gov/tradeact. COBRA and USERRA When you are called to active duty, you may be covered under the Uniformed Services Employment and Reemployment Rights Act (USERRA) and COBRA. Any benefit continuation for USERRA and COBRA will cause the time periods to run concurrently.
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Administrative Information
Administration Information Highlights ............................................................................................ 165
Keep Your Address Current .................................................................................................. 165
Claims and Appeals ......................................................................................................................... 165
Health and Welfare Benefit Appeals .................................................................................... 165
Statute of Limitations – Health & Welfare Benefits ........................................................................ 172
Your Rights ....................................................................................................................................... 172
Receiving Information About Your Plan and Benefits .......................................................... 172
Continuing Group Health Plan Coverage ............................................................................. 172
Prudent Actions by Plan Fiduciaries .................................................................................... 172
Enforcing Your Rights .......................................................................................................... 172
Getting Answers to Your Questions ...................................................................................... 173
HCA’s Rights .................................................................................................................................... 173
Health and Welfare Benefits ................................................................................................ 173
Retirement and 401(k) Plans ................................................................................................ 174
Basic Administrative Information ................................................................................................... 175
Plan Year, Plan Sponsor and Plan Administrator ................................................................. 175
Plan Administrator Discretion ............................................................................................... 176
Agent for Service of Legal Process ...................................................................................... 176
Plan Structure ...................................................................................................................... 176
Administrative Information Highlights It is important that you understand basic administrative information about your benefits. You may need this information if:
You change your address You want to know how distributions are taxed and how they can rollover tax-free A claim for health and welfare or retirement benefits has been denied and you want to know how to appeal (see
below) You want to know your basic rights with respect to benefits You want to know HCA’s rights with respect to benefits You want to know when benefits may be changed or terminated You are eligible for continuation of group health coverage under COBRA You get divorced You need basic plan or program administrative information
Keep Your Address Current If your most recent address is not on file with your Human Resources Department or LifeTimes Connection, and your facility cannot locate you, benefits may be delayed. Be sure to keep your address current by contacting your local Human Resources Department (if you are currently an employee) or LifeTimes Connection (if you have terminated your employment).
Claims and Appeals
Health and Welfare Benefit Plan Claims and Appeals
Making a Claim Each benefits program or benefits option has its own procedures and time limits for making claims. Refer to the appropriate section for more information about the particular benefits at issue and combine that information with the discussion that follows. You may designate an authorized representative to act on your behalf in pursuing a benefit claim or appealing a claim denial.
For insured benefits (Vision, Life Insurance, AD&D, Long-Term Disability), HMOs and the Dental HMO, all claim decisions are made by the insurance carrier or HMO. No claim decisions are made by HCA. Furthermore, HCA has delegated all authority to interpret and apply contract terms, claims decisions and appeal processes to the insurance carrier, HMO or Dental HMO.
For the self-funded benefits (Medical, Dental, and Health Care FSA), HCA has delegated to the Claims Administrator initial claim determinations.
Claims will be either an eligibility claim or a benefit claim.
Definition of an Eligibility Claim An “eligibility claim” is a claim to participate in a plan option or to change an election to participate during the year. For example, it may be a claim to start, add or stop participation in the plan. Definition of a Benefit Claim A “benefit claim” includes any claim that is not a claim for eligibility, such as a request for Medical, Dental, Vision or Health Care FSA benefits (healthcare benefit claims). A healthcare benefit claim includes:
Urgent care claims — Claims for medical care or treatment for which using the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the claimant or the claimant’s ability to regain maximum function, or — in the opinion of a physician with knowledge of the claimant’s medical condition — would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim
Concurrent care claims — Claims related to an approved, ongoing course of treatment over a period of time or number of treatments
Pre-service claims — Claims for medical or dental benefits for which the plan requires prior approval of the benefit before you receive medical care
Post-service claims — Claims for health benefits that are not pre-service or urgent care claims
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When you file a claim, the Claims Administrator reviews the claim and makes the initial decision to either approve or deny the claim.
If you fail to follow the plan’s procedures for filing a pre-service or urgent claim, you’ll be notified of this failure and the plan’s procedures for filing a claim for benefits. This failure involves a communication — made by you or your authorized representative to a person or unit customarily responsible for handling benefit matters — that does name a specific claimant, specific medical condition or symptom and a specific treatment, service or product for which approval is requested but for some other reason does not follow the plan’s claims procedures. In the case of a failure in a pre-service claim, you’ll be notified no later than five days (24 hours in case of a failure to file a claim involving urgent care) after the failure. You may be notified orally, unless you request written notification.
Understanding a Claim Denial A claim denial may take more than one form. It may be a denial of the claim itself, or it may be a reduction or termination of the benefits you are seeking (or have been receiving), or it may be a decision not to provide or make payment for a particular benefit.
If any of these occurs, you will receive written notice within the required time limits below. The notice will:
State the specific reason(s) for the denial Refer to the specific plan provisions on which the decision is based Describe what additional material or information from you, if any, is necessary, and explain why that material or
information is necessary Describe the plan’s review (appeal) procedures and the time limits applicable to those procedures, and state your
right to sue under section 502(a) of ERISA, 29 U.S.C. § 1132(a), if your appeal is denied
For healthcare and disability claims, if an internal rule, guideline, protocol or similar criterion is relied upon to make the adverse determination, the notice will either contain that rule, etc., or state that such a rule, etc., was relied upon and that you may receive a free copy of it upon request.
For all urgent claims, the notification will also contain a description of the expedited review process applicable to such claims.
For healthcare and disability claims only, if the benefit determination is based on medical necessity, experimental treatment or similar exclusion or limit, the notification must also contain either:
An explanation of the scientific or clinical judgment for the determination, applying the terms of the plan, as applicable, to the claimant’s medical circumstances; or
A statement that such explanation will be provided free of charge upon request
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Type of Claim Time Limits for Notice of Claim Decision Extension of Time Limits
Medical claims: Urgent care
As soon as possible, taking into account the medical demands, but no later than 72 hours after receipt of the claim by the plan, HMO or carrier
If additional information is needed, you'll be notified with 24 hours after receipt of the claim as to what additional information is needed, and you'll have 48 hours to provide this information
The plan, HMO or carrier must respond no later than 48 hours after the earlier of the receipt of the information or the end of the period you're given to provide the information
Medical claims: Concurrent care decisions
Non-urgent claims for ongoing care (reduction or elimination of a course of treatment before the end of the course of treatment or number of treatments) — Sufficiently in advance of the reduction or termination of a course of treatment to allow the claimant time to appeal and obtain a review before the benefit is reduced or eliminated
Urgent claims for ongoing care (extension of the course of treatment or number of treatments) — As soon as possible, taking into account the medical demands, but no later than 24 hours after receipt of the claim by the plan, HMO or carrier, If received 24 hours prior to the end of the course of treatment
If necessary, the period may be extended one time for 15 days. If an extension is necessary because additional information is needed, the extension notice will describe the information needed, and you'll have at least 45 days to provide the information
If the concurrent care is considered urgent, you'll fall under the urgent care rules described above
Medical claims: Pre-service
Within a reasonable period of time appropriate to the medical circumstances but no later than 15 days after receipt of the claim by the plan, HMO or carrier
If necessary, the period may be extended one time for 15 days. If an extension is necessary because additional information is needed, the extension notice will describe the information needed, and you'll have at least 45 days to provide the information
Medical claims Post-service
Within a reasonable time period, but no later than 30 days after receipt of the claim by the plan, HMO or carrier
If necessary, the period may be extended one time for 15 days. If an extension is necessary because additional information is needed, the extension notice will describe the information needed, and you'll nave at least 45 days to proved the information
Disability claims (Long-Term and Short-Term)
Within a reasonable time period, but no later than 45 days after receipt of the claim by the insurance carrier
If necessary, the period may be extended two times for up to 30 days each. You'll have at least 45 days to provide the information
All other claims (Life, AD&D, other welfare plans)
Within a reasonable time period, but no later than 90 days after receipt of the claim by the insurance carrier
If special circumstances require an extension, the period may be extended for an additional 90 days
A few words about counting time under these deadlines: The time period begins when a claim is filed in accordance with the reasonable procedures of the plan, without regard to whether the claim includes all the necessary information. If time is extended because you failed to provide necessary information, then the extension period will be “tolled” (in other words, days will not count against the extension limits) from the date notice of the extension is sent until the date you respond to the request for additional information.
