2015 Plan Options Benefit Guide

Transcription

1 2015 Plan Options Benefit Guide Prepared For: Nova Management Summary of Benefits and Coverage To obtain an electronic copy of the Summary of Benefits and Coverage, and Benefit Guide please visit enter your group ID SEMC096, then select View Summary. You may also request a paper copy at any time by contacting us at Claims administered by: Marketed by: DMC211Rev8/2014 Copyright 2011 Pan-American Benefits Solutions Insurance Agency

2 Plan Options For this year open enrollment period Nova Management. is providing you with 3 health plan options that satisfy the individual mandate for you to choose from, giving you the opportunity to select the one that best meets your coverage and affordability needs. You may choose between: Options - Plan 1 or Plan 3, that includes full Preventive Care Coverage (to help identify potential health risks for early diagnosis and treatment), combined with a Limited Benefit Indemnity Coverage that pays a fixed benefit amount to help cover the cost of common services such as doctor s office benefit, hospitalization, intensive care, accidents, surgeries and much more. Benefits are paid no matter if they are performed in-network or out-of-network. Eligible Preventive Services are covered at 100% only when performed in-network. The preventive care coverage is provided under a self-funded plan established by Nova Management. Pan-American Life Insurance Company does not insure these benefits. For a full list of covered benefits and services of Plan 1 and 3, please refer to the Benefit Guide. Minimum Value Copay Option, where the covered benefits require a Copay* of $10 to $500. The plan also has an Outof-Pocket of $5,000 for single coverage and $10,000 for family coverage. The Minimum Value Copay option plan only covers when services are provided by an in-network provider. the Minimum Value Copay Plan is a self-funded plan established by Nova Management. Pan-American Life Insurance Company does not insure these benefits. The effective date for your new plan will be Enrollment Period Open Enrollment: December 1 st December 15 th. Remember that Open Enrollment is your once-a-year opportunity to enroll or make changes to your benefits plan. Otherwise, you will have to wait until next year. So make sure to enroll by December 15 th for coverage effective 1/1/15. New Hire Enrollment: You must enroll within your new hire waiting period of 60 days. To receive your ID card before your effective date please enroll by the 15th of the month prior to your effective date. You must enroll before the new hire waiting period expires or you will have to wait until the next annual open enrollment in How To Enroll Enrollment is easy, fast and convenient. You will be able to enroll online or through our toll free Enrollment Center Dedicated Line in just a few minutes. Online: You can easily and conveniently enroll online 24/7 at Your ID is your 9 digit SSN, and Password your last 4 digits SSN. By Phone: To enroll now, call the toll free Enrollment Center Dedicated Line and a representative will answer your questions and enroll you over the phone. Call , Monday - Friday, 7:30 AM - 6:00 PM, CST. Full bilingual (English-Spanish) services. The information provided in this guide is a brief outline of benefits. Your plan document governs the terms and conditions of the plan. *Copay is a fixed dollar amount you pay each time for certain services and for prescription drugs. The amount varies by the type of service. 2 Please keep this guide with you for future references.

3 Member Cost Per Pay Period Weekly (52) Pay Period PLAN 1 PLAN 3 Minimum Value Copay MEMBER $4.73 $28.27 $34.62 MEMBER + SPOUSE $27.15 $76.27 $ MEMBER + CHILD(REN) $23.82 $63.42 $92.42 FAMILY $49.90 $ $ For a full list of covered benefits and services of Plan 1 & 3, refer to the Benefit Guide. BENEFIT DESCRIPTION Plan 1 Plan 3 PLAN PAYS In-Network and Out-of-Network Minimum Value Copay YOU PAY DEDUCTIBLE $0 $0 $0 COINSURANCE 0% 0% 0% OUT-OF-POCKET LIMIT (includes Deductible/Coinsurance/Copays) N/A N/A $5,000 (Single Coverage) $10,000 (Family Coverage) INPATIENT HOSPITAL $100 per day 60 days CYM $500 per day 60 days CYM HOSPITAL FIRST DAY ADMISSION $800 per admission $1,000 per admission INPATIENT SURGICAL BENEFIT $750 per day $2,500 per day INPATIENT ANESTHESIA BENEFIT $187.5 per day $625 per day OUTPATIENT SURGICAL BENEFIT $375 per day $1,250 per day OUTPATIENT ANESTHESIA BENEFIT $93.75 per day $ per day GROUP TERM LIFE WITH AD&D $5,000 $5,000 ADDITIONAL MEDICAL ACCIDENT WITH AD&D BENEFIT $2,500 per occurrence $5,000 accidental death $2,500 per occurrence $5,000 accidental death CYM = Calendar Year Maximum. 3 To locate in-network providers call or visit to search online.

