Package 2. Enrollment Guide. American Blue Ribbon Holdings. For the Employees of. Medical Plan Options and Enrollment Information

Transcription

1 Package 2 Enrollment Guide For the Employees of American Blue Ribbon Holdings Medical Plan Options and Enrollment Information

2 Minimum Essential Coverage MEC Benefits In-Network Out-of-Network 19 Adult Preventative Services 100% N/A 23 Preventative Services for Women 100% N/A 29 Preventative Services for Child(ren) 100% N/A PPO Network First Health 2

3 MEC Covered Preventive Services For All Adults Abdominal Aortic Aneurysm screening Alcohol Misuse screening and counseling Aspirin use to prevent cardiovascular disease Blood Pressure screening Cholesterol screening Colorectal Cancer screening Depression screening Diabetes screening Falls prevention screening Healthy diet and physical activity counseling Hepatitis B screening Hepatitis C virus infection screening HIV screening Lung cancer screening Obesity screening and counseling Sexually Transmitted Infection (STI) prevention counseling Skin cancer behavioral counseling Syphilis screening Tobacco use counseling For Women & Pregnancy Anemia screening Bacteriuria screening BRCA risk assessment Breast Cancer preventive medications counseling Breast cancer screening mammography Breastfeeding counseling during pregnancy Cervical Cancer screening Chlamydia Infection screening Folic Acid supplements for women Gestational Diabetes mellitus screening Gonorrhea screening Hepatitis B screening Human Immunodeficiency Virus (HIV) screening Intimate partner violence screening Osteoporosis screening Preeclampsia prevention medication Rh incompatibility screening for Rh (D) blood typing Sexually Transmitted Infections (STI) counseling Syphilis screening for all pregnant women Tobacco use counseling One well-woman preventive care visit per Policy Year High-risk human papillomavirus DNA testing One counseling session on sexually transmitted infections One counseling session and screening for human immune-deficiency virus All FDA approved contraceptive methods One screening and counseling for domestic violence Breastfeeding support, supplies and counseling Routine prenatal obstetrical office visits For Children Alcohol and drug use assessments for adolescents Autism screening at 18 and 24 months Behavioral assessments for all ages Blood Pressure screening for children Cervical Dysplasia screening Congenital Hypothyroidism screening for newborns Depression screening for adolescents Developmental screening for children under age 3, and surveillance throughout childhood Dyslipidemia screening for children at higher risk of lipid disorders Fluoride Chemoprevention supplements Gonorrhea preventive medication for the eyes of all newborns Hearing screening for all newborns Height, Weight, and Body Mass Index measurements Hematocrit or Hemoglobin screening Hemoglobinopathies or sickle cell screening for newborns Hepatitis B screening for adolescents at high risk for infection HIV screening for adolescents at higher risk Immunization vaccines Iron supplements for children ages 6 to 12 months who are at increased risk for anemia Lead screening for children at risk of exposure Medical history for all children throughout development Obesity screening and counseling Oral Health risk assessment for young children Phenylketonuria (PKU) screening for this genetic disorder in newborns Sexually Transmitted Infection (STI) prevention counseling and Sexually Transmitted Infection Tuberculin testing for children at higher risk of tuberculosis disorders Vision screening for all children Routine prenatal obstetrical office visits For a complete description of these services, consult your copy of fulfillment kit. 3

4 Fixed Indemnity Option underwritten by Madison National Life Insurance Company, Inc. Fully-Insured Fixed Indemnity Benefits Inpatient Hospital Confinement: per day, maximum benefit of 60 days per year Inpatient Mental Illness Disorder Treatment: per day, maximum benefit of 60 days per year Inpatient Substance Use Disorder Treatment: per day, maximum benefit of 60 days per year Intensive Care: per day, maximum benefit of 30 days per year, paid in lieu of Inpatient Hospital Confinement Inpatient Surgical: Outpatient Surgical: Minor Outpatient Surgical: Inpatient Anesthesia: Outpatient Anesthesia: Outpatient Physician Office: per day, maximum benefit of $300 per year Outpatient Diagnostic Lab: per day, maximum benefit of 3 days per year Outpatient X-Ray: per day, maximum benefit of 2 days per year Outpatient Advanced Studies: per day, maximum benefit of 3 days per year Prescription Drug: per day, maximum benefit of 6 days per year $100 $100 $100 $200 $500 $250 $75 $125 $62.50 $50 $20 $75 $300 $10 4 INNOMNL 0317

