Enroll Now! Minimum Essential Coverage (MEC) Highlights: OPEN ENROLLMENT DECEMBER 2 ND - 18 TH OPEN ENROLLMENT WILL BE HELD DECEMBER 2 ND - 18 TH!

Transcription

1 Enroll Now! OPEN ENROLLMENT DECEMBER 2 ND - 18 TH Minimum Essential Coverage (MEC) Highlights: MEC Preventive Services Medical Coverage Other Benefit Options FAQ s Missed Premium Additional Programs Important Notices As a valued OnLine Interpreters team member, we continually seek to provide you with benefits that deliver excellent coverage and valuable options for you and your family. With that in mind, we are pleased to off offer a Minimum Essential Coverage (MEC) program. The MEC is designed to provide you and your family preventive services and to meet the Individual Mandate under the Affordable Care Act (ACA) in order to avoid being subject to tax penalties during the time that you are covered. If you are currently enrolled in the fixed indemnity program you can continue with this program separately or in addition to the MEC program to help supplement your healthcare costs. We are providing you with affordable options that will meet your coverage requirement. Please carefully review the coverage options to determine which plan might be right for you and your dependents. The plans offered are not major medical insurance and not designed to protect you from cost associated with chronic illnesses or diseases. OPEN ENROLLMENT WILL BE HELD DECEMBER 2 ND - 18 TH! Enroll by one of two methods: 1) Go online to and enroll yourself in the coverage of your choice. 2) Call the Enrollment Center at and speak with an Enrollment Representative to answer your questions and process your elections. LanguageLine Solutions is contributing 75% of the cost of the coverage for employee only coverage in MEC plan! You will not be eligible to enroll in the MEC program after your initial enrollment period, unless you experience a qualified life event, or at a later annual open enrollment period. COVERAGE IS EFFECTIVE, DECEMBER 27, 2015 IF A DEDUCTION FOR THE MEC PLAN IS TAKEN FROM YOUR JANUARY 1, 2016 PAYCHECK.

2 Minimum Essential Coverage (MEC) As mandated by the Affordable Care Act (ACA), all individuals must purchase health insurance that meets certain requirements beginning January 1, 2014 in order to avoid paying a penalty tax. Minimum Essential Coverage (MEC) is the coverage level that is required to avoid the Individual Mandate penalty under the ACA. If you don t have health insurance in 2016, you ll pay the higher of these two amounts: 2.5% of your yearly household income (Only the amount of income above the tax filing threshold, about $10,150 for an individual in 2014, is used to calculate the penalty.) The maximum penalty is the national average premium for a Bronze plan. $695 per person ($ per child under 18). The maximum penalty per family using this method is $2,085. There are 63 preventive services covered at 100% under the required government list of Preventive and Wellness Benefits when utilizing an in-network provider and are not subject to a deductible. A full list of the covered services is included on the next page. WHAT IS IT? Minimum Essential Coverage or MEC for short, is coverage that satisfies the Individual Mandate under the Affordable Care Act. An individual is required to have coverage under this new law or they will face penalties. When you file your taxes, you will need to provide the IRS with information regarding your healthcare coverage. This plan you are being offered will satisfy this new requirement and you won t be subject to any fines. WHAT DOES THIS PLAN COVER? The Preventive Only plan covers 63 specific tests and procedures that the government has outlined and requires that all plans cover these at 100% coverage which means there is no cost to you and there are no limits on the coverage. WHAT DOESN T IT COVER? This plan won t help you if you are sick or if you ve already been diagnosed with an illness or ailment. We offer another benefits program the fixed indemnity plans that can help you if you get sick or have a chronic condition. WHY SHOULD I ENROLL? The Preventive Only Plan will help you stay healthy and hopefully will allow you to catch any problems in their early stages, so that there is a greater likelihood of a quick recovery. Procedures are covered at 100% - so there is no cost to you and there is no limit on the number of times the plan can be used. Also, it s priced very affordably. CAN I USE ANY DOCTOR? No, with the Preventive Only plan you are required to see a First Health network provider. The plan does not cover outof-network providers. You can call Member Services at (800) for assistance in finding a network provider or research for yourself at WHAT WILL HAPPEN IF I DON T SIGN UP? If you don t enroll during Open Enrollment, you will have to wait till next year, unless you have a qualifying event. If you don t get qualifying coverage this year, you may be subject to tax penalties when you file your taxes. IS THIS MAJOR MEDICAL OR SIMILAR TO COVERAGE ON THE EXCHANGE? No, the Preventive only plan is not major medical and only covers the 63 procedures. Fixed Indemnity Benefits Fixed Indemnity Benefits pay a set dollar amount for non-preventive medical services you may need that are not covered under MEC such as doctor s office or emergency room visits if you get sick, hospital stays, surgery, lab work or X-rays. These benefits do not meet the ACA requirements but do pay in addition to other coverage you may have. Claims payments can be made to the service provider or directly to the individual as a reimbursement. With a low cost, these benefits can really help to supplement your medical expenses.

