EMPLOYEE PACKET
This employee packet contains forms and information
for all employees, Elected Officials and
Commissioners. If you are a new employee,forms
must completed and turned into the County Clerk’s
Office 5 days prior to your start date.
Revised January
2014
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Table of Contents
Check List........................................................................................................................................... 1
Direct Deposit Authorization Form ................................................................................................... 3
Benefits Bulletin................................................................................................................................ 4
County Sponsored Benefits ............................................................................................................... 6
Deferred Comp .................................................................................................................................. 6
Health Care for Alpena County ......................................................................................................... 7
Medical Benefits ............................................................................................................................... 8
Blue Cross Vision – VSP 12-12-12 Plan.............................................................................................. 8
Delta Dental Plan Specifications- ...................................................................................................... 9
Deductible Limitations- None ......................................................................................................... 10
Short Term Disability ...................................................................................................................... 10
Life and AD&D Policy ...................................................................................................................... 10
Retirement ...................................................................................................................................... 10
Defined Benefit Plan ....................................................................................................................... 10
Defined Contribution Plan .............................................................................................................. 10
Hybrid Plan ..................................................................................................................................... 11
Benefits Table ................................................................................................................................. 12
Electronic Mail and Internet Access ............................................................................................... 13
Policy Acknowledgment Form ........................................................................................................ 13
HIPAA Notice of Privacy Practices for Personal Health Information .............................................. 14
Employee Rights and Responsibilities ............................................................................................ 17
Family & Medical Leave Act ............................................................................................................ 17
Prescription Drug Coverage and Medicare ..................................................................................... 18
Market Place Coverage...................................................................................................................29
Time & Attendance Instructions...........................................................................................................................32
Benefits Summary ................................................................................................................................................39
Policy and Procedures .........................................................................................................................................
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Alpena County Clerk’s Office
Bonnie Friedrichs, County Clerk
Phone: 989-354-9520 Fax: 989-354-9644 Email: [email protected]
Welcome to Alpena County Employment
Please refer to “Benefit Bulletin” for description of each benefit you may be eligible for. As an Employee of the
County, you will need to complete the following forms listed below. Also, keep in mind that some of the forms
listed will take you to an outside links as marked. When complete, please place a check mark next to the
completed forms and turn them into the Clerk's office no later than 5 business days after employment.
Check List: These forms must be turned in by the first date of employment
*I-9 (Employment Eligibility Form)
With copies of two proofs of identity as listed on the I-9
*W-4 (Federal Tax Withholding)
*MI-W4 (Michigan Withholding)
Payroll Direct Deposit Form
Benefit Bulletin Form
Electronic Mail and Internet Policy
Need to submit to IT and then back to Clerk's office to file
_______ Union Authorization Card (If applicable ask for card)
_______ Employee ID Badge (if required by Supervisor)
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The forms listed below must be submitted within 5 business days from the date of hire
______ Health Care Enrollment/Waiver of Benefits
______ Life Insurance, Sick & Accident Form
_____*Municipal Employee’s Retirement Enrollment Form
Voluntary Payroll Deductions: More in depth information will be provided upon request
______ AFLAC Enrollment is required within 5 days of hire or at open enrollment period
______ Deferred Comp Deductions You can enroll at anytime for the below services
______ AXA
______ Manulife
______ Nationwide
Notices: please review, print and retain for your referencing
______ Family and Medical Leave Act Notice
______ Health Insurance Marketplace Coverage Options
______ HIPAA Notices
______ Life Insurance Policy
______ Notice of Creditable Prescriptions Drug Coverage
______ Short Term Disability Policy (does not apply to Base Security Employees)
Resources:
______ Divisions
______ Personnel Handbook
______ Time Attendance Instructions
*External link
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Direct Deposit Authorization Form
Full Service Direct Deposit (FSDD) Enrollment Form
To enroll in Full Service Direct Deposition (FSDD) simply fill out this form and give it to the Alpena County
Clerk’s Office. You must attach a voided check for each checking account – not a deposit slip. If you are
depositing to a savings account, ask your bank to give you’re the Routing/Transit Number for your account. It
isn’t always the same as the number on a savings deposit slip. This will help ensure that you are paid timely
and correctly.
IMPORTANT! PLEASE READ AND SIGN BEFORE COMPLETING AND SUBMITTING!
I hereby authorize Alpena County (hereinafter the “County”) to deposit any amounts owed to me by initiating
credit entries to my accounts at the financial institutions (hereinafter “Bank) indicated on this form. Further, I
authorize Bank(s) to accept and to credit to any credit entries indicated by the County to my accounts. In the
event that the County deposits funds erroneously into my account, I authorize the County to debit my account
for an amount not to exceed the original amount of the erroneous credit.
This authorization is to remain in full force and effect until the County and Bank(s) have received written notice
from me of its termination in such time and in such manner as to afford the County and Bank(s) reasonable
opportunity to act on it.
Employee Name: _______________________________________________________________
Social Security Number: _______________________________________________ (if necessary)
Employee Signature: ____________________________________________Date: ___________
Email Address: _________________________________________________________________
Account Information: You may choose up to three (3) accounts.
1. Bank Name/City/State: ________________________________________________________
Routing/Transit #: ___________________________ Account Number: _________________
[ ] Checking
[ ] Savings
I wish to deposit $ ______________ OR [ ] Entire Amount
2. Bank Name/City/State: ________________________________________________________
Routing/Transit #: ___________________________ Account Number: _________________
[ ] Checking
[ ] Savings
I wish to deposit $ ______________ OR [ ] Entire Amount
3. Bank Name/City/State: ________________________________________________________
Routing/Transit #: ___________________________ Account Number: _________________
[ ] Checking
[ ] Savings
I wish to deposit $ ______________ OR [ ] Entire Amount
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Alpena County - 2014 SMART Form
Waive all Coverage- attach copy of health insurance card
Last, First, Middle Initial:_____________________________________________________________________________
Email address:___________________________ Social Security:___________________ Date of Birth:______________
Marital Status:_____________ Sex:__________ Street Address:_________________________ City_________________
State:________ Zip Code:_____________ Home Phone:________________________ Work Phone:_____________________
Full Time: __________________ Part Time:__________________(Part time employees will be responsible for premium on prorated basis)
Please Choose an Option:
HRA Option #1
HRA Option #2
Monthly Rates:
BCBS PPO
BCN HMO
200/400
200/400
10%
0%
500/1000
N/A
10/40/80*
4/15/40/80/20%/20%
20/80/160*
2/35/110/230/20%/20%
$20
$20
$20
$20 (after ded)
$250
$150
Single
126.00
0.00
Monthly Rates:
Double
301.00
0.00
Family
376.00
0.00
Dental/Vision
Employee Paid**
Employee Paid**
*Rx is reimbursed, by the County, up to $250 maximum per family per calendar year
Deductible
Co-Pay
Maximum Stop Loss
Prescription
Mail Order
Office Visit Co-Pay
Chiro Visit Co-Pay
ER Co-Pay
Dental**
Single:
Double:
Family:
$35.34
$77.00
$103.31
Vision**
Single:
Double:
Family:
$9.24
$22.10
$27.74
List all persons to be enrolled, including dependents up to age 26:
Middle
Social
First Name
Initial
Last Name
Sex
Security #
Health
Date of Birth
Coverage Electing:
Dental
Vision
Spouse:
Dependent:
Dependent:
Dependent:
Coordination of Benefits Information
OTHER COVERAGE
YES
NO
CIC at (855) 306-1099 or Alpena County Clerk's Office (989) 354-9520
NAME OF SPOUSE'S EMPLOYER:
NAME OF SPOUSE'S GROUP INSURANCE OR HMO:
TYPE OF COVERAGE
MEDICAL COVERAGE
YES
NO
IF YES, GROUP #:
SINGLE
FAMILY
DENTAL COVERAGE
YES
NO
IF YES, GROUP #:
SINGLE
FAMILY
VISION COVERAGE
YES
NO
IF YES, GROUP #:
SINGLE
FAMILY
PRESCRIPTION COVERAGE
YES
NO
IF YES, GROUP #:
SINGLE
FAMILY
*MEDICARE ENROLLEES
YOURSELF
MEDICARE #:
* MEDICARE ENROLLEES
SPOUSE
MEDICARE #:
MEDICARE / MEDICAID /OTHER
ELIGIBLE DEPENDENT
DEPENDENT NAME:
ID#
MEDICARE / MEDICAID /OTHER
ELIGIBLE DEPENDENT
DEPENDENT NAME:
ID#
MEDICARE / MEDICAID /OTHER
ELIGIBLE DEPENDENT
DEPENDENT NAME:
ID#
MEDICARE / MEDICAID /OTHER
ELIGIBLE DEPENDENT
DEPENDENT NAME:
ID#
*Attach a copy of Medicare card.
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BCN Primary Care Physician Selection - REQUIRED IF ENROLLING IN BCN COVERAGE
If you are enrolling in BCN, you need to select a primary care physician for you and each person on your contract. List your selection (s) below. You can
choose a different PCP for each member of your family, or one to care for your entire family. If you select to have one doctor for your entire family, you must
select a family or general practice physician. You cannot choose a specialist as a PCP. If you do not list a PCP, one will automatically be assigned.
Member Information
Member's Name
Physician Name
Physician NPI#
Physician address
Seen in last 12 months?
Subscriber
YES
NO
Spouse
YES
NO
Dep. 1
YES
NO
Dep. 2
YES
NO
Dep. 3
YES
NO
Dep .4
YES
NO
YES, I ELECT TO PARTICIPATE IN THE HRA PLAN
Certification
By signing this form I certify that these are my benefit elections and that:
1.
2.
3.
4.
5.
6.
