MYBENEFITS - 2020 BENEFT HIGHLIGHTS - CARING FOR OUR EXCEPTIONAL EMPLOYEES
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2020 Beneft Highlights
MyBenefits
Caring for our
exceptional employeesTable of contents
We value and appreciate Important Beneft Contacts ......................... 3
you as a member of our
exceptional team at
SSM Health. Thank you for Eligibility ................................................................ 4
being a healing presence to
our patients, their families,
each other and all those we Medical Plans....................................................... 5
serve. You are SSM Health!
At SSM Health, we are
Pharmacy Benefts ........................................... 9
committed to ofering a just
and fair benefts package that Discounted Medical Premiums ................... 11
you can personalize to ft
your needs and those of your
family. You may choose the Dental Plans ........................................................13
benefts that are best for you.
To understand the beneft Vision Plans .........................................................14
options completely, including
benefts that may be ofered
at no cost, it is important Pre-Tax Savings .................................................15
that you read the materials
outlined in this guide.
Retirement ...........................................................16
Once again, thank you
for your commitment and Paid Time Of...................................................... 17
dedication to our Mission and
for providing an exceptional
experience for our patients Life Insurance .....................................................19
and those we serve.
Other Benefts.................................................. 20
Glossary of Health Coverage and
Medical Terms .................................................... 21
This informational booklet provides key features of the personal benefts ofered at SSM Health and is
for reference purposes only. When there is a discrepancy between this information and information in
the Summary Plan Description (SPD), the SPD will prevail.
2020 Beneft Highlights | SSM Health | October 2019 | 2Beneft/HR Contact Information
We are here to help you!
Comprehensive Beneft Information
Access informational videos, helpful tools and comprehensive plan documents by visiting:
Outside SSM Health
Inside SSM Health
ssmhealth.com/benefts
Technical Assistance
For Employee Self-Service access issues, log in and password support,
call the Technology Service Center (TSC) at 1-866-776-4357.
Benefts Support IMPORTANT NOTICE:
Via phone: At SSM Health, we send
Call People Services at 1-844-SSM-MyHR (1-844-776-6947) benefts reminders and
during business hours, Monday – Friday, 7 am – 5 pm notifcations via email.
Remember to check your
Via the SSM Health intranet: SSM Health work email
Submit a ticket through AskHR 24/7 on a regular basis.
Beneft Vendors/Administrators - 2020 Plan Year
Vendor Name Beneft Administered Website Phone
wellfrstbenefts.com/
WellFirst Health Medical Plan 877-274-4693
employees
Navitus Prescription Plan navitus.com 866-333-2757
Delta Dental of Missouri Dental Plan deltadentalmo.com 800-335-8266
VSP Vision Plan vsp.com 800-877-7195
Connect Your Care (CYC) HSA and FSA Accounts connectyourcare.com 844-881-0124
403(b)/401(k)/457(b)
Empower Retirement empowermyretirement.com 855-728-7526
Plans
Securian Financial Life Insurance securian.com 833-810-8262
Short- and
UNUM Long-Term Disability, unum.com 866-240-5800
Leave of Absence
Employee Assistance paseap.com
Personal Assistance Services 800-356-0845
Program company code 0420
Employees at Greater Fond
Agnesian.com/services/
du Lac ministries (Agnesian Employee Assistance
eap-employee-assistance- 800-922-3400
Health Care) will continue to Program
program
use their internal EAP
2020 Beneft Highlights | SSM Health | October 2019 | 3Eligibility
To be benefts-eligible, you must be regularly scheduled to work at least half-time (40 hours) or more per pay period.
“Regularly scheduled” means that you are on fle with Human Resources as having a 0.5 full-time equivalent (FTE)
or higher status. For example, a 0.4 FTE working extra hours does not qualify as “regularly scheduled.” Benefts are
efective on the frst day of the month coinciding with or following hire date.
Full-time Part-time
Benefts-Eligible Status Benefts-Eligible Status
64+ hours pp (.80 - 1.00 FTE) 40 – 63 hours pp (.50 - .79 FTE)
If you are a benefts-eligible employee, you may also choose to cover your eligible dependents. Eligible
dependents include:
• An eligible child up to age 26 (your child(ren): biological, foster, adopted, step or legal guardian)
• Disabled child(ren) age 26 and older may be eligible for benefts
• Your spouse
• A Legally Domiciled Adult (LDA)
- Note: Only ONE adult (Spouse or LDA) may be covered on all plans
• The dependent child(ren) of an LDA
Legally Domiciled Adult
If you are not covering a spouse on your plan(s), you have an opportunity to cover another adult on your plan(s) through
the Legally Domiciled Adult (LDA) option.
An LDA could be an adult child who no longer meets the defnition of eligible child, a parent, relative or another adult.
The LDA must reside in the same household as you. The LDA’s dependent child(ren), even if the child(ren) reside in
another household, can also be covered.
There are important tax implications and requirements that apply to the LDA option. If you are interested in covering an
LDA on your beneft plan(s), please click here to view an informational presentation.
Important Notice: Making Changes to Your Benefts
Qualifed Change in Status
If you have a qualifed change in status during the plan year, you may be allowed to change your level of coverage
before December 31. IRS guidelines limit the type of election change that can be made following each type of change
in status. Report ANY qualifed changes in status to your Human Resources Department within 31 days of the event if
you want to change your beneft election(s) to refect the change.
Eligible changes in status include, but are not limited to:
• Family changes such as marriage, divorce, legal separation, annulment, death of your spouse or dependent, birth, adoption
or placement for adoption of your child, your dependent child ceases to satisfy the plan’s eligibility requirements.
• Changes in employment status by you or your family member such as termination or commencement of
employment, strike or lockout, commencement of or return from an unpaid leave of absence, change in worksite, or
a switch from full-time to part-time or from salaried to hourly employment (or vice versa) that causes you or your
family member to lose or gain eligibility for coverage.
Loss of Medicaid or Children’s Health Insurance Program (CHIP) Eligibility
Notifcation to Human Resources must be within 60 days after the Medicaid or CHIP coverage terminates.
Open Enrollment
The other opportunity to make changes to your benefts is during the benefts open enrollment period. This gives you
a chance to re-evaluate your beneft needs and make changes. You will receive open enrollment materials in October
for elections to be efective on Jan. 1.