3 Covered Preventive Services The following procedures are covered at 100% when using a First Health provider. This product is not underwritten by Nationwide Life Insurance Company. 15 COVERED PREVENTIVE SERVICES FOR ADULTS 1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked 2. Alcohol Misuse screening and counseling 3. Aspirin use for men and women of certain ages 4. Blood Pressure screening for all adults 5. Cholesterol screening for adults of certain ages or at higher risk 6. Colorectal Cancer screening for adults over Depression screening for adults 8. Type 2 Diabetes screening for adults with high blood pressure 9. Diet counseling for adults at higher risk for chronic disease 10. HIV screening for all adults at higher risk 11. Immunization vaccines for adults - doses, recommended ages, and recommended populations vary: Hepatitis Hepatitis B, Herpes Zoster, Human Papillomavirus, Influenza (Flu Shot), Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Tetanus, Diphtheria, Pertussis, Varicella, Haemophilus influenzae tybe b. 12. Obesity screening and counseling for all adults 13. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk 14. Tobacco Use screening for all adults and cessation interventions for tobacco users 15. Syphilis screening for all adults at higher risk 22 COVERED PREVENTIVE SERVICES FOR WOMEN, INCLUDING PREGNANT WOMEN 1. Anemia screening on a routine basis for pregnant women 2. Bacteriuria urinary tract or other infection screening for pregnant women 3. BRCA counseling about genetic testing for women at higher risk 4. Breast Cancer Mammography screenings every 1 to 2 years for women over Breast Cancer Chemoprevention counseling for women at higher risk 6. Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies for pregnant and nursing women 7. Cervical Cancer screening for sexually active women 8. Chlamydia Infection screening for younger women and other women at higher risk 9. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs 10. Domestic and Interpersonal Violence screening and counseling for all women 11. Folic Acid supplements for women who may become pregnant 12. Gestational Diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes 13. Gonorrhea screening for all women at higher risk 14. Hepatitis B screening for pregnant women at their first prenatal visit 15. Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women 16. Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older 17. Osteoporosis screening for women over age 60 depending on risk factors 18. Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk 19. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users 20. Sexually Transmitted Infections (STI) counseling for sexually active women 21. Syphilis screening for all pregnant women or other women at increased risk 22. Well-woman visits to obtain recommended preventive services 26 COVERED PREVENTIVE SERVICES FOR CHILDREN 1. Alcohol and Drug Use assessments for adolescents 2. Autism screening for children at 18 and 24 months 3. Behavioral assessments for children of all ages up to age Blood Pressure screening for children up to age Cervical Dysplasia screening for sexually active females 6. Congenital Hypothyroidism screening for newborns 7. Depression screening for adolescents 8. Developmental screening for children under age 3, and surveillance throughout childhood 9. Dyslipidemia screening for children up to age 17 at higher risk of lipid disorders 10. Fluoride Chemoprevention supplements for children without fluoride in their water source 11. Gonorrhea preventive medication for the eyes of all newborns 12. Hearing screening for all newborns 13. Height, Weight and Body Mass Index measurements for children up to age Hematocrit or Hemoglobin screening for children 15. Hemoglobinopathies or sickle cell screening for newborns 16. HIV screening for adolescents at higher risk 17. Immunization vaccines for children from birth to age 18 - doses, recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis, Haemophilus influenzae type b, Hepatitis A, Hepatitis B, Human Papillomavirus, Inactivated Poliovirus, Influenza (Flu Shot), Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Rotavirus, Varicella 18. Iron supplements for children ages 6 to 12 months at risk for anemia 19. Lead screening for children at risk of exposure 20. Medical History for all children throughout development up to age Obesity screening and counseling 22. Oral Health risk assessment for young children up to age Phenylketonuria (PKU) screening for this genetic disorder in newborns 24. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk 25. Tuberculin testing for children at higher risk of tuberculosis up to age Vision screening for all children

