5M Program - Enrollment Form

Transcription

1 1. Enrollee Information Group Name: Last Name: First Name: 5M Program - Enrollment Form Plan Coverage Effective Date: Date you became a Full time Employee: 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 MEC Plus Plan MEC Heavy Plan MEC Heavy Plus Plan MVP Plan Beneficiary of Life Insurance (If applicable): Full Name: Address: City, State Zip: Phone #: Date of Birth: Relationship: 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 Disabled 1 Court Ordered 2 Last Name: First: SS#: DOB: Male Female Child Disabled 1 Court Ordered 2 Last Name: First: SS#: DOB: Male Female Child Disabled 1 Court Ordered 2 Last Name: First: SS#: DOB: Male Female Child Disabled 1 Court Ordered 2 Last Name: First: SS#: DOB: Male Female Child Disabled 1 Court Ordered 2 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. Individual coverage through Marketplace I am waiving/declining plan coverage because I have other coverage Spousal coverage Medicare coverage Military Coverage Carrier Name Carrier Phone Number Primary Insured Full Name Policy # Member ID Primary Insured Date of Birth Employee (print name): Employee Signature: Date:

2 5M Enrollment Guide Medical Plan Options and Enrollment Information Administered by Key Benefit Administrators, Inc. PLANS DESIGNED FOR THE EMPLOYEES OF American StaffCorp. Inc.

3 Minimum Essential Coverage (MEC) Minimum Essential Coverage covers 100% of the government s listed Preventive and Wellness Benefits when you visit a network provider (40% out-of-network). Self-Insured by your employer, this coverage is required to satisfy your individual mandate under the new healthcare law. As outlined under the new healthcare law, ACA, all individuals must have Minimum Essential Coverage (MEC) beginning January 1, 2014, or pay a penalty tax. Employees can prevent being taxed the Individual Mandate penalty tax by purchasing Minimum Essential Coverage through their employer. If you don t purchase Minimum Essential Coverage (MEC), beginning January 1, 2014, you will face a tax of the greater of 1% of adjusted household income or $95 per adult plus $47.50 per child. In 2015, you will have to pay the greater of 2% of adjusted household income or $325 per adult plus $ per child. Thereafter, the tax will be the greater of 2.5% of adjusted household income or $695 per adult plus $ per child. 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-ofnetwork 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. 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. The MEC comes with a medical ID Card that needs to be presented to your medical provider at your time of service.

4 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 men ages and women ages to prevent CVD when prescribed by a physician 4. Blood Pressure screening 5. Cholesterol screening for adults 6. Colorectal Cancer screening for adults starting at age 50 limited to one every 5 years 7. Depression screening 8. Type 2 Diabetes screening 9. Diet Counseling 10. HIV Screening 11. Immunizations vaccines (Hepatitis A & B, Herpes Zoster, Human Papillomavirus, Influenza (flu shot), Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Tetanus, Diptheria, Pertussis, Varicella) 12. Obesity screening and counseling 13. Sexually Transmitted Infection (STI) prevention counseling 14. Tobacco Use screening and cessation interventions 15. Syphilis screening 16. Hepatitis B screening for non-pregnant adolescents and adults. 17. Lung Cancer screening years old who smoke 30 packs a year. 18. Fall Prevention Physical therapy and vitamin D for 65 and older at risk for falling 19. Hepatitis C screening for high risk individuals and a onetime screening for HCV infection if born between 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 and genetic testing for women at higher risk 4. Breast Cancer Mammography screenings every year for women age 40 and over 5. Breast Cancer Chemo Prevention counseling for women 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 8. Chlamydia Infection screening 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 when prescribed by a physician 12. Gestational diabetes screening 13. Gonorrhea screening 14. Hepatitis B screening for pregnant women 15. Human Immunodeficiency Virus (HIV) screening and counseling 16. Human Papillomavirus (HPV) DNA Test: HPV DNA testing every three years for women with normal cytology results who are 30 or older 17. Osteoporosis screening over age Rh Incompatibility screening for all pregnant women and followup testing 19. Tobacco Use screening and interventions and expanded counseling for pregnant tobacco users 20. Sexually Transmitted Infections (STI) counseling 21. Syphilis screening 22. Well-woman visits to obtain recommended preventive services 23.Aspirin for Preeclampsia prevention *Includes routine prenatal visits for pregnant women Covered 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 Blood Pressure screening 5. Cervical Dysplasia screening 6. Congenital Hypothyroidism screening for newborns 7. Depression screening for adolescents age 12 and older 8. Developmental screening for children under age 3, and surveillance throughout childhood 9. Dyslipidemia screening for children 10. Fluoride Chemo Prevention supplements for children without fluoride in their water source when prescribed by a physician 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 14. Hematocrit or Hemoglobin screening for children 15. Hemoglobinopathies or sickle cell screening for newborns 16. HIV screening for adolescents 17. Immunization vaccines for children from birth to age 18; doses, recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis, Hepatitis A & B, Human Papillomavirus, Inactivated Poliovirus, Influenza (Flu Shot), Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Rotavirus, Varicella, Haemophilus influenzae type b 18. Iron supplements for children up to 12 months when prescribed by a physician 19. Lead screening for children 20. 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 21. Obesity screening and counseling 22. Oral Health risk assessment for young children up to age Phenylketonuria (PKU) screening in newborns 24. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents 25. Tuberculin testing for children 26. Vision screening for all children under the age of Skin Cancer Behavioral Counseling age for exposure to sun 28. Tobacco intervention and counseling for children 29. Fluoride varnish for primary teeth through age 5. This list above summarizes some but not all services. Please reference the US Preventative Service Task Force website for the entire list.