I understand that having agreed to enroll, that I will have no right to participate in the benefit plan and that this benefit will not
be available to me, until I have completed, signed and returned the enrollment form and my enrollment is accepted
My health reimbursement account election is for eligible medical expenses for myself, my spouse and my tax dependents
Reimbursement claims must be accompanied by IRS approved documentation of the out-of-pocket expense that includes
date, type, recipient and provider of service along with the amount charged and balance due
I certify that I will not seek reimbursement for expenses reimbursed by the HRA Plan under any major medical plan or any
other health plan, such as an individual policy or my spouse’s or dependent’s health plan. I understand that the expenses for
which I am reimbursed may not be used to claim any federal income tax deduction or credit
I understand that coverage applies only to expenses incurred during my participation in the plan
I understand, that as of the first day of the plan year, that this agreement cannot be changed or revoked during the plan year
unless I experience a qualified change in my family status as defined in the Plan Documents which includes a change in my
employment or spouse’s employment status
NOTES:
EMPLOYEE SIGNATURE ____________________________________________________
DATE________________________
*Any cost share premiums will be deducted from payroll earnings biweekly
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ALPENA COUNTY BENEFITS BULLETIN
Contact: Bonnie Friedrichs
Telephone No. (989) 354-9520
IMPORTANT INFORMATION FOR
ALPENA COUNTY EMPLOYEES
Please Sign and Return this Copy
As an employee of Alpena County, you receive regular pay for the services you provide to the County. The other part of
your employment is the benefits you receive as an employee. Alpena County provide various benefits to eligible employees
and their eligible dependents The enclosed document is intended to give you a summary of benefits that are available to
you and some basic information about your benefits. The SPD supplements the booklets and certificates provided by
insurers.. .
I understand those copies of the HIPPA Policy; Family Medical Leave Rights; Electronic Mail and Internet Policy; Notice of
Creditable Prescription Drug Coverage for Medicare-Eligible Employees, Retirees, and Dependents; Health Insurance
Marketplace Coverage Options along with Union Contracts and the County Personnel handbook and employee benefit
forms are available at on http://www.alpenacounty.org/employeeaccess.html.
As an employee with Alpena County, I understand the benefits offered to me thru my employment with Alpena County. I
realize that it is my responsibility to read this information; I understand that benefits and policies can change from time to
time. I further understand that only the Board of Commissioners are authorized to agree to conditions of employment that
are different from those set forth in the Union Contract and/or Personnel Policy Handbook. Any changes must be in writing
and placed in my benefit file located in the County Clerk’s Office.
I further understand that any action or suit against the County, its agents or employees, arising out of my employment or
termination of employment, including, but not limited to, claims arising under State and Federal Law, but not Federal civil
rights statute containing a separate limitations period, must be brought within 180 days of the event giving rise to the
claims or be forever barred unless the applicable statute of limitations period is shorter than 180 days in which case I will
continue to be bound by that shorter limitations period. I waive any limitation periods to the contrary. 9
I acknowledge that I have received information regarding benefits offered by the County of Alpena. I understand that
benefits and policies may change and will be provided to me by email-which I will be responsible to review. I understand
that no policy or procedure contained in the Employee Handbook creates a contract of employment, either expressed or
implied, between me and the County. If I have any questions, I am to direct them to my Supervisor, who if unable to
answer, will refer me to the proper person in regards to my questions. Or, as an alternative, I may contact the County
Clerk’s Office with a question.
Dated ___________________
Signature of Employee _____________________________
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ALPENA COUNTY BENEFITS BULLETIN
Contact: Bonnie Friedrichs
Telephone No. (989) 354-9520
IMPORTANT INSURANCE INFORMATION FOR ALPENA
COUNTY EMPLOYEES
Please Retain This Bulletin for Future Reference
As an employee of Alpena County, you receive regular pay for the services you provide to the County. The other part of
your employment is the benefits you receive as an employee. Alpena County provide various benefits to eligible employees
and their eligible dependents The enclosed document is intended to give you a summary of benefits that are available to
you and some basic information about your benefits. The SPD supplements the booklets and certificates provided by
insurers.. .
I understand those copies of the HIPPA Policy; Family Medical Leave Rights; Electronic Mail and Internet Policy; Notice of
Creditable Prescription Drug Coverage for Medicare-Eligible Employees, Retirees, and Dependents; Health Insurance
Marketplace Coverage Options along with Union Contracts and the County Personnel handbook and employee benefit
forms are available at on http://www.alpenacounty.org/employeeaccess.html.
As an employee with Alpena County, I understand the benefits offered to me thru my employment with Alpena County. I
realize that it is my responsibility to read this information; I understand that benefits and policies can change from time to
time. I further understand that only the Board of Commissioners are authorized to agree to conditions of employment that
are different from those set forth in the Union Contract and/or Personnel Policy Handbook. Any changes must be in writing
and placed in my benefit file located in the County Clerk’s Office.
I further understand that any action or suit against the County, its agents or employees, arising out of my employment or
termination of employment, including, but not limited to, claims arising under State and Federal Law, but not Federal civil
rights statute containing a separate limitations period, must be brought within 180 days of the event giving rise to the
claims or be forever barred unless the applicable statute of limitations period is shorter than 180 days in which case I will
continue to be bound by that shorter limitations period. I waive any limitation periods to the contrary.
I acknowledge that I have received information regarding benefits offered by the County of Alpena. I understand that
benefits and policies may change and will be provided to me by email-which I will be responsible to review. I understand
that no policy or procedure contained in the Employee Handbook creates a contract of employment, either expressed or
implied, between me and the County. If I have any questions, I am to direct them to my Supervisor, who if unable to
answer, will refer me to the proper person in regards to my questions. Or, as an alternative, I may contact the County
Clerk’s Office with a question.
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COUNTY SPONSORED BENEFITS
COUNTY HEALTH PLAN PPO BCBSM State
of Michigan Service Center (800) 5790237
bcbsm.com/som
BLUE CARE NETWORK
(800) 662-6667
mibcn.com
VISION PLAN
BCBSM State of Michigan Service Center
(800) 877-7195
vsp.com
CADILLAC INSURANCE (855)
306-1099
Fax – (855) 306-1098 – Claims
cicbcg.com
DENTAL PLAN
Delta Dental Plan of Michigan
(800) 524-0149
deltadentalmi.com
Life & Short Term Disability
Dearborn National
(800) 423-2765
dearbornnational.com
Bob Grochowski- 354 -3185
Municipal Employees Retirement System
(MERS)
(800) 767-6377
Fax (517) 703-9704
mersofmich.com
DEFERRED COMP
NATIONWIDE
Anna Rivette
(877) 677-3678
CELL (989) 714-1661
Email – [email protected]
AXA EQUITABLE
Matt List
(989) 799-9630
Fax - (989) 799-5548
[email protected]
JOHN HANCOCK/MANULIFE
Russ Courtney
(989) 356-2100
Fax – (989) 354-5028
courtneyretirement.com
AFLAC Duane
Cordes (800)
798-3588
Fax – (989) 742-2100
Email - [email protected]
aflac.com
ALPENA COUNTY CLERK
Bonnie Friedrichs
(989) 354-9520
Email: [email protected]
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2014 Health Care for Alpena County
Monthly –Premium Rates
County
Employee
Premium Total
BCN
One Person
$428.16
$0.00
$428.16
Two-Person
$1027.58
$0.00
$1,027.58
Family
$1,284.48
$0.00
$1,284.48
One Person
$428.37
$126.00
$553.37
Two Person
$1,027.09
$301.00
$1,328.09
Family
$1,284.12
$376.00
$1,660.12
One Person
$0.00
$35.34
$34.34
Two Person
$0.00
$77.00
$77.00
Family
$0.00
$103.31
$103.31
One Person
$0.00
$9.24
$9.24
Two Person
$0.00
$22.10
$22.10
Family
$0.00
$27.74
$27.74
PPO Plan
Dental
Vision
Paid from Self Insurance Fund
Consult a Doctor
Affordable Care fees/assessments
$6.50
$6.50
Monthly $4,584.00
$4,584.00
MI 1% Claims Tax
Limited HRA RX Bucket- over $40
prescriptions
County pays
1% of premium
Yearly reimbursement
up to $250. 00 per
family member
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Each regular employee who is classified as full-time (or eligible part time-as outline in union
contracts or personnel handbook) is eligible for the benefits as described in this Summary Plan
Description the first billing date following 30 days of employment.
Billing Date:
First of the month
Termination of Coverage:
Coverage generally ends the last day of work.
Re-Opening Period:
November 1-30 of each year
Plan Fiscal Year End:
Dec. 31 of each year
Medical Benefits
HRA Option #1
PPO
Deductible
Co-Pay
Maximum Stop Loss
Annual OOP Max
Prescription
Mail Order
Office Visit Co-Pay
Chiro Visit Co-Pay
ER Co-Pay
Dental/Vision
200/400
10%
500/1000
$5,000/$10,000
20/40
20/40
$20
$20
$250
Employee pays
HRA Option #2
BCN
200/400
0%
n/a
$2,500/$5,000
$4/15;/40/80;/20%/20%
3x copay minus $10
$20
$20 (after ded)
$150
Employee pays
Blue Cross Vision – VSP 12-12-12 Plan
Eye Exam- once every 12
consecutive months
Lenses-standard lenses; one pair
every 12 consecutive months
Frames- standard eyeglass
frames; one frame every 12
consecutive months
*Contact Lenses-covers
medically necessary contact
lenses (requires prior
authorization approval from
VSP) Once every 12 consecutive
VSP Network Doctor
Covered $5 co pay
Covered $10 co pay
Covered $10 co pay
Covered $10 co pay
Non-VSP Provider
Reimbursement up to
$35, less a $5 co pay
Reimbursement up to
predetermined amount
based on lense type after
co pay
Reimbursement up to
$45, less a $10 co pay
Reimbursement up to
$210 less a $10 co pay
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months
Covers elective contact lenses
that improve vision (prescribed,
but do not meet criteria of
medically necessary) Once every
12 consecutive months
Co pays:
Eye exam
Lenses
Covered - $120 allowance that is
applied toward contact lens exam
(fitting and materials) and the
contact lenses
Covered -$103 allowance
that is applied toward
contact lens exam (fitting
and materials)
$5 co pay
$5 co pay applies to
charge
Member responsible for
difference between
approved amount and
provider’s charge less a
$10 co pay
A combined $10 co pay
*Members may choose between prescription glasses (lenses and frame) or contact lenses, but not both. See Blue Vision Benefit ata-Glance for additional information
Delta Dental Plan SpecificationsClass I Benefits
Diagnostic Services
Preventive Services
Emergency Palliative Treatment
Radiographs
Class II Benefits
Oral Surgery
Restorative Services
Periodontics
Endodontic
Class III Benefits
Prosthodontics
Class IV Benefits
Orthodontics
Plan Pays
100%
100%
100%
100%
Patient Pays
0%
0%
0%
0%
75%
75%
25%
25%
25%
75%
75%
25%
50%
50%
0%
100%
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Deductible Limitations- None
Maximum Payment - $1000 per person total per calendar year for Class I, II, and Class III Benefits.