4 Medical Coverage Options The MEC preventative procedures are provided through a self-insurance plan with employer contributions made on your behalf. The Fixed Indemnity benefit is underwritten by Nationwide. MEC MEC Preventive 63 procedures are covered at 100%, when utilizing a First Health provider FIXED INDEMNITY Doctor s Office Benefit Hospital Admission Benefit Daily In-Hospital Indemnity - Intensive Care - Mental Illness - Substance Abuse - In-Patient Skilled Nursing Surgical Indemnity Benefit - Daily Inpatient Surgical - Daily Outpatient Surgical - Daily Outpatient Minor Surgical - Outpatient Benefit Maximum - Anesthesia Outpatient Diagnostic X-Ray Outpatient Diagnostic Laboratory Outpatient Diagnostic Advanced Studies Indemnity Benefit Emergency Room Benefit for Illness Only $60 per day, 6 days per person per year $500 per confinement $200 per day, 500 days lifetime max $400 per day, 30 days per person per year $100 per day, 30 days per person per year $100 per day, 30 days per person per calendar year $100 per day, 60 days per in-patient stay $1,000 per day, 1 day per year $500 $100 1 day per year 30% of Surgical Benefit $100 per testing day, 3 days per person per year $85 per testing day, 3 days per person per year $100 per testing day, 3 days per person per year $75 per day, 4 days per person per year *The above benefits are underwritten by Nationwide Life Insurance Company First Health Network Prescription Drugs Discount Program Teladoc, Medical Bill Saver, Counseling, Nurseline, Chiropractic/Vision/ Hearing discounts ADDITIONAL PROGRAMS BI-WEEKLY RATES Doctors and Hospitals Discount Pharmacy Program Included Employee Only $11.73 Employee + Child $51.61 Employee + Spouse $65.53 Family $88.36 Nationwide Insurance and the Nationwide framemark are service marks of Nationwide Mutual Insurance Company.

