2019 ENROLLMENT GUIDE. Administration services by Key Benefit Administrators. Information for eligible employees of: Personnel Solutions Plus Inc.

Transcription

1 2019 ENROLLMENT GUIDE Administration services by Key Benefit Administrators Information for eligible employees of: Personnel Solutions Plus Inc.

2 MEC Minimum Essential Coverage MEC provides first dollar coverage with access to one of the largest national preferred provider organizations (PPO) available with great discount savings for MEC benefits. The network savings can also be used for services not covered by the MEC. You will have access to a simple-to-use web portal for your local or out-of-town provider look up to be sure your provider is in the PPO Network. There are preventive services covered at 100% under the required government list of Preventive and Wellness Benefits when you visit a network provider. The benefits drop to 40% if you use an out-of-network provider. Services covered include immunizations, blood pressure screenings, diabetes and cholesterol screenings, prenatal visits for pregnant women and more. A full list of the covered services is included in this information. The MEC comes with a medical ID Card that needs to be presented to your medical provider at your time of service. Administration services provided by Key Benefit Administrators. Minimum Essential Coverage (MEC) covers 100% of the government listed Preventive and Wellness Benefits when you visit a network provider (40% out-of-network). CARE SERVICES 81PREVENTIVE COVERED AT 100% UNLIMITED access to RealTimeTelemed, RealTimeHealth and RealTimeChoices VALUABLE BENEFITS FOR THE ENTIRE FAMILY Access to board-certified doctors by phone or mobile application - at anytime from anywhere with a $0 copay. RealTimeTelemed was designed as an alternative to costly urgent care, ER visits or days of waiting for an appointment to see your primary care doctor for non-emergency medical issues. RealTimeHealth is a diabetic management program that uses a state of the art cellular based glucometer to automatically, consistently and accurately take and record a member s glucose readings. Choices RealTimeChoices is a healthcare price transparency solution that gives you the tools you need to better manage your healthcare. *Please see Plan Documents for more information about the Plans outlined in this Guide. The Plan Documents govern if there is a conflict with this Guide.