The plan specifications are subject to Delta Dental’s standard exclusions and limitations.
Short Term Disability
WEEKLY DISABILITY INCOME INSURANCE
Benefit Percentages: 66 2/3%
Maximum Weekly Benefit: $400 to $650 (per union contract or personnel handbook
Maximum Benefit Period:
26 weeks;
Day Benefits Begin: 1st day of Hospitalization, including outpatient (for 8 hours or more); 1st day
of Disability due to accidental injury; and 9th consecutive day of Disability due to sickness
Life and AD&D Policy (Accidental Death or Dismemberment Insurance)-refer to your policy for
coverage. This policy under certain circumstances may be converted to an individual policy when
group coverage ends).
$15,000
Commissioners
$40,000
Elected Officials excluding Commissioners
$40,000
Salaried
$20,000
Non Union Hourly
$20,000
Deputy and Corrections
$20,000
Base Security
$20,000
211 Union
$20,000
911 Union Full Time
$7,500
911 Union Part Time
Retirement
Alpena County participates in Municipal Employee Retirement System (MERS) in which you are
eligible to participate. You will receive an annual statement of your retirement benefits through
this plan and may also access your personal account information online at
https://mymers.mersofmich.com/
Defined Benefit Plan
The MERS Defined Benefit Plan gives employees an important tool to help them reach their
retirement goals with a lifetime benefit from employers. With a MERS Defined Benefit Plan, future
benefits do not fluctuate due to investment gains or losses.
Defined Contribution Plan
The MERS Defined Contribution Plan is a qualified retirement plan under Section 401(a) of the IRS
Code. This plan also allows employers and employees to make pre-tax contributions to their
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individual accounts that accumulate tax-deferred. Contributions are invested under the
employee’s direction. The future retirement benefit is determined by the account balance, which is
directly affected by how much is contributed, the performance of the investment, and the years
invested. When an employee retires, their benefits are based on the total amount of money in
their account. As a qualified plan, employees are not taxed on employer contributions, mandatory
employee contributions, or earnings until assets are withdrawn.
Hybrid Plan
Hybrid Benefit Plan. The County maintains a Hybrid benefit retirement plan for full-time
employees hired on or after July 1, 2013. Non-union employees were offered the election to
convert to the Hybrid Plan effective January 1, 2014 with an enrollment deadline of November 24,
2013. Part-time employees are not eligible for the Hybrid benefit plan unless they become fulltime. No service credit will be accrued while an employee is on part-time status. The Hybrid
retirement plan provides the following benefits:
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BENEFITS
Division
Local 211
Sheriff
Elected/Non Union
911 Employees
Defined Contributions
Elected/Non-Union hired after
1/1/03 and who did not elect to
convert to Hybrid
Hybrid
Elected/Non-Union hired after
7/1/13; and elected/nonunion
who did elect to convert effective
1/1/14
Defined Contributions
Base Security
Benefit
B-2
Normal Ret Age: 60
V-8
FAC-5
0.00% Member Contrib.
Act 88 Election
B-4 – 80% Max.
Normal Ret Age: 60
V-10
F55 (25)
FAC-3
3.94% Member Contr.
Act 88 Election
B-2
Normal Ret Age: 60
V-8
FAC-5
0.00% Member Contrib.
DC Plan for New Hires 1/1/03)
Act 88 Election
B-2
Normal Ret Age: 60
V-8
FAC-5
0.00% Member Contrib.
Act 88 Election
Vesting
20% 3yr
40% 4 yr
60% 5 yr
80% 6 yr
100% 7 yr
Vesting DB side
6 years
DC side
2 yrs-20%
3 yr – 40%
4 yr – 60%
5 yr -80%
6 yr -100%
Act 88
Vesting
20% 3yr
40% 4 yr
60% 5 yr
80% 6 yr
100% 7 yr
Act 88 Election
% paid on 2014 wages
20.07%
23.677%
18.70%
11.29%
4% County
3% Voluntary Employee contribution
3% County Match
7.59% Employer contribution
1% mandatory employee
With the option of contributing and
additional 1,2,3,4, or 5%
4% County
3% Voluntary Employee contribution
3% County Match
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County of Alpena
Electronic Mail and Internet Access
Policy Acknowledgment Form
This confirms that I have read and understand the Computer and Internet Use Policy along with the E-Mail Use
Policy (Personnel Policy Handbook Chapter 9 page 22-30). I understand that the electronic communication system
(e-mail) is to be used for conducting the County’s business, and that I am not permitted to access a file or retrieve
stored communication other than as authorized in the performance of my job duties. I further understand that all
electronic communications systems and all information transmitted by, received from or stored in these systems,
including e-mail, are the property of the County of Alpena. I acknowledge that I have no expectation of privacy in
connection with the use of this equipment or with the transmission, receipt, or storage of information of this
equipment, including information for personal purposes.
I acknowledge and consent to the County of Alpena’s monitoring my use of this equipment at any time at its
discretion. Such monitoring may include printing and reading all e-mail messages entering, leaving, or stored in
these systems. I also understand that any violations of the Electronic Mail and Internet Access Policy may be
cause for disciplinary action, up to and including discharge from employment.
The County of Alpena reserves the right to change or amend its Electronic Mail and Internet Access Policy at any
time-with or without notice.
The following employee, by his/her signature, indicates that the Electronic Mail and Internet Access Policy was
read and understood. This notice is acknowledged by the Employee.
Employee Signature: ____________________________
Date_____________________
Print Name:____________________________________
IT REQUEST –Please add new employee to everyone list, employee alert, department head if applicable
Users Full Name: _________________________________________________________________________
Department: ____________________________________________________________________________
IT Signature: _______________________________________________ Date _______________________
New User
Name of Request
New Email Address
Phone Extension
Additional requests:
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HIPAA Notice of Privacy Practices for Personal Health Information
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
The Health Insurance Portability and Accountability Act and related rules (HIPPA) require group health
plans to protect the privacy of health information. The County Clerk’s Office administers group health
plans, sickness and disability insurance, dental/optical reimbursement plan, life insurance, prescription
drug reimbursement. Federal law requires that the plans listed above send the notice of privacy practices
below to all current enrollees. If you are not enrolled in any plan listed above, please disregard the notice
below.
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
This notice gives you information about the duties and practices to protect the privacy of your medical of
health information for each health benefit administered. The County of Alpena sponsors each" Plan.
Each plan is required by law to maintain the privacy of protected health information. Each plan provides
health benefits to you as described in your benefit policies copies of these may be obtained at the Clerk’s
Office, if you have misplaced yours). Each Plan receives and maintains health information in providing
these benefits to you. Each Plan hires business associates to help provide these benefits. These business
associates also receive and maintain health information related to you in the course of assisting each Plan.
The effective date of this notice is April 14, 2003. Each Plan is required to follow the terms of this
notice until it is replaced. Each Plan reserves the right to change their terms of this notice at any time. If
a plan amends this notice, the Plan will send a new notice to all subscribers covered by the Plan. Each
Plan reserves the right to make the new changes apply to all your health information maintain by the Plan
before and after the effective date of the new notice.
When a Plan may use or disclose your medical or health information without your consent or
authorization. The following categories describe when a Plan may use or disclose your medical or health
information without your consent or authorization. Each category includes general examples of the type of
use or disclosure, but not every use or disclosure that falls within a category will be listed:
Treatment. For example, a Plan may disclose health information at your doctor's request to facilitate receipt
of treatment.
Payment. For example, a plan may use or disclose your health information to determine eligibility or
plan responsibility for benefits; confirm enrollment and overages; facilitate payment for treatment and covered
services received; coordinate benefits with other insurance carriers; and adjudicate benefit claims and appeals.
Health Care Operations. For example, a Plan may use or disclose your health information to conduct
quality assessment and improvement activities; underwriting, premium rating, or other activities related to creating
an insurance contract; data aggregation services; care coordination, case management, and customer services,
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auditing, legal and medical review of the Plan; and to manage, plan or develop a Plan's business.
Health Services. A Plan or its business associates may use your health information to contract you with
information about treatment or other health-related benefits and services that may be of interest to you.
To Business Associates. A Plan may disclose your health information to business associates that assist
the Plan in administrative, billing, claims, and other matters. Each business associated must agree in
writing to ensure the continuing confidentiality and security of your health information.
To Plan Sponsor. A Plan may disclose to the Plan Sponsor, in summary form, claims history and other
similar information. Such summary information does not disclose your name or other distinguishing
characteristics. A Plan may also disclose to the Plan Sponsor that you are enrolled in or dis enrolled from
the Plan. A Plan may disclose your health information to the Plan Sponsor for authorized administrative
functions that the Plan Sponsor provides for the Plan. The Plan Sponsor will not use or disclose your
health information for employment-related activities or any other benefit plan.
As Required by Law. A Plan may use or disclose your personal health information for other important
activities permitted or required by state or federal law, with or without your authorization. These include,
for example:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
The U.S. Department of Health and Human Services to audit Plan records.
As authorized by state workers' compensation laws.
To comply with legal proceedings, such as a court or administrative order or subpoena.
To Jaw enforcement officials for limited Jaw enforcement purposes.
To a governmental agency authorized to oversee the health care system or government programs.
To public officials for lawful intelligence, counterintelligence, and other national security
purposes.
To public health authorities for public health purposes.
Each Plan may also use and disclose your health information as follows:
To a family member, friend or other person, to help with your health care or payment for health
care, if you are in a situation such as a medical emergency and cannot give your agreement to a
Plan to do this.
To your personal representatives appointed by you or designated by applicable Jaw.
To consider claims and appeals regarding coverage, exclusion, cost, and privacy issues.
For research purposes in limited circumstances.
To a coroner, medical examiners, or funeral director about a deceased person.
To an organ procur m nt_organization in limited circumstances.
To avert a serimis'ihie;i( to your health dr-safety-of the health or safety of others.
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Uses an disclosures with volir permission
Each Plan will not use or disclose your health information for other purposes, unless you give a Plan your
written authorization. If you give a Plan written authorization to use or disclose your health information
for a purpose that is not described in this notice, then, in most cases, you may revoke it in writing at any
time. Your revocation will be effective for all your health information a Plan Maintains, unless the Plan has
taken action in reliance on your authorization.