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Request for Review if Your Claim Is Denied You have the right to request a review of a claim’s denial:
You, or your authorized representative, shall be entitled to request a review of this denial upon written application You have the right to examine the relevant documents that establish and control the plan. These documents may be
seen in the office of the Plan Administrator upon request You, or your representative may submit additional documents or comments in writing if you believe such items would
reverse the denial of your claim
For post service health claims, you have 180 days after receiving the claim denial to appeal the decision.
Types of Review or Appeal Certain reviews or appeals have a one-step appeal procedure and other appeals have a two-step appeal procedure. This chart indicates the appeal levels available in most situations. However, if you are covered by an HMO or Dental HMO, you must refer to your booklet for their specific procedures. Type of Claim Appeal Procedure
Medical: Urgent Care One-step with Claims Administrator
Medical: Concurrent Care One-step with Claims Administrator
Medical: Pre-Service One-step with Claims Administrator
Medical: Post-Service Two steps: First-step with Claims Administrator and Second-step with Benefit Appeals Committee
Behavioral Health – Smart Care Same as Medical listed above
Prescription Drug (retail or mail-order) Same as Medical listed above
Dental Claims Two steps with Dental Claims Administrator
Vision Claims One-step with Insurance Carrier
Long-Term Disability One-step with Insurance Carrier
Short-Term Disability Two steps with Insurance Carrier
Life, AD&D One-step with Insurance Carrier
Flexible Spending Account One-step with Benefit Appeals Committee
Long-Term Care One-step with Insurance Carrier
Voluntary Permanent Life One-step with Insurance Carrier
Where to Send Appeals
Fully Insured Benefit Appeals: For fully-insured benefits, such as HMOs, Dental HMOs, Life and AD&D Insurance, Long-Term Care, Voluntary Permanent Life, Long-Term Disability and Short-Term Disability coverage, the insurance carrier is the fiduciary and determines all claim issues. Therefore, you must appeal any denied claims directly to the HMO, Dental HMO, Life and AD&D or Long-Term Disability and Short-Term Disability insurance company (see page 189). You may also find this information on your ID card or within the Plan Identification information listed in this Summary Plan Description.
Dental PPO Appeals: If you wish to appeal a dental PPO claim, the Dental Claims Administrator identified on your dental ID card is the designated party and determines all claim issues including the two-step appeal procedure.
Smart Care Program Appeals: If you wish to appeal a Smart Care urgent care, concurrent care or pre-service claim, the Claims Administrator identified on your medical ID card is the designated party and determines all claim issues including the one-step appeal procedure.
If you wish to appeal a Smart Care post-service claim, the Claims Administrator identified on your medical ID card is the designated party for the initial claim determination and first level of appeal. The Benefit Appeals Committee is the fiduciary for the second level of appeal.
Flexible Spending Account Appeals: If you wish to appeal a Flexible Spending Account denial, the Benefit Appeals Committee is the fiduciary for the one-step appeal process.
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In General At each level of appeal you will receive a full and fair review of the claim and its denial. The review will not be performed by the same individual who made the initial determination on the claim. Also, you must complete the entire appeal process (whether one-step or two-step) as a precondition to filing a lawsuit or suing for benefits under section 502(a) of ERISA. As part of your appeal, you may submit written comments, documents, records and other information relating to your claim. The review of the appeal will take into account all of the information you submit related to your claim, without regard to whether it was submitted or considered in the initial claim decision. At your request, you will have reasonable access to and may have copies (without charge) of all documents, records and other information relevant to your claim. For this purpose, “relevant” means the item:
Was relied upon in making the benefit determination; Was submitted, considered or generated in the course of making the benefit determination (even if not relied upon); Demonstrates compliance with the administrative process and safeguards for ensuring that claim determinations are
made in accordance with governing plan documents and that, where appropriate, the plan provisions have been applied consistently to similarly-situated individuals; or
Is a statement of the policy or guidance for your diagnosis (even if not relied upon) Required Information to Submit a Smart Care, Dental PPO, Vision or Flexible Spending Account (FSA) Appeal To be considered an appeal you must submit (a) a copy of the Explanation of Benefits (EOB) for the disputed claim, (b) an explanation which describes the basis of your appeal, (c) your name and home address and (d) any additional information or documentation supporting your appeal. If you submit an incomplete appeal, you will be notified in writing of the missing items and your request is not considered an appeal until it is complete. For appeals which are submitted to the Benefit Appeals Committee, you must submit (a) a copy of the EOB for the disputed claim, (b) a copy of the first appeal letter, (c) denial letter from the Claims Administrator, (d) an explanation which describes the basis of your second appeal, (e) your name and home address and (f) any additional information or documentation supporting your appeal. If you submit an incomplete appeal, you will be notified in writing of the missing items and your request is not considered an appeal until it is complete. Notice of Decision on Appeal Type of Claim Notice of Decision on Appeal
Medical: Urgent Care As soon as possible, taking into account the medical demands, but no later than 72 hours after receipt of the appeal by the HMO, Carrier or Claims Administrator.
Medical: Concurrent Care If an urgent claim for ongoing care, within 72 hours. If a non-urgent claim for ongoing care, timing of the notice of decision on appeal will either be handled under pre-service or post-service claim time frames addressed below (depending on the type of claim).
Medical: Pre-Service A reasonable time period appropriate to the medical circumstances but no later than 30 days after receipt of the request for appeal by the HMO, Carrier or Claims Administrator.
Medical: Post-Service A reasonable time period for first appeal but no later than 30 days after receipt of the appeal by the HMO, Carrier or Claims Administrator. A reasonable time period for the second appeal but no later than 30 days after receipt of the second appeal by the HMO, Carrier or Benefit Appeals Committee.
Behavioral Health – All types See Medical above.
Prescription Drug (retail or mail-order)
See Medical above.
Dental Claims A reasonable time period appropriate to the medical circumstances but no later than 30 days after receipt of the request for appeal by the HMO, Carrier or Claims Administrator.