2020 Beneft Highlights | SSM Health | October 2019 | 4Medical Plans
At SSM Health, the needs of the patient come frst – and that includes you and your family. That’s why all SSM Health Plan
options cover the same services. There is no need to compare your medical plan options based on services. Instead, review
the cost-sharing amounts – the premiums, deductibles, copayments and out-of-pocket maximums – to determine what
meets your preferences or needs. If you would like help choosing the plan best for you and your dependents, click here .
SSM Health has an online Beneft Enrollment Decision Support Tool to help you compare your medical plan options.
All SSM Health employees will be able to choose from the same three
medical plan options:
IMPORTANT NOTICE:
• WellFirst Plus option ($400 individual deductible)
You will be issued a new medical
• WellFirst Base option ($1,000 individual deductible)
card for Plan Year 2020. The new
• WellFirst Health Savings option ($1,500 individual deductible; card will be used for both your
paired with an SSM Health funded Health Savings Account) medical and pharmacy benefts.
Employees will select one of four coverage tiers: You will not receive a separate
• Employee Only • Employee + Spouse/LDA pharmacy card.
• Employee + Child(ren) • Employee + Family
Cost-sharing WellFirst Plus WellFirst Base WellFirst Health
Amounts Option Option Savings Option
$400 per person $1,000 per person $1,500 per person
Annual Deductible
$800 per family $2,000 per family $3,000 per family
Coinsurance 15% 15% 15%
Deductible/ $2,500 per person $5,000 per person $3,000 per person
Co-Insurance Limit $5,000 per family $10,000 per family $6,000 per family
Annual Out-of-Pocket $4,000 per person $6,500 per person $4,500 per person
Maximum $8,000 per family $13,000 per family $9,000 per family
Many preventive services are covered at no cost to you. For additional information
Preventive Services
on these services, click here .
Primary Care Visit $20 $25 $20 copay after deductible
Specialist Ofce Visit $30 $40 15% after deductible
Urgent Care $40 $40 $40 after deductible
Emergency Services $200 copay $200 copay $200 copay after deductible
Prescription Drug $5/$15/$30 copay
$5/$15/$30 copay $5/$15/$30 copay
(SSM Health Pharmacy) after deductible
Prescription Drug
$12/$35/$70 copay
(Other In-Network $12/$35/$70 copay $12/$35/$70 copay
after deductible
Retail Pharmacies)
Prescription copays are waived for
Medical Plan Prescription copays are waived for employees who
employees who have been approved for
Contribution Discount have been approved for the Medical Plan
the Medical Plan Contribution Discount
pharmacy beneft Contribution Discount.
once the deductible has been met.
2020 Beneft Highlights | SSM Health | October 2019 | 5Medical Plans - Southern Illinois, Mid-Missouri, Oklahoma
The SSM Health Network remains the primary provider network for plan members. In the Southern Illinois, Mid-Missouri,
and Oklahoma regions where employees have local limited access to SSM Health Network options for care, they may
choose to use providers in a Secondary Network, where higher deductibles, coinsurance, copays and out-of-pocket
maximums apply. Secondary Networks in Oklahoma are available through Health Care Highways. Secondary Networks
for Mid-Missouri and Southern Illinois are available through HealthLink.
Cost Sharing
Amounts –
WellFirst Health
Secondary Network WellFirst Plus Option WellFirst Base Option
Savings Option
(Southern Illinois, Secondary Network Secondary Network
Secondary Network
Mid-Missouri and
Oklahoma only)
$600 per person $1,500 per person $2,000 per person
Annual Deductible
$1,200 per family $3,000 per family $4,000 per family
Coinsurance 30% 30% 30%
Deductible/ $4,500 per person $6,500 per person $4,500 per person
Coinsurance Limit $9,000 per family $13,000 per family $9,000 per family
Annual Out-of-Pocket $6,000 per person $8,000 per person $6,000 per person
Maximum $12,000 per family $16,000 per family $12,000 per family
Many preventive services are covered at no cost to you.
Preventive Services
For additional information on these services, click here .
After April 1, secondary network copays for primary care visits will be reduced.
Primary Care Visit 1/1/2020 - $35 1/1/2020 - $45 1/1/2020 - $35 after deductible
4/1/2020 - $20 4/1/2020 - $25 4/1/2020 - $20 after deductible
Specialist Ofce Visit $35 $45 $35 after deductible
Urgent Care $40 $40 $40 after deductible
Emergency Services $200 copay $200 copay $200 copay after deductible
Prescription Drug $5/$15/$30 copay
$5/$15/$30 copay $5/$15/$30 copay
(SSM Health Pharmacy) after deductible
Prescription Drug
$12/$35/$70 copay
(Other In-Network $12/$35/$70 copay $12/$35/$70 copay
after deductible
Retail Pharmacies)
Prescription copays are
waived for employees who
Medical Plan Prescription copays are waived for employees who
have been approved for the
Contribution Discount have been approved for the Medical Plan
Medical Plan Contribution
pharmacy beneft Contribution Discount.
Discount once the
deductible has been met.
2020 Beneft Highlights | SSM Health | October 2019 | 6Medical Plans
Important Announcement!
The WellFirst Health Savings Option is paired with a Health Savings Account (HSA).
SSM Health will provide HSA contributions to employees who elect the WellFirst Health
Savings Option. For more information on the HSA, please refer to page 14 or click here
for information on how the WellFirst Health Savings Option election and HSA accounts
work together.
WellFirst Health Savings Option Annual HSA Contribution Provided by SSM Health
Coverage Tier Full-Time Employees Part-Time Employees
Employee $500 $250
Employee + Child(ren) $1,000 $500
Employee + Spouse/LDA $1,000 $500
Family $1,000 $500
Employees may contribute additional pre-tax dollars to the HSA account. HSA funds are deposited on a pay period basis
and the annual HSA contribution is pro-rated based on the date an employee becomes beneft eligible. HSA funds may
be used as they become available.
