We are pleased to announce a new medical benefit plan to all current employees and their families effective January 1, 2016.

Transcription

1 Enrollment Packet

2 November 17, 2015 Dear Lamers Bus Lines, Inc. employee: We are pleased to announce a new medical benefit plan to all current employees and their families effective January 1, Health care in America is changing, and The Boon Group is leading the way. Starting November 23, 2015, as an employee of Lamers Bus Lines, Inc., you may enroll in a new plan that offers you and your family affordable, minimum essential coverage and meets the requirements for minimum essential coverage under the Affordable Care Act (ACA). The details of these plans are contained in the attached enrollment materials along with the premium you will be charged for the insurance. Page 3 Page 4 Page 8 Page 11 Benefit Plan Rates SmartMEC Benefit Details SmartMVP Silver Benefit Details Additional Benefit Information >>> DEADLINE TO ENROLL You must enroll by December 4, 2015 in order to participate for January 1, If you do not enroll by this deadline, your next open enrollment opportunity will be November 23, The choice is yours! Sincerely, The Boon Group Enrollment Services Team

3 Open enrollment is here! Sign up for your benefit plan. Go to boongroup.com/getsmart Distributed by Bi-Weekly Premium Rates If you choose to participate, the following premium costs will be deducted from your paycheck: Option 1 SmartMEC Offered by The Boon Group Employee Only $25.00 Additional for Spouse $46.02 Additional for Child(ren) $50.22 Additional for Family $67.04 Option 2 SmartMVP Silver Offered by The Boon Group Employee Only $68.79 Employee & Spouse $ Employee & Child(ren) $ Employee & Family $276.10

4 SmartMEC Plan Administered by Boon Administrative Services, Inc. Minimum Essential Coverage Plan with Dependents The following is a brief description of the benefits provided. For more detailed information and the frequency and ages for each benefit, please refer to the Schedule of Benefits. This Plan intends to comply with the Patient Protection and Affordable Care Act s (PPACA) requirement to offer coverage for certain preventive services without cost-sharing. To comply with PPACA, and in accordance with the recommendations and guidelines, the Plan will provide coverage for: 1. Evidence-based items or services rated A or B in the United States Preventive Services Task Force recommendations; 2. Recommendations of the Advisory Committee on Immunization Practices adopted by the Director of the Centers for Disease Control and Prevention; 3. Comprehensive guidelines for infants, children, and adolescents supported by the Health Resources and Services Administration (HRSA); and 4. Comprehensive guidelines for women supported by the Health Resources and Services Administration (HRSA). Copies of the recommendations and guidelines may be found here: or at Preventive Care Services for Adults Charges for covered Preventive Services as listed below: 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 50, including bowel preparation medications, physician charges, facility charges, anesthesia charges, specialist consultation prior to preventive colonoscopy if recommended by attending provider and polyp biopsy associated with preventive colonoscopy. 7. Depression screening for adults; 8. Type 2 Diabetes screening for adults with high blood pressure and adults who are over weight; 9. Diet counseling for adults at higher risk for chronic disease; 10. HIV screening for all adults at higher risk; 11. Immunizations 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; and Varicella 12. Obesity screening and intensive, multicomponent behavioral interventions including counseling as specified in the Schedule of Benefits; 13. Prostate screening including exam and Prostate Specific Antigen (PSA) test for men age 40 and over 14. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk; 15. Syphilis screening for all adults at higher risk; 16. Tobacco Use screening for all adults and cessation interventions for tobacco users; 17. Well Adult Routine Physical Exams The Boon Group, Inc. ::: SmartMEC Plan Minimum Essential Coverage Plan

5 SmartMEC Plan Administered by Boon Administrative Services, Inc. Preventive Care Services for Children Charges for covered Preventive Services as listed below: 1. Alcohol Misuse screening and counseling for adolescents; 2. Autism screening for Children at 18 and 24 months; 3. Behavioral assessments for Children of all ages as specified in the Schedule of Benefits; 4. Blood Pressure screening for Children as specified in the Schedule of Benefits; 5. Cervical Dysplasia screening for sexually active females; 6. Congenital Hypothyroidism screening for newborns; 7. Depression screening for adolescents ages as specified in the Schedule of Benefits; 8. Developmental screening for Children as specified in the Schedule of Benefits; 9. Dyslipidemia (Cholesterol) screening for Children at higher risk of lipid disorders as specified in the Schedule of Benefits; 10. Fluoride Chemoprevention as specified in the Schedule of Benefits; 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 as specified in the Schedule of Benefits; 14. Hematocrit or Hemoglobin screening for Children; 15. Hemoglobinopathies or sickle cell screening for newborns; 16. HIV screening for adolescents at higher risk; 17. Immunizations for Children from birth to age 18 - doses, recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis; Haemophilus influenza type b; Hepatitis A; Hepatitis B; Human Papillomavirus; Inactivated Poliovirus; Influenza (Flu Shot); Measles, Mumps, Rubella; Meningococcal; Pneumococcal; Rotavirus; and 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 as specified in the Schedule of Benefits; 21. Obesity screening and counseling as specified in the Schedule of Benefits; 22. Oral Health risk assessment for young Children as specified in the Schedule of Benefits 23. Phenylketonuria (PKU) screening for this genetic disorder in newborns; 24. Prenatal and related preventative care related to the pregnancy of a dependent child; 25. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk; 26. Tuberculin testing for children at higher risk of tuberculosis (ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years); and 27. Vision screening for all Children; The Boon Group, Inc. ::: SmartMEC Plan Minimum Essential Coverage Plan