Vision Claims A reasonable time period for the first appeal but no later than 30 days after receipt of the appeal by the carrier or claims administrator. A reasonable time period for the second appeal but no later than 30 days after receipt of the second appeal by the carrier or Benefit Appeals Committee.
Disability (Long-Term and Short-Term)
A reasonable time period but no later than 45 days of receipt of the claimant’s request for appeal by the Carrier. If necessary, the period may be extended for an additional 45 days.
Life, AD&D, Long-Term Care, Voluntary Permanent Life
A reasonable time but no later than 60 days of receipt of the Claimant’s request for appeal by the Carrier. If necessary, the period may be extended for an additional 60 days.
Flexible Spending Account A reasonable time period appropriate to the medical circumstances but no later than 30 days after receipt of the request for appeal by the Benefit Appeal Committee.
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Time Periods to Appeal
Type of Appeal Time Period
Life and AD&D, Long-Term Care, Voluntary Permanent Life
60 Days from original denial
Disability (Long-Term and Short-Term) 180 Days from original denial
HMO and Dental HMO Generally 180 days but refer to your HMO or Dental HMO booklet
Smart Care post service claims 9 Months from original denial for first appeal 3 Months from first appeal denial for second appeal
Smart Care urgent , concurrent and pre-service 9 Months from original denial
Dental PPO 9 Months from original denial for first appeal 3 Months from first appeal denial for second appeal
Vision 180 days from original denial
Flexible Spending Accounts, Prescription Drug 9 Months from original denial In addition, your claim will be reviewed anew on appeal. No deference will be given to the original denial. The review will be conducted by an appropriate named fiduciary of the plan who is not (and is not subordinate to) the person who made the original claim denial. If the decision is based in whole or part on medical judgment, then the review will include consultation with a healthcare professional who has appropriate training and experience in the field of medicine involved, and who was not consulted with (and is not subordinate to someone who was consulted with) about the original denial. Any medical or vocational experts consulted in connection with your claim will be identified, without regard to whether their advice was relied upon in making the determination. For all appeals, you will receive written notice of the decision on appeal within the required time limits. If your appeal is denied (in whole or part), the notice will:
State the specific reason(s) for the denial Refer to the specific plan provisions on which the decision is based State that you are entitled to receive, upon request, reasonable access to and free copies of all documents, records
and other information relevant to your claim Describe procedures for further appeal, if any, and the time limits applicable to those procedures, and state your right
to sue under section 502(a) of ERISA, 29 U.S.C. § 1132(a) State that you and your plan may have other voluntary alternative dispute resolution options, such as mediation. One
way to find out what may be available is to contact your local U.S. Department of Labor Office and your state’s insurance regulatory agency
For healthcare and disability claims, if an internal rule, guideline, protocol or similar criterion is relied upon to decide your appeal, the notice will either contain that rule, etc., or state that such a rule, etc., was relied upon and that you may receive a free copy of it upon request. For healthcare and disability claims only, if the benefit determination is based on medical necessity, experimental treatment or similar exclusion or limit, the notification must also contain either:
An explanation of the scientific or clinical judgment for the determination, applying the terms of the plan, as applicable, to the claimant’s medical circumstances; or
A statement that such explanation will be provided free of charge upon request For all urgent claims, the notification will also contain a description of the expedited review process applicable to such claims. Although you ordinarily should receive notice of the determination on appeal within the required time limits, special circumstances sometimes may require an extension of time for processing an appeal of a claim that does not involve healthcare benefits. If it is determined that an extension is required, written notice of the extension will be provided to you prior to the end of the notice period. This extension notice will indicate the special circumstances requiring the extension and the date by which a decision is expected. The specific time periods begin when an appeal is filed in accordance with the reasonable procedures of the plan, without regard to whether the appeal includes all the necessary information. Except for healthcare benefit claims if time is extended because you failed to provide necessary information, then the extension period will be “tolled” (in other words, days will not count against the extension limits) from the date notice of the extension is sent until the date you respond to the request for additional information.
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Retirement Program Claims and Appeals
Time Frame for Claim Determination If you make a claim for benefits and the claim is denied, you will be notified of the denial within a reasonable period of time, but generally not later than 90 days after the date you made the claim. This 90-day period to determine whether a claim should be approved or denied may be extended for up to an additional 90 days, if it is determined that special circumstances require an extension of time for processing the claim. If such is the case, you will be notified of the need for additional time before the initial 90-day period expires. Such notice will supply the date by which you can expect to receive a decision. Also, the 90-day period may be tolled (in other words, days will not count against any time limit) for any period during which the claims administrator is awaiting information necessary to administer the claim. If You Receive an Adverse Benefit Determination You will receive notification of any adverse benefit determination (i.e., claim reduction or denial), which will set forth, among other things:
The specific reason(s) for the adverse benefit determination Reference to the specific Plan provisions on which the benefit determination is based A description of any additional material or information necessary for you to perfect the claim and an explanation of
why that material or information is necessary A description of the Plan’s appeal procedures and time limits applicable to such procedures, including a statement of
your right to bring a civil action under ERISA after an adverse determination on appeal.
Procedures for Appealing an Adverse Benefit Determination You, or your authorized representative, have 60 days following the receipt of a notification of an adverse benefit determination within which to appeal the determination. The appeal must be sent to the Benefits Appeals Committee of HCA Inc. You have the right to:
Submit written comments, records, documents, and other information relating to the claim for benefits Request, free of charge, reasonable access to, and copies of all documents, records and other information relevant to
your claim for benefits. For this purpose, a document, record, or other information is treated as “relevant” to your claim if it:
o Was relied upon in making benefit determinations o Was submitted, considered, or generated in the course of making the benefit determination, regardless of
whether such document, record, or other information was relied upon in making the benefit determination o Demonstrates compliance with the administrative processes and safeguards required in making the benefit
determination A review that takes into account all comments, documents, records, and other information submitted by you relating
to the claim, regardless of whether such information was submitted or considered in the initial benefit determination.
The Benefits Appeals Committee will notify you of the Plan’s determination on review within a reasonable period of time, but generally not later than 60 days after receipt of your request for review. This 60-day period may be extended for up to an additional 60 days, if the Benefits Appeals Committee determines that special circumstances require an extension of time for processing. If such is the case, you will be notified before the initial 60-day period expires of the special circumstances requiring the extension of time and the date by which the Benefits Appeals Committee expects to render a determination on review.
The appeals consideration period may be tolled for any period during which the Benefits Appeals Committee is awaiting information necessary to consider the appeal.
The Benefit Appeals Committee notice of an adverse benefit determination on appeal will contain all of the following information:
The specific reason(s) for the adverse benefit determination Reference to the specific Plan provisions on which the benefit determination is based A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all
documents, records, and other information relevant to your claim, and A statement describing your right to bring an action under ERISA.
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Statute of Limitations — Health and Welfare Benefits For self-insured benefits, no legal action may be taken if such action is filed more than one year after a claim is denied.
Your Rights As a participant in HCA’s benefit plans, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA).
Receiving Information About Your Plan and Benefits
Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as worksites and union halls, all documents governing the plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.
Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated SPD. The administrator may make a reasonable charge for the copies.
Receive a summary of the plan’s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report.
Obtain a statement telling you whether you have a right to receive a retirement benefit at normal retirement age (age 65) and if so, what are your retirement benefits would be at normal retirement age if you stop working under the plan now. If you do not have a right to a retirement benefit, the statement will tell you how many more years you have to work to get a right to a retirement benefit. This statement must be requested in writing and is not required to be given more than once every 12 months. The plan must provide the statement free of charge.
Continuing Group Health Plan Coverage
Continue healthcare coverage for yourself, spouse or dependents under COBRA if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for such coverage.
You may be eligible for a reduction or elimination of exclusionary periods of coverage for pre-existing conditions under your group health plan if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under the plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage.
Prudent Actions by Plan Fiduciaries In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called “fiduciaries” of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a plan benefit or exercising your rights under ERISA. If your claim for a benefit is denied or ignored — in whole or in part — you have a right to know why this was done, to obtain copies of documents relating to the decision without charges, and to appeal any denial, all within certain time schedules.
Enforcing Your Rights Under ERISA, there are steps you can take to enforce your ERISA rights. For instance:
If you request a copy of the plan documents or the latest of any report and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials — unless the materials were not sent because of reasons beyond the control of the Administrator.
If you have a claim for benefits, which is denied or ignored — in whole or in part — you may file suit in a state or federal court, but only after you have exhausted the plan’s claims and appeals procedures.
If you disagree with the plan’s decision or lack of response to your request concerning the qualified status of a qualified medical child support order (QMSCO), you may file suit in federal court.
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If it should happen that plan fiduciaries misuse the plan’s money, or if you’re discriminated against for asserting your ERISA rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court.
If you file suit against the plan, the court will decide who should pay court costs and legal fees. If you’re successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees — for example, if it finds your claim is frivolous.
Getting Answers to Your Questions If you have any questions about your plan, you should contact the Plan Administrator (for health and welfare plans) or call LifeTimes Connection at 1-800-566-4114 (for retirement and savings plans). If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration (EBSA), U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, DC 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the EBSA at 1-866-444-3272, by logging on to the Internet at www.dol.gov/ebsa, or by contacting the EBSA field office nearest you.
HCA’s Rights HCA provides the benefits described in this Summary Plan Description (SPD) as part of your total compensation package. However, HCA does not guarantee that these benefits will continue, and the offering of such benefits and the enrollment in the various plans and programs does not guarantee your employment. The Company’s employment decisions are made without regard to the benefits to which you are or may be entitled due to employment. This SPD does not constitute an expressed or implied contract to guarantee of employment. If you terminate employment or are discharged, you have no right to benefits unless these rights are specifically provided for in the plans or required by law. This SPD provides important benefit plan information. For the Health and Welfare Benefits Plan, the plan document consists of this SPD, the insurance contracts for the fully insured benefits and the plan document. For the fully insured benefits, if there are differences between this document and the insurance contracts, the insurance contracts will control. For the HCA 401(k) Plan, if differences exist between this SPD and the plan documents, the plan documents always govern. The plan documents are on file with the Plan Administrator. HCA has the right to amend or terminate the HCA Health and Welfare Benefit Plan, any of the benefit options, any of the cost sharing arrangements, including benefit contributions made by HCA, an HCA-Affiliated Facility or employees at any time. HCA has the right to amend or terminate the HCA 401(k) Plan at any time.
Health and Welfare Benefits
Future of the Health and Welfare Plans HCA intends to continue operating the HCA Health and Welfare Benefits Plan indefinitely, but future business conditions or other reasons could cause HCA to discontinue them. If so, valid claims for healthcare and death benefits pending at the time would be paid to the extent allowable under the terms of the plan or program or benefit option. HCA reserves the right to terminate the HCA Health and Welfare Benefits Plan and/or any benefit options at any time. The HCA Health and Welfare Benefits Plan will end automatically if HCA ceases to exist and no successor company continues the plans. When Benefits May Change or End Subject to special statutory rules regarding plan amendments, and to the fullest extent allowed by law, HCA reserves the right to amend or terminate any of the benefit plans described in this SPD, as well as any of their underlying insurance or HMO policies, contracts or agreements, in whole or in part, both prospectively and retroactively, at any time, with or without notice. However, any retroactive amendment will not affect a claim already incurred, except as necessary to comply with federal law. Benefit plans are amended or terminated as provided in the plan’s documents. Any underlying insurance or HMO policies, contracts or agreements are amended or terminated according to their terms. Subrogation and Reimbursement This provision applies only to the Medical PPO and Dental PPO programs. For other programs, HCA has delegated the responsibility for obtaining subrogation and reimbursement to the entities that underwrite and manage these programs. Medical PPO and Dental PPO benefits are not payable to or for a person covered under this plan when the injury or illness of the covered person occurs through the act of omission of another person or party. However, HCA may elect to advance
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payment for medical expenses incurred for an injury or illness caused by a third party. The covered person, guardian or legal representative (including a wrongful death beneficiary pursuing a claim due to the death of the covered person) must sign an agreement to repay HCA in full and in first order of priority (regardless of whether the covered person is “made whole”) any sums advanced for such medical expenses from any judgment or settlement which has been paid or is payable. HCA has the right to recover, in full, the medical expenses advanced regardless of whether that person actually signs the repayment agreement and regardless of whether payments from the settlement or judgment are designated for specified or other damages.
As soon as the plan pays benefits for a covered expense, HCA is entitled to all rights of recovery the covered person may have against another party who may be responsible for making payments to the covered person due to the covered person’s illness or injuries. These rights also extend to benefits which may be payable to the covered person by the covered person’s own auto-insurer through any type of medical or uninsured/underinsured motorist coverage.
As a participant in this plan, the covered person is required to cooperate with efforts to recover benefits paid by HCA. The covered person must also notify the Plan Administrator within 45 days of the notice which is given to a third party of the intention to recover damages due to the covered person’s illness or injury.
This cooperation includes providing HCA with relevant information, signing and delivering documents HCA reasonably requests, and obtaining HCA’s consent before releasing any party from liability. If you enter into litigation or settlement negotiations regarding the obligations of other parties, you must not prejudice, in any way, HCA’s rights under subrogation proceedings. The costs of HCA’s legal representation in matters related to subrogation shall be borne solely by HCA. The costs of your legal representation shall be borne solely by you.
If the covered person recovers any charges for covered expenses from a third party (for example, as a result of a lawsuit), the amount of the benefit that this plan will pay will be reduced by the amount recovered. If benefits have already been paid, the covered person is required to reimburse the plan regardless of whether payments from the settlement or judgment are designated as payment for specified or other damages.
The plan’s rights to recovery and reimbursement are a first priority claim and will be paid before any other claim for damages, even if the total amount of the recovery is not sufficient to reimburse or compensate the covered person in entirety for the damages. The plan is also not required to pay legal fees the covered person may incur in pursuing the damage claim. The plan is entitled to the full right of recovery regardless of any admission of liability by the third party or regardless of whether the settlement identifies the Medical and Dental Plan benefits. The plan has a right to recover plan benefits from any and all settlements or judgments, even those designated as “pain and suffering” or “non-economic damages.”