Out-of-Area Coverage
If you or a covered family member is residing outside of the SSM Health service area, you may apply to have your
medical claims covered as out-of-area. If you are an employee located in St. Louis or Wisconsin and are eligible for
coverage, you may access care by seeing a Multiplan provider. If you are an employee located in Mid-Missouri, Oklahoma
or Southern Illinois and are eligible for coverage, you may access care by seeing a PHCS provider. For a provider
directory, visit multiplan.com. Out of area coverage applications will be available during the enrollment process.
Your Annual Total Cost for Health Care
Because your health care needs are personal to you and there are many factors to consider, here’s a link to the
Beneft Enrollment Decision Support Tool. The tool allows you to enter basic information about yourself and your
anticipated health care expenses. It will provide you information about your total anticipated costs under each of the
SSM Health Medical Plan options - including the premiums you would pay out of your paycheck - and your estimated
out-of-pocket cost-sharing expenses. This tool is completely confdential and is designed to assist you with your beneft
enrollment decisions.
2020 Beneft Highlights | SSM Health | October 2019 | 7Medical Plan Premiums for 2020
SSM Health reviews the costs of the employee health plans and options each year and is committed to ensuring
afordable health care is available. Medical premiums are outlined in the table below with both pre-tax monthly and
per pay period amounts.
IMPORTANT! You may qualify for a Medical Plan Contribution
Discount which provides up to a 25% - 100% reduction in your
medical premiums. To see if you qualify for this discount, please
refer to page 11 or click here to view an informational video.
WellFirst WellFirst WellFirst Health
Plus Option Base Option Savings Option
Per Pay Per Pay Per Pay
Monthly Monthly Monthly
Period Period Period
Full-Time Employee Premiums (64 – 80 hours per pay period)
Employee $105 $48.46 $70 $32.31 $70 $32.31
Employee + Child(ren) $210 $96.92 $140 $64.62 $140 $64.62
Employee + Spouse/LDA $275 $126.92 $180 $83.08 $180 $83.08
Family $380 $175.38 $250 $115.38 $250 $115.38
Part-Time Employee Premiums (40 - 63 hours per pay period)
Employee $180 $83.08 $120 $55.38 $120 $55.38
Employee + Child(ren) $350 $161.54 $240 $110.77 $240 $110.77
Employee + Spouse/LDA $450 $207.69 $290 $133.85 $290 $133.85
Family $650 $300.00 $460 $212.31 $460 $212.31
Note: The premium is taken out of each pay period, so the amount shown per pay period is taken out of your paycheck
26 times per year. The amount shown does not include the $69.23 per pay period Spouse/LDA surcharge (if applicable).
The surcharge may be waived if you qualify; see more information below.
Spouse/LDA Surcharge
A $69.23 pre-tax per pay period surcharge will be added to the medical plan for employees who are covering a spouse
or LDA on their medical plan, if that spouse/LDA is eligible for group medical coverage through his/her employer. You are
eligible to waive this surcharge and must submit a waiver each year if your spouse/LDA is:
• also employed by SSM Health
For more
• self-employed or unemployed information about
• retired with no other group health coverage available the Spouse/LDA
surcharge and
• eligible for Medicare/Medicaid/Tricare with no other group health coverage available
instructions on
• employed but not eligible for employer-provided medical coverage or how to WAIVE
• medical coverage provided by employer does not meet ACA afordability standards. the surcharge,
Your spouse/LDA may contact their employer’s human resources department to verify click here .
whether or not the coverage provided meets the ACA afordability standard.
2020 Beneft Highlights | SSM Health | October 2019 | 8Pharmacy Benefts
Pharmacy benefts are included in your medical plan and are accessible nationwide at most major pharmacies with
the exception of CVS. See next page for a list of SSM Health Pharmacies. Visit navitus.com for a complete list of
other In-Network Retail Pharmacies.
WellFirst Plus and WellFirst Health
WellFirst Base Option Savings Option
Other
SSM Health In-Network
Other
Pharmacy Retail
SSM Health In-Network
Pharmacy
Pharmacy Retail
Pharmacy
30-day 90-day 30-day 90-day
supply supply supply supply
Tier 1
$5 $12.50 $12 $30
Formulary generic and Copays after Deductible
copay copay copay copay
preferred drug
Tier 2
$15 $37.50 $35 $87.50
Formulary brands and Copays after Deductible
copay copay copay copay
high cost generics
Tier 3
$30 $75 $70 $175
Non-Formulary brands Copays after Deductible
copay copay copay copay
and generics*
Mail order can be a convenience for members who take
maintenance medications. You can receive up to a 90-day supply
Mail Order Service from an SSM Health pharmacy or through your
mail order provider, Costco. Contact your local SSM Health
pharmacy or start the process online at pharmacy.costco.com.
*Certain specialty prescriptions are covered under the plan only when flled by the Navitus Specialty Pharmacy, Lumicera
or by an SSM Health pharmacy. This program is part of your pharmacy beneft and is mandatory. Mandatory means your
specialty medication must be obtained via a Lumicera or SSM Health pharmacy.
2020 Beneft Highlights | SSM Health | October 2019 | 9SSM Health Pharmacy Locations
Mid-Missouri Wisconsin
SSM Health St. Mary’s Hospital SSM Health Pharmacy Agnesian Pharmacy Main
2505 Mission Dr. 1821 S. Stoughton Rd. Suite 300 145 N. Main St.
Jeferson City, MO 65109 Madison, WI 53716 Fond du Lac, WI 54935
573-681-3740 608-260-6500 920-926-4600
SSM Health Pharmacy SSM Health Pharmacy Agnesian Pharmacy West
140 Northstar Dr. 1313 Fish Hatchery Rd. Suite 300, 912 S. Hickory Rd.
Holts Summit, MO 65043 Madison, WI 53715 Fond du Lac, WI 54935
573-896-4579 608-252-8044 920-929-7480
SSM Health Pharmacy SSM Health Prescription Center Agnesian Pharmacy Markesan
875 Highway 5 South 3200 E. Racine St. Suite 300 730 N Margaret St.
Tipton, MO 65081 Janesville, WI 53546 Markesan, WI 53946
660-433-5404 608-371-8100 920-398-3261
SSM Health Prescription Center Agnesian Pharmacy Waupun
Oklahoma 752 N. High Point Rd. Suite 300, 904 W. Main St.