6 SmartMEC Plan Administered by Boon Administrative Services, Inc. Preventive Care Services for Women, Including Pregnant Women Charges for covered Preventive Services as listed below: 1. Anemia screening on a routine basis for pregnant women; 2. Aspirin for treatment of pre-eclampsia in pregnant women; 3. Bacteriuria urinary tract or other infection screening for pregnant women; 4. BRCA counseling about genetic testing for women at higher risk; 5. Breast Cancer Mammography screenings every year for women over 40; 6. Breast Cancer Chemoprevention counseling for women at higher risk; 7. Breastfeeding comprehensive support and counseling from trained providers, as well as the purchase of breast pumps, for pregnant and nursing women; 8. Cervical Cancer screening for sexually active women; 9. Chlamydia Infection screening for younger women and other women at higher risk; 18. Osteoporosis screening for women; 1 time per year, women age 65 years and older; 1 per year for younger women if recommended by a physician. 19. Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk; 20. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users; 21. Sexually Transmitted Infections (STI) counseling for sexually active women; 22. Syphilis screening for all pregnant women or other women at increased risk; and 23. Well-woman visits to obtain recommended preventive services, including prenatal visits as specified in the Schedule of Benefits. 10. Contraception: Food and Drug Administrationapproved contraceptive methods, sterilization procedures (including facility charges, physician charges and anesthesia charges), and patient education and counseling, not including abortifacient drugs; 11. Domestic and interpersonal violence screening and counseling for all women; 12. Folic Acid supplements for women who may become pregnant; 13. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes; 14. Gonorrhea screening for all women at higher risk; 15. Hepatitis B screening for pregnant women at their first prenatal visit; 16. Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women; 17. Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older; The Boon Group, Inc. ::: SmartMEC Plan Minimum Essential Coverage Plan

7 SmartMEC Plan Administered by Boon Administrative Services, Inc. Limitations and Exclusions Some health care services are not covered by the Plan. The following is an example of services that are generally not covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Any medical service, treatment, or procedure not specified as covered under this Plan. Charges for the treatment of illness or disease, or charges other than those that are: Evidence-based items or services rated A or B in the United States Preventive Services Task Force recommendations; Recommendations of the Advisory Committee on Immunization Practices adopted by the Director of the Centers for Disease Control and Prevention; Comprehensive guidelines for infants, children, and adolescents supported by the Health Resources and Services Administration (HRSA); and Comprehensive guidelines for women supported by the Health Resources and Services Administration (HRSA). The Boon Group, Inc. ::: SmartMEC Plan Limitations and Exclusions

8 SmartMVP Silver Buy-Up Plan Benefit Overview of plan features. The Plan Document and Summary Plan Description contain detailed information about benefits and exclusions and shall prevail over the terms of this Benefit Overview. Self-Funded Medical Benefits Plan Coinsurance Individual / Family Deductible Individual / Family Maximum Out of Pocket Lifetime Maximum 100% $0 / $0 $3,150 / $12,700 Unlimited Doctor s Office & Specialist Office Visits Office Visit Copay Specialist Copay $15 $25 Prescription Drug Benefit Generic Prescription Copay Preferred Brand Prescription Copay Non-Preferred Brand Prescription Copay (Specialty Drugs excluded) Emergency Room Copay Urgent Care Copay Outpatient Laboratory and Professional Services Copay (Not covered if services are provided at a hospital) Outpatient X-rays and Diagnostic Imaging (Not covered if services are provided at a hospital) Outpatient Imaging (CT, PET scans, MRI) Copay (Not covered if services are provided at a hospital) Hospitalization (Room & Board Only) including MHSA (Mental Health & Substance Abuse) Coinsurance Per Admission Copay Maximum number of covered days per admission Preventative Care/Screening/Immunization Services (MEC) Disease Management Medicare Reference $15 $25 $75 $400 $200 $50 $50 $400 60% $ days 100% Covered Included Included

