MINIMUM ESSENTIAL COVERAGE

Transcription

1 MINIMUM ESSENTIAL COVERAGE FOR NEWLY ELIGIBLE EMPLOYEES Important to Note: You are receiving this guide because you qualify for the MEC Plan based on the hours you worked After you have reviewed this guide, log in to Workday to make your benefit elections 1 of 9

2 MEC ENROLLMENT Dear Employee, Discount Tire/America s Tire/Discount Tire Direct (the Company) cares for and cultivates our people by providing options to help you stay healthy. Your wellness is important to us. Please carefully review the three Minimum Essential Coverage (MEC) plan options to determine which plan might be right for you. WHAT IS MINIMUM ESSENTIAL COVERAGE? Minimum Essential Coverage, or MEC for short, is coverage that satisfies the Individual Mandate under the Affordable Care Act (ACA). An individual is required to have coverage under this law or they may pay a penalty tax. This MEC Plan you are being offered will satisfy this requirement. Each year, your eligibility for the MEC plan is reevaluated based on hours you worked. When you log in to Workday, you will see an Inbox notification to start your enrollment process. Please note: You must enroll in one of the MEC Medical plans in order to elect the optional Dental/ Vision Insurance, Life Insurance, and/or Disability Insurance. Refer to the enclosed Workday MEC Enrollment Quick Reference Guide (QRG) for instructions. 2 of 9

3 MEC ELIGIBILITY ELIGIBILITY Who is Eligible to Enroll for Minimum Essential Coverage (MEC) Benefits? Employees: Part-time employees are eligible for the Company s benefit plans based on the number of hours worked over the past 12 months. Dependents: Eligible dependents include your legal spouse and children up to age 26. The definition of child includes any of the following: Your child / stepchild A child placed with you for adoption Your legally adopted child A child for whom you have legal guardianship Your child for whom health coverage is required through a Qualified Medical Child Support Order (QMCSO) Information About Making Mid-year Changes: Please enroll your covered dependents in Medical and Dental/Vision if needed. This is the only time during the year you may do so, unless a qualifying life event occurs in your family or employment status. Once a qualifying life event occurs, you have 31 days from the date of the event (or 60 days in the event of Children s Health Insurance Program) to log in to Workday to submit the changes to your benefits elections and upload your supporting documents (i.e. birth certificate, marriage certificate, Social Security card, etc.). Changes will be effective on the date of the qualifying event. If you do not submit your changes within 31 days, you may not be eligible to change your benefit elections until the next open enrollment. The table below outlines Qualifying Life Events and the documentation needed to make changes to your elected benefits. Qualifying Life Event A change in marital status: Marriage Divorce Death of Spouse A change in the number of your dependents: Birth or adoption Death of a dependent Dependent(s) obtain their own coverage Termination or commencement of employment by employee, spouse, or dependent Any significant change in your family s health care plan coverage through your spouse s health care plan A dependent child exceeds the maximum age for coverage 3 of 9 Documentation Required Marriage Certificate and Social Security card Divorce Decree Death Certificate Birth Certificate/Adoption Agreement and Social Security card Death Certificate Proof of other coverage and effective date Documentation from the employer confirming prior coverage and effective date Documentation from spouse s employer confirming change in coverage and effective date of change Benefits for dependents over age 26 are automatically terminated the last day of the month of their 26th birthday

4 MEC MEDICAL COVERAGE OPTIONS Value Standard Premier Preventive Services* 63 procedures are covered at 100% when using an in-network provider 63 procedures are covered at 100% when using an in-network provider 63 procedures are covered at 100% when using an in-network provider Additional Preventive Care (in addition to the 63 procedures covered at 100%, you may be eligible for additional preventive care coverage based on your election) Not Included $100 per day, 1 day per year $100 per day, 1 day per year Office Sick Visits $10 co-pay per visit 5 visits per calendar year $10 co-pay per visit 5 visits per calendar year $10 co-pay per visit 5 visits per calendar year Additional Doctor s Office Benefit $60 per day 6 days per calendar year $60 per day 6 days per calendar year $75 per day 6 days per calendar year Daily In-Hospital Indemnity $200 per day 500 days lifetime max $300 per day 500 days lifetime max $600 per day 500 days lifetime max Intensive Care $400 per day $600 per day $1,200 per day 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 Lab Outpatient Diagnostic Advanced Studies Emergency Room Sickness Life + AD&D Insurance Employee Spouse (Life Only) Child (Life Only) Infant (Life Only) $100 per day $100 per day $100 per day 60 days per in-patient stay max Not Included $50 per testing day $50 per testing day N/A $75 per day 4 days per calendar year $5,000 $2,500 $1,250 $200 $150 per day $150 per day $150 per day 60 days per in-patient stay $500 per day, 1 day per year $250 $50 1 day per year 30% of Surgical Benefit $75 per testing day $75 per testing day $100 testing per day $75 per day 4 days per calendar year $5,000 $2,500 $1,250 $200 $300 per day $300 per day $300 per day 60 days per in-patient stay max $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 calendar year $85 per testing day 3 days per calendar year $300 testing per day $75 per day 4 days per calendar year $5,000 $2,500 $1,250 $200 Accident Expense Benefit $1,000 per occurrence $1,000 per occurrence $2,500 per occurrence Critical Illness Benefit * This benefit not underwritten by Nationwide Life Insurance $5,000 Employee $2,500 Spouse $1,250 Child 4 of 9 $5,000 Employee $2,500 Spouse $1,250 Child $5,000 Employee $2,500 Spouse $1,250 Child