Your Rights
You may request in writing that a Plan do the following concerning your health information that the Plan
maintains:
•
Put additional restrictions on a Plan’s use and disclosure of your health information. A Plan does
not have to agree to your request.
•
Communicate with you in confidence about your health information by a different means or at a
different location than a Plan currently does. Your request must specify the alternative means or location
to communicate with you. A Plan does not have to agree to your request.
•
See or Receive copies of your health information. A Plan may charge a reasonable fee to cover
expenses associated with your request. In limited cases, a Plan does not have to agree to your request.
•
Amend your health information. In some cases, a Plan does not have to agree to your request.
•
Receive a list of disclosures of your health information from a stated time period during the prior
years (but not before April
14, 2003) that the Plan made for certain purposes. This listing will not include disclosures made to you;
for treatment, payment, or health care operation purposes or other exceptions. In some cases, the Plan
may charge a nominal, cost-based fee to carry out your request.
•
Send you a paper copy of this notice.
Complaints
If you believe your privacy rights have been violated by the Plan, you have the right to complain in
writing to the Plan, County Board of Commissioners, or to the Secretary of the U.S. Department of
Health and Human Services. We will not retaliate against you if you choose to file a complaint (U.S.
Department of Health & Human Services; 233 N. Michigan Ave. Suite 240; Chicago, Ill60601; phone
(312-886-1807)
Contact Office
Bonnie Friedrichs, Alpena County Clerk
720 W. Chisholm St.; Ste. #2
Alpena, Mi 49707
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EMPLOYEE RIGHTS AND RESPONSIBILITIES
UNDER THE FAMILY AND MEDICAL LEAVE ACT
Basic Leave Entitlement
FMLA requires covered employers to provide up to 12 weeks of unpaid, jobprotected leave to eligible employees for the following reasons:
•
For incapacity due to pregnancy, prenatal medical care or child birth;
•
To care for the employee’s child after birth, or placement for adoption or foster care;
•
To care for the employee’s spouse, son or daughter, or parent, who has a serious health
condition; or
•
For a serious health condition that makes the employee unable to perform the
employee’s job.
Military Family Leave Entitlements
Eligible employees with a spouse, son, daughter, or parent on active duty or
call to active duty status in the National Guard or Reserves in support of a contingency
operation may use their 12-week leave entitlement to address certain qualifying exigencies.
Qualifying exigencies may include attending certain military events, arranging for alternative
childcare, addressing certain financial and legal arrangements, attending certain counseling
sessions, and attending post-deployment reintegration briefings.
Use of Leave
An employee does not need to use this leave entitlement in one block. Leave
can be taken intermittently or on a reduced leave schedule when medically necessary.
Employees must make reasonable efforts to schedule leave for planned medical treatment
so as not to unduly disrupt the employer’s operations. Leave due to qualifying exigencies
may also be taken on an intermittent basis.
Substitution of Paid Leave for Unpaid Leave
Employees may choose or employers may require use of accrued paid leave
while taking FMLA leave. In order to use paid leave for FMLA leave, employees must
comply with the employer’s normal paid leave policies.
Employee Responsibilities
Employees must provide 30 days advance notice of the need to take FMLA
leave when the need is foreseeable. When 30 days notice is not possible, the employee must
provide notice as soon as practicable and generally must comply with an employer’s normal
call-in procedures.
FMLA also includes a special leave entitlement that permits eligible employees to take up to
26 weeks of leave to care for a covered servicemember during a single 12-month period. A
covered servicemember is a current member of the Armed Forces, including a member of the
National Guard or Reserves, who has a serious injury or illness incurred in the line of duty on
active duty that may render the servicemember medically unfit to perform his or her duties
for which the servicemember is undergoing
medical treatment, recuperation, or therapy; or is in outpatient status; or is on the temporary
disability retired list.
Employees must provide sufficient information for the employer to determine if the leave may
qualify for FMLA protection and the anticipated timing and duration of the leave. Sufficient
information may include that the employee is unable to perform job functions, the family
member is unable to perform daily activities, the need for hospitalization or continuing
treatment by a health care provider, or circumstances supporting the need for military family
leave. Employees also must inform the employer if the requested
leave is for a reason for which FMLA leave was previously taken or certified. Employees also
may be required to provide a certification and periodic recertification supporting the need for
leave.
Benefits and Protections
During FMLA leave, the employer must maintain the employee’s health
coverage under any “group health plan” on the same terms as if the employee had continued to
work. Upon return from FMLA leave, most employees
must be restored to their original or equivalent positions with equivalent pay, benefits, and
other employment terms.
Employer Responsibilities
Covered employers must inform employees requesting leave whether they
are eligible under FMLA. If they are, the notice must specify any additional information
required as well as the employees’ rights and responsibilities. If they are not eligible, the
employer must provide a reason for the ineligibility.
Use of FMLA leave cannot result in the loss of any employment benefit that accrued prior to
the start of an employee’s leave.
Covered employers must inform employees if leave will be designated as FMLA-protected
and the amount of leave counted against the employee’s leave entitlement. If the employer
determines that the leave is not FMLA- protected, the employer must notify the employee.
Eligibility Requirements
Employees are eligible if they have worked for a covered employer for at
least one year, for 1,250 hours over the previous 12 months, and if at least 50 employees are
employed by the employer within 75 miles.
Definition of Serious Health Condition
A serious health condition is an illness, injury, impairment, or physical or
mental condition that involves either an overnight stay in a medical care facility, or
continuing treatment by a health care provider for a condition that either prevents the
employee from performing the functions of the employee’s job, or prevents the qualified
family member from participating in school or other daily activities.
Subject to certain conditions, the continuing treatment requirement may be met by a period
of incapacity of more than 3 consecutive calendar days combined with at least two visits to a
health care provider or one visit and a regimen of continuing treatment, or incapacity due to
pregnancy, or incapacity due to a chronic condition. Other conditions may meet the
definition of continuing treatment.
Unlawful Acts by Employers
FMLA makes it unlawful for any employer to:
•
Interfere with, restrain, or deny the exercise of any right provided under
FMLA;
•
Discharge or discriminate against any person for opposing any practice made unlawful
by FMLA or for involvement in any proceeding under or relating to FMLA.
Enforcement
An employee may file a complaint with the U.S. Department of Labor or
may bring a private lawsuit against an employer.
FMLA does not affect any Federal or State law prohibiting discrimination, or supersede any
State or local law or collective bargaining agreement which provides greater family or medical
leave rights.
FMLA section 109 (29 U.S.C. § 2619) requires FMLA covered employers to post the text
of this notice. Regulations 29
C.F.R. § 825.300(a) may require additional disclosures.
For additional information:
1-866-4US-WAGE (1-866-487-9243) TTY: 1-877-889-5627
WAGEHOUR.DOL.GOV
U.S. Department of Labor | Employment Standards Administration | Wage and Hour Division
WHD Publication 1420 Revised January 2009
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OMB 0938-0990
Important Notice from Alpena County about Your
Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug
coverage with Alpena County and about your options under Medicare’s prescription drug coverage. This information can help you
decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current
coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription
drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at
the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a
Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage.
All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage
for a higher monthly premium.
2. Alpena County has determined that the prescription drug coverage offered by the Blue Cross/Blue Shield Group Benefit Plan is, on
average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is
therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and
not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two
(2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
CMS Form 10182-CC
Updated April 1, 2011
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
18
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OMB 0938-0990
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
Your existing coverage is creditable so you can choose not to enroll in a Medicare drug plan. If you decide to join a Medicare
drug plan, your current Blue Cross/Blue Care Network coverage will be affected.
Your current coverage pays for other health expenses in addition to your prescription drugs. If you enroll in a Medicare
prescription drug plan, you and your eligible dependents will no longer be eligible to receive all of your current health and
prescription drug benefits. You cannot enroll in a Part D plan and still keep your existing coverage.
If you do decide to join a Medicare drug plan and drop your current Blue Cross/Blue Care Network coverage, be aware that
you and your dependents will not be able to get this coverage back.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with Alpena County and don’t join a Medicare drug plan within
63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least
1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go
nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base
beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug
coverage. In addition, you may have to wait until the following October to join.
For More Information About This Notice Or Your Current Prescription Drug Coverage…
Contact the person listed below for further information or call CIC Benefit Consulting Group at (888) 775-1293. NOTE: You’ll
get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage
through Alpena County changes. You also may request a copy of this notice at any time.
For More Information about Your Options under Medicare Prescription Drug Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook.
You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug
plans.
CMS Form 10182-CC
Updated April 1, 2011
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
19
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OMB 0938-0990
For more information about Medicare prescription drug coverage:
• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare &
You” handbook for their telephone number) for personalized help
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For
information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213
(TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug
plans, you may be required to provide a copy of this notice when you join to show whether or not you
have maintained creditable coverage and, therefore, whether or not you are required to pay a higher
premium (a penalty).
Date:
Name of Entity/Sender:
Contact--Position/Office:
Address:
Phone Number:
CMS Form 10182-CC
Alpena County
Bonnie Friedrichs/County Clerk
720 W. Chisholm St.; Ste. #2; Alpena, MI 49707
989 354-9520
Updated April 1, 2011
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
20
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Enrollment and Change Form
Administrative Offices: Downers Grove, Illinois I Dallas, Texas
Underwritten by Fort Dearborn Life Insurance Company®
q New Enrollment
q Change
q Open Enrollment
q COBRA
q Retiree
Employer/ Employee Section
Enrollment forms must be submitted directly to Dearborn National unless the group is self-administered. If the group is self-administered, submit
enrollment forms to Dearborn National only if evidence of insurability is required.
EMPLOYER
GROUP NO. / ACCOUNT NUMBER
LOCATION
EMPLOYEE NAME - LAST
MIDDLE INITIAL
FIRST
SEX
DATE OF BIRTH
DATE OF HIRE (FULL TIME)
Mq Fq
EARNINGS $
SOCIAL SECURITY NO.
Weekly
JOB TITLE
Monthly
q
q
Annual
HOME ADDRESS
CITY
HOME PHONE
CLASS
q
ZIP
STATE
CELL PHONE
WORK PHONE
BENEFIT SELECTION - Life & Disability
COVERAGE SELECTION: Your non-medical group insurance program may not include all the benefits listed below. Ask your employer for the
details about the benefits available to you, your cost, if any, and whether you will be required to complete a health questionnaire.