SSM Health St. Anthony Hospital
Madison, WI 53717 Waupun, WI 53963
608 N.W. Ninth St. Third Floor
608-824-4500 920-324-3010
Oklahoma City, OK 73102
405-815-5655 SSM Health Prescription Center Agnesian Pharmacy Plus
700 S Park St., Suite 300 420 E. Division St.
Southern Illinois Madison, WI 53715 Fond du Lac, WI 54935
SSM Health Good Samaritan Hospital 608-256-6465 920-926-8585
2 Good Samaritan Way #120
SSM Health Prescription Center Agnesian Prescription Center -
Mt. Vernon, IL 62864
753 N Main St. Suite 300 Health Plaza, 421 Camelot Dr.
618-899-4999
Oregon, WI 53575 Fond du Lac, WI 54935
608-835-7175 920-926-5455
St. Louis
SSM Health St. Mary’s Hospital SSM Health Prescription Center Monroe Clinic Pharmacy
1035 Bellevue Ave. 2825 Hunters Trail 515 22nd Ave.
St. Louis, MO 63117 Portage, WI 53901 Monroe, WI 53566
314-768-8870 608-745-3001 608-325-3111
SSM Health Depaul Hospital SSM Health Prescription Center
12266 DePaul Dr. Suite 105 10 Tower Dr. Suite 300
Bridgeton, MO 63044 Sun Prairie, WI 53590
314-344-7300 608-825-3690
SSM Health Outpatient Center SSM Health Prescription Center
711 Veterans Memorial Parkway 740 Reena Ave., Suite 300
Suite 102 Fort Atkinson, WI 53538
St. Charles, MO 63303 920-568-3515
636-669-2223
2020 Beneft Highlights | SSM Health | October 2019 | 10Discounted Medical Premiums
At SSM Health, we believe care must not only address the physical needs of our employees, it must also address the
spiritual, social and emotional needs by ensuring peace of mind and access to quality health care. To help us achieve this
vision for optimum employee health, we ofer a medical plan contribution discount program for employees. This program
is ofered to improve access to afordable health care coverage by discounting employee contribution requirements based
on family size and household income as determined by the annual Federal Income Guidelines and as reported on your
2018 Federal Tax Return. The current federal income guidelines can always be accessed here and are also shown below.
(A) (B) (C) (D)
100% of the 200% of the 300% of the 400% of the
# in Household
Federal Income Federal Income Federal Income Federal Income
Guidelines Guidelines Guidelines Guidelines
1 $12,490 $24,980 $37,470 $49,960
2 $16,910 $33,820 $50,730 $67,640
3 $21,330 $42,660 $63,990 $85,320
4 $25,750 $51,500 $77,250 $103,000
5 $30,170 $60,340 $90,510 $120,680
6 $34,590 $69,180 $103,770 $138,360
7 $39,010 $78,020 $117,030 $156,040
8 $43,430 $86,860 $130,290 $173,720
Based on your 2018 family income and number (#) of dependents, if you are a full-time employee, you will be eligible
for a 25 – 100% discount on your medical plan contributions (premiums). Part-time employees will receive the same
dollar amount a full-time employee receives for the same election/level of discount.
The discount applies to all levels of medical coverage (Employee Only, Employee + Child(ren), Employee + Spouse/LDA or
Employee + Family). The discount does not apply to any other benefts. The table below illustrates how the discount applies.
Full-Time Employee Discount (64 – 80 hours per pay period)
(A) Household Income less than 100% of the Federal
100% discount
Income Guidelines
(B) Household Income >100% but 200% but 300% butDiscounted Medical Premiums – Example & Calculator
To see how the Medical Plan Contribution Discount would apply to you, please review the example and use the calculator
shown below.
Eddie Example
Employee Name Your Information Here
Full-Time Employee
2018 Family Size
(# of dependents plus yourself
and your spouse (if applicable)
4
claimed on your 2018 Federal
Tax Return)
2018 Household Income (Total
Income as reported on Federal
$36,345
Tax Return)
Household Income
Federal Income Guidelines
>100% butDental Plans
Healthy teeth are an important part of wellness. SSM Health provides two dental plans from which to choose. Delta
Dental ofers a cost-sharing plan with a participating provider network. This plan provides fexibility, network savings and
preventive services. To make the most of your dental beneft dollars, you may want to consider using one of the dental
providers in their PPO or Premier Network. You may use any dentist you choose, but your in-network beneft will always
provide the most afordable option and it will enhance the total services that you can receive under the annual maximum
beneft. Visit deltadentalmo.com for information on the provider network. You can choose the Dental Base or Dental
Plus Plan options. Click here for more information about how to make the most of your Dental Plan.
Dental Plus Dental Base
Annual Deductible – you will pay $50 per person/$150 family $100 per person/$300 family
Annual Maximum – plan will pay $2,000 per person $1,000 per person
Preventive Services –
Deductible does not apply 100% 100%
Routine exam, cleaning, X-rays
Basic Services 80% 50%
Major Services 50% 50%
Orthodontic Services (includes adults) 50% N/A
Lifetime Ortho Maximum Plan will pay $2,000 N/A
Dental Plan Premiums
Premiums are taken out of your paycheck 26 times per year.
Dental Plus Dental Base
Per Pay Per Pay
Monthly Monthly
Period Period
Full-Time Employee Premiums (64 – 80 hours per pay period)
Employee $10.25 $4.73 $7.00 $3.23
Employee + Child(ren) $30.75 $14.19 $15.75 $7.27
Employee + Spouse/LDA $25.50 $11.77 $17.50 $8.08
Family $38.50 $17.77 $26.25 $12.12
Part-Time Employee Premiums (40 - 63 hours per pay period)
Employee $17.50 $8.08 $12.00 $5.54
Employee + Child(ren) $52.50 $24.23 $24.00 $11.08
Employee + Spouse/LDA $43.75 $20.19 $30.00 $13.85
Family $61.25 $28.27 $42.00 $19.38
2020 Beneft Highlights | SSM Health | October 2019 | 13Vision Plans
The Vision Plan can assist with the cost of eye exams, lenses, frames and contact lenses. The plan is administered
by VSP, a national leading vision plan provider. The plan design includes copays for in-network coverage and
reimbursements (up to plan limits) for out-of-network coverage. Click here for more information about how to
make the most of your vision plan.