5 COVERED PREVENTIVE SERVICES 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 A; Hepatitis B; Herpes Zoster; Human Papillomavirus; Influenza (Flu Shot); Measles, Mumps, Rubella; Meningococcal; Pneumococcal; Tetanus, Diphtheria, Pertussis; Varicella 12. Obesity screening and counseling for all adults 13. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk 14. Tobacco Use screening and cessation interventions for tobacco users 15. Syphilis screening for all adults at higher risk 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 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 4. Blood Pressure screening 5. 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 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 14. Hematocrit or Hemoglobin screening for children The above list is subject to change per government agency 5 of 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 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 21. Obesity screening and counseling 22. Oral Health risk assessment for young children up to 10 years 23. 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 26. Vision screening for all children

6 OTHER BENEFIT OPTIONS You must enroll in one of the medical plans in order to elect Dental/Vision Insurance, Life Insurance, and/or Disability Insurance. Dental Annual Deductible Annual Maximum $50 per covered person $500 per covered person Co-Insurance Type 1 - Preventive and Diagnostic (routine exam and cleanings, fluoride treatments, x-rays) Plan pays 80% of Usual and Customary Rate (no waiting period) Type 2 - Basic Treatments (extractions, fillings, endodontics, periodontics) Plan pays 80% of Usual and Customary Rate (3 month waiting period) Type 3 - Major Treatment (crowns and dentures) Plan pays 50% of Usual and Customary Rate (no waiting period) Orthodontia Plan pays 50% of Usual and Customary Rate, Lifetime Maximum of $250 Vision Life/AD&D Insurance Short Term Disability Co-Insurance Plan pays 80% Benefit Maximum Benefit Frequency Life/AD&D Insurance Short Term Disability (STD) Benefit $150 calendar year max per covered person 1 exam every 12 months 1 pair of glasses or contacts every 24 months $20,000 (employee only, age restrictions apply) Pays up to 66 2/3% of your pre-disability income up to $300 per week. You must satisfy a 14 day waiting period and then benefits will pay for up to 26 weeks should you become disabled due to a non-occupational injury or illness. RATES Premiums will be paid through payroll deductions every week. See the table below for the weekly deduction amounts. MEDICAL PLAN CHOICES OPTIONAL BENEFITS Employee Employee + Spouse Employee + Child(ren) Family Value Plan $12.41 $26.04 $22.54 $31.13 Standard Plan $17.92 $37.77 $31.59 $43.13 Premier Plan $24.84 $55.11 $43.71 $61.08 Dental/Vision $5.75 $14.38 $10.35 $14.92 Life/AD&D $1.98 N/A N/A N/A Short Term Disability (STD) $3.33 N/A N/A N/A 6 of 9

7 FREQUENTLY ASKED QUESTIONS WHAT DOESN T THE MEC PLAN COVER? The MEC plans offered provide limited benefit coverage and may not be right for everyone. These plans differ from comprehensive major medical insurance, and are not intended to replace major medical insurance. CAN I USE ANY DOCTOR? No, with the MEC Plan you are required to see a First Health Network Provider. The MEC Plan will only cover claims when a First Health Network Provider is used. You can call Member Services at for assistance in finding Network Providers or log on to WHAT WILL HAPPEN IF I DON T SIGN UP? If you don t have qualifying medical coverage, you may be subject to Individual Mandate tax penalties when you file your taxes. The penalty is a flat dollar amount or percentage of your annual income, whichever is greater. The flat dollar and percentage fees are established by the IRS and rise with inflation. Visit to view penalty amounts for the current year. IS THIS SIMILAR TO COVERAGE AVAILABLE ON THE HEALTHCARE.GOV EXCHANGE? Research what medical plan options are available to you. You may be eligible for subsidies through the Marketplace website at For further assistance with your choices for medical plans through the Marketplace, you may contact Mylo, a free service provided to you by the Company at 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 the original bill for service which includes the patient name, date of service, diagnosis code and itemized charges, along with a reimbursement form. The benefit will be payable to you. ONLINE RESOURCES FOR EMPLOYEES AND FAMILIES Have you visited yet? The Discount Tire Family website can be accessed from work or at home; for more information on Minimum Essential Coverage, simply type MEC in the search box. Browse the site to stay informed and up-to-date on: Employee Benefits and Assistance Financial Resources Health and Wellness 7 of 9 Discount Tire In the News Healthy Recipes And more!

8 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 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, Medical Health Advisor, Nurseline ) Telephonic Counseling Services TELADOC 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 at no additional charge to you. 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! More information on how to access services will be sent in your welcome kit. HEALTH ADVOCATE SERVICES 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 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. 8 of 9

9 IMPORTANT NOTICES 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 offered by Nationwide Life Insurance Company. Additional information will be provided upon enrollment in the Program. Plan exclusions and limitations apply. The Discount Health Savings Program and Discount Prescription Program are administered by New Benefits, Ltd. 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. 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, non-therapeutic 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 7 a.m. to 9 p.m., 7 days a week. Minimum Essential Coverage (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 though 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. 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. 9 of 9