5 MEC Heavy As outlined under the new healthcare law, ACA, all individuals must have Minimum Essential Coverage (MEC) beginning January 1, 2014, or pay a penalty tax. Employees can prevent being taxed the Individual Mandate penalty tax by purchasing Minimum Essential Coverage through their employer. Because the MEC plan covers specific preventative services we also offer the MEC Heavy plan that provides meaningful benefits for those looking for a more encompassing MEC plan. The MEC Heavy plan covers the required MEC preventative services in addition to Emergency Room Services, Primary Care and Specialist visits, Imaging (CT, PET Scans, MRI s), Laboratory Services, X-Ray and Diagnostic Imaging and Prescription Drugs. The MEC Heavy includes our acclaimed Chronic Disease management program along with the RealTime Health Diabetic Program and the RealTime Choices Price Transparency tool. The MEC Heavy plan offers meaningful benefits at an affordable price. Covered Benefit Categories for the MEC Heavy Plans: - Emergency Room Services - Primary Care Visit to Treat an Injury or Illness - Specialist Visit - Imaging (CT, PET Scans, MRIs) - Preventative Care/Screening/Immunization (MEC Services) - Laboratory Outpatient and Professional Services - X-Rays and Diagnostic Imaging - Prescription Drugs - Chronic Disease Services under the AHDI CDM Benefit The MEC Heavy offers a Co-Pay plan design with a $2,500 single Out-of-Pocket Maximum. Out-of-Network benefits are covered with a $500 single/$1,000 family deductible with a 40% coinsurance and no out of pocket maximum. As a MEC Heavy member, you will receive a medical ID Card that needs to be presented to your medical provider at your time of service.