Basic Coverage
(Check all that apply)
q Term Life / AD&D
Spouse includes Domestic Partner and Party to a Civil Union as defined in the Certificate.
q Short-Term Disability (STD)
q Long-Term Disability (LTD)
q Dependent Term Life / AD&D
(Check all that apply)
Voluntary Coverage
Spouse includes Domestic Partner and Party to a Civil Union as defined in the Certificate.
q Term Life
Employee
q Term Life
Spouse
q Term Life
Child(ren)
q Voluntary AD&D
Spouse Name - Last
q Employee
First
(A)Add, (C)Change Total Amount of
Coverage Desired
(D)Delete
If (C)hange, list
Prior Coverage
q Family
M.I.
(If Applicant)
Sex
Spouse Date of Birth Spouse Social Security #
qM qF
Has the employee (if applying) used any tobacco products in the last 2 years?
q Yes
q No
Has the spouse (if applying) used any tobacco products in the last 2 years?
q Yes
q No
BENEFICIARY DESIGNATION: (For Employee Only: Must Be Completed if you have applied for Life or AD&D insurance.) If two or
more primary beneficiaries are named, and you do not list benefit percentages, proceeds will be paid in equal shares to the named
primary beneficiaries who survive you. If no primary beneficiary survives you, proceeds will be paid to the contingent beneficiary(ies). If
you list benefit percentages, the total must equal 100%. (Employee is the beneficiary of proceeds from spouse or child coverage.)
First Name
Last Name
Social Security No.
Date of Birth
Relationship
Percentage
%
Primary
Primary
%
Contingent
%
Contingent
%
I hereby request to be insured and authorize deductions, if any, from my compensation for my share of the cost of the benefits to which I
may be entitled under the group policy (ies) issued to the employer listed above. I understand that if I am not actively at work on the
effective date of my coverage, my insurance will not begin until the day I return to work. I understand that if I do not remain actively at
work that my coverage may lapse or terminate. For those coverages I have declined, I understand that if I choose to enroll at a later
date, my cost may be higher and a health questionnaire may be required.
FOR FDL USE ONLY
EMPLOYEE SIGNATURE
Waiver of Coverage:
DATE
/
/
I DO NOT WISH TO ENROLL at this time and understand that the opportunity to enroll at any future time will be subject to such
arrangements as may be made with the company.
EMPLOYEE SIGNATURE
DATE
/
/
Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Fort Dearborn Life Insurance Company®
(Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico.
9-552-411
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Fraud Notices
Administrative Offices: Downers Grove, Illinois | Dallas, Texas
The laws of some states require us to furnish you with the following notice:
FOR APPLICATIONS AND CLAIMS:
Colorado: It is unlawful to knowingly provide false,
incomplete, or misleading facts or information to an
insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and
civil damages. Any insurance company or agent of
an insurance company who knowingly provides false,
incomplete, or misleading facts or information to a
policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with
regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado division of
insurance within the department of regulatory agencies.
District of Columbia: WARNING: It is a crime to
provide false or misleading information to an insurer
for the purpose of defrauding the insurer or any other
person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by
the applicant.
Florida: Any person who knowingly and with intent to
injure, defraud, or deceive any insurer files a statement
of claim or an application containing any false,
incomplete, or misleading information is guilty of a felony
of the third degree.
New Mexico: Any person who knowingly presents a
false or fraudulent claim for payment of a loss or benefit
or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to
civil fines and criminal penalties.
Ohio: Any person who, with intent to defraud or
knowingly that he is facilitating a fraud against an insurer,
submits an application or files a claim containing a false
or deceptive statement is guilty of insurance fraud.
Oklahoma: Any person who knowingly, with intent to
injure, defraud or deceive any insurer, makes a claim
for the proceeds of an insurance policy containing false,
incomplete or misleading information is guilty of a felony.
Pennsylvania: Any person who knowingly and with
intent to defraud any insurance company or other person
files an application for insurance or statement of claim
containing any materially false information or conceals for
the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act,
which is a crime and subjects such person to criminal
and civil penalties.
Kentucky: Any person who knowingly and with intent
to defraud any insurance company or other person files
an application for insurance or a statement of claim
containing any materially false information or conceals,
for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act,
which is a crime.
Puerto Rico: Any person who knowingly and with the
intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of
a loss or any other benefit, or presents more than one
claim for the same damage or loss, shall incur a felony
and, upon conviction, shall be sanctioned for each
violation with the penalty of a fine of not less than five
thousand dollars($5,000) and not more than ten thousand
dollars ($10,000), or a fixed term of imprisonment for
three (3) years, or both penalties. Should aggravating
circumstances be present, the penalty thus established
may be increased to a maximum of five (5) years,
if extenuating circumstances are present, it may be
reduced to a minimum of two (2) years.
Louisiana: Any person who knowingly presents a false
or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to fines
and confinement in prison.
Rhode Island: Any person who knowingly presents a
false or fraudulent claim for payment of a loss or benefit
or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to
fines and confinement in prison.
Maine & Washington: It is a crime to knowingly
provide false, incomplete, or misleading information to
an insurance company for the purpose of defrauding the
company. Penalties include imprisonment, fines and
denial of insurance benefits.
Tennessee: It is a crime to knowingly provide false
incomplete or misleading information to an insurance
company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of
insurance benefits
Maryland: Any person who knowingly and willingly
presents a false or fraudulent claim for payment of a loss
or benefit or who knowingly and willfully presents false
information in an application for insurance is guilty of a
crime and may be subject to fines and confinement in prison.
Virginia: It is a crime to knowingly provide false,
incomplete or misleading information to an insurance
company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of
insurance benefits.
Hawaii: For your protection, Hawaii law requires you be
informed that presenting a fraudulent claim for payment
of a loss or benefit is a crime punishable by fines or
imprisonment, or both.
Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Fort Dearborn Life Insurance Company®
(Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico.
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Fraud Notices
Administrative Offices: Downers Grove, Illinois | Dallas, Texas
The laws of some states require us to furnish you with the following notice:
FOR CLAIMS ONLY:
Alaska: A person who knowingly and with
intent to injure, defraud, or deceive an
insurance company files a claim containing
false, incomplete, or misleading information
may be prosecuted under state law.
Arizona: For your protection, Arizona law
requires the following statement to appear on
this form. Any person who knowingly presents
a false or fraudulent claim for payment of a loss
is subject to criminal and civil penalties.
New Hampshire: Any person who, with a
purpose to injure, defraud or deceive any
insurance company, files a statement of claim
containing any false, incomplete or misleading
information is subject to prosecution and
punishment for insurance fraud, as provided in
RSA 638:20.
New Jersey: Any person who knowingly files
a statement of claim containing any false or
misleading information is subject to criminal
and civil penalties.
Arkansas: Any person who knowingly
presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false
information in an application for insurance is
guilty of a crime and may be subject to fines
and confinement in prison.
Texas: Any person who knowingly presents a
false or fraudulent claim for the payment of a
loss is guilty of a crime and may be subject to
fines and confinement in state prison.
California: For your protection California law
requires the following to appear on this form.
Any person who knowingly presents false or
fraudulent claim for the payment of a loss is
guilty of a crime and may be subject to fines
and confinement in state prison.
Massachusetts: Any person who knowingly
presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false
information in an application for insurance is
guilty of a crime and may be subject to fines
and confinement in prison.
Delaware: Any person who knowingly, and
with intent to injure, defraud or deceive any
insurer, files a statement of claim containing
any false, incomplete or misleading information
is guilty of a felony.
New Jersey: Any person who includes any
false or misleading information on an
application for an insurance policy is subject to
criminal and civil penalties.
FOR APPLICATIONS ONLY:
Idaho: Any person who knowingly, and with
intent to defraud or deceive any insurance
company, files a statement or claim containing
false, incomplete, or misleading information is
guilty of a felony.
Indiana: A person who knowingly and with
intent to defraud an insurer files a statement
of claim containing any false, incomplete, or
misleading information commits a felony.
Minnesota: A person who files a claim with
intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Fort Dearborn Life Insurance Company®
(Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico.
Page 2 of 2
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R 6.28/11
New Health Insurance Marketplace Coverage
Options and Your Health Coverage
Form Approved
OMB No.
PART A: General Information
When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health
Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic
information about the new Marketplace and employment­based health coverage offered by your employer.
What is the Health Insurance Marketplace?
The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The
Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible
for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance
coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.
Can I Save Money on my Health Insurance Premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or
offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on
your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible
for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be
eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does
not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your
employer that would cover you (and not any other members of your family) is more than 9.5% of your household
income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the
Affordable Care Act, you may be eligible for a tax credit.1
Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your
employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer
contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for
Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an aftertax basis.
How Can I Get More Information?
For more information about your coverage offered by your employer, please check your summary plan description or
contact CIC at (855) 306-1099 or Alpena County Clerk's Office (989) 354-9520
.
The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the
Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health
insurance coverage and contact information for a Health Insurance Marketplace in your area.
1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered
by the plan is no less than 60 percent of such costs.
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PART B: Information About Health Coverage Offered by Your Employer
This section contains information about any health coverage offered by your employer. If you decide to complete an
application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered
to correspond to the Marketplace application.
3. Employer name
4. Employer Identification Number (EIN)
38-6004834
County of Alpena
5. Employer address
6. Employer phone number
989 354-9520
720 W. Chisholm St.; Ste #2
7. City
8. State
9. ZIP code
MI
49707
Alpena
10. Who can we contact about employee health coverage at this job?
Bonnie Friedrichs, Alpena County Clerk
11. Phone number (if different from above)
12. Email address
[email protected]
Here is some basic information about health coverage offered by this employer:
•
As your employer, we offer a health plan to:
All employees.
✔
Some employees. Eligible employees are:
employees who are regularly scheduled to work over 30 hours per week and as outlined in union contracts and
employee handbooks
•
With respect to dependents:
✔
We do offer coverage. Eligible dependents are:
spouse and dependents as outlined in union contracts and employee handbooks
We do not offer coverage.
✔
If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to
be affordable, based on employee wages.
** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium
discount through the Marketplace. The Marketplace will use your household income, along with other factors,
to determine whether you may be eligible for a premium discount. If, for example, your wages vary from
week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly
employed mid-year, or if you have other income losses, you may still qualify for a premium discount.
If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the
employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your
monthly premiums.