Exam + Materials
How often you can
Out-of-Network
VSP Provider use services
Provider
per covered member
Comprehensive Vision Examination $10 copay $40 allowance Once every 12 months
$40 - $125
Lenses - Glass or Plastic $25 copay Once every 12 months
allowance
OR
$150 allowance + $105 allowance
evaluation and ftting ($210 allowance
Contact Lenses Once every 12 months
covered + additional if medical
discounts necessity)
$190 allowance; $25
Standard Frames copay if lenses not $45 allowance Once every 24 months
purchased
Exam Only
Note: If you are electing the WellFirst Plus or WellFirst Base Medical Plan in 2020, these plans cover an annual eye exam.
However, the copay is higher and the network of providers is limited. If you elect one of these medical plan options and
do not need lenses or frames, you may want to opt out of the vision plan.
How often you can
Out-of-Network
VSP Provider use services
Provider per covered member
Comprehensive Vision Examination $10 copay $40 allowance Once every 12 months
Vision Plan Premiums
Premiums are taken out of your paycheck 26 times per year.
Exam + Materials Exam Only
Monthly Per Pay Period Monthly Per Pay Period
Part-Time and Full-Time Employee Premiums (40 – 80 hours per pay period)
Employee $6.50 $3.00 $3.50 $1.62
Employee + Child(ren) $12.50 $5.77 $7.75 $3.58
Employee + Spouse/LDA $11.75 $5.42 $7.25 $3.35
Family $20.00 $9.23 $12.50 $5.77
2020 Beneft Highlights | SSM Health | October 2019 | 14Pre-Tax Savings
Health Savings Account
A Health Savings Account (HSA) allows participants to set aside pre-tax dollars today to pay for out-of-pocket medical
expenses in the future. IRS guidelines outline eligibility for participating in an HSA. To participate in the HSA, you must
be enrolled in the WellFirst Health Savings Option. If you elect the WellFirst Health Savings Option, SSM Health will
provide contributions to your HSA account. You may also contribute additional pre-tax funds, up to the annual IRS limit,
to your HSA. To learn more, click here .
Annual HSA
Contribution Limits
WellFirst Health Savings Annual HSA Contribution (amount Employee can add to the HSA
Option Coverage Level Provided by SSM Health with their own pre-tax contributions)
If you will be at least age 55 during
plan year 2020, you may contribute
an additional $1,000 to your HSA
Full-time Employee
Employee $500 $3,050
Employee + Child(ren)
Employee + Spouse/LDA $1,000 $6,100
Family
Part-time Employee
Employee $250 $3,300
Employee + Child(ren)
Employee + Spouse/LDA $500 $6,600
Family
HSA funds are deposited on a pay period basis and the annual HSA contribution is pro-rated based on the date an
employee becomes beneft eligible. To pay for an eligible service or purchase, you need to have the available funds
in your account.
Flexible Spending Account – Health Care FSA
The Health Care FSA allows participants to set aside pre-tax income (up to $2,700 maximum annual contribution per
employee) to pay for eligible health care expenses incurred, but not covered by, other plans. Click here for more
information and to see if a Health Care FSA is right for you.
Important Note: This amount may be updated for 2020 based on new IRS maximums.
Important Note: Per IRS Regulations, the Health Care FSA beneft is not available to participants in the WellFirst Health
Savings Option who have an HSA. If you have funds from your 2019 FSA account as of 1/1/2020, you have to wait until
4/1/2020 to begin participation in the HSA.
Flexible Spending Account – Dependent Care FSA
The Dependent Care FSA allows participants to set aside pre-tax income (up to $5,000 maximum annual contribution
per household) to pay for eligible child or other dependent care expenses. Click here for more information and to see if
a Dependent Care FSA is right for you. You may participate in a Dependent Care FSA and the HSA. Participating in the
HSA does not impact your ability to participate in the Dependent Care FSA.
Important Note: This amount may be updated for 2020 based on new IRS maximums.
Important Note: FSA funds are subject to IRS guidelines and are “use it or lose it.” Information about important timelines
and planning tools that can help you determine how much you may want to set aside in a Flexible Spending Account will
be provided prior to Open Enrollment.
2020 Beneft Highlights | SSM Health | October 2019 | 15Retirement
SSM Health provides a market-competitive retirement program that is consistent with our Mission and Values
and is designed to assist you in achieving fnancial security for your retirement. To learn more about the retirement
savings program, click here to view an informational video or visit the Empower Retirement website
at empowermyretirement.com. Click here to schedule a one-on-one appointment with Empower.
Please note: The plans outlined below are the new SSM Health Defned Contribution Plans, efective January 1, 2020.
However, there are some groups that will continue to provide diferent benefts in 2020 and possibly beyond, as follows:
If you are grandparented in the defned beneft pension plan (DB), your benefts during 2020 will remain the same,
including the DB plan and the 50% of 3% match that you currently receive. Beginning in 2021, the benefts summarized
below will be the plan in which you will participate.
Note: Physician employer contribution benefts will not change for 2020.
Fixed Contribution
SSM Health provides an annual basic/fxed contribution for employees who qualify. To qualify, employees must be 18
years of age, work a minimum of 1,000 hours in the plan year and be actively employed on the last day of the plan year.
The employer basic/fxed contribution is 3% of employee salary (up to the annual IRS limit) or a minimum of $1,400,
whichever is greater. The $1,400 minimum contribution is pro-rated based on hours worked in the plan year.
Match Contribution
Employees who are 18 years of age and who work a minimum of 1,000 hours per year are eligible for the Employer
Match. SSM Health will match $0.50 on the dollar for the frst 6% of employee contributions on a per pay period basis
(up to IRS annual limits).
Employees are vested in both the basic/fxed and match contributions after three years of eligible service.
Retirement Savings Plans: 403(b) and 401(k)
The voluntary 403(b) or 401(k) plans allow eligible employees to contribute pre-tax or post-tax (Roth) dollars to an
investment plan administered by Empower Retirement. There are many investment options from which to choose.
Currently, you may contribute up to $19,000. If you are going to be age 50 or older in the 2020 plan year, you may also
contribute up to an additional $6,000 under the catch-up provision. You may defer up to the annual IRS limit.