6 Minimum Value Plan (MVP) The Minimum Value Plan (MVP) is a high deductible plan offering very limited coverage. The MVP plan does include the required MEC services and does prevent the employee from being taxed the Individual Mandate penalty tax by purchasing Minimum Essential Coverage through their employer. Unlike the plans being offered on the Exchange and individual market this MVP does have a list of services that are not covered by the plan. The MVP plan covers the following services after your $6,500 deductible is met. Emergency Room Services, Inpatient Hospital Services, Primary Care and Specialist visits, Imaging, Laboratory Services, X-rays and Diagnostic Imaging, and certain Generic and Preferred Brand drugs. Please pay close attention to the list of excluded benefit categories outlined below. The MVP offers a very limited benefit plan design excluding the following major service categories: - Mental/Behavioral Health and Substance Abuse Disorder Outpatient Services - Rehabilitative Speech Therapy - Rehabilitative Occupational and Rehabilitative Physical Therapy - Skilled Nursing Facility - Outpatient Facility Fees. - Outpatient Surgery Physician/Surgical Services - Non-Preferred Brand Drug. - Specialty Drugs (including compound drugs) - Drugs related to mental health such as ADHD The MVP offers a plan design with a $6,500 single deductible and a $13,200 family deductible. The Coinsurance responsibility is 40% paid by the enrolled. The out-of-pocket maximum is $6,500 for single and $13,200 for a family. Note: Because almost every benefit category is subject to the deductible it is important that you budget for the $6,500 deductible which comes out to be $541 a month in addition to your maximum premium contribution. As a MVP member, you will receive a medical ID Card that needs to be presented to your medical provider at your time of service.

7 MEC MEC Plus Covered Benefits In-Network In-Network Deductible (single/family) You pay $0/$0 You pay $0/$0 Coinsurance (employee portion) Out-of-Pocket Maximum PPO Network You pay 0% You pay 0% You pay $0/$0 Multiplan Network You pay $0/$0 Multiplan Limited Network Emergency Room Services N/A N/A Inpatient Hospital Services N/A N/A Primary Care Visit to Treat an Injury or Illness N/A N/A Specialist Visit N/A N/A Mental/Behavioral Health and Substance Abuse Disorder Outpatient Services N/A N/A Imaging (CT, PET Scans, MRIs) N/A N/A Rehabilitative Speech Therapy N/A N/A Rehabilitative Occupational and Rehabilitative Physical Therapy Preventive Care/ Screening/Immunization (MEC) Laboratory Outpatient and Professional Services N/A N/A 100% covered 100% covered N/A N/A X-rays and Diagnostic Imaging N/A N/A Outpatient Facility Fee N/A N/A Outpatient Surgery Physician/Surgical Services Chronic Disease Management (CDM) Benefit N/A N/A N/A N/A Life AD&D Benefit N/A N/A * Out of network benefits include a $500 single $1,000 family deductible with a 40% coinsurance and no out of pocket maximum.

8 Inpatient Hospital Daily Indemnity Benefit MEC Plus Fully Insured Indemnity Benefits $200 daily benefit, 180 maximum days Inpatient Surgery & Anesthesia Daily Indemnity Benefit Outpatient Surgery & Anesthesia Daily Indemnity Benefit Outpatient Physician Office Visit Daily Indemnity Benefit Outpatient Diagnostic X Ray and Lab Daily indemnity Benefit Daily Prescription Drug Benefit Initial Hospital Admission Daily Indemnity Benefit Critical Illness Benefit Emergency Room Visit Daily Indemnity Benefit *covers illness and accidents Ambulance Service Daily Indemnity Benefit Employee Group Term Life Cobra $1,000 per day/$200 Anesthesia, 1 day maximum per benefit period $500 per day/$100 Anesthesia, 1 day maximum per benefit period $60 per day, 6 day maximum per benefit period $50 per day with a 3 day maximum per benefit period $15 per day, 20 day maximum per benefit period $1,000 per day,1 day maximum with 1 Admission per benefit period $5,000 per Employee $100 daily benefit with a max of 3 days per benefit period $100 per day, 3 day maximum per benefit period $5,000 per Employee Included