5 Other Great Benefit Options Below are critical illness/life/accident, short term disability (STD) and dental/vision benefits which can also be purchased. All plans are insured by Nationwide Life Insurance Company. Please review these plans and make the choice that best suits your needs. The Enrollment Center can answer your questions regarding eligibility and how the plan works. CRITICAL ILLNESS (C.I.) / LIFE / AD&D / ACCIDENT Critical Illness (C.I.) Benefit Amount (Includes first occurence of one of the following covered conditions: End-Stage Renal Failure, Heart Attack, Life Threatening Cancer, Major Organ Transplant, Stroke) Employee (Age reductions apply): $10,000 Spouse: $5,000 Child (6 mos to 26 yrs): $2,500 Life Benefit Amount Employee (Age reductions apply): $10,000 Spouse: $5,000 Child (6 mos to 26 yrs): $2,500 Infant (10 days to 6 mos): $400 AD&D Benefit Amount Employee (Age reductions apply): $10,000 Accident Expense Benefit Amount Per Person, per occurrence: $2,500 Premium Bi-Weekly Employee Only $12.36 Employee + Child $22.25 Employee + Spouse $26.41 Family $28.26 SHORT-TERM DISABILITY This benefit is payable for non-occupational injuries and sickness only. Benefit Amount: Waiting Period: Max Benefit Period: $125 per week 15 Days 26 Weeks Premium Bi-Weekly Employee Only $3.04 DENTAL / VISION Dental Care: Annual Deductible: Annual Maximum: Preventative and Diagnostic (routine exams and cleanings, fluoride treatment, x-rays) Basic Treatment: (extractions, fillings, endodontics, periodontics) Major Treatments (crowns, dentures) Orthodontia: $50 per covered person $500 per covered person Plan pays 100% of Usual & Customary Rate (UCR) Plan pays 60% of UCR after a 6 months waiting period Plan pays 50% of UCR after a 12 months waiting period Not covered Vision Care: Annual Maximum: Co-insurance: Routine Exam: Lenses/Frames or Contacts: $300 per covered person 80% 1 every 12 months 1 pair every 24 months Premium Bi-Weekly Employee Only $12.16 Employee + Child $21.89 Employee + Spouse $30.41 Family $32.84

6 Other Great Benefit Options The Inpatient Hospital Benefit provides coverage based on a schedule of benefits per service. This benefit is insured by Nationwide Life Insurance Company. Please review these plans and make the choice that best suits your needs. The Enrollment Center can answer your questions regarding eligibility and how the plan works. INPATIENT HOSPITAL Benefit Detail Plan Pays Description Hospital Admission Benefit: $1,000 Benefit payable only once during any period of confinement. Requires a 24 hour hospital stay. Daily In-Hospital Benefit: $100 per day Benefit payable per day. Up to a lifetime maximum of 500 days of confinement. Requires a 24-hour hospital stay. Intensive Care Benefit $200 per day Double the daily in-hospital benefit will be paid, up to a maximum of 30 days per calendar year. Mental Illness Disorder $50 per day $50 per day will be paid up to $5,000 per cal year maximum and lifetime maximum of $30,000. In-Patient Skilled Nursing Facility $50 per day $50 per day will be paid up to a maximum of 60 days per confinement. The confinement is covered only if it follows a covered hospital stay of at least 3 days. Substance Abuse $50 per day $50 per day will be paid, up to a maximum of 30 days per calendar year. Lifetime maximum is $30,000. Bi-Weekly Premium Employee Only $ 7.70 Employee + Child $13.86 Employee + Spouse $19.25 Family $24.40 Nationwide Insurance and the Nationwide framemark are service marks of Nationwide Mutual Insurance Company.