Note: the contribution limits will be updated if the IRS announces new limits for 2020.
Deferred Compensation: 457(b)
Eligible employees who are on track to contribute the maximum amount to the 403(b) may also contribute to the 457(b)
up to the annual IRS limit. Currently, up to $19,000 may be contributed. Due to IRS regulations, this plan may only be
ofered to employees of non-proft ministries.
2020 Beneft Highlights | SSM Health | October 2019 | 16Paid Time Of
Paid Time Of (PTO) includes vacation time, holidays, sick days, personal time and the elimination period for short-term
disability benefts. PTO is accrued each pay period based on the actual number of hours that an employee is paid and
on low census hours (up to a maximum of 80 hours per pay period). To be eligible to accrue PTO, you must be regularly
scheduled to work at least half-time (40 hours) or more per pay period. “Regularly scheduled” means that you are on fle
with Human Resources as having a 0.5 full-time equivalent (FTE) or higher status.
Unused PTO time carries over from year to year but the maximum amount of PTO that you have in your accrual bank is
1.5 times your annual accrual amount.
If you reach your maximum PTO hours, you will need to utilize PTO time in order to accrue additional hours. During Plan
Year 2020, both a PTO sell and PTO donation program will be introduced. Click here to view an informational video.
Note: These schedules do not apply to executives, physicians and directors.
Annual Overall
Annual Max Overall Max
Accrual Rate Max (days) Max (days)
(hours) *based on (hours) *based on
8 hour days 8 hour days
Staf PTO Schedule
Fewer than 5 years of service .0923 per hour paid 192 24 288 36
More than 5 but fewer than 10 years of service .1077 per hour paid 224 28 336 42
More than 10 but fewer than 15 years of service .1192 per hour paid 248 31 372 46.5
More than 15 but fewer than 20 years of service .1269 per hour paid 264 33 396 49.5
More than 20 years of service .1385 per hour paid 288 36 432 54
Management PTO Schedule
Fewer than 5 years of service .1192 per hour paid 248 31 372 46.5
More than 5 but fewer than 10 years of service .1269 per hour paid 264 33 396 49.5
More than 10 years of service .1385 per hour paid 288 36 432 54
PTO Sell
Beginning in plan year 2020, employees may elect to “sell” unused PTO. Employees may elect to sell up to 80 hours of
PTO each year and must maintain a PTO balance of at least 40 hours. The PTO hours sold will be paid at 85% of full value
following the Open Enrollment election period (but prior to the end of the year).
PTO Donation
Beginning in plan year 2020, employees may elect to donate up to 80 hours of PTO to a medical emergency leave
sharing bank. The donor employee must retain a minimum of 40 hours of PTO. The donor may recommend the recipient,
but may not make the donation contingent on the PTO being awarded to the desired recipient. Additional program
details will be provided in early 2020.
2020 Beneft Highlights | SSM Health | October 2019 | 17Paid Time Of
Short-Term Disability
As a benefts-eligible employee, you are covered by a Short-Term Disability (STD) plan that replaces 60% of your
income when you are medically unable to work due to a serious health condition. The frst week (seven calendar days)
of disability is an elimination period during which disability benefts are not paid. You must use PTO to satisfy the
elimination period while you are medically unable to work before STD benefts begin (unless taking unpaid WI FMLA).
Following the elimination period you may be eligible to receive a beneft. The 60% Short-Term Disability coverage is
provided by SSM Health at no premium cost to you (with minimum and maximum weekly benefts). You have the
option to “buy up” to a 75% STD plan.
Note: Executives and Physicians have a separate short-term disability plan.
Employees transitioning into the STD beneft from former illness banks or salary continuation may receive an employer-
paid buy-up to 75% at no cost, based on their former illness bank balance at 2019 year-end.
Balance as of 12/2019 Automatic “buy up” provided through the last payroll occurring in:
25 – 49% of maximum December 2022
50 – 74% of maximum December 2024
75% + of maximum December 2026
Short-Term Disability Premium Calculator Based on Hourly Rate of Pay 75% Buy – Up Option Example
(A) Hourly Rate of Pay $__________ $20.00
(B) # of hours worked each pay period __________ 80
(C) Bi-weekly pay (multiply (A) the # of hours worked each pay
$__________ $1,600.00
period times (B) hourly rate of pay)
(D) Divide your bi-weekly pay (C) by 100 $__________ $16.00
(E) Multiply (D) times .47 $0.47 $0.47
(F) Buy-Up Premium cost per pay period $__________ $7.52
Short-Term Disability Premium Calculator Based on Annual Salary 75% Buy – Up Option Employee Example
(A) Annual Salary $__________ $40,000
(B) Bi-weekly Salary (annual salary divided by 26) __________ $1,538.46
(C) Divide your bi-weekly salary (B) by 100 $__________ $15.38
(D) Multiply (C) times .47 $0.47 $0.47
(E) Buy-Up Premium cost per pay period $__________ $7.23
Maternity Benefts
If you are accessing Short-Term Disability due to maternity leave, 100% of your income will be replaced for up to six
weeks for a routine delivery or up to eight weeks for a c-section. The frst week (seven calendar days) elimination period
still applies. The 100% maternity leave coverage is provided by SSM Health with no premium cost to you.
Long-Term Disability
After 90 days of being medically unable to work, you are eligible to apply to receive a Long-Term Disability beneft of
60% of your salary up to a maximum of $10,000 per month. The 60% Long-Term Disability coverage is provided by
SSM Health with no premium cost to you.
Note: This plan does not apply to executives and physicians.
For more information about the Short- and Long-Term Disability plans, please click here . To initiate a claim, please
contact UNUM at unum.com or 1-866-240-5800.
2020 Beneft Highlights | SSM Health | October 2019 | 18Life Insurance
SSM Health ofers both employer-paid and voluntary life insurance to provide fnancial security should the unexpected
occur. For more information about life insurance, please click here .