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The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for
employers, but will help ensure employees understand their coverage choices.
13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in
the next 3 months?
Yes (Continue)
13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the
employee eligible for coverage?
No (STOP and return this form to employee)
(mm/dd/yyyy) (Continue)
14. Does the employer offer a health plan that meets the minimum value standard*?
Yes (Go to question 15)
No (STOP and return form to employee)
15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include
family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she
received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on
wellness programs.
a. How much would the employee have to pay in premiums for this plan? $
b. How often?
Weekly
Every 2 weeks
Twice a month
Monthly
Quarterly
Yearly
If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don't
know, STOP and return form to employee.
16. What change will the employer make for the new plan year?
Employer won't offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan
available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for
wellness programs. See question 15.)
a. How much will the employee have to pay in premiums for that plan? $
b. How often?
Weekly
Every 2 weeks
Twice a month
Monthly
Quarterly
Yearly
Date of change (mm/dd/yyyy):
• An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by
the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
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Employee Self Service .O vervi.ew
Your Web Address is:
hHps . Htubeate . attenda.nGeQPd.emantf~or:n/.d.efalU.t, aewMefault
--~
Step 1: Login with your ID number and your
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Employee Self Service
attendance
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Punch IN or OUT
Request time off
Review Information
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To Punch IN/Ol-!T - ·
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Click on the
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To Review I nformation
1. nme Card - Review current/previous period time cards
2.
3.
4.
5.
Schedules - Review personal schedules and time off
Personal - Review personal information
Benefit- Review detailed benefit balances
Archive - Review archived time cards
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Request Time Off
Use the " Request Time Off" options to request benefit time- such as vacation - for approval by your manager. You have
3 different request options available:
Request T ime
· Off - One 0~)' :
.
. One Day- This option allows the employee to request
time off in full day increments. Click on "Request Time Off- One
Day" and then enter the date, amount of time and any notes. Once
you click "OK", your manager can then either "Approve" or "Deny"
the request.
1. ·.
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wish to have off, the amount of time, benefit requesting, and any
additional notes.
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request multiple consecutive days off. Click on "Request Time Mult Days", and enter the date range of the request, amount of
hours, benefit requesting, and any additonal notes.
-
-
Regardless of the option used, the request will show on the Activity screen as "Pending" until your supervisor either
"Approves" or Denies" it.
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NOTE: While in a pending state the employee can remove the request.
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.Airport Joint Use Acjfeement
·Alpena
Boiliff Family Division
'Bailiff·CitcuiiO
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MINUTES
MINUTES
100THS
0
0.00
0.02
1
0.03
2
0.05
3
0.07
4
0.08
5
0.10
6
0.12
7
0.13
8
0.15
9
0.17
10
0.18
11
12
0.20
0.22
13
14
0.23
0.25
15
0.27
16
17
0.28
18
0.30
19
0.32
20
0.33
21
0.35
0.37
22
0.38
23
0.40
24
0.42
25
0.43
26
0.45
27
0.47
28
0.48
29
0.50
30
100THS
31
0.52
32
0.53
33
0.55
0.57
34
35
0.58
0.60
36
37
0.62
0.6'3
38
0.65
39
40
0.67
41
0.68
42
0.70
43
0.72
0.73
44
45
0.75
0.77
46
47
0.78
48
0.80
49
0.82
50
0.83
0.85
51
0.87
52
0.88
53
0.90
54
0.92
55
0.93
56
0.95
57
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58
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59
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2am
3am
4am
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7am
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9am
10am
11am
12pm
1pm
2pm
3pm
4pm
Spm
6pm
7pm
8pm
9pm
10pm
11pm
Midnight
MILITARY
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
00
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1-1-2014
Employee Benefits
Summary
Questions about
coverage?
We can help!
CIC Benefit Consulting Group
1406 N. Mitchell Street
Cadillac, MI 49601
855.306 . 1099
www. cicbcg. com
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Alpena County - 2014
Hea lth 8 eneft1 Summary Sh eet - PPO
BCBS PPO 15
+<uJ
-·
WI"th
-C~••
'!~..!!....,
........,.,--
--
HRA
~econd- Submit HRA Plan- You Pay
Deductible
$2,500 single/$5,000 family
in-network deductible
%Co-pay
p%
Non- Union/Union $200 single/$400 family
in-network deductible
~he riffs Department $100 single/$200 family
in-network deductible
10%
0% Copayment
Put-of-pocket
maximum
~0 single/$0 family
~500 single/$1 ,000 family
in-network copayment
in-network copayment
Annual COP Max ~5,000/$1 0,000
Office Visit
~40
~hiropractic
~40
Emergency Room ~250
~opay
Prescription
Drugs*
$10 Generic
$40 Formulary Brand Name
$80 Non-Formulary Brand Name
Mail Order $20/$80/$160
Vision
Eye Exam - every 12 months
Lenses/Contacts - every 12 months
Olasses - every 12 months
Preventative-1 00% coverage
Restorative- 75% coverage
Major Services- 50% Coverage
$1000 Maximum
VSP
Dental
Delta Dental
$5,000/$10,000
Reimburse down to
Reimburse down to
Reimburse down to
Reimburse down to
Reimburse down to
Reimburse down to
$20 Non-Union/ Union
$30 Sheriffs Department
$20 Non-Union/Union
$30 Sheriffs Department
$250 Non-Union/Union (no reimbursement)
$150 Sheriffs Department
$10 Generic
$40 Formulary Brand Name
$40 Non-Formulary Brand Name
Mail Order $20/$40/$40
~*Reimburse up to $250 per member per calendar year on Rx
pver$40
Employee Paid-See Benefits at a Glance for further coverage
information on vision allowance & out of network coverage
Employee Paid -See Benefits at a Glance for further coverage
information on dental allowance & out of network coverage
Visit www.bcbsm.com for additional information including participating doctors in your area.
Alpena County - 2014
Hea lth 8 ene ft1 Summary Sh ee t - BCN
WI'th
HRA
BCN10
•
·~
Deductible
~2 ,000 single/$4,000 family deductible
Reimbursed down to $200 single/$400 family deductible
Yo Co-pay
P%
P%
$0 single/$0 family
$0 single/$0 family
:Annual OOP Max
$2,500/$5,000
$2,500/$5,000
Office Visit
$20
No Reimbursement
Specialist Visit
$40
No Reimbursement
Chiropractic
~40 copay (up to 30 visits per year)
No Reimbursement
Urgent Care
$50 copay
No Reimbursement
Emergency Room
Copay
$150 after deductible
No Reimbursement
~% Copayment
put-of-pocket
0
Networl<
BlueCare
O l MIChiQfU\
!Seamless HRA Plan- You Pay
~aximum
Prescription Drugs ~4/15/40/80/20%/20%
Mail Order- 3x copay minus $10
Eye Exam - every 12 months
Lenses/Contacts - every 12 months
Glasses - every 12 months
Vision
VSP
Dental
Delta Dental
Preventative-1 00% coverage
Restorative- 75% coverage
Major Services- 50% Coverage
~1 000 Maximum
$4/15/40/40/40/40
"'Reimburse up to $250 per member per calendar year on Rx
over$40
Employee Paid-See Benefits at a Glance for further coverage
information on vision allowance & out of network coverage
Employee Paid -See Benefits at a Glance for further coverage
information on dental allowance & out of network coverage
Visit www.bcbsm.com for additional information including participating doctors in your area.
+.., VQ
_
A
~fDbt CO'pol'.llOn
Blue Care
Network
of M1chigan
CLSSLG with Deductibles
lind II"Ktepen()IIN llcet\liA!e
of tnt 8 ue Cross and Be"e Shr~ A.~soc~o~ton
00189731 Count y of Alpena
Deductible, Copays and Dollar Maximums
Note: The Deductible will apply to certain services as defined below.
Deductible
$2,000 individual/$4 ,000 family per benefit year YOU PAY $200/$400
Fixed Dollar Copays
$5 for allergy injections
$20 for office visits
$50 for u rgent c are visits
$150 for emergency room visits
No fixed dollar copay for ambulance services. See below for applicable coinsurance
$40 for referral physician visits
Coinsurance
50% for select services as noted below
Out of Pocket Maximum - applies to deductibles,
copays and coinsurance amounts for all covered
services
$2,500 per individuall$5,000 per f amily
20% for select services as noted below
Preventive Services
Health Maintenance Exam
100%
Annual Gynecological Exam
100%
Pap Smear Screening
100%
Well-Baby and Child Care
100%
Immunizations
100%
Prostate Specific Antigen (PSA) Screening
100%
Routine Colonoscopy
100%
Mammography Screening
100%
Voluntary Female Sterilization
100%
Breast Pumps (DME guidelines apply. Limited to no
more than one per 24 month period.)
Maternity Pre-Natal care
100%
---
100%
Physician Office Services
Office Visits
$20 Copay
Consulting Specialist Care
$40 copay
Emergency Medical Care
Hospital Emergency Room - Copay waived if
admitted
Urgent Care Center
$1 50 Copay after deducti ble
Ambulance Services
80% after deductible
$50 Copay
Benefits Selected WDRPOV,UR50,Cl20%,D2000,DSR20%,1MG150,ER150.C020,2500PM,P415CL,MOPD20,BENYR,40RP
bcbsm.com
10/29/2013 12:27:51 pm
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10/13-ss
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+QU
~
BlueCare
Network
of M1ch1gan
CLSSLG with Deductibles
00189731 County of Alpena
Diagnostic Services
r-
Laboratory and Pathology Tests
Diagnostic Tests and X-rays
High Technology Radiology Imaging (MRI, MRA,
CAT, PET)
Radiation Therapy
100%
- -
-----
80% after deductible
$150 copay after deductible
--
--
--
80% after deductible
Maternity Services Provided by a Physician
Post-Natal and Non-routine Pre-Natal Care
$20 Copay
Delivery and Nursery Care
100% (For professional services. See Hospital Care for facility charges) after deductible
-------~-----
Hospital Care
General Nursing Care. Hospital Services and
Supplies
Outpatient Surgery - included all related surgical
services and anesthesia - see member certificate for
specific surgical copay_s ._ _ _ _ _ __
80% after deductible
80% after deductible
Alternatives to Hospital Care
Skilled Nursing Care
80% after deductible
Up to 45 days per member per benefit year
Hospice Care
100% after deductible
Home Health Care
$40 copay after deductible
Surgical Services
Surgery - includes all related surgical services and
anesthesia - see member certificate for specific
surgical copays .