9 MEC Heavy MEC Heavy Plus MVP Covered Benefits In-Network In-Network In-Network Deductible (single/family) You pay $0/$0 You pay $0/$0 You pay $6,500/$13,200 Coinsurance (employee portion) You pay 0% You pay 0% You pay 40% Out-of-Pocket Maximum You pay $2,500/$13,200 You pay $2,500/$13,200 You pay $6,500/$13,200 PPO Network Multiplan Network Multiplan Network Emergency Room Services Facility Charges: $400 copay then plan pays 100% of daily benefit up to $7,500. Physician Charges: $400 copay then plan pays 100% of daily benefit up to $2,500. Facility Charges: $400 copay then plan pays 100% of daily benefit up to $7,500. Physician Charges: $400 copay then plan pays 100% of daily benefit up to $2,500. Multiplan Limited Network You pay $6,500 deductible Inpatient Hospital Services NOT COVERED NOT COVERED You pay $6,500 deductible Primary Care Visit to Treat an Injury or Illness Specialist Visit Mental/Behavioral Health and Substance Abuse Disorder Outpatient Services Imaging (CT, PET Scans, MRIs) You pay first $15 then plan pays 100% You pay first $25 then plan pays 100% You pay first $15 then plan pays 100% You pay first $25 then plan pays 100% You pay $50 copay and 40% coinsurance You pay $70 copay and 40% coinsurance NOT COVERED NOT COVERED NOT COVERED You pay first $400 then plan pays 100% You pay first $400 then plan pays 100% You pay $6,500 deductible Rehabilitative Speech Therapy NOT COVERED NOT COVERED NOT COVERED Rehabilitative Occupational and Rehabilitative Physical Therapy NOT COVERED NOT COVERED NOT COVERED Preventive Care/ Screening/Immunization (MEC) Laboratory Outpatient and Professional Services X-rays and Diagnostic Imaging 100% covered 100% covered 100% covered You pay first $50 then plan pays 100% You pay first $50 then plan pays 100% You pay first $50 then plan pays 100% You pay first $50 then plan pays 100% You pay $6,500 deductible You pay $6,500 deductible Outpatient Facility Fee NOT COVERED NOT COVERED NOT COVERED Outpatient Surgery Physician/Surgical Services NOT COVERED NOT COVERED NOT COVERED Chronic Disease Management (CDM) Benefit 100% covered 100% covered 100% covered Life AD&D Benefit $10,000 $10,000 Not Available Certain Generics Certain Preferred Brand Drugs Certain Non-Preferred Brand Drugs You pay first $15 then plan pays 100% You pay first $25 then plan pays 100% You pay first $75 then plan pays 100% You pay first $15 then plan pays 100% You pay first $25 then plan pays 100% You pay first $75 then plan pays 100% You pay $6,500 deductible You pay $6,500 deductible NOT COVERED Specialty Drugs & Compounds NOT COVERED NOT COVERED NOT COVERED * The MEC Heavy out of network benefits include a $500 single $1,000 family deductible with a 40% coinsurance and no out of pocket maximum. The MVP plan does not cover out of network benefits.

10 MEC Heavy Plus Fully Insured Indemnity Benefits Inpatient Hospital Daily Indemnity Benefit $400 per day with 180 day benefit period maximum. N/A Initial Hospital Admission Daily Indemnity Benefit Inpatient Surgery & Anesthesia Daily Indemnity Benefit Outpatient Surgery & Anesthesia Daily Indemnity Benefit $500 1 day benefit with a maximum of 1 admission per benefit period. $500 daily benefit with a maximum of 1 day per benefit period. Includes a 20% Daily Anesthesia Benefit. $250 daily benefit with a maximum of 1 day per benefit period. Includes a 20% Daily Anesthesia Benefit. Intensive Care Daily Indemnity Benefit $500 daily benefit with a maximum of 30 days per benefit period. N/A Critical Illness Benefit $5,000 Employee Benefit and 50% benefit for the spouse. Covered conditions include Major Organ Transplant, Angioplasty, Bypass Surgery, Renal Failure, Heart Attack, and Stroke. MVP N/A N/A N/A N/A Terms and Conditions Specialty drugs and Compound drugs are excluded from coverage under the MVP and MEC Heavy and MEC Heavy Plus plans. This includes the exclusion of all drugs related to the treatment of mental and nervous conditions and alcohol and drug abuse. Enrollees who reside in the state of MA will not have access to the fully insured limited medical plans offered with the MEC Plus and MEC Heavy Plus. All plans are setup on a calendar year. This plan does prevent an otherwise qualified individual from obtaining a premium tax credit through the HealthCare Marketplace.