4 BENEFIT DESCRIPTION PRIMARY CARE VISITS SPECIALTY CARE VISITS (also covers mental health and substance abuse) OUTPATIENT DIAGNOSTIC LABS OUTPATIENT DIAGNOSTIC RADIOLOGY OUTPATIENT ADVANCED STUDIES (CT/PET, ADVANCED MRI) EMERGENCY ROOM CYM = Calendar Year Maximum. *Covers emergency room sickness only. PLAN 1 The Minimum Value Copay Plan Exclusions No coverage for services performed out-of-network No coverage for in-patient services (e.g. hospital room and board, in-patient surgeries, in-patient prescription drugs) No coverage for outpatient surgeries and outpatient facilities No coverage for skilled nursing facilities No coverage for specialty drugs No coverage for home health care or hospice care No coverage for durable medical equipment or prosthetics No coverage for orthotics Check plan documents for a full list of exclusions PLAN 3 PLAN PAYS In-Network and Out-of-Network $75 per day 4 days CYM $25 per day 3 days CYM $70 per day $300 per day $75 per day* 4 days CYM $100 per day 6 days CYM $65 per day 3 days CYM $150 per day $500 per day $100 per day* 4 days CYM GENERIC RX $15 copay $10 copay PREFERRED BRAND RX Discount $40 copay NON-PREFERRED BRAND RX Discount $75 copay Minimum Value Copay YOU PAY $15 Copay $25 Copay $50 Copay $50 Copay $500 Copay $500 Copay $10 Copay $40 Copay $100 Copay RX MAXIMUM $300 per month $1,000 per year N/A PREVENTIVE SERVICES No Cost Share No Cost Share No Cost Share NETWORK First Health First Health First Health TELADOC Included Included Not Included PALIC LIMITED DENTAL /DISCOUNT VISION Buy-up Buy-up Not Included The Plan Exclusions The limited benefit indemnity coverage pays a stated fixed indemnity amount. Check plan documents for preventive care coverage list of exclusions 4 The limited benefit indemnity coverage which is offered as a component of plans is issued by Pan-American Life Insurance Company onpolicyform number PAN-POL-13., PAN-POL-13-FL, PAN-POL-13-LA, PAN-POL-13-NC, PAN-POL-13-T, PAN-POL-13-TX, or PAN-POL-13-WA. There are no exclusions for pre-existing conditions except for pregnancy in most states. The plan will not pay benefits for any care provided prior to the coverage effective date or if the insured is confined in a hospital at the time the coverage is effective. Hospital does not include a nursing home, convalescent home or extended care facility. Coverage is not available in all states. Like most group benefit programs, our products have exclusions, limitations, waiting periods and terms for keeping them in force. The preventive care coverage under all Plan options is offered under a self-funded plan maintained by the plan sponsor. All coverages under the Minimum Value Copay option are offered under a self-funded plan offered by the plan sponsor. Pan-American Life Insurance Company does not insure benefits under these self-funded plans.

5 Dental/Vision Combo (Optional) See rates on next page. Highlights Fully Insured No Deductible No Waiting Periods Covered services pays at 80%-90% Access to DentalGuard Preferred Select Network for discounts on covered services $1,000 calendar year maximum for each employee and each covered dependent Benefits* Class I Preventative and Diagnostic Plan Pays 90% 2 routine examinations per calendar year 2 prophylaxis (cleanings) per calendar year 1 series of bitewing X-rays per calendar year Class II Basic Procedures Plan Pays 80% Simple extraction of teeth Fillings of amalgam, silicate, acrylic, synthetic porcelain and composite filling materials * Preauthorization of benefits if dental work exceeds $200 * Out-of-network claims paid up to the 85 th percentile of UCR Our members benefit from discounted provider prices through DentalGuard Preferred Select Network, one of the industry s largest dental preferred provider networks with dentists at over 120,000 locations across the country. Whenever a member or a covered dependent needs dental care, they are free to visit any dentist or specialist they wish. If they choose to visit a dentist from the DentalGuard Preferred Select Network, they can save money and stretch their annual plan maximums further. Members have access to an easy to use website and a toll-free number to locate nearby network dentists. Dental/Vision may be selected Stand-Alone or combined with the PanaMed Limited Benefit Indemnity plan. For those employees who enroll in PanaMed you must elect the same coverage tier as your PanaMed selection. For example, If you elect Employee + Spouse medical, then you can only elect Employee + Spouse on the Dental/Vision as well. To find participating network dentist go to: Select your Dental Plan: PPO, and then Select your Dental Network: DentalGuard Preferred Select Dental Provider Network services are provided by DentalGuard Preferred Select Network Pan-American Life and DentalGuard Preferred Select Network are not affiliated. 18 Group dental insurance is issued by Pan-American Life Insurance Company on form number DEN-06-P. Coverage is not available in all states. Dentist is not Group obligated dental to insurance provide is a discount issued by for Pan-American a non-covered Life service. Insurance Like Company most group on benefit form number programs, DEN-06-P. our products Coverage have is exclusions, not available limitations, in all states. waiting Dentist periods is not and obligated terms for keeping to provide them a in discount force. Please for a non-covered contact us for service. complete Like details most group benefit programs, our products have exclusions, limitations, waiting periods and terms for keeping them in force. Please contact us for complete details

6 Dental/Vision Combo (Optional) Highlights Discount Vision Plan No health restrictions, can be used immediately No limits on frequency of use No paperwork 30 day money-back guarantee on eyewear Low price guarantee on eyeglasses Discounts on LASIK surgery included Members save 10% to 60% off provider retail prices on eyeglasses, contacts, eye exams and surgical procedures from more than 12,000 locations nationwide. Coast to Coast Vision network is the most comprehensive in the United States and includes ophthalmologists, optometrists, independent optical centers and national chain locations such as Pearle Vision, JCPenney Optical, Sears Optical, Target Optical, LensCrafters, EyeMasters and QualSight LASIK. Discount Vision Plan Savings Benefits In-Network Eye Exams 10% to 30% off provider retail fees Prescription Eyeglasses Frames Lenses (single, bifocal, trifocal, and non-standard) Specialty Coatings and Tints 20% to 60% off provider retail fees Contact Lenses Mail Order Service 10% to 40% off provider retail fees LASIK (refractive surgery) Weekly 40% to 50% off the overall national average Member Member + Spouse Member + Children Family $4.55 $8.78 $9.61 $15.14 Vision Provider services are not insurance and are provided by New Benefits, Ltd. For provider look-up: call EYES ( ) - Pan-American Life and New Benefits, Ltd. are not affiliated. The discount vision plan contains a 30 day cancellation period. Not available in KS, UT, VT, and WA. For a full list of disclosures, visit 19