7 Frequently Asked Questions WHEN CAN I ENROLL? If you do not enroll during Open Enrollment, you will not be able to make changes during the year unless you experience a qualified status change. Newly hired employees may enroll within 30 days of their date of hire. WHO IS ELIGIBLE TO ENROLL? You and your eligible dependents may enroll. An eligible dependent is an employee s spouse and child(ren) from birth to age 26. WHEN DOES MY COVERAGE BEGIN? Coverage will begin on the pay date in which you have the first deduction taken. New hires must satisfy a 30 day waiting period before coverage will begin. The effective date of coverage for your eligible dependent(s) will be the same as yours, unless dependent coverage is added at a later time. WILL I RECEIVE AN ID CARD? Yes, you will receive three ID cards along with information about each coverage you elect. These will be mailed to your home address. WHO CAN I CONTACT IF I HAVE QUESTIONS ABOUT MY BENEFITS? Contact Member Services, toll-free at They are open Monday through Friday from 7:00 a.m. to 7:00 p.m. Central Time. WHAT IS THE MEC PREVENTIVE COVERAGE? This is coverage that satisfies the Individual Mandate under the Affordable Care Act. An individual is required to have coverage under this new law or they will face penalties. When you file your taxes, you will need to provide the IRS with information regarding your healthcare coverage. This plan you are being offered will satisfy this new requirement and you won t be subject to any fines during the period for which you are covered. HOW WILL MY PREMIUMS BE PAID? Premiums will be paid through payroll deductions on a bi-weekly basis. Benefit deductions will be on a pretax basis. Elections cannot be changed during the plan year, unless you have qualifying event, per IRS code rules. The term life/ad&d, dependent life and short-term disability premiums will be deducted on an after-tax basis. HOW DO I SUBMIT A MEDICAL CLAIM? There are two ways to file a claim for benefits under this plan: Option 1 - Present your ID card to the provider at the time of service. If the provider will file the claim with the insurance company on your behalf, then you do not have to pay for the services in advance. The insurance carrier will pay that benefit to the provider. You would be responsible for paying the provider any billed amount that the insurance company does not pay them. Option 2 - Pay the full billed amount to the provider and submit a claim for reimbursement to the insurance carrier. When filing a claim for reimbursement, you need to provide the certificate or member number from your insurance booklet and original bill for service which includes the patient name, date of service, diagnosis code and itemized charges, along with a reimbursement form. Benefit will be payable to you. CAN I USE ANY DOCTOR FOR PREVENTIVE SERVICES? No, with the Preventive plan you are required to see a First Health network provider. The plan does not cover out-ofnetwork claims. You can call Member Services at for assistance in finding a network provider or go to WHAT WILL HAPPEN IF I DON T SIGN UP FOR MEC PREVENTIVE COVERAGE? If you don t enroll, you will have to wait until the next annual open enrollment period, unless you have a qualifying event. If you don t get qualifying coverage this year, you may be subject to Individual Mandate tax penalties when you file your taxes. HOW DO I GET REIMBURSED FOR MY CONTRACEPTIVE PRESCRIPTIONS? Contraceptive prescriptions are covered at 100% under all medical plans as a preventive service. You will need to pay out of pocket when picking up your prescription. Then you will complete and submit a reimbursement form for payment.

8 Missed Premium DOES YOUR INCOME VARY FROM PAYCHECK TO PAYCHECK? SOME PAYROLL PERIODS MAY NOT HAVE ENOUGH FUNDS TO COVER THE COST OF YOUR BENEFITS. You have 30 days to pay for the premiums that could not be deducted from your paycheck. If you do not pay the missed premiums within 30 days you will be unable to pay for them at a later date. If you have missed premium deductions and want to find out the balance due or have questions about making a payment, contact Member Services at or go online to You can authorize us to charge a credit/debit card or draft your bank account anytime you have had a missed deduction from your paycheck. This authorization can be setup online at www. IAmEnrolling.com at any time or when you are enrolling. HOW DO I PAY MISSED PREMIUMS? To pay by credit/debit card or electronic check: Go to If this is your first time visiting the site, use the New User? box and sign in using your Social Security Number and date of birth (if requested, the Group ID is 97640). From there you will be prompted to verify your contact information (one time process) and setup a username and password. If you have already created a user account select the Returning User? box and enter your username and password. The Security Question tool can assist in instances where you cannot remember your username or password. Once logged in, click Billing and follow the instructions. To pay missed premiums by check or money order: Attach the payment to a missed premium form and write the group number, FV1220, on your payment. Make sure the check or money order is written for the total amount due and is made payable to Nationwide Life Insurance Company. Mail your payment along with the missed premium form to: Nationwide Life Insurance Company Anderson Mill Road, Suite 401 Austin, TX 78726