11 Weekly Healthcare Budget (employee responsibility) MEC MEC Plus MEC Heavy MEC Heavy Plus *MVP EMPLOYEE $8.30 $28.44 $36.70 $47.94 EMPLOYEE + SPOUSE $17.48 $56.61 $74.28 $95.26 EMPLOYEE + CHILD(REN) $31.84 $70.97 $72.65 $92.91 FAMILY $41.02 $ $ $ Please see MVP Enrollment Instructions Below * The MVP Rate will consist of 9.5% of your gross income, the MVP Enrollment Flyer will walk you through the 9.5% calculation in addition to the deductible budget calculation of $541 per month to account for the $6,500 deductible. Please review the MVP Enrollment Flyer prior to enrollment to ensure the MVP is the best plan for you. Please note the services below that are not covered by the MVP. - Mental/Behavioral Health and Substance Abuse Disorder Outpatient Services - Rehabilitative Speech Therapy - Rehabilitative Occupational and Rehabilitative Physical Therapy - Skilled Nursing Facility - Outpatient Facility Fees. - Outpatient Surgery Physician/Surgical Services - Non-Preferred Brand Drug. - Specialty Drugs (including compound drugs) - Drugs related to mental health such as ADHD

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13 Customer Service Contacts KEYSOLUTION TM MEC AND MVP Administered by KBA Claims: Key Benefit Administrators, Inc. PO BOX 129, Fort Mill, SC, PPO NETWORK Offered through Key Benefit Administrators, Inc. Multiplan PPO Network or

14 MEC Employee Monthly Cost Employee Weekly Cost Employee Only $36.00 $8.30 Employee + Spouse $75.75 $17.48 Employee + Child/ren $ $31.84 Employee + Family $ $41.02 MEC Plus ASC Employee Insurance Rates December 1, 2015 November 30, 2016 Employee Monthly Cost Employee Weekly Cost Employee Only $ $28.44 Employee + Spouse $ $56.61 Employee + Child/ren $ $70.97 Employee + Family $ $ MEC Heavy Employee Monthly Cost Employee Weekly Cost Employee Only $ $36.70 Employee + Spouse $ $74.28 Employee + Child/ren $ $72.65 Employee + Family $ $ MEC Heavy Plus Employee Monthly Cost Employee Weekly Cost Employee Only $ $47.94 Employee + Spouse $ $95.26 Employee + Child/ren $ $92.91 Employee + Family $ $ MVP Employee Only Employee + Spouse Employee + Child/ren Employee + Family Employee Monthly Cost Employee Weekly Cost Please contact American StaffCorp for Cost. (918) 362 WORK (9675)

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16 American Staffing, Inc. MEC Health Plan: Key Benefit Administrators Coverage Period: 12/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual or 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 policy or plan document at or by calling Important Questions What is the overall deductible? Are there other deductibles for specific services? Is there an out-ofpocket 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? Answers Why this Matters: $0 See the chart starting on page 2 for your costs for services this plan covers. No. No. This plan has no out-of-pocket limit. No. Yes. For a list of providers, see or call No. You don t need a referral to see a specialist. 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's 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 on what the plan will pay for specific covered services, such as office visits. 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 the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 4. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at or call to request a copy. 1 of 7

17 American Staffing, Inc. MEC Health Plan: Key Benefit Administrators Coverage Period: 12/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family Plan Type: PPO Common Medical Event Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance 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 coinsurance 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.) This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts. If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition Services You May Need Primary care visit to treat an injury or illness Your Cost If You Use Participating Provider Non-Participating Provider 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 60% co-insurance Diagnostic test (x-ray, blood work) Not covered Not covered -none- Imaging (CT/PET scans, MRIs) Not covered Not covered -none- Generic drugs Not covered Not covered -none- Preferred brand drugs Not covered Not covered -none- Non-preferred brand drugs Not covered Not covered -none- Specialty drugs Not covered Not covered -none- Limitations & Exceptions Services are limited to those mandated by the Patient Protection Affordable Care Act. Questions: Call or visit us at or call to request a copy. 2 of 7