Employer-Paid Life Insurance Coverage
Part-Time and Full-Time Employees (40 – 80 hours per pay period)
Staf 1X pay up to $500,000
Manager and Above 2X pay up to $1M
Employer-Paid Accidental Death and Dismemberment Insurance (AD&D)
Part-Time and Full-Time Employees (40 – 80 hours per pay period)
Staf 1X pay up to $500,000
Manager and Above 2X pay up to $1M
Note: per industry standards, employee and spouse life insurance and AD&D are subject to beneft reduction
based on age. The beneft reduces to 65% at age 65 and to 50% at age 70.
Employee-Paid Optional Insurance (Life and AD&D)
Part-Time and Full-Time Employees Guaranteed Issue and Evidence of Insurability
(40 – 80 hours per pay period) (EOI - only applies to Life Insurance)
Multiples of pay up to 8X,
Staf During the 2020 Open Enrollment, current amount of
capped at $2M supplemental
Optional Life Insurance is guaranteed. You may elect to enroll
for life insurance;
in or increase your coverage up to the lesser of
Management Multiples of pay up to 8X,
3X annual salary or $1M without EOI.
capped at $1M for AD&D.
Dependent Life Insurance
Part-Time and Full-Time Employees Guaranteed Issue and
(40 – 80 hours per pay period) Evidence of Insurability (EOI)
During the 2020 Open Enrollment, current amount of Optional Life
Increments of $25,000 Insurance for your Spouse is guaranteed up to $250,000. You may
Spouse
up to $250,000 elect to enroll or increase the coverage up to $50,000 without EOI.
Increases in coverage over $50,000 will require EOI.
Increments of $5,000
Eligible Child All coverage is guaranteed issue – no EOI required.
up to $25,000
Dependent AD&D
Part-Time and Full-Time Employees Guaranteed Issue and Evidence of Insurability
(40 – 80 hours per pay period) (EOI – only applies to Life Insurance)
Increments of $25,000
Spouse
up to $100,000 All coverage is guaranteed issue – no EOI required.
Eligible Child $10,000 or $25,000
Additional Lifestyle Benefts
Additional services are automatically ofered to those enrolled in Life Insurance; there is no additional cost for these benefts.
Travel Assistance: Planning to travel 100 miles or more from home? Access pre-trip planning and emergency services
through RedpointWTP. Learn more at: LifeBenefts.com/travel
Financial Wellness: Convenient educational seminars that provide actionable strategies to help employees address some
of the most common aspects of fnancial stress. Learn more at securian.com/fnancialwellness360
Legal, fnancial and grief resources: access to resources for creating wills and other key legacy documents. Learn more
at LifeBenefts.com/lfg, username: lfg and password: resources.
2020 Beneft Highlights | SSM Health | October 2019 | 19Other Benefts
Employee Assistance Program
A free, confdential counseling and referral service designed to assist both you and your immediate family. The
Employee Assistance Program (EAP) can provide resources on health, fnances, retirement planning, childcare
planning, family issues and much more. EAP services are provided by Personal Assistance Services (PAS). You
may reach them at: paseap.com (company code: 0420) or 1-800-356-0845.
Note: Employees at Greater Fond du Lac ministries (Agnesian HealthCare) will continue to use their internal EAP.
Employees of these ministries may reach them at: Agnesian.com/services/eap-employee-assistance-program or
1-800-922-3400.
Bereavement Leave
You may take up to three scheduled shifts with pay in the event of the death of a family member; up to fve
scheduled shifts with pay are provided if the loss is a spouse or child/step-child. Click here to view the
bereavement leave guidelines.
Tuition Reimbursement
The tuition reimbursement policy is designed to provide fnancial assistance in support of your professional
development. If you are in good standing, you are eligible once you have been with SSM Health for 90 days. Full-time
employees are eligible for up to $4,200 annually and part-time employees are eligible for up to $2,100 annually to help
cover the cost of tuition towards a job-related degree program at an accredited college or university. Books and fees are
not eligible for reimbursement. To learn more about tuition reimbursement, click here to view an informational video.
Adoption Reimbursement
You may be reimbursed for normal agency and legal fees incurred to adopt a minor child, up to the maximum beneft,
set at the cost of an uncomplicated childbirth ($8,900).
Virtual Visits
Online virtual visits are a quick, afordable and convenient way to connect with trusted SSM Health providers and receive
treatment for common, non-urgent medical conditions. The virtual visit guides patients through an adaptive interview,
asking only relevant questions about their symptoms, just like an in-person ofce visit. SSM Health employee health plan
members: $10 Non-members: $25 Note: this beneft will become available to Agnesian and Monroe ministries in 2020.
2020 Beneft Highlights | SSM Health | October 2019 | 20Glossary of Health Coverage and Medical Terms
The Summary of Benefts and Coverage (SBC) fnal regulations require group health plans and health insurance issuers
to provide the Uniform Glossary in a common format and use terminology that is understandable by the average plan
enrollee or individual covered under an individual policy.
The Uniform Glossary includes many commonly used health coverage and medical terms, but isn’t a full list. These terms
and defnitions are intended to be educational and may be diferent from the terms and defnitions for a plan. Some of
these terms might not have exactly the same meaning when used in a policy or plan, and in any such case, the policy or
plan governs.
The glossary may not be modifed by plans or issuers. Examples of insurance-related terms to be defned are:
coinsurance, copayment, deductible, excluded services, grievance, appeal, non-preferred provider, out-of-network
copayment, out-of-pocket limit, preferred provider, premium and UCR (usual, customary and reasonable) fees.
Examples of medical terms to be defned are: durable medical equipment, emergency medical transportation,
emergency room care, home health care, hospice services, hospital outpatient care, hospitalization, physician services,
prescription drug coverage, rehabilitation services, and skilled nursing care.
How to Access the Uniform Glossary
The Uniform Glossary may be reviewed and obtained at the following websites:
• The Center for Consumer Information & Insurance Oversight (CCIIO) at cciio.cms.gov
• U.S. Department of Labor at dol.gov/ebsa/healthreform and healthcare.gov
• Paper copies of the Uniform Glossary are also available upon request.