In addition:
The covered person or his or her representative is deemed to have assigned to HCA all rights of recovery against other parties to cover because of his or her injuries or sickness
The plan’s first priority right of recovery will not be limited due to the covered person’s own negligence Settlement or judgment also includes other award (not limited to mediation or arbitration) regardless of whether the
settlement, judgment or other award identifies the payment as payment for “medical expenses”
401(k) Plan
When Benefits May Change or End Subject to special statutory rules regarding plan amendments, and to the fullest extent allowed by law, HCA reserves the right to amend or terminate any of the benefit plans described in this SPD, as well as any of their underlying insurance or HMO policies, contracts or agreements, in whole or in part, both prospectively and retroactively, at any time, with or without notice. However, any retroactive amendment will not affect a claim already incurred, except as necessary to comply with federal law. Benefit plans are amended or terminated as provided in the respective plan documents. Any underlying insurance or HMO policies, contracts or agreements are amended or terminated according to their terms. Future of the Retirement Plans Subject to possible future amendments, HCA currently plans to continue operating the 401(k) Plan indefinitely. However, HCA has the right to amend, modify, suspend or terminate one or both of the Plans, in whole or in part. Plan amendment, modification, suspension, or termination may be made for any reason, and at any time, and can result in the reduction or elimination of benefits to the extent allowed by law.
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Regardless of any changes made to the Plan, you will always be entitled to the current value of your vested account, to the extent required by law. Benefits provided under the Plan are not insured by the Pension Benefit Guaranty Corporation (PBGC) under Title IV of ERISA because the insurance provisions of ERISA are not applicable to this type of plan. If the Plan is terminated, all contributions to the terminated Plan will stop. Furthermore, if a Plan is terminated or there is a complete discontinuance of contributions to the Plan, you will be entitled to the full amount in your accounts as of the date of termination or complete discontinuance, regardless of the percent you are vested at the time of termination or complete discontinuance. If the Plan Becomes Top Heavy Under a complicated set of IRS rules set out in the Plan document, the Plan may become a “top heavy plan.” A top heavy plan is one where more than 60% of the contributions or benefits have been allocated to “key employees.” Key employees are generally certain officers and owners of HCA. The Plan Administrator is responsible for determining whether the Plan is a top heavy plan each year. In the unlikely event that the Plan becomes top heavy in any year, non-key employees may be entitled to certain minimum benefits and special rules will apply. If the Plan becomes top heavy, the Plan Administrator will advise you of your rights under the top heavy rules. Limitations on Assignment Except under limited circumstances, your rights and benefits under this Plan cannot be assigned, sold, transferred, or pledged by you or reached by your creditors or anyone else. However, the law does permit the assignment of all or a portion of your interest in the Plan to your former spouse or children as part of a Qualified Domestic Relations Order (see below). In addition, a Federal tax lien on the Plan Administrator would result in payment of your benefit to the IRS. Qualified Domestic Relations Order A Qualified Domestic Relations Order (QDRO) is a legal judgment, decree, or order that recognizes the rights of an alternate payee under the retirement plan with respect to a former spouse, child, or other dependent for support, alimony, or marital property rights. The company is legally required to recognize QDROs. If you become legally separated or divorced, a portion of all of your benefit under the retirement plan may be assigned to someone else to satisfy a legal obligation you may have to a spouse, former spouse, child, or other dependent. There are specific requirements the court order must meet to be recognized by the Plan Administrator and specific procedures regarding the amount and timing of payments. Participants and beneficiaries may obtain, without charge, a copy of the procedures governing QDRO determinations under the retirement plan from the Plan Administrator by contacting LifeTimes Connection. If you wish for a QDRO to be processed, you must submit it to LifeTimes Connection upon issuance by the court. Otherwise, the QDRO may not be processed. Receiving Advice HCA cannot advise you regarding tax, investment, or legal considerations relating to the 401(k) Plan. Therefore, if you have questions regarding benefit planning, you should seek advice from a personal advisor. If you have any questions about the 401(k) Plan, or if you wish to make a claim for benefits, you should contact LifeTimes Connection.
Basic Administrative Information
Plan Year, Plan Sponsor and Plan Administrator
The plan year for HCA Health and Welfare Benefits Plan and the HCA 401(k) Plan is the same as the calendar year — January 1 through December 31. HCA Inc. is the Plan Sponsor for HCA 401(k) Plan and the HCA Health and Welfare Benefits Plan. The address is: HCA Inc. One Park Plaza, 1-2W Nashville, TN 37203 HCA’s Employer Identification Number (EIN) is 75-2497104. The HCA Plan Administration Committee is the Plan Administrator for the HCA 401(k) Plan and the HCA Health and Welfare Benefits Plan. The address and phone number are: Plan Administration Committee c/o HCA Inc. One Park Plaza, 1-2W
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Nashville, TN 37203 1-615-344-9551 The Plan Administration Committee uses the help of many persons and organizations, including LifeTimes Connection, in administering the plans. If you have questions about these Plans, you can visit HCArewards.com or call LifeTimes Connection at 1-800-566-4114. If LifeTimes Connection cannot answer your question, you should contact: HCA Inc. Plan Administration Committee c/o Human Resources Department One Park Plaza, I-2W Nashville, TN 37203
Plan Administrator Discretion The Plan Administrator shall perform its duties as the Plan Administrator and in its sole discretion shall determine appropriate courses of action in light of the reason and purpose for which each plan is established and maintained. In particular, the Plan Administrator shall have full and sole discretionary authority to interpret all plan documents and to make all interpretive and factual determinations as to whether any individual is entitled to receive any benefits under the terms of a plan. Any construction of the terms of any plan document and any determination of fact adopted by the Plan Administrator shall be final and legally binding on all parties.
Any interpretation, determination or other action of the Plan Administrator shall be subject to review only if it is arbitrary or capricious or otherwise an abuse of discretion. Any review of a final decision or action of the Plan Administrator shall be based only on such evidence presented to or considered by the Plan Administrator at the time it made the decision that is the subject of review. Accepting any benefits or making any claim for benefits under certain plans described in this SPD constitutes agreement with and consent to any decisions that the Plan Administrator makes, in its sole discretion and, further, constitutes agreement to the limited standard and scope of review described in the applicable section.
The Plan Administrator may delegate any of its duties and responsibilities to one or more persons or entities. Such delegation of authority must be in writing, and must identify the delegate and the scope of the delegated responsibilities. For the insured benefit options under the HCA Health and Welfare Benefits Plan, the Plan Administrator has delegated its fiduciary duties to interpret the insurance contracts and to make all interpretive and factual determinations as to whether any individual is entitled to receive any benefits under the terms of the insurance contract. These delegates have the full extent of the Plan Administrator’s authority and duties with respect to those responsibilities delegated to them.
Agent for Service of Legal Process The name and address of the designated agent for service of legal process are: General Counsel/Secretary HCA Inc. One Park Plaza, I-2E Nashville, TN 37203
Legal process also can be served on the Plan Administrator or Trustee.
Plan Structure The HCA benefit plans described in these SPDs include the HCA Health and Welfare Benefits Plan and the HCA 401(k) Plan.