9 Additional Programs FIRST HEALTH NETWORK The First Health Network provides access to one of the nation s largest and most respected networks. By going to a First Health provider you can reduce your out-of-pocket expenses and stretch your benefit dollars. Access to more than 490,000 provider locations across all 50 states and the District of Columbia First Health logo on medical ID card for fast and easy recognition by the provider Re-priced claims will be assigned directly to the provider to simplify the claims process To find a provider online, visit Members retain the ability to choose any doctor they wish and have those claims assigned under the illness and accident plans. All illness and accident benefits will pay as specified in the benefit provisions of the policy regardless of the provider chosen. The MEC Preventive Plan requires First Health network use. DISCOUNT HEALTH SAVINGS PROGRAM Administered by New Benefits, Ltd. Your membership provides significant savings on the following services: Vision Hearing Chiropractic Vitamins & Diabetic Supplies In addition, members also receive access to the following: Teladoc Health Advocate Services (Medical Bill Saver TM, Medical Health Advisor, Nurseline TM ) Counseling Services TELADOC Administered by New Benefits, Ltd. Teladoc provides 24/7 access to a national network of U.S. board-certified doctors who can resolve many of your medical issues via telephone. Teladoc doctors can diagnose, treat and prescribe medication, when necessary, for medical issues including cold and flu symptoms, allergies, bronchitis, sinus problems, urinary tract infection, respiratory infection, pink eye, ear infection and more! HEALTH ADVOCATE SERVICES Administered by New Benefits, Ltd. Medical Bill Saver - The Health Advocate Medical Bill Saver benefit can lower out-of-pocket costs on medical bills not covered by insurance. Advocates will work with healthcare providers and attempt to lower the balance on any uncovered medical or dental bill over $400. Medical Health Advisor - The services are organized around Personal Health Advocates, typically registered nurses, supported by a team of medical directors and administrative experts, who assist individuals in getting the most value from their healthcare benefits. One call to Medical Health Advisor and we ll help members resolve insurance claims and billing issues. Health Advocate does not replace health insurance, provide medical care or recommend treatment. DISCOUNT PRESCRIPTION PROGRAM Administered by New Benefits, Ltd. The neighborhood pharmacy program assures members the lowest price on prescription drugs, saving 10% to 85% on most prescriptions. It s simple to use. The member simply presents the membership card to the pharmacist with the prescription. The pharmacist calculates the discount and the member pays the discounted price. No other forms required. Pharmacy locations may be obtained by contacting customer service at Pharmacy Discounts are Not Insurance and are Not Intended as a Substitute for Insurance. The discount is only available at participating pharmacies.

10 Important Notices Fixed indemnity medical benefits provided under the Minor Illness and Accident plans. The Nationwide program is not intended or recommended to replace any comprehensive program of insurance in which you currently participate, or intend to participate. This plan is not designed to replace or provide major medical or catastrophic coverage. This brochure is for summary purposes only. The insurance benefits for the medical indemnity plan are underwritten by Nationwide Life Insurance Company. Additional information will be provided upon enrollment in the Program. Plan exclusions and limitations apply. DISCLOSURES The Discount Health Savings Program is NOT insurance. The plan is not insurance coverage and does not meet the minimum creditable coverage requirements under the Affordable Care Act or Massachusetts M.G.L. c. 111M and 956 CMR This plan provides discounts at certain healthcare providers for medical services. This plan does not make payments directly to the providers of medical services. The plan member is obligated to pay for all healthcare services but will receive a discount from those healthcare providers who have contracted with the discount plan organization. This discount card program contains a 30 day cancellation period. The range of discounts for medical or ancillary services provided under the plan will vary depending on the type of provider and medical or ancillary service received. Member shall receive a full refund of membership fees if membership is cancelled within the first 30 days after the effective date. AR and TN residents: A refund of all fees will be issued if membership is cancelled within the first 30 days. Discount Medical Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box Dallas, TX , Website to obtain participating providers: MyMemberPortal.com. The Discount Prescription Program is not considered Creditable Coverage under the Medicare Part D regulations. Medicare eligible individuals may have to pay higher costs if they delay enrolling in the Medicare Pharmacy plan. Teladoc is not available to Idaho residents Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are registered trademarks of Teladoc, Inc. and may not be used without written permission. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, nontherapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services. Teladoc phone consultations are available 24 hours, 7 days a week while video consultations are available during the hours of 7am to 9pm, 7 days a week. MEC PREVENTIVE INFORMATION This Plan is designed to provide Plan Participants with minimum essential coverage under the federal income tax rules. This Plan is designed so that Plan Participants may enroll in this Plan and not have to pay a federal individual income tax penalty. However, while you are enrolled in this Plan, you will not be eligible for a federal tax credit through a federal or state exchange (sometimes referred to as the insurance marketplace). If you do not enroll in this Plan, you may be eligible for a federal tax credit that lowers your monthly premium or a reduction in certain cost-sharing if you enroll in a health insurance plan through the federal or state exchange. This plan does not provide essential health benefits that an individual can purchase through the exchange. NETWORK BENEFITS ONLY IMPORTANT: This Plan only pays benefits if you receive care through a Network Provider. No benefits are paid or provided if you receive care from an out of network provider.