3 Covered Preventive Services for Adults (ages 18 and older) 1. Abdominal Aortic Aneurysm one time screening for age Alcohol Misuse screening and counseling 3. Aspirin use for adults ages to prevent Cardiovascular Disease and Colorectal Cancer when prescribed by a physician 4. Blood Pressure screening for all adults 5. Cholesterol screening for all adults 6. Colorectal Cancer screening for adults starting at age 56 and continuing until age Depression screening for adults 8. Type 2 Diabetes screening for adults 9. Diet counseling for adults 10. Fall Prevention to include physical therapy to prevent fall in community dwellings age 65 and older 11. Hepatitis B screening for adults 12. Hepatitis C screening for adults at high risk and one time for everyone born between HIV screening for all adults Covered Preventive Services for Women, Including Pregnant Women 1. Anemia screening on a routine basis for pregnant women 2. Aspirin for pregnant women at high risk for preeclampsia 3. Bacteriuria urinary tract or other infection screening for pregnant women 4. BRCA counseling and genetic testing for women at higher risk 5. Breast Cancer Mammography screenings every 1 to 2 years for women age 40 and over 6. Breast Cancer Chemoprevention counseling as well as breast cancer testing and medications for women with increased risk for breast cancer 7. Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women. Non-network services will be payable as network services. 8. Cervical Cancer screening 9. Chlamydia Infection screening 10. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs 11. Diabetes screening for women with history of gestational diabetes who are not currently pregnant and who have not previously been diagnosed with type 2 diabetes. 12. Domestic and interpersonal violence screening and counseling for all women Preventive Care 14. Immunization vaccines for adults: Hepatitis A, Hepatitis B, Herpes Zoster, Human Papillomavirus, Influenza (Flu Shot), Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Tetanus, Diphtheria, Pertussis, Varicella. 15. Lung Cancer Screening for adults age who are at high risk because they smoke 30 packs a year (or have quit in the past 15 years) 16. Obesity screening and counseling for all adults 17. Sexually Transmitted Infections (STI) prevention counseling and screening for adults 18. Skin Cancer behavioral counseling for adults to age 24 with fair skin 19. Tobacco Use screening, counseling and cessation interventions for all adults 20. Syphilis screening for all adults 21. Latent tuberculosis infection screening for adults 22. Statin preventive medication for adults ages years with no history of cardiovascular disease, 1 or more cardiovascular disease risk factors and a calculated 10 year cardiovascular disease event risk of 10% or greater. 13. Folic Acid supplements for women who may become pregnant when prescribed by a physician 14. Gestational diabetes screening 15. Gonorrhea screening for all women 16. Hepatitis B screening for pregnant women 17. Human Immunodeficiency Virus (HIV) screening and counseling 18. Human Papillomavirus (HPV) DNA Test: HPA DNA testing every three years for women with normal cytology results who are 30 or older 19. Osteoporosis screening over age Preeclampsia screening in pregnant women with blood pressure measurements throughout pregnancy 21. Routine prenatal visits for pregnant women 22. RH Incompatibility screening for all pregnant women and follow-up testing 23. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users 24. Sexually Transmitted Infections (STI) counseling 25. Syphilis screening 26. Urinary Incontinence screening 27. Well-woman visit to obtain recommended preventive services Covered Preventive Services for Children 1. Alcohol and Drug Use assessments 2. Autism screening for children limited to two screenings up to 24 months 3. Behavioral assessments for children limited to 5 assessments up to age Bilirubin concentration screening for newborns 5. Blood screening for newborns 6. Blood pressure screening 7. Cervical Dysplasia screening 8. Congenital Hypothyroidism screening for newborns 9. Depression screening for adolescents age 12 and older 10. Developmental screening for children under age 3, and surveillance throughout childhood 11. Dyslipidemia screening for children 12. Fluoride Chemoprevention to include supplements for children without fluoride in their water source when prescribed by a physician and fluoride varnish to primary teeth through age Gonorrhea preventive medications for the eyes of all newborns 14. Hearing screening for all newborns and 3 additional screenings at periodic ages up to age Height, Weight and Body Mass Index measurements for children 16. Hematocrit or Hemoglobin screening for children 17. Hemoglobinopathies or sickle cell screening for newborns 18. Hepatitis B screening for adolescents 19. HIV screening for adolescents 20. Immunization vaccines for children from birth to age 18 - doses, recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis, Hemophilus influenza type b, Hepatitis A, Hepatitis B, Human Papillomavirus, Inactivated Poliovirus, Influenza (Flu Shot), Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Rotavirus, Varicella 21. Iron supplements for children ages 6-12 months when prescribed by a physician 22. Lead screening for children 23. Maternal depression screening for mothers of infants at 1, 2, 4 and 6 months visits 24. Medical History for all children throughout development. Ages:0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years 25. Obesity screening and counseling 26. Oral Health risk assessment for young children up to age Pheylketonuria (PKU) screening in newborns 28. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents 29. Skin Cancer behavioral counseling for adolescents age 10 and up who have fair skin 30. Tobacco Use screening, counseling, and cessation interventions for children and adolescents 31. Tuberculin testing for children 32. Vision screening for children. For complete information on preventative services, visit the following US Health and Human Services website:

4 MEC Minimum Essential Coverage Covered Benefits MEC In-Network Weekly RATES EMPLOYEE Deductible (single/family) $0/$0 Coinsurance (employee portion) 0% Out-of-Pocket Maximum $0/$0 PPO Network $13.77 EMPLOYEE + SPOUSE $19.55 EMPLOYEE + CHILDREN Emergency Room Services Inpatient Hospital Services Primary Care Visit to Treat an Injury or Illness Specialist Visit Mental/Behavioral Health and Substance Abuse Disorder Services Advanced Imaging (CT, PET Scans, MRls) Rehabilitative Speech Therapy Rehabilitative Occupational and Rehabilitative Physical Therapy Preventive Care/ Screening/Immunization (MEC) Laboratory Outpatient and Professional Services X-rays and Diagnostic Imaging Outpatient Facility Fee Outpatient Surgery Physician/Surgical Services Chronic Disease Management (CDM) Benefit Life AD&D Benefit RealTime Services RealTimeTelemed RealTimeChoices RealTImeHealth w/a Covers 100% of the 81 listed Preventive and Wellness Benefits Unlimited Calls Unlimited Access 100% Covered $36.84 FAMILY $42.60