The HCA Health and Welfare Benefits Plan, which is an ERISA plan, consists of Medical, Dental, Vision, Life and Accidental Death & Dismemberment, Employee Supplemental Life, Dependent Life, Long-Term Disability, Employee Assistance Program, Pre-Paid Legal, Auto and Home, Short-Term Disability, Long-Term Care, Voluntary Permanent Life Insurance and the Health Care Flexible Spending Account. A portion of the HCA Health and Welfare Benefits Plan is a cafeteria plan, which consists of pre-tax employee contributions for Medical, Dental, Vision and Flexible Spending Account benefits and after-tax employee contributions for Life and AD&D, Employee Supplemental Life, Long-Term Disability and Short-Term Disability. Other benefits described in this SPD are not ERISA benefit and are not part of the cafeteria plan.
For the HCA 401(k) Plan and the insured or collectively bargained benefits under the HCA Health and Welfare Benefits Plan, this material is intended to summarize HCA's benefits in non-technical language. The benefits themselves are governed by their respective plan documents, and any underlying insurance or HMO policies, contracts or agreements, and collective
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bargaining agreements, if any. In the event of a conflict between this SPD and any of these other documents, the other documents control.
One or more of the plans are maintained pursuant to one or more collective bargaining agreements. Participants or beneficiaries may obtain a copy of the collective bargaining agreement upon written request to the Plan Administrator. The collective bargaining agreements are available for examination by participants or beneficiaries covered by those agreements.
Funding
Health and Welfare Benefits Plan Some of the benefit options are self-funded by HCA and HCA-Affiliated Facilities. That means HCA and the HCA-Affiliated Facilities pay the benefits from their general assets and the benefits are not provided through insurance. Other benefits are insured. That means HCA’s and, if applicable, HCA-Affiliated Facilities’ contributions and your (if any) contributions are used to pay insurance premiums to insurance companies, and the insurance companies pay the benefits under insurance policies or contracts. Below is a list of the benefits that are self-funded and insured. HCA and the HCA Affiliates pay part of the cost for some benefit options and you are responsible through your benefit contributions for paying your share of the cost of these benefit options for yourself and your family. The benefits provided under the plan will be paid, to the extent permitted under ERISA and the Internal Revenue Code, from the general assets of HCA, employee contributions, HCA Affiliates contributions and insurance contracts. Nothing in this plan will be construed to require HCA to maintain any fund for its own contributions or segregate any amount which it is obligated to contribute for the benefit of any participant, and no participant or other person will have any claim against, right to, or security or other interest in any fund, account or asset of HCA or HCA Affiliates from which any payment under the plan is made. 401(k) Plan The 401(k) Plan is a “defined contribution plan.” This means that the value of your account depends on the amount of contributions made, earnings or losses, and the market value of the plans’ investments. However, the assets of the Plan are held in trusts and, as such, are protected from the creditors of HCA Inc. The 401(k) Plan is funded by employee contributions based on individual elections and matching contributions from HCA affiliates based on the amount each employee contributes. Those contributions are held in a trust fund separate from company assets. The money in the trust is set aside for the exclusive benefit of Plan participants and beneficiaries. The trustee pays benefits to participants on request from the Plan Administrator (or an agent thereof). Benefits and expenses are paid from assets held by the trust.
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Plan Identification Information HCA Health and Welfare Benefits Plan: Plan Number 550 Benefit Options Funding Claims Administrator or
Insurance Carrier Benefit Contributions Other Insurance
Carrier Information
Medical HMO Insured Contact your HCA –Affiliated Facility for more information
You pay part of the cost of coverage with your pre-tax benefit contributions. The HCA-Affiliated Facility pays part of the cost of for this benefit option
Dental HMO
Insured Contact your HCA –Affiliated Facility for more information
You pay part of the cost of coverage with your pre-tax benefit contributions. The HCA-Affiliated Facility pays part of the cost of for this benefit option
Medical Smart Care Program
Self-funded
Refer to your medical ID card for Claims Administrator information
You pay part of the cost of coverage with your pre-tax benefit contributions. The HCA-Affiliated Facility pays part of the cost of for this benefit option
Prescription Drugs Smart Care
Self-funded
Caremark P. O. Box 52136 Phoenix, AZ 85072-2136 1-866-216-5767
See Medical Smart Care Program
Behavior Health Smart Care
Self-funded All Divisions (except Midwest Division): ValueOptions P.O. Box 1347 Latham, NY 12110 Midwest Division: New Directions P. O. Box 399 Shawnee Mission, KS 66201-0399 1-800-528-5763
See Medical Smart Care Program
Vision Smart Care
Self-funded EyeMed Vision Care P.O. Box 8504 Mason, OH 45040-7111
See Medical Smart Care Program
EyeMed Vision Care P.O. Box 8504 Mason, OH 45040-7111
Dental PPO
Self-funded MetLife You pay part of the cost of coverage with your pre-tax benefit contributions. The HCA-Affiliated Facility pays part of the cost of for this benefit option
Life and Accidental Death and Dismemberment Insurance
Insured
The Prudential Insurance Company of America Group Life Claim Division P.O. Box 8517 Philadelphia, PA 19176
HCA and the HCA-Affiliated Facility pays for the cost of basic Life and AD&D insurance coverage. You pay for the cost of any supplemental employee or dependent life insurance with our after-tax contributions.
Prudential Insurance Company of America 751 Broad Street Newark, NJ 07102
Long-Term Disability
Insured The Prudential Insurance Company of America Disability Management Services P.O. Box 13480 Philadelphia, PA 19176 1-800-842-1718
You pay part of the cost of coverage with your pre-tax benefit contributions. The HCA-Affiliated Facility may pay part of the cost of for this benefit option
Prudential Insurance Company of America 751 Broad Street Newark, NJ 07102
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Benefit Options Funding Claims Administrator or Insurance Carrier
Benefit Contributions Other Insurance Carrier Information
Flexible Spending Accounts
Self-funded (Health Care FSA)
Planned Benefit Systems P. O. Box 4594 Greenwood Village CO 80155-4594 Fax: 1-303-221-2785
You may pre-tax employee contributions for the cost of this coverage.
Employee Assistance Program
Self-funded All Divisions (except Midwest Division): ValueOptions P.O. Box 1347 Latham, NY 12110 Midwest Division: New Directions P. O. Box 399 Shawnee Mission, KS 66201-0399 1-800-528-5763
HCA and the HCA Affiliated Facility pays the cost for this benefit.
CorePlus Short-Term Disability
Insured Prudential Insurance Company of America P. O. Box 14633 Lexington, KY 40512-4633
You pay the entire cost for this benefit with after-tax benefit contributions
Prudential Insurance Company of America 751 Broad Street Newark, NJ 07102
CorePlus Long-Term Care
Insured Metropolitan Life Insurance Company Long-Term Care Group PO Box 937 Westport, CT 06881-0937
You pay the entire cost for this benefit with after-tax benefit contributions
Metropolitan Life Insurance Company One Madison Avenue New York, NY 10010-3690
CorePlus Voluntary Permanent Life Insurance
Insured Texas Life Insurance Company P. O. Box 830 Waco, TX 76703
You pay the entire cost for this benefit with after-tax benefit contributions
Texas Life Insurance Company P. O. Box 830 Waco, TX 76703
HCA 401(k) Plan: Plan Number 004 Benefit Options Type of Plan Plan Administrator Benefit Contributions Other Information
HCA 401(k) Plan Retirement/Defined Contribution 401(k)
Plan Administration Committee
The plan is funded by employee contributions and matching contributions from HCA affiliates. Assets are held in a trust.