Voluntary Male Sterilization -See Preventive
Services section for voluntary female sterilization
First Trimester Termination of Pregnancy (One
procedure per two year period of membership)
Human Organ Transplants
Reduction Mammoplasty
80% after deductible
Male Mastectomy
50% after deductible
50% after deductible
Temporomandibular Joint Syndrome
Orthognathic Surgery
Weight Reduction Procedures (Limited to one
procedure per lifetime)
50% after deductible
50% after deductible
80% after deductible
50% after deductible
---
50% after deductible
50% after deductible
Benefits Selected WDRPOV.UR50.CI20%,02000.DSR20%.1MG 150.ER150.C020,2500PM.P415CL .MOPD20,BENYR ,40RP
bcbsm .com
10/29/2013 12:27:51 pm
Current 01/14
10/13-ss
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+ {IQ
"
Blue Care
Network
of M1chigan
CLSSLG with Deductibles
00189731 County of Alpena
Mental Health Care and Substance Abuse Treatment
Inpatient Mental Health Care
80% after deductible
Inpatient Substance Abuse Care
80% after deductible
Outpatient Mental Health Care
$20 Capay
Outpatient Substance Abuse
$20 Capay
Autism Spectrum Disorders, Diagnoses and Treatment
Applied behavioral analyses (ABA) treatment Limited to 25 hours per week for line therapy for
children through age 18
Outpatient physical therapy, speech therapy,
occupational therapy, nutritional counseling for
autism spectrum disorder through age 18
Other covered services, including mental health
services, for Autism Spectrum Disorder
$20 Capay
$40 capay after deductible
See your outpatient mental health benefit and medical office visit benefit
Other Services
Allergy Testing and Therapy
50% after deductible
Allergy Injections
$5 capay
Chiropractic Spinal Manipulation - when referred (up
to 30 visits per calendar year)
$40 capay
Outpatient Physical, Speech and Occupational
Therapy (One period of treatment for any
combination of therapies within 60 consecutive days
per calendar year)
Infertility Counseling and Treatment (Excludes Invitro fertilization)
Durable Medical Equipment
$40 capay after deductible
50% after deductible
100%
Prosthetic and Orthotic Appliances
100%
Diabetic Supplies
80%
Prescription Drugs
Tier 1A - $4 capay, Tier 1 B - $15 capay, Tier 2 - $40 capay Tier 3- $80 capay, Tier4/Tier5 20% coinsurance
Sexual Dysfunction drugs - 50% Coinsurance
Female Contraceptives- Tier 1A - Covered in Full . Tier 18- $15 capay. Tier 2 - $40 capay.
Tier 3 - $80 capay
Mail Order Prescription Drugs
Three times applicable capay minus $10 for 90 day supply
Prescription Drug Deductible
None
Hearing Aid
Not Covered
Rx reimbursed up to $250 er member er calendar year any co_Qay over $40
bcbsm.com
10/29/ 2013 12:27:52 pm
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10/13-ss
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+"
0
~
..
Blue Cross
Blue Shield
of Miehtgan
A nonprolol corporehon and 10dependent lansee
ol the Blue Cross and Blue Sh~eld AsSOCiation
---------
Blue Vision 12/12/125 M
Benefits-at-a-Glance County of Alpena
Group 007016435-0000
This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and
exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay. For a complete
description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your
group uses, if your group is self-funded. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan
document will control.
Blue Vision benefits are provided by Vision Service Plan (VSP) , the largest provider of vision care in the nation. VSP is an independent company
providing vision benefit services for Blues members. To find a VSP doctor, call 1-800-877-7195 or log on to the VSP Web site at vsp.com.
Note: Members may choose between prescription glasses (lenses and frame) or contact lenses, but not both.
VSP network doctor
Non-VSP provider
Member's responsibility (copays)
Eye exam
$5 capay
$5 copay applies to charge
Prescription glasses (lenses and/or frames)
Combined $10 capay
Member responsible for difference between
approved amount and provider's charge ,
after $10 capay
Medically necessary contact lenses
$10 copay
Member responsible for difference between
approved amount and provider's charge ,
after $10 capay
I
Eye exam
Complete eye exam by an ophthalmologist or
optometrist. The exam includes refraction,
glaucoma testing and other tests necessary to
determine the overall visual health of the patient.
$5 capay
Reimbursement up to $35 less $5 capay
(member responsible for any difference)
One eye exam in any period of 12 consecutive months
Lenses and frames
Standard lenses (must not exceed 60 mm in
diameter) prescribed and dispensed by an
ophthalmologist or optometrist. Lenses may be
molded or ground , glass or plastic. Also covers
prism, slab-off prism and special base curve
lenses when medically necessary.
Note: Discounts on additional prescription
glasses and savings on lens extras when
obtained from a VSP doctor.
$10 capay (one capay applies to both
lenses and frames)
Standard frames
Note: All VSP network doctor locations are
required to stock atleast 100 different frames
within the frame allowance.
$130 allowance that is applied toward
frames (member responsible for any cost
exceeding the allowance) less $10 copay
(one copay applies to both frames and
lenses)
Reimbursement up to approved amount
based on lens type less $10 copay
(member responsible for any difference)
One pair of lenses, with or without frames. in any period of 12 consecutive months
Reimbursement up to $451ess $10 copay
(member responsible for any difference)
One frame in any period of 12 consecutive months
Contact lenses
Medically necessary contact lenses (requires
prior authorization approval from VSP and
must meet criteria of medically necessary)
$10 capay
Reimbursement up to $210 less $10 capay
(member responsible for any difference)
Elective contact lenses that improve vision
(prescribed , but do not meet criteria of medically
necessary)
$130 allowance that is applied toward
contact lens exam (fitting and materials)
and the contact lenses (member
responsible for any cost exceeding the
allowance)
One pair of contact lenses in any period of 12 consecutive months
$105 allowance that is applied toward
contact lens exam (fitting and materials)
and the contact lenses (member
responsible for any cost exceeding the
allowance)
Contact lenses are covered up to allowance every 12 consecutive months
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent l icensee of the Blue Cross and Blue Shield Association.
Current 01/ 14
Blue V ision 12/12/12
10/ 13-ss
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0
DELTA DENTAL
DELTA DENTAL OF MICHIGAN
Delta Premier Spec(fic Plan Characteristics
For
ALPENA COUNTY
DEFINITION OF SUBSCRIBER- All employees who do not have coverage through another source.
PLAN SPECIFICATIONS -
Class I Benefits
Diagnostic Services
Preventive Services
Emergency Palliative Treatment
Radiographs
Plan Pays
100%
100%
100%
100%
Patient Pays
0%
0%
0%
0%
Class n Benefits
Oral Surgery
Restorative Services
Periodontics
Endodontics
Plan Pays
75%
75%
75%
75%
Patient Pays
25%
25%
25%
25%
Class III Benefits
Prosthodontics
Plan Pays
50%
Patient Pays
50%
Class IV Benefits
Orthodontics
Plan Pays
0%
Patient Pays
100%
DEDUCTIBLE LIMITATIONS - None.
MAXIMUM PAYMENT - $1,000 per person total per calendar year for Class I, Class II and Class III
Benefits.
The plan specifications are subject to Delta Dental's standard exclusions and limitations. A complete listing is
included in the group contract and subscriber certificate and can be obtained from your Delta Dental
representative.
This plan includes access to the International SOS Assistance, Inc., (1-SOS) worldwide network of dentists and
dental clinics for enrollees who are outside of the United States. Delta Dental coverage outside of the United
States is the same as Delta Dental coverage within the United States. For more information about the 1-SOS
network program, check our Web site at or contact your Delta Dental representative.
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Yo ur primary care physician, yo L~r :
Blue C are Network connection to care
Why a primary care physician
Selecting a primary care physician. or PCP, is an
important first step to a healthful lifestyle. Your doctor
wi l become your partner in maintaining ~ur good
health and will manage most of your care.
PCP care starts with regular checkups, health
screenings and immunizations. It includes treatment
for Ulness. lnjury and c hronic conditions, ltke a heart
condition or asthma. Your PCP also arranges for
specialty care. lab tests or hospitalization.
Connect to care
It's important to choose a PCP as soon as you
become a member, so your ooverage is activated.
If you don't select a PCP within 30 days of becoming
a member, one is selected for you to make sure you
can get the care you need.
You have choices
Your BCN primary care physician may be an MD .
(medical doctor) or a D.O. (osteopathic docto r) in one
of these categories:
How to choose a primary care
physician
With thousands of qualified primary care physicians in
our network, how do you decide?
Start with convenience. Onllne or i1 our prtnt
directory, physicians are listed by county and c ity. You
can also search for a doctor by hospital affiliation and
extended office hours.
If you want more information, we encourage you to
call the doctor's office or BCN Customer SerVice.
Here are some other questions to ask:
•
Is the physician a man or a woman?
•
How many years has the doctor been
In practice?
•
What languages are spoken in the
physician's office?
Online at MIBCN.comlflnd. you can search for and
print your customized search results.
Which doctor did you select?
We need to know your PCP.
•
•
•
•
Family or general practice physicians treat
patients of all ages, from newborns to adults . They
commonty provide obstetrical and gynecological
care as well.
Internists specialize in all aspects of medical care.
Most of our network internists treat patient s age
18 and older.
Pediatricians specialize in the treatment of infants
and children age 18 or younger.
Physicians trained as both intemists and
pediatricians treat c hildren and adults.
Each member of your family can select a PCP. or you
can choose one for your whole famify. You can select
a family or general practitioner doctor or a pediatr1cian
for your children. Females can also see an 08-GYN
(obstebician-gynecorog·st). or aoother woman's health
specialist, without a referral, as part of our Women's
Choice p rogram.
MiBCN.com
If you named your PCP on your enrollment form,
you've given us the information we need.
If you selected a PCP online and clicked SUbmit,
you've given us the information we need.
You can also call Customer Service, and tell us Which
PCP you selected.
Questions?
To reach Customer Service, cal the num ber on
the back of your BCN card or our m ain number
(1-800-662-6667) 8 a.m. to 5 :30 p.m. Monday
through Friday. The TIY number is 1-800-257-9980.
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Woman's Choice program '\
\
,,
You choose. No referral needed.