18 American Staffing, Inc. MEC Health Plan: Key Benefit Administrators Coverage Period: 12/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family Plan Type: PPO Common Medical Event If you have outpatient surgery If you need immediate medical attention If you have a hospital stay 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 Services You May Need Facility fee (e.g., ambulatory surgery center) Your Cost If You Use Participating Provider Non-Participating Provider 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- 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 -none- Substance use disorder inpatient services Not covered Not covered -none- Prenatal and postnatal care No charge for routine prenatal office visits. All other services not covered. 60% co-insurance for routine prenatal office visits. All other services not covered. 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- Limitations & Exceptions Limited to routine prenatal office exams only. Questions: Call or visit us at or call to request a copy. 3 of 7

19 American Staffing, Inc. MEC Health Plan: Key Benefit Administrators Coverage Period: 12/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family Plan Type: PPO Common Medical Event If your child needs dental or eye care Services You May Need Your Cost If You Use Participating Provider Non-Participating Provider Eye exam Not covered Not covered -none- Glasses Not covered Not covered -none- Dental check-up Not covered Not covered -none- Limitations & Exceptions 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 Hearing aids Private duty nursing Bariatric surgery Infertility Routine eye care (Adult) Chiropractic care Long-term care Routine foot care Cosmetic surgery Dental care (Adult) Non-emergency care when traveling outside the U.S. 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.) Weight loss programs Questions: Call or visit us at or call to request a copy. 4 of 7

20 American Staffing, Inc. MEC Health Plan: Key Benefit Administrators Coverage Period: 12/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual or 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 You may also contact your state insurance department, the US 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: Key Benefit Administrators at or Employee Benefits Security Administration 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. Language Access Services: SPANISH (Español): Para obtener asistencia en Español, llame al TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa CHINESE ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 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 or call to request a copy. 5 of 7

21 American Staffing, Inc. MEC Health Plan: Key Benefit Administrators Coverage Period: 12/01/ /30/2016 Coverage Examples Coverage for: Individual or 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 $90 Patient pays $7,450 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 Copays $0 Coinsurance $0 Limits or exclusions $7,450 Total $7,450 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $140 Patient pays $5,260 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $0 Copays $0 Coinsurance $0 Limits or exclusions $5,260 Total $5,260 Questions: Call or visit us at or call to request a copy. 6 of 7

22 American Staffing, Inc. MEC Health Plan: Key Benefit Administrators Coverage Period: 12/01/ /30/2016 Coverage Examples Coverage for: Individual or 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 coinsurance 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. 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 copayments, deductibles, and coinsurance. 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. Questions: Call or visit us at or call to request a copy. 7 of 7

23 American Staffing, Inc. MEC Heavy Health Plan: Key Benefit Administrators Coverage Period: 12/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual or 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 policy or plan document at or by calling Important Questions Answers Why this Matters: Network $0; Non-network $500 You must pay all the costs up to the deductible amount before this plan begins person/$1,000 family to pay for covered services you use. Check your policy or plan document to see What is the overall Doesn t apply to network when the deductible starts over (usually, but not always, January 1st). See the deductible? preventive care. Co-payments chart starting on page 2 for how much you pay for covered services after you do not apply to the deductible. meet the deductible. 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. Yes. Network providers $2,500 person/$13,200 family; Non-Network providers no maximum Premiums, balance-billed charges, penalties & health care this plan doesn t cover. All co-pays apply to the out-ofpocket limit. No. Yes. For a list of providers, see or call No. You don t need a referral to see a specialist. 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. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-ofpocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. 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 in-network, 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 the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at or call to request a copy. 1 of 8