Trustee: The Northern Trust Company 50 South LaSalle Street Chicago, IL 60675
This information about the administration of the 401(k) Plan is provided in compliance with the Employee Retirement Income Security Act (ERISA) of 1974, as amended. While you should not need these details on a regular basis, the information may be useful if you have specific questions about the plan.
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Key Terms
Allowable Amount: The Medical benefit option pays benefits based on the allowable amount (sometimes referred to as “reasonable and customary charges”) for that service. When determining the allowable amount, the Claims Administrator considers factors such as the complexity of the treatment, the degree of skill needed to provide the treatment, the provider’s specialty, the range of services and supplies provided by the facility or provider, and the prevailing charge in the same area for that service. You will be responsible for any amounts over the allowable amount.
Annual Maximum: Under a benefit plan, the maximum benefit payable for a covered person during the plan year.
Annual Pay: Annual Pay is your base pay determined by your employer; however, base pay excludes commissions, bonuses, overtime pay or any other extra compensation or income received from your employer. It is not your W-2 wages.
If you are a commissioned salesperson, annual pay includes your base pay plus commissions but excludes renewal commissions. Commissions will be averaged for the 12-full calendar month period of your employment just before the date of loss or the period you actually worked for your facility, whichever is less.
If you are a pieceworker, annual pay is based on your average monthly piecework earnings for the three months just prior to the date of loss.
Asset Class: A group or type of investment that all share the same risk and return characteristics and that are structured in essentially the same way. Three basic asset classes are cash (money market), bonds, and stocks.
Basic Living Expenses: Basic Living Expenses means shelter, utilities and all other costs directly related to the maintenance of the common household of the shared residence of the domestic partners. It also means any other cost, such as medical care, if some or all of the cost is paid as a benefit because a person is another person’s domestic partner.
Beneficiary: The person or persons you name to receive any benefits provided by a benefit plan in the case of your death.
Bond: A financial instrument issued by a government or a company to borrow money. The bond specifies an interest rate that will be paid and the number of years (the bond’s term) until the bond will be repaid.
“Cafeteria” Plan: A benefit plan under Section 125 of the Internal Revenue Code that allows you to choose among two or more benefits consisting of cash and qualified benefits. Generally, cafeteria plans allow you to pay premiums for benefits on a before-tax basis and elections may only be changed during annual enrollment, except in limited circumstances.
Capital Gain: A gain from disposition of an investment, equal to the excess of the sales price over the original cost.
Cash-Out Dollars: Taxable money that you may receive if you waive certain benefits. Cash-Out Dollars are considered taxable income and will be taxed in the same way that your current pay is taxed. You can view the amount of Cash-Out Dollars available to you by logging on to LifeTimes Connection at HCArewards.com.
Claims Administrator: The company responsible for administering and paying claims under a benefit plan.
Coinsurance: The percent of covered expenses that you must pay after the annual deductible, if applicable. For example, if the plan pays 80% of covered expenses, your coinsurance — after you pay your annual deductible — is 20%.
Commingled Fund: A fund that includes assets from several different accounts. The assets of participants are pooled together as a group and invested by several different investment managers that hold diversified portfolios to reduce management risk and expenses. Management risk can occur when a manager’s investment strategy is not performing in line with expectations of a particular investment category. Each manager will select securities using criteria unique to other strategies that can periodically expose investors to significant underperformance or out performance when compared to the fund’s benchmark.
Copayment (or copy): The dollar amount that you pay to the network provider each time you receive a covered service — for example, a $15 copay for an office visit. The balance of the cost for care is usually paid at 100%. Copays do not count toward the deductible and there are no copay maximums.
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Covered Expenses: Those expenses that are within the allowable amounts, medically necessary and otherwise eligible for reimbursement under a benefit plan.
Deductible: The amount you pay toward covered expenses each year before the plan begins paying benefits.
Disability: You are considered disabled if your physical or mental condition qualifies as a total and permanent disability for benefits from the Social Security Administration and your disability occurred while you were employed by an HCA affiliate. You must prove your disability by supplying the letter from the Social Security Administration approving your eligibility for disability benefits to Lifetimes Connection.
Disability Earnings: Your disability earnings are the monthly earnings you receive from any employer or for any work while you are disabled and eligible for partial disability under the LTD Plan.
Dividend: A payment by a company to an owner of its stock, as an investment return produced by the company’s profit.
Eligible Pay:
Health and Welfare Benefits: For purposes of the plan, your eligible pay generally includes all wages reported on your W-2 form, including your contributions to the plan and any before-tax dollars you use to pay for additional benefits through the HCA Health and Welfare Benefits Plan. Pay also includes any retention bonuses you receive. If your eligible pay increases during the year because of a raise or promotion, your contributions for the balance of the year are based on the increased amount. There are some exceptions to eligible pay.
Retirement Benefits: For purposes of the Plan, your eligible pay generally includes all wages reported on your W-2 form. It also includes your contributions to the 401(k) Plan and any before-tax dollars you use to pay for benefits through the HCA Health and Welfare Benefits Plan. Retention bonuses are also considered eligible pay. Eligible pay does not include certain taxable non-cash compensation such as group life imputed income. Compensation that is eligible may include child care, meals reimbursement, and adoption reimbursement. If your eligible pay increases during the year because of a raise or promotion, your contributions for the balance of the year are based on the increased amount. There are some exceptions to eligible pay.
Evidence of Insurability: Proof of physical condition or occupation provided to an insurance carrier to determine acceptance for coverage under Life Insurance and the Long-Term Disability Plan.
Experimental Procedures: Any medical procedure, equipment, treatment or course of treatment, or drugs or medicines that are:
limited to research not proven in an objective manner to have therapeutic value or benefit restricted to use by medical facilities capable of carrying out scientific studies of questionable medical effectiveness or would be considered inappropriate medical treatment
To determine whether a procedure is experimental, HCA will consider, among other things, commissioned studies, opinions and references to or by the American Medical Association, the federal Food and Drug Administration, the Department of Health and Human Services, the national Institutes of Health, the Council of Medical Specialty Societies and any other association or program or agency that has the authority to review or regulate medical testing or treatment.
Generic and Brand-Name Drugs: Most prescription drugs have two names: a “generic” name that identifies the active chemical ingredient and a “brand name” used for advertising purposes. Generic equivalents have the same active ingredient, dosage form and strength as the brand-name drugs and generally cost less than brand-name drugs.
Growth Fund: A growth fund attempts to produce long-term capital gains by investing in stocks that are generally considered to be growth stocks. Selection of such growth stocks involves following strategies that focus on companies that are experiencing significant earnings or revenue growth, rather than companies that pay out dividends. Growth funds tend to have more volatile returns than value funds and will often underperform the general equity market during a bear market or periods of economic contraction.