5 Key Group Dental Insurance THE GROUP DENTAL PLAN* Key Group dental plans cover allowable charges for dental services at 100% coverage for preventive services, 80% coverage for basic services and 50% coverage for major services. The combined annual deductible is only $50 per person, which applies to all covered dental services. PREVENTIVE SERVICES INCLUDE: Routine exams and cleanings, emergency treatment for dental pain (minor), bitewing x-rays and fluoride, fluoride treatment for children under age 19. BASIC SERVICES INCLUDE: Simple restorative services, simple teeth removal, sealants for children ages 6-15 (one per 36 months), x-rays (full mouth or panorex, one per 36 months), x-rays of the roots of teeth. MAJOR SERVICES INCLUDE: Space maintainers, endodontics (includes root canals), periodontics, surgical teeth removal and other oral surgery, medically appropriate anesthesia related to covered surgery, major restorative services (crowns and inlays), dental implants (age 17 and up), denture relines (if over six months of installation), recementation and repair of crowns, inlays, bridges and dentures. PREVENTIVE Plan 4*** Deductible $50 Waiting Period Coinsurance 100% Exams 2 per Calendar Year Bitewing and Fluoride 1 per Calendar Year Deductible $50 Waiting Period Coinsurance 80% MAJOR Deductible $50 Waiting Period 12 month Coinsurance 50% WEEKLY RATE Plan 4 ORTHO CHILD ONLY** Employee Only $6.75 Coinsurance Employee + Spouse $13.51 Deductible Employee + Children $15.02 Lifetime Max Family Coverage $22.10 Waiting Period CALENDAR YEAR MAX $750 **Only Plan 1 includes orthodontics ***Plan 4 options covers anesthesia, endodontics, simple and surgical extractions, oral surgery and periodontics under the basic services *Policy form 514 Payment is based upon allowable charges in the area in which service is rendered. This is a general outline of covered benefits and does not include all the benefits, limitations and exclusions of the policy. Please see your certificate for details. KEY BENEFIT ADMINISTRATORS (KBA) is one of the largest, privately held third party administrators (TPA) organizations in the country. KBA is licensed as a TPA, where required. POLICY BENEFITS, FEATURES AND RATES MAY VARY BY STATE. Plan offerings are subject to state limitation. Not all benefits are available in all states. Please consult your Key Benefit Administrator representative with questions regarding plan offerings. Companion Life Insurance Company is the insurance company underwriting the life insurance plan. The company is located in Columbia, SC, and has been rated A+ (Superior), an independent opinion from the leading provider of insurer ratings of a company s financial strength and ability to meet its obligations to policyholders, based on an analysis of the financial position and operating performance as of December 21, 2016, by A.M. Best Company, an independent analyst in the insurance industry. For the latest rating, access This document represents a summary of services offered under the above mentioned insurance policy. Particulars of this plan may differ depending upon group size, plan category and other underwriting considerations which are subject to state insurance laws and the benefits and provisions as described may vary due to said statues. All products described, herein are subject to the terms, conditions, exceptions and limitations of the specific policy. Please see the specific policy and certificate for details. Policies may not be available in all states. Benefits provided under this plan are a supplement, and not a substitute for medical coverage. This plan, or its benefits, do not meet minimum essential coverage standards as outlined in the Affordable Care Act. Key Benefit Administrators Allison Pointe Trail - Indianapolis, IN KG_DNT_EE_022818

6 KEY BENEFIT ADMINISTRATORS Key Group Vision Plan Vision Exam Copay $10 Frames $100 Allowance Weekly RATES Employee Only $2.20 Eye Exam Frequency Lenses Frequency Frames Frequency Contact Lenses Frequency 12 months 12 months 24 months 12 months Employee and Spouse $5.49 Employee and Children $6.50 Family $8.64 KG_VSN_EE_ Underwritten by Companion Life Insurance Company Administered by Key Benefit Administrators

