1. Ivy Tech Community College Limited Medical Insurance Plans

2. PLAN INFORMATION
Ivy Tech Community College currently offers two limited medical insurance plans to adjunct faculty members who do not also have a full-time appointment with Ivy Tech, or part-time (less than 60%) hourly or administrative employees who are not eligible for the full-time Ivy Tech benefit plan. Eligible employees may purchase one of the plans to cover you, your spouse and eligible dependent children.
The two limited medical insurance plans offered include:
Basic Medical Plan
Enhanced Medical Plan
Welcome to Ivy Tech Community College.

3. Plan comparison at a glance
PLAN SUMMARY COMPARISON
Plan comparison at a glance
Here is a plan summary comparison of the two plans offered by Ivy Tech.
You’ll note there are differences in benefits. 3

4. MultiPlan Network BASIC MEDICAL PLAN SUMMARY
Office Visit Benefit $20 co-pay
Rx Benefit (name brands and generics) Covered at 50% up to
$750 per Calendar Year
Hospital Care (inpatient and outpatient) 60% after per occurrence deductible
Physician Services 60% after per occurrence deductible
Additional In-patient Benefit $400 Per Day
30 Days Per Calendar Year
Lab/X-ray/Diagnostic Care 60% up to $750 per occurrence
Office visit co-pays are not subject to the deductible.
The physician services benefit also includes chiropractic services
The In-patient benefit pays after the per accident or sickness maximum benefit is used.

5. BASIC MEDICAL PLAN SUMMARY (continued)
MultiPlan Network
Emergency Room/Ambulance Covered at 60%
($350 per visit Emergency Room Deductible – waived if due to an accident or results in hospital admission)
Surgery (inpatient and outpatient) 60% after per occurrence deductible
Other Covered Medical Services
(home health, hospice, physical therapy) 60% after per occurrence deductible
Deductible Per Accident or Sickness $200
Maximum Benefit Per Accident/Sickness $2,500 Per Occurrence
The Emergency Room/Ambulance benefit applies after a $350 ER deductible has been met. This deductible is waived if admitted into the hospital or due to an accident.

6. ENHANCED MEDICAL PLAN SUMMARY
MultiPlan Network Office Visit Benefit $15 co-pay Rx Benefit (name brands and generics) Covered at 50% up to $1,000 per Calendar Year Hospital Care (inpatient and outpatient) 80% after per occurrence deductible Physician Services 80% after per occurrence deductible Additional In-patient Benefit $500 Per Day 30 Days Per Calendar Year Lab/X-ray/Diagnostic Care 80% up to $1,000 per occurrence
Office visit co-pays are not subject to the deductible.
The physician services benefit alsoincludes chiropractic services
The In-patient benefit pays after the per accident or sickness maximum benefit is used.

7. ENHANCED MEDICAL PLAN SUMMARY (cont.)
MultiPlan Network
Emergency Room/Ambulance Covered at 80%
($350 per visit Emergency Room Deductible – waived if due to an accident or results in hospital admission)
Surgery (inpatient and outpatient) 80% after per occurrence deductible
Other Covered Medical Services
(home health, hospice, physical therapy) 80% after per occurrence deductible
Deductible Per Accident or Sickness $150
Maximum Benefit Per Accident/Sickness $5,000 Per Occurrence
The Emergency Room/Ambulance benefit applies after a $350 ER deductible has been met. This deductible is waived if admitted into the hospital or due to an accident.

8. COVERAGE BASICS 90% of claims incurred are between $1 and $3,500
Both plans cover all State Mandates
$10,000 Accidental Death Coverage
No Medical Underwriting – Guarantee Issue
Vision Discount Program – National Vision Administrators
Prescription Benefits Available
Express Scripts is the discount prescription vendor on both plans.
Pre-existing condition clause does not apply to Pregnancy
Plan policies are underwritten by American Sentinel Insurance Co.
$100 Wellness Benefit Included
$10,000 ADD applies to covered employees and covered dependents.
Vision Discount Program – this is a discount only program. After enrolling, members receive a vision discount card from National Vision Administrators.
The prescription plan under the Basic Plan is a discount program. Information for the plan is located on the back of your ID card. It allows you to purchase brand name Rx at a discounted cost. After purchasing the Rx, submit the receipt to HCH Admin. For reimbursement. $750 annual maximum.

9. Monthly Premiums PREMIUM INFORMATION Basic Plan Enhanced Plan
Employee Only $ per month $ per month
Employee + 1 $ per month $ per month
Family $ per month $ per month
Premiums are direct billed to the employee. Payments can be made through debit card, credit card or ACH Debit monthly.
The $10 processing fee can be reduced by paying semi-annually.
Checks are not accepted
There is no payroll deduction for this plan.

10. FREQUENTLY ASKED QUESTIONS
Why are there dollar limits on this plan? The American Sentinel Plan was not designed to replace a traditional health insurance plan, only to offer affordable coverage to individuals who otherwise wouldn’t be able to buy coverage. Can an employee be turned down for coverage? No, an eligible person cannot be turned down. Can dependents be covered? Yes. Due to changes with Health Care Reform, dependents can now be covered to age 26, if the dependent is not eligible for another employer-sponsored health plan.

11. FREQUENTLY ASKED QUESTIONS (continued)
Is there a pre-existing condition clause? Yes, a pre-existing condition is an injury or illness for which you have received medical advice, treatment, or incurred expenses within 6 months prior to your enrollment date. Pre-existing conditions are covered after 12 continuous months from your enrollment date or after 6 continuous months of receiving no treatment and incurring no expenses for the condition. These periods may be reduced by any creditable coverage that you may have had with a previous employer-sponsored or individual insurance plan. No pre-existing limitation will be applied to pregnancy. Lastly, due to changes with Health Care Reform, the pre-existing clause will not apply to any enrollee that is under the age of 19. Who do I contact with questions? Contact American Sentinel customer service at or you can questions to

12. ENROLLMENT INFORMATION
To Enroll in one of the Plans:
Complete the Enrollment Packet. Packets are located in the Employee Services and Faculty Tabs of Campus Connect. You may also obtain an Enrollment Packet from your Regional Human Resources Department.
Once the Enrollment Packet is complete, submit the completed forms to your Regional Human Resources Department within 31 days from your date of hire.
Coverage becomes effective on the first day of the month following your completion and return to your Regional Human Resources Department of the appropriate paperwork, and the Regional Human Resources Department’s verification of eligibility. Employees must have an active assignment on the effective date of coverage.

13. CHANGE & TERMINATION INFORMATION
To make changes to your Plan:
Complete the Change Form located in the Employee Services tab on Campus Connect under College Benefits Website via Adjunct Faculty/Part-Time Employees Forms & Resources link. You may also obtain an Change Form from your Regional Human Resources Department.
Once the Change Form is complete, submit the completed form to your Regional Human Resources Department.
To Terminate your Plan:
To cancel your coverage please notify Christine Butler by sending an to
Your coverage will end at the end of the month coverage is canceled.

14. UPCOMING OPEN ENROLLMENT PERIOD
An Open Enrollment period will be conducted September 2012.
Effective date of coverage for the Open Enrollment period will be October 1, 2012.
Check with your local Human Resources Department for information on meeting dates and times.
OPEN ENROLLMENT