24 American Staffing, Inc. MEC Heavy Health Plan: Key Benefit Administrators Coverage Period: 12/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family Plan Type: PPO Common Medical Event Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance 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 coinsurance 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.) This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts. If you visit a health care provider s office or clinic If you have a test Services You May Need Primary care visit to treat an injury or illness Minimum annual care requirements for 25 chronic diseases Specialist visit Minimum annual care requirements for 25 chronic diseases Other practitioner office visit Preventive care/screening/ immunization Diagnostic test (x-ray, blood work) Your Cost If You Use Network Provider Non-Network Provider $15 co-pay/visit 60% co-insurance No charge $25 co-pay/visit No charge No coverage for chiropractor or acupuncture No charge $50 co-pay/service 60% co-insurance 60% co-insurance 60% co-insurance No coverage for chiropractor or acupuncture 60% co-insurance 60% co-insurance Limitations & Exceptions Co-pay applies to the office visit charge only. Services are limited to those stated in the plan document. Co-pay applies to the office visit charge only. Services are limited to those stated in the plan document. Questions: Call or visit us at or call to request a copy. 2 of 8 -none- Services are limited to those mandated by the Patient Protection Affordable Care Act. -none- Minimum annual care requirements No charge 60% co-insurance Services are limited to those stated for 25 chronic diseases in the plan document. Imaging (CT/PET scans, MRIs) $400 co-pay/image 60% co-insurance -none-

25 American Staffing, Inc. MEC Heavy Health Plan: Key Benefit Administrators Coverage Period: 12/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family Plan Type: PPO Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Your Cost If You Use Services You May Need Non-Network Limitations & Exceptions Network Provider Provider Generic drugs $15 co-pay retail & $37.50 Limit of 34 day supply retail & 90 Not covered co-pay mail order day supply mail order. Preferred brand drugs $25 co-pay retail & $62.50 Limit of 34 day supply retail & 90 Not covered co-pay mail order day supply mail order. Non-preferred brand drugs $75 co-pay retail & Limit of 34 day supply retail & 90 Not covered $ co-pay mail order day supply mail order. 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 $400 co-pay/day applies to facility $400 co-pay/day applies to physician 400 co-pay/day applies to facility $400 co-pay/day applies to physician Limited to $7,500 facility and $2,500 physician per day. Facility & physician co-pays are separate. Co-pay applies to network out-ofpocket. Non-network applies to network out-of-pocket. Emergency medical transportation Not covered Not covered -none- Urgent care Primary care physician Co-pay applies to the office visit $15 co-pay/visit; Specialist 60% co-insurance charge only. $25 co-pay/visit Facility fee (e.g., hospital room) Not covered Not covered -none- Primary care physician Physician/surgeon fee $15 co-pay/visit; Specialist Not covered Surgeon fees are not covered. $25 co-pay/visit Questions: Call or visit us at or call to request a copy. 3 of 8

26 American Staffing, Inc. MEC Heavy Health Plan: Key Benefit Administrators Coverage Period: 12/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual or 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 Your Cost If You Use Services You May Need Non-Network Limitations & Exceptions Network Provider Provider 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 -none- Substance use disorder inpatient services Not covered Not covered -none- No charge for ACA-mandated Prenatal and postnatal care 0% co-insurance 60% co-insurance routine prenatal care. In-patient Hospital charges are not covered. 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 Not covered Not covered -none- Glasses Not covered Not covered -none- Dental check-up Not covered Not covered -none- Questions: Call or visit us at or call to request a copy. 4 of 8

27 American Staffing, Inc. MEC Heavy Health Plan: Key Benefit Administrators Coverage Period: 12/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual or 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 Bariatric surgery Chiropractic care Cosmetic surgery Dental care (Adult) Hearing aids Infertility Long-term care Non-emergency care when traveling outside the U.S. Private duty nursing Routine eye care (Adult) Routine foot care 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.) Weight loss programs (PPACA services only) 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 You may also contact your state insurance department, the US 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: Key Benefit Administrators at or Employee Benefits Security Administration at Questions: Call or visit us at or call to request a copy. 5 of 8

28 American Staffing, Inc. MEC Heavy Health Plan: Key Benefit Administrators Coverage Period: 12/01/ /30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family Plan Type: PPO 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. This plan does not prevent an otherwise qualified individual from obtaining a premium tax credit through the Health Care Marketplace. Language Access Services: SPANISH (Español): Para obtener asistencia en Español, llame al TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa CHINESE ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 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 or call to request a copy. 6 of 8