7 Key Group Vision Insurance A comprehensive plan providing members with a paid-in-full exam, after the specific co-pay is applied, contact lens fitting and follow-up and allowances for eyewear, such as frames, lenses and contact lenses. VISION CARE SERVICES*: IN-NETWORK OUT-OF-NETWORK Exam with Dilation (as necessary) Contact Lens Fit and Follow-up: (Contact lens fit and two follow-up visits are available once a comprehensive eye exam has been completed) Standard** Premium*** $10 Copay $0 Copay $0 Copay, 10% off retail, then apply $55 allowance $35 Allowance $40 Allowance $40 Allowance FRAMES: IN-NETWORK OUT-OF-NETWORK Any available frame at provider location $100 Frame allowance, 20% off balance over allowance $45 Allowance STANDARD PLASTIC LENSES: IN-NETWORK OUT-OF-NETWORK Single Bifocal Trifocal $10 Copay $10 Copay $10 Copay $25 Allowance $40 Allowance $55 Allowance STANDARD PLASTIC LENSES: IN-NETWORK OUT-OF-NETWORK UV Coating Tint (Solid and Gradient) Standard Scratch Resistant Coating Standard Polycarbonate Standard Anti-Reflective Coating Standard Progressive (Add-On to Bifocal) Other Add-Ons and Services $15 Copay $15 Copay $15 Copay $40 Copay $45 Copay $65 Copay 20% off retail Discount available only at Network providers and retailers CONTACT LENSES (MATERIAL ONLY): IN-NETWORK Conventional and Disposable OUT-OF-NETWORK Not Medically Necessary Medically Necessary $0 Copay, $80 allowance, 15% off balance over allowance (conventional only). Paid in full $64 allowance $200 allowance FREQUENCY: Examination Frames Eyeglass Lenses Contact Lenses (in lieu of eyeglass lenses) 12 months 24 months 12 months 12 months Rates are guaranteed for 12 months. *Representative of policy VGRP-300 (11/05) **Standard Contact Lens Fitting: spherical clear contact lenses in conventional wear planned replacement (examples include, but not limited to, disposable, frequent replacement, etc.). ***Premium Contact Lens Fitting - all lenses design, materials and fittings other than Standard (examples include, but not limited to, toric, multifocal, etc.) Eyeglass lenses are paid in lieu of the contact lenses benefit. Once in a 12-month period defined by last date of service. The contact lens benefit is paid in lieu of eyeglass lenses. Once in a 12-month period defined by last date of service. Disclaimer: This is a summary of benefits only. Please refer to the policy for comprehensive benefit details. Payment is based upon allowable charges in the area in which the service is rendered. KEY BENEFIT ADMINISTRATORS (KBA) is one of the largest, privately held third party administrators (TPA) organizations in the country. KBA is licensed as a TPA, where required. POLICY BENEFITS, FEATURES AND RATES MAY VARY BY STATE. Plan offerings are subject to state limitation. Not all benefits are available in all states. Please consult your Key Benefit Administrator representative with questions regarding plan offerings. Companion Life Insurance Company is the insurance company underwriting the voluntary vision plan. The company is located in Columbia, SC, and has been rated A+ (Superior), an independent opinion from the leading provider of insurer ratings of a company s financial strength and ability to meet its obligations to policyholders, based on an analysis of the financial position and operating performance as of December 21, 2016, by A.M. Best Company, an independent analyst in the insurance industry. For the latest rating, access This document represents a summary of services offered under the above mentioned insurance policy. Particulars of this plan may differ depending upon group size, plan category and other underwriting considerations which are subject to state insurance laws and the benefits and provisions as described may vary due to said statues. All products described, herein are subject to the terms, conditions, exceptions and limitations of the specific policy. Please see the specific policy and certificate for details. Policies may not be available in all states. Benefits provided under this plan are a supplement, and not a substitute for medical coverage. This plan, or its benefits, do not meet minimum essential coverage standards as outlined in the Affordable Care Act. Key Benefit Administrators Allison Pointe Trail - Indianapolis, IN KG_VSN_EE_022818

8 Welcome to MDLIVE! Using MDLIVE, you can visit with a doctor 24/7/365 from your home, office or onthe-go. With zero co-pay! You have a telehealth benefit giving you virtual care, anywhere. Your virtual doctor is here. Join for free today! Available anytime, day or night Consults by mobile app, video or phone Prescriptions can be sent to your nearest pharmacy if medically necessary We treat over 50 routine medical conditions including: Acne Allergies Cold / Flu Constipation Cough Diarrhea Ear Problems Insect Bites Nausea / Vomiting Pink Eye Rash Respiratory Problems Sore Throats And More Download the app. Join for free. Visit a doctor. MDLIVE.com/ks Copyright 2017 MDLIVE Inc. All Rights Reserved. MDLIVE may not be available in certain states and is subject to state regulations. MDLIVE does not replace the primary care physician, is not an insurance product and may not be able to substitute for traditional in person care in every case or for every condition. MDLIVE does not prescribe DEA controlled substances and may not prescribe non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE does not guarantee patients will receive a prescription. Healthcare professionals using the platform have the right to deny care if based on professional judgment a case is inappropriate for telehealth or for misuse of services. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit

9 Welcome to MDLIVE! Your anytime, anywhere doctor s office. Avoid waiting rooms and the inconvenience of going to the doctor s office. Visit a doctor by phone, secure video, or MDLIVE App. Pediatricians are available 24/7, and family members are also eligible. Meet Sophie, Your Personal Health Assistant! Sophie makes creating an account quick and easy using your smartphone, anytime, anywhere! It s easy to register! Steps To Connect to Chatbot: 1.Member will text KS to Tap to load preview. Member also presented with Stop/Help language. 3.Tap Let s Chat to launch a web browser page which simulates a texting conversation. Download the app. Join for free. Visit a doctor. MDLIVE.com/KS +1 (888) Copyright 2018 MDLIVE Inc. All Rights Reserved. MDLIVE may not be available in certain states and is subject to state regulations. MDLIVE does not replace the primary care physician, is not an insurance product and may not be able to substitute for traditional in person care in every case or for every condition. MDLIVE does not prescribe DEA controlled substances and may not prescribe non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE does not guarantee patients will receive a prescription. Healthcare professionals using the platform have the right to deny care if based on professional judgment a case is inappropriate for telehealth or for misuse of services. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit MCR-1316

10 RX DISCOUNT CARD Brought to you by Key Benefit Administrators Dear Valued Member, CerpassRx is excited to partner with Key Benefit Administrators to provide you with a Prescription Discount. I You will also gain access to our free CerpassRx member portal and mobile app. If you have any further questions about your KeySolutions prescription discount, please contact our Member Services at We look forward to surpassing your expectations on prescription discounts! Start using your new KeySolutions prescription discount It's as easy as Detach & save your new KeySolutions ID card once you get it Present your KeySolutions ID card anytime you are filling a prescription at your local pharmacy. Save up to 80% on your prescriptions! Have questions? Please call CerpassRX Member Services or info@cerpassrx.com

11 MEMBER ACCESS YOUR PRIVATE, SECURE MEMBER PORTAL TODAY VISIT CERPASSRX.COM OR DOWNLOAD OUR MOBILE APP MEMBER PORTAL & MOBILE APP This private, secure website is designed just for you. Your pharmacy plan information is available and kept up-to-date in real time. You can access your member portal by visiting OR by download-ing our mobile app. The mobile app provides easy, on-the-go access to your personalized health information. Once you have your member ID number, download the app to take advantage of the benefits your pharmacy plan offers. EASY ACCESS ALLOWS YOU TO: CELL 9:30 AM My Best Pharmacy Stay on top of medication refills. See when refills are due, get refill reminders and quickly contact your pharmacy. Pull up your medication history anytime to show your doctor what medications you are taking. Learn about medication side effects and interactions. Find network pharmacies by ZIP code or location, then check and compare current prescription prices. Learn ways to save on your prescription by switching from brand name to generic or splitting a higher dosage pill. Track individual and family spend. CREATE YOUR MEMBER PORTAL ACCOUNT: Visit cerpassrx.com and click on the member portal button. Click activate your account and enter your member ID shown on your ID card. From there, proceed with completing your personal information to activate your member portal account. Have questions? For more information, call or click today at // 5904 Stone Creek Dr, Ste. 120 The Colony, TX Get the app by searching for CerpassRX or at the Apple App store or with Google Play. 98%

12 1. Enrollee Information Group Name: Last Name: KeySolution Enrollment Form Plan Coverage Effective Date: Date you became a Full time Employee: First Name: Date of Birth (DOB): Sex: M F SS #: No. Hours Work/per week: Home Phone #: Work Phone #: Street Address: City: State: Zip: Plan Selection (per your enrollment guide): MEC Plan Vision Dental 2. Dependent Information I would like to be covered under this plan along with the following dependents: Spouse Domestic Partner Last Name: First: SS#: DOB: Male Female Last Name: First: SS#: DOB: Male Female Child Disable Court Ord Last Name: First: SS#: DOB: Male Female Child Disable Court Ord Last Name: First: SS#: DOB: Male Female Child Disable Court Ord Last Name: First: SS#: DOB: Male Female Child Disable Court Ord Last Name: First: SS#: DOB: Male Female Child Disable Court Ord 1 For disabled dependents; SUBMIT appropriate documentation as proof of disabled status with this enrollment form. 2 If a court decree requires you to cover your dependent under this plan, SUBMIT that portion of the court decree with this enrollment form. I hereby apply for benefit plan participation for myself and/or my dependents listed above and agree to abide by the terms, provisions and limitations as outlined by the Plan Sponsor in the issuance of the Summary Plan Description. I declare all statements contained in this entire form are true and correct and that no material information has been withheld or omitted. I agree that no benefits will be effective until the date specified by Key Benefit Administrators. I agree a photographic copy of this authorization shall be as valid as the original and that said authorization shall be valid for the maximum length of time permitted by law. I understand that I have the right to receive a copy of this authorization upon request. I authorize my employer to deduct from earnings the contributions (if any) required toward the benefits. I am waiving/declining coverage for myself and my dependents Employee (print name): Employee Signature: Date: Revised