11 LanguageLine Interpreters Benefits Plan Coverage Period: 12/27/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the plan document at iamenrolling.com or by calling Important Questions Answers Why this Matters: What is the overall deductible? $0 See the chart starting on page 2 for your costs for services this plan covers. Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? No No This plan has no out-ofpocket limit No Yes - For a list of Network Providers, see No - You don t need a referral to see a specialist who is a Network Provider. Yes You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. There is no limit on how much you could pay during a coverage period for your share of the cost of covered services. Not applicable because there s no out-of-pocket limit on your expenses. The chart starting on page 2 describes any limits the plan will pay for specific covered services. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term innetwork, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see a network provider specialist you choose without permission from this plan. Non-network provider specialists are not covered under the plan. Some of the services this plan doesn t cover are listed on page 4. See your plan document for additional information about excluded services. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Uniform Glossary. You can view the Glossary at or call 1-(855) to request a copy. 1 of 8

12 LanguageLine Interpreters Benefits Plan Coverage Period: 12/27/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family Plan Type: PPO Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) If you have an insured medical plan it may encourage you to use certain providers by charging you lower deductibles, co-payments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Your Cost if You Use Network Provider Non-Network Provider Limitations & Exceptions Primary care visit to treat an injury or illness Not Covered Not Covered None Specialist visit Not Covered Not Covered None Other practitioner office visit Not Covered Not Covered None Preventive care/screening/immunization No Charge Not Covered Services limited to preventive care mandated by the Patient Protection and Affordable Care Act. Diagnostic test (x-ray, blood work) Not Covered Not Covered None Imaging (CT/PET scans, MRIs) Not Covered Not Covered None Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Uniform Glossary. You can view the Glossary at or call 1-(855) to request a copy. 2 of 8

13 LanguageLine Interpreters Benefits Plan Coverage Period: 12/27/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family Plan Type: PPO Common Medical Event If you need drugs to treat your illness or condition If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Your Cost if You Use Network Provider Non-Network Provider Limitations & Exceptions Generic drugs Not Covered Not Covered FDA approved contraceptive methods as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). Preferred brand drugs Not Covered Not Covered FDA approved contraceptive methods as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). Non-preferred brand drugs Not Covered Not Covered FDA approved contraceptive methods as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). Specialty drugs Not Covered Not Covered None Facility fee (e.g., ambulatory surgery center) Not Covered Not Covered None Physician/surgeon fees Not Covered Not Covered None Emergency room services Not Covered Not Covered None Emergency medical transportation Not Covered Not Covered None Urgent care Not Covered Not Covered None Facility fee (e.g., hospital room) Not Covered Not Covered None Physician/surgeon fee Not Covered Not Covered None Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Uniform Glossary. You can view the Glossary at or call 1-(855) to request a copy. 3 of 8