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Growth Stock: Growth stocks are typically companies that have high P/E ratios, and stocks that have gained popularity with mainstream investors, often due to changing investor preferences, a very positive quarterly earnings report, or growth in a particular industry. The prices of growth stocks tend to be more volatile than the prices of value stocks, meaning that growth stocks generally underperform the general equity market, as measured by the S&P 500 index, during a bear market or periods of economic contraction.
HCA: The term “HCA” refers to HCA Inc. and its affiliated facilities, unless otherwise stated. HCA Inc. is a holding company, which has no employees.
Incurred: Expenses are treated as having been incurred when the participant is provided care that gives rise to the expenses, and not when the participant is formally billed or charged, or pays for the care.
Incapable of Caring for Oneself: Incapable of caring for oneself means the person cannot dress, clean or feed themselves because of a physical or mental problem or must have constant attention to prevent them from injuring themselves or others
Lifetime Maximum: Under a benefit plan, the maximum amount payable for a covered person during the combined time of coverage.
LifeTimes Connection: LifeTimes Connection is HCA’s benefits information system that allows you to access personalized, automated information about your benefits through the Web site at HCArewards.com or interactive voice response system and Benefits Center Representative at 1-800-566-4114.
Medically Necessary: The Medical benefit option pays benefits only for services that are “medically necessary” as determined by the Plan Administrator. To be considered “medically necessary,” a service or supply must:
Be consistent with the diagnosis Meet the standards of good medical practice Be the most appropriate level of service (in the case of hospital inpatient care, this means care that couldn’t be
appropriately provided on an outpatient basis) Be recognized as an accepted medical practice and have received the required federal approval, and Not be primarily for the convenience of the patient
Out-of-Pocket Maximum: The most you pay during a plan year for eligible expenses under a benefit plan. Copayments do not count toward the annual out-of-pocket maximum.
Partially or Totally Disabled:
You have an illness or injury that limits you from performing the material and substantial duties of your regular occupation during the first 24 months of disability, and after the first 24-month period, you are unable to perform the material and substantial duties of any gainful occupation for which you are reasonably fitted by education, training or experience, and
Your current monthly income is at least 30% lower than your indexed pre-disability earnings, due to that same illness or injury.
Indexed pre-disability earnings means your monthly earnings adjusted yearly by 10% or the current annual percentage increase in the Consumer Price Index, whichever is less. Your indexed earnings may increase or remain the same, but will never decrease. Indexing is used only to determine your percentage of lost earnings while you are disabled and working.
Plan Administrator: For the purposes of most benefit plans described in this Summary Plan Description (SPD), all references to Plan Administrator refer to the Plan Administrative Committee.
Plan Disability: Pre-disability pay is your monthly benefit pay for the last full pay period before the period of total disability begins. It does not include bonuses, overtime and any other extra compensation, nor does it include income received from sources other than HCA.
If you’re a commissioned salesperson, your pre-disability pay includes income you actually receive from commissions, but it does not include renewal commissions, bonuses, overtime pay and any other extra compensation, nor does it include income received from sources other than HCA.
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If you’re a pieceworker, pay is calculated based on your average monthly piecework earnings for the three months prior to the period your disability begins.
Precertification: The process of notifying the Claims Administrator before you receive care to ensure you receive the maximum benefits payable under the plan.
Price-Earnings Ratio (P/E Ratio): Shows the multiple of earnings at which a stock sells. It is determined by dividing current stock price by current earnings per share (adjusted for stock splits). Earnings per share for the P/E ratio are determined by dividing earnings for past 12 months by the number of common shares outstanding. A higher multiple often means investors have higher expectations for future growth, and have bid up the stock’s price.
Price-to-Book Ratio: The number produced by dividing the total value of a company’s outstanding stock by the company’s book value (with a company’s book value equal to the excess of its financial accounting assets over liabilities).
Reasonable and Customary: Reasonable and customary (R&C) limits are payment limits based on the prevailing rates charged for certain procedures. When R&C limits apply, reimbursements will not exceed these amounts. You will be responsible for paying the additional amount.
Russell 1000 Growth Index: An unmanaged index commonly used as a benchmark to measure a growth stock manager’s performance. It includes the companies in the Russell 1000 Index (about 92% of the total estimated U.S market capitalization) with relatively higher price-to-book ratios and higher forecasted growth values.
Russell 1000 Value Index: An unmanaged index commonly used as a benchmark to measure a value manager’s performance. It includes the companies in the Russell 1000 Index (about 92% of the total estimated U.S market capitalization) with lower price-to-book ratios and relatively lower forecasted growth values.
Russell 2000 Growth Index: An unmanaged index commonly used as a benchmark to measure a growth stock manager’s performance. It includes the companies in the Russell 2000 Index (about 8% of the total estimated U.S market capitalization) with relatively higher price-to-book ratios and higher forecasted growth values.
Russell 2000 Value Index: An unmanaged index commonly used as a benchmark to measure a value manager’s performance. It includes the companies in the Russell 2000 Index (about 8% of the total estimated U.S. market capitalization) with lower price-to-book values and lower forecasted growth values.
S&P 500 Index: An unmanaged index commonly used as a benchmark to measure U.S. stock market performance. It includes a representative sample of 500 leading companies in leading industries of the U.S. economy.
Section 125 Plan: See “Cafeteria” plan.
Stock: A share of ownership in a company or corporation. The price of a share of common stock is determined in the market by what other investors are willing to pay for it.
Totally and Permanently Disabled: For purposes of the Plan, you are considered disabled if your physical or mental condition qualifies as a total and permanent disability for benefits from the Social Security Administration and your disability occurred while you were employed by an HCA affiliate. You must prove your disability by supplying the letter from the Social Security Administration approving your eligibility for disability benefits to LifeTimes Connection.
Totally Disabled: Totally disabled means that, as a result of an injury, a sickness or a disorder, your dependent:
Is confined in a hospital or similar institution Is unable to perform two or more activities of daily living due to a physical or mental incapacity. Activities of daily
living include bathing, toileting, transferring (moving in and out of a bed without cane or crutches), continence and eating
Is cognitively impaired Has a life-threatening condition
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Value Funds: A value fund attempts to produce long-term capital gains and current income through dividends by investing in stocks that are generally considered to be value stocks. Selection of such value stocks involve following strategies that focus on companies that appear underpriced by fundamental measures. Assuming that a company’s share price will not remain undervalued indefinitely, the fund looks to make money by buying before the expected upturn. A value fund tries to focus on relative safety rather than growth, and often chooses stocks providing dividends as well as capital appreciation. Value funds tend to have less volatile returns than growth funds and will often underperform the general equity market, as measured by the S&P 500 index, during a bull market or periods of rapid economic growth.
Value Stock: Value stocks are typically companies that have low P/E ratios and have fallen out of favor with mainstream investors, often due to changing investor preferences, a poor quarterly earnings report, or hard times in a particular industry. Value stocks are often mature companies that have slowed or stopped growing and that use their earnings to pay dividends.
Volatility: The relative rate at which the price of a fund or its underlying securities move up and down. If the price moves up and down rapidly over short time periods, it has high volatility. If the price almost never changes, it has low volatility.