5 Limited Medical Benefits: Limitations & Exclusions Fixed Indemnity Benefits are excluded as follows: Preventive Services, except as specified if the Preventive Care Fixed Indemnity Benefit is shown as included; Not: due to Sickness or Injury; Medically Necessary; recommended by a Doctor. No charge is made; weekend hospital admissions for non-emergencies; eligible to be paid under Worker s compensation; examinations required by a third party; active duty in the military; war; illegal occupation; drug or alcohol use; cosmetic or plastic surgery except medically necessary reconstructive surgery due to Sickness; eye surgery to correct refractive errors; routine eye exams, glasses, visual therapy or contact lenses except as covered under the Optional Fixed Indemnity Vision Benefit Rider if included; Hearing exams, hearing aids or adjustments; fertility or sterility studies; sterilization or reversal of any kind; insemination and fertilization of any kind; abortion except if the life of the mother would be in danger if the fetus were carried to term, or for complications of a voluntary abortion; Mental health disorder or substance use disorder treatment of any kind unless the Optional Mental Illness Fixed Indemnity Benefit Rider or the Optional Substance Use Fixed Indemnity Benefit Rider is included; tobacco cessation; counseling or therapy unless specifically covered; Sexual reassignments or sexual dysfunctions or inadequacies; Acupuncture; treatment of the feet including orthotics unless medically necessary; Obesity, morbid obesity, or weight reduction, including bariatric surgery and complications thereof; treatment by a close relative; custodial care, non-u.s. treatment unless travelling for less than 90 days and is an emergency. Fees for consultations and missed appointments; fees related to the costs of obtaining medical records as necessary under the Required Information provision; Outpatient Prescription Medication unless the Outpatient Prescription Medication Fixed Indemnity Benefit is shown as included; Dental treatment including the jaw unless due to an Injury or the Optional Dental Fixed Indemnity Benefit Rider is included; Hospice or Home Health care. This material provides a very brief description of the important features of this product. This brochure is not a certificate of coverage and only the actual certificate provisions will control. The certificate itself sets forth in detail the rights and obligations of both the certificate holder and the insurance company. It is, therefore, important that you READ THE CERTIFICATE CAREFULLY. For complete details, refer to Form #MNL LMB CERT 1215 (Form number may change depending on state) GROUP LIMITED MEDICAL BENEFIT HOSPITAL INDEMNITY INSURANCE (FIXED) IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR THE MINIMUM ESSENTIAL COVERAGE REQUIRED BY THE AFFORDABLE CARE ACT. (ACA) LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. About Madison National Life Insurance Company, Inc. Madison National Life Insurance Company, Inc. was founded in 1961 and is domiciled in Wisconsin and licensed to sell insurance products in 49 states, the District of Columbia, Guam, American Samoa and the U.S. Virgin Islands. Its core products and services are group life and disability income and specialty health insurance. It is rated A- (Excellent) for financial strength by A.M. Best Company, a widely recognized rating agency that rates insurance companies on their relative financial strength and ability to meet policyholder obligations (an A++ rating from A.M. Best is its highest rating). About The IHC Group Independence Holding Company (NYSE: IHC) is a holding company that is principally engaged in underwriting, administering and/or distributing group and individual disability, specialty and supplemental health, pet, and life insurance through its subsidiaries since The IHC Group (including through its 92% ownership of American Independence Corp. (NASDAQ: AMIC)) owns three insurance companies (Standard Security Life Insurance Company of New York, Madison National Life Insurance Company, Inc. and Independence American Insurance Company), a majority of Ebix Health Administration Exchange, Inc., a fully insured third party administrator, and IHC Specialty Benefits, Inc., which is a technology-driven insurance sales and marketing company that creates value for insurance producers, carriers and consumers (both individuals and small businesses) through a suite of proprietary tools and products (including ACA plans and small group medical stop-loss). All products are placed with highly rated carriers. IHC and The IHC Group are the brand names for plans, products and services provided by one or more of the subsidiaries and affiliate member companies of The IHC Group ( IHC Entities ). Plans, products and services are solely and only provided by one or more IHC Entities specified on the plan, product or service contract, not The IHC Group. Not all plans, products and services are available in each state. INNOMNL

6 Package Rates and FAQ Monthly Rates Package 2 Employee $ EE + Spouse $ EE + Child(ren) $ Family $ How Can You Participate? All current team members are eligible to enroll during the open enrollment period. New team members are eligible to enroll after a 30 day waiting period. Dependents to include spouses, and children and stepchildren under the age of 26, are also eligible during open enrollment for current team members or after the initial waiting period for newly hired team members. How Are Premium Payments Made? Premiums are to be paid through auto bank draft (ACH), or by credit or debit card. Payments will be drafted 3-4 days prior to the 1st of each month. If you miss a payment, your insurance will be terminated and you will not be eligible to re-enroll until the next open enrollment period. PPO Network First Health To check if your provider is in the network, go to firsthealthlbp.com or speak to a representative at , Monday Friday, 7am 7pm CST. What if I do not enroll? Benefits are being offered to you during an open enrollment period. If you do not enroll in benefits during this open enrollment, you will be unable to enroll in benefits until the next open enrollment period unless you experience a qualifying change in status. Newly hired team members must enroll for benefits within the first 30 days of becoming eligible. If you are a newly hired team member and you do not enroll within the first 30 days of becoming eligible, you will not be able to enroll until the next open enrollment period, unless you experience a qualifying change in status. Can I Sign Up For Insurance At Any Time? No. You must enroll during the open enrollment period. Newly hired team members must enroll for benefits within the first 30 days of becoming eligible. If you are a newly hired team member and you do not enroll within the first 30 days of becoming eligible, you will not be able to enroll until the next open enrollment period, unless you experience a qualifying change in status. Can I Cancel My Insurance At Any Time? Yes. However, if you cancel your insurance, you will not be able to re-enroll until the next open enrollment period, unless you have a qualifying change in status.