14 LanguageLine Interpreters Benefits Plan Coverage Period: 12/27/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family Plan Type: PPO Common Medical Event If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your Cost if You Use Network Provider Non-Network Provider Limitations & Exceptions Mental/Behavioral health outpatient services Not Covered Not Covered None Mental/Behavioral health inpatient services Not Covered Not Covered None Substance use disorder outpatient services Not Covered Not Covered Alcohol Misuse screening is covered if conducted by a network provider. Substance use disorder inpatient services Not Covered Not Covered None No charge for Prenatal and postnatal care routine prenatal Not Covered None office visits Delivery and all inpatient services Not Covered Not Covered None Home health care Not Covered Not Covered None Rehabilitation services Not Covered Not Covered None Habilitation services Not Covered Not Covered None Skilled nursing care Not Covered Not Covered None Durable medical equipment Not Covered Not Covered None Hospice service Not Covered Not Covered None Eye exam Covered Not Covered Vision screening only. Glasses Not Covered Not Covered None Oral Health risk assessment for Dental check-up Not Covered Not Covered young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Uniform Glossary. You can view the Glossary at or call 1-(855) to request a copy. 4 of 8

15 LanguageLine Interpreters Benefits Plan Coverage Period: 12/27/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family Plan Type: PPO Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Acupuncture Allergy testing, serum and injections Ambulance Service Jaw Joint/TMJ Bariatric surgery Chiropractic care Chiropractic Services Orthotics Cosmetic surgery Dental care (adult) Diagnostic testing (e.g. X-ray imaging, Labs) Durable Medical Equipment Emergency Services / Emergency Room Visit Organ Transplants Outpatient Care Hearing aids Heart Disease treatment Home Health Care Hospice Care Hospital Room & Board Skilled Nursing Facility or Hospice Inpatient or Outpatient Care Intensive Care Unit Long-term care Natural / Cesarean Child birth Care when traveling outside the U.S. Physical or Speech Therapy Cancer Treatment Prescription Drugs (except birth control for women with reproductive capacity) Private duty nursing Routine eye care (adult) Routing foot care Surgery Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Please visit the Healthcare.gov for a complete and current list of Preventative Care Benefits that are required and covered under this plan. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Uniform Glossary. You can view the Glossary at or call 1-(855) to request a copy. 5 of 8

16 LanguageLine Interpreters Benefits Plan Coverage Period: 12/27/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family Plan Type: PPO Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 1-(855) You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact the plan at 1-(855) Additionally, some states provide a consumer assistance program which can help you file your appeal. A list of states with Consumer Assistance Programs is available at Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does not meet the minimum value standard for the benefits it provides. To see examples of how this plan might cover costs for a sample medical situation, see the next page. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Uniform Glossary. You can view the Glossary at or call 1-(855) to request a copy. 6 of 8

17 LanguageLine Interpreters Benefits Plan Coverage Period: 12/27/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family Plan Type: PPO About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $40 Patient pays Up to $7,500 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Co-pays $0 Co-insurance $0 Limits or exclusions $7,500 Total $7,500 Note The plan reimburses breastfeeding support and supplies, folic acid supplements, gestational diabetes screening at weeks, hepatitis B screening on first prenatal visit, Rh incompatibility screening, syphilis, urinary tract and other infection screening for pregnant women. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Uniform Glossary. You can view the Glossary at or call 1-(855) to request a copy. Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $4,100 Plan pays $140 Patient pays Up to $3,960 Sample care costs: Prescriptions $1,500 Medical Equipment and Supplies $1,300 Office Visits and Procedures $730 Education $290 Laboratory tests $140 Vaccines, other preventive $140 Total $4,100 Patient pays: Deductibles $0 Co-pays $0 Co-insurance $0 Limits or exclusions $3,960 Total $3,960 Note The plan reimburses diabetes (Type 2) screening for adults with high blood pressure and gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes. 7 of 8

18 LanguageLine Interpreters Benefits Plan Coverage Period: 12/27/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Family Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Uniform Glossary. You can view the Glossary at or call 1-(855) to request a copy. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as co-payments, deductibles, and co-insurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 8 of 8