The Woman's Chok::e pro gram Is a self-referral program. TMs means for routine wo men's health oorvk::oo. you may
visit certain Blu9 Care Network-contracted spoclallsts without a r~erral from your primary care physician.
Find a Woo)a!)'s Choica doctor at MiBCN.com/find.
Woman's health services
Woman's Chok::e health s peclall~ts lnch.Jde obstetr1clans, gyneco logists, obstetrk:: tan-gynoco loglsts, gynecologic oncologists. IQproducttve 9ndocr1nologlsts . maternal and fetal medicine Sp9Ciallsts, neonatologists. per1natologlsts and certified
nurse midwives. Your women's health spoclallst may perfon'Yl or order servtcoo• without your PCP's referral, such as:
Gynecological care
Obstetrical care
• Breast exams and mammograms
• Bone d£0Sity studies
• Gynocological BXBmS, Pap smears, ocntmcepti~
management and in-office surgical and n::nsurgbal
treatment of gyneoologic disorders
• Dagnosis c:nd in-office surgical and nonsurgcal trgatmant
of al (bnecok:lgi::al infections as well as bladder infections
• 1-bspital admissions fof infant deliwry and all obstetrical
cam and procedures
• Maternity ultrasrund
• PeMc ultmsrunds
• ln ~ffi::e surgcal proooduras
• Treatment of suspectoo or confirmed malignanot
• Vduntary sterilization
You need your PCP's referral for these s.ervk::oo•:
• Dagnosis and tmatment for all obstetrical diagnoses
Ondudng obs1etrk::-r91ated llnessas)
• Fetalronstress tests
• Amniocentesis and FJ1oG.aM injections
• Elective pregnancy termination
• Tubal ligatic:os pec1ormed at delivery
• Laboratory.. and pathology seM:es rglated to gynecok:lgc
problems and all obstetric cam
• Q)stetrt prooedres, inducing d~nosfu lab•• and radi::lbgy
• Surgical treatment of spontan€0.JS or missed abortion
• S urgk::al proceduroo performed h an o utpatient facUlty
•Benefits vary by plan . To ch9Ck ~ur covgrage, k:lg in to
MiBCN.com for ~t.r plan's oonefit details.
• Hospital admission for condition other than dellvei"J
•'Must oo Sl3n1: to Jont Venture Hospital Laboratories affiliate
Questions?
Call theo number on the back of your BCN 10 card o r our
main number (1-000-662-6667) 8 a.m. to 6:30 p.m.
Monday thro ugh Friday. The TTY number Is
1-800-26 7-9980.
MiBCN.com
CB 1029.i 101 11
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About your Blues prescription drug
coverage
This guide lists the most commonly used drugs available t o
members with Blue Cross Blue Shield of M ichigan or Blue
Care Network prescription drug coverage. Drugs on this
list are grouped into categories, called tiers, with the safest
and least expensive drugs included in the lower tiers. Your
copayment, or ou t-of-pocket cost, is outlined in your drug
benefit and defined by one of these five ti ers.
Tier 1 -
Lowest copayment
All d rugs in this cat egory are generic d rugs. You'll pay the
lowest copayment for generics, which makes them the most
cost-effective opt ion for treatment . BCN groups generic
d rugs into two tiers:
• Tier 1A (lowest generic copayment) includes preferred
generic d rugs to treat chronic diseases like high blood
pressure, cholesterol, d iabetes, heart disease, certain
eye diseases, depression and congestive heart failure.
• Tier 1 B (highest generic copayment) includes other
covered generic d rugs
•
Tiers 1A and 1B only apply to BCN. BCBSM considers all
generic d rugs tier 1.
Tier 2 -
Higher copayment
This category includes preferred, brand-name d rugs. These
d rugs are more expensive than generics, and you 'll pay a
hig her copayment for t hem.
Tier 3 -
Highest copayment
In this category are nonpreferred brand-name drugs for
which there is either a generic alternative o r a more costeffective preferred brand. You'll pay the highest copayment
for these nonspecialty d rugs.
Specialty drugs are used t o treat complex cond it ions,
such as cancer, multiple sclerosis or rheumatoid arthritis.
These drugs usually need special handling or monitoring.
They also may need special approval, and you m ay
have to order th em through a specialty pharmacy.
Specialty drugs are limited t o a 30-day supply. We also
limit the first prescription for certain specialty drugs
to a 15-day supply. Your cost share will be reduced by
one-half for this prescription.
Most plans group specialty drugs into tiers 4 and 5. If
you don't have this type of plan, you'll find specialty
drugs grouped under tiers 1, 2 or 3. For more information
about specialty drugs, visit bcbsm.com/pharmacy.
How do I know what type of
prescription coverage I have?
Individual drug plans vary. For details about your d rug
benefit, please call the Customer Service phone number
on the back of your Blues ID card. Or, if you have online
access, log in to your account at bcbsm.com.
Generic drugs deliver better value
Brand-name drugs can be costly, but many are now
available as generics, which cost less. Frequently, your
prescription will be filled wit h a generic drug, for a lower
copayment. That's because generic d ru gs work t he same
as brand-name drugs. The Food and Drug A dministration
requires that generic drugs have the same active ingredients
as their brand-name versions. If you're taking a brand-name
drug, ask your doctor if there's an alternat ive for your
condition.
Tier 4 - Lowest specialty drug copayment
Tier 4 preferred specialty d rugs are generally more effective
and less expensive than nonpreferred specialty drugs in tier 5.
Tier 5 - Highest specialty drug copayment
You'll pay the highest copayment for nonpreferred specialty
d ru gs in t ier 5. That's because a more cost-effective g eneric
or preferred b rand may be available.
Und er the Affordable Care Act, some members can
receive certain commonly prescribed drugs with no cost
sharing. These include aspirin, folic acid, fluoride, iron,
vitamin D, smoking cessation products and certain
cont raceptive medications. To g et these drugs, you
need a prescription from your doctor, and you must
meet plan requirements. For a complete list of these
products, please visit bcbsm.com/pharmacy.
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Why do some drugs need approval?
The Blues review the use of certain d rugs to make sure that
our members receive the most appropriate and costeffective drug therapy. For example, you may be required
to try one or more preferred drugs to treat your health
condition, or you may have to get approval before a certain
drug is covered.
Drugs that requ ire approval are identified in the drug list.
The conditions for approval are based on current medical
information and the recommendations of the Blues
Pharmacy and Therapeutics Committee, a group of doctors,
pharmacists and other health care experts.
If the drug is not approved, you may have to pay the full
cost of the drug. For a list of drugs that require prior
approval, please visit bcbsm.com/pharmacy.
How do I fill my prescription?
There are two ways to fill your prescription:
• At a retail pharmacy
More than 2,400 reta il pharm acies in Michigan and
65,000 retail pharmacies outside of Michigan accept
your Blues card. You may f ill prescriptions at any of
these pharmacies.
Most retail pharmacies can fill a 90-day supply of your
prescription. BCN requires a 30-day trial of brandname drugs before covering 90-day p rescriptions.
• Mail order (home delivery)
You can receive your prescriptions through one of
ou r mail-order vendors. The type of drug you take
determines which mail-order vendor you use:
- Specialty drugs should be ordered through
Walgreens Specialty Pharmacy.
- All other drugs should be ordered through
Express Scripts mail order pharmacy.
If you have questions about which mail order vendor to use,
please call the Customer Service number on the back of
your Blues ID card, or visit bcbsm.com/pharmacy.
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Talk to a doctor 24/7/365
by phone, video or email
CALL.
An innovative approach to health care
You and your fam ily have 24/ 7/365 phone, video
and e-mail access to board-certified doctors who
can treat many non-emergent medical conditions.
TeladoC'!l has re define d t radit ional health care by
harnessing the power of telehealth technology. The
result: Americans nationwide ca n now experience
real-time, quality care- anyti me , anywhere.
Talk to
ConsultADoctor.com
Talk to a doctor
anytime online or by
phone and skip the
waiting room
~
1-800-DOC-CONSULT (362-2667)
Fill your prescriptions
Avoid the wait
•0
I
•
Download the mobile app
iDr 24/ 7 gives you anytime
access to a doctor through
your mobile phone. Scan t he
code to download today.
Receive t1mely
p rescription refi lls,
if approp riate, and
pickup at your local
pharmacy.
( (ll1'
Teladoc.
ldt / •, [
( r ...
t(ll
!C... 110\.','
lt I
,r),
Watch for product tmprovements & brand changes coming soon
With your consent, Teladoc can send consult inform ation to your primary care physician.
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0')1'
to cons It
ANYTIME, ANYWHERE
PHONE CONSULT OPTIONS
B
a
ent
able
ACCESS TO QUALITY MEDICAL CARE
What can you use it for?
When should you use it?
Who are the doctors?
Telad oc ca n treat m any o f yo ur
medical cond it 1ons, including:
Telad oc does not replace your primary
care physician. It is a convenient
alternative:
Teladoc is simply a new way to
access qualified and experienced
doctors who:
• W hen yo u need care now
• A re practici ng PCPs, pediatricians,
and family medicine physicians
• Cold & flu symptoms
• Respiratory infection
• A llergies
• Bronchit is
• Sinus problems
• Pediatric care
• And mo re!
• If you're considering t he ER or
urgent care center for a non·
em ergency issue
• O n vacation, on a b usiness trip, or
away f rom home
• For shor t-term p rescription refills, if
appropriate
• Average 15 yea rs experience
• Are U.S. board-certified and
licensed 1n your st ate
• Are credentialed every three years,
meeting NCQA standards
TM
INTEGRATED HEALTH TECHNOLOGY AT YOUR FINGERTIPS
M y Personal Health Manag er (M yPH M '") is a one- stop w eb portal t hat combines 24/7 d octor access
with cutting-edge health app lications, empowering members to lead healthier, more productive lives.
My Consult Center: Schedule appointment s,
email a doctor, store and for ward you r medical
Health Monitoring: Track and manage yo ur
own wellness program with a few easy clicks
history to your primary care physician
Personal Health Record (PHR): Store,
manage, and share your PHRs from one central
lo cation
Symptom Checker: Interactive
q uestionnaires d esigned t o narrow d own
sym ptoms, med ica l cond itions, and treat ments
Risk Assessments: Identify health risks with
interactive lifestyle quizzes
Health library: The latest health articles and
research at your fingert ips
1t
Health Alerts: Receive t he latest health
ind ust ry news and policy updates
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