Written Translation of the Uniform Glossary
Plans and issuers are also required to provide notices in a culturally and linguistically appropriate manner. This includes
providing access to written translation of the Uniform Glossary in Spanish, Tagalog, Chinese and Navajo for certain
geographic areas. HHS will provide written translation of the Uniform Glossary in the above listed languages at the
following websites: cciio.cms.gov and dol.gov/ebsa/healthreform
2020 Beneft Highlights | SSM Health | October 2019 | 21Dean Health Plan provides free language assistance services to help you communicate with us in your preferred language for health care. Ask your
health care professional or call: (800-279-1301)
Español
Dean Health Plan proporciona servicios de asistencia de idiomas para ayudarle a comunicarse con nosotros en su idioma preferido para obtener atención médica.
Pregúntele a su profesional de atención médica o llame al: (800-279-1301)
简体中文
Dean Health Plan 提供免费语言协助服务，帮助您以母语与我们沟通健康护理。请咨询您的健康护理专员，或拨打：
(800-279-1301)
Tiếng Việt
Dean Health Plan cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí để giúp bạn giao tiếp với chúng tôi bằng ngôn ngữ ưu tiên của bạn về việc chăm sóc sức khỏe. Hãy
hỏi chuyên gia chăm sóc sức khỏe của bạn hoặc gọi: (800-279-1301)
Polski
Dean Health Plan zapewnia bezpłatne usługi tłumaczeniowe, aby ułatwić komunikację w preferowanym języku w celu uzyskania opieki zdrowotnej. W celu
uzyskania dodatkowych informacji należy zwrócić się do lekarza lub zadzwonić pod nr: (800-279-1301)
DEUTSCH
Dean Health Plan stellt unentgeltliche Sprachassistenzdienste bereit, damit Sie mit uns im Rahmen Ihrer Gesundheitsversorgung in Ihrer bevorzugten Sprache
kommunizieren können. Wenden Sie sich an das Personal oder an folgende Rufnummer: (800-279-1301)
Korean
Dean Health Plan에서는 무료 언어 지원 서비스를 제공하여 건강 관리에 대해 원하시는 언어로 의사소통하실 수 있도록 도와드립니다. 의료 전문가에게
문의하시거나 다음 전화번호로 연락하십시오. (800-279-1301)
Hmoob
Dean Health Plan pab txhais lus pub dawb rau koj raws li hom lus koj nyiam hais thaum sib tham txog kev saib xyuas mob nkeeg nrog peb. Nug koj tus kws
khomob lossis hu xovtooj rau: (800-279-1301)
ا ﻟﻌرﺑﯾﺔ
اﺳﺄل أﺧﺻﺎﺋﻲ ا ﻟرﻋﺎﯾﺔ ا ﻟﺻﺣﯾﺔ ا ﻟﺧﺎص ﺑك أو اﺗﺻل. ﻟاﺻل ﻣﻌﻧﺎ ﺑﺎ ﻟﻠﻐﺔ ا ﻟﺗﻲ ﺗﻔﺿﻠﮭﺎ أﺛﻧﺎء ﺣﺻو ﻟك ﻋﻠﻰ ا ﻟرﻋﺎﯾﺔ ا ﻟﺻﺣﯾﺔ
ﻠﻟرﻋﺎﯾﺔ ا ﻟﺻﺣﯾﺔ ﺧدﻣﺎت ا ﻟﻣﺳﺎﻋدة ا ﻟﻠﻐوﯾﺔ ا ﻟﻣﺟﺎﻧﯾﺔ ﻟﻣﺳﺎﻋدﺗك ﻋﻠﻰ ا ﺗوDean Health Plan ﯾوﻓر ﻧظﺎم
: (800-279-1301)ﺑﺎ ﻟرﻗم
РУССКИЙ
Dean Health Plan предоставляет бесплатные услуги языкового сопровождения, чтобы помочь Вам общаться на предпочитаемом языке для получения
медицинских услуг. Обратитесь к медработнику или позвоните по номеру: (800-279-1301)
HRVATSKI
Dean Health Plan Vam pruža besplatnu jezičnu podršku kako biste mogli komunicirati s nama na jeziku koji Vam je bliskiji kad se radi o zdravstvenoj skrbi. Upitajte
svog zdravstvenog djelatnika ili nazovite: (800-279-1301)
Tagalog
Nagbibigay ang Dean Health Plan ng mga libreng serbisyo ng tulong para sa wika upang matulungan kayong makipag-ugnayan sa amin para sa pangangalagang
pangkalusugan sa inyong ginagamit na wika. Magtanong sa inyong propesyunal sa pangangalagang pangkalusugan o tumawag sa: (800-279-1301)
Français
Dean Health Plan propose des services d’assistance linguistique gratuits pour vous aider à communiquer avec nous dans votre langue préférée dans le cadre de
vos soins de santé. Demandez à votre professionnel de santé ou appelez le : (800-279-1301)
Pennsylvaanisch Deitsch
Dean Health Plan gebt Schprooch Helfe Services mitaus Koscht um dich zu helfe mit Schwetze mit uns in dei Schprooch fer Health Care. Froog dei Health Care
Professional odder rufe uff: (800-279-1301)
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Mયવસાયીને H ૂછો અથવા કૉલ કરો: (800-279-1301)
Hindi
Dean Health Plan, !वा!$य सेवा देखभाल के िलए आपक1 पसदीदा
ं भाषा म6 हमसे सचार
ं करने के िलए िनःश>क
ु भाषा सहायता सवाएँ
े Aदान करता है। अपने !वा!$य सेवा दखभाल
े Aदान करने
वाले पशे
े वर से पछ
ू 6 या िनGन पर कॉल कर6 : (800-279-1301)
Non-Discrimination Statement: SSM Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national
origin, age, disability or sex. SSM Health provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign
language interpreters and written information in other formats (large print, audio, accessible electronic formats, and other formats). SSM Health provides free
language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these
services, contact your health care professional.
If you believe that SSM Health has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex,
you can file a grievance.
If you need help filing a grievance, the SSM 24 hour equal rights helpline is available to help you. You can file a grievance in person or by mail, email, or website:
Scott Didion, System Director, Corporate Responsibility
10101 Woodfield Lane
St. Louis, MO 63132
Phone: (844) 719-2850
E-Mail: EqualRights.Coordinator@ssmhealth.com
Website: SSM.EqualRights.EthicsPoint.com
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil
Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
2020 Beneft Highlights | SSM Health | October 2019 | 22 ©2020 SSM Health. All rights reserved.
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