9 SmartMVP Silver Plan Administered by Boon Administrative Services, Inc. Limitations and Exclusions Some health care services are not covered by the Plan. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. The following is a list of services that are generally not covered. Abortion Acupuncture Ambulance Ambulatory Surgical Center Anesthesia Applied Behavioral Analysis Autism Spectrum Disorder, other than physician offi ce visits Behavioral Health Services Birthing Center Custodial Care Charges: From provider error In excess of any Plan maximums For services provided by a family member Payable by the government For injury or sickness from a hazardous pursuit or hobby Injury while taking part in an illegal activity Incurred prior to coverage Incurred for non-emergency care outside of the United States Chemotherapy Consultations Cosmetic Services and Surgery Counseling Custodial Care Dental services and X-rays Durable Medical Equipment, except for equipment and supplies for diabetes Education or Training Program Experimental or investigational procedures Equipment or changes to a home, workplace or vehicle to impact mobility or access Eye Refractions, eyeglasses, contact lenses Foot care Growth or height treatment or medications Hearing Exam and hearing aids Home Births Hospice Care Hospital. Charges made by a Hospital for: Inpatient Treatment - General nursing services; and - Medically Necessary services and supplies furnished by the Hospital, other than Room and Board Outpatient Treatment - Treatment for chronic conditions - Physical Therapy treatments - Hemodialysis - X-ray, laboratory and linear therapy Pre-Admission Testing Hypnosis Immunizations for travel or work Implantable Drugs and associated devices, except as required by the Affordable Care Act Infertility services, including artifi cial insemination, injectable infertility drugs, advance reproductive technology including IVF, ZIFT, GIFT, and ICSI Injectable Drugs Inpatient Charges, other than Room and Board in a hospital Newborn care Non-emergency services outside of the United States Non-emergency or non-urgent care provided in a hospital emergency room or by another emergency or urgent care provider Non-medically necessary services or supplies Nursing Services Nutritional supplies or food item Occupational injury or illness Over the counter medications, except as required by the Affordable Care Act Pregnancy of a Dependent Child, except for prenatal care as required by the Affordable Care Act Private Duty Nursing Prosthetics, Orthotics and supplies Reversal of Sterilization Procedures Rehabilitative therapy, including speech, physical and occupational therapy Services for sexual dysfunction, including therapy, supplies, counseling or prescription drugs other than those listed as being covered. Sex change service, drugs or supplies Skilled Nursing Facility Specialty Drugs Strength and Performance - Services, devices and supplies to enhance strength, physical condition, endurance or physical performance Surgery, except for sterilization procedures for women required under the Affordable Care Act Therapies and tests other than those listed as being covered Vision-related services or tests, except as required by the Affordable Care Act Vitamins, except for prenatal vitamins Weight: Except as specifi ed under the Affordable Care Act and listed as a covered expense under Preventative Care services, any treatment, Drug, service or supply intended to decrease or increase body weight, control weight or treat obesity, including morbid obesity.

10 Welcome to the Healthcare Revolution We re saying no to surprise hospital bills and overcharging for healthcare services. Will you join us? What is the FairPrice.Network? The FairPrice.Network is an open market of doctors and medical providers who accept fair levels of payment for their services, such as Medicare or other reference-based pricing*. The FairPrice.Network lets you search for doctors in your area, make requests for particular doctors to participate in FairPrice.Network, and voluntarily share your experiences with other FairPrice.Network users. *Medicare reference-based pricing is a fixed pricing method that relies on referencing Medicare reimbursements and other normative data for the repricing of claims. In this way, medical providers are still paid fairly for their services, but don t have the power to charge at the egregious rates that major health insurance carrier plans pay.

11 Benefits of the FairPrice.Network More choice. With the FairPrice.Network, you choose the medical provider that s best for you. The FairPrice.Network provides access to a wide range of doctors and medical providers, with more being added every day. More control. The FairPrice.Network puts you in the driver s seat, allowing you to shop for healthcare services the way you would for any other kind of service. Search by doctor, region, specialty, or payment reimbursement level. You can rest easy knowing you re receiving the best care possible and paying a fair price for it. More support. Patient Advocates are dedicated to helping guide you through the process of finding a doctor, getting medical care, and answering any questions about your plan benefits and how they work. Your Patient Advocate also communicates directly with medical providers on your behalf, making it easier and more comfortable for you to receive care. More community. The FairPrice.Network employer wall allows you to build your own online health care community by sharing your experiences with other members. Want to recommend a great FairPrice.Network doctor to your coworkers? Share it with them on the engagement wall! Sign up today and take back control of your healthcare! See your enrollment kit for details on how to sign up.

12 SPECIAL ENROLLMENT RIGHTS If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents other coverage). However, you must request enrollment within 30 days after your or your dependents other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. To request special enrollment or obtain more information, contact the benefits administrator. WOMEN S HEALTH AND CANCER RIGHTS ACT OF 1998 If you are receiving covered benefits for a Mastectomy, you should know that your Plan complies with the Women s Health and Cancer Rights Act of 1998 (WHCRA). The Act provides for: All stages of reconstruction of the breast on which the mastectomy was performed;; Surgery and reconstruction of the other breast to produce a symmetrical appearance;; Prostheses;; and Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same copays, deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan as stated in the Plan Summary provided with these materials. If you would like more information on WHCRA benefits, contact the benefits administrator.

13 Important Notice from Your Employer About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with your employer s plan and about your options under Medicare s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Your employer has determined that the prescription drug coverage offered by your employer s plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 to December However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current coverage through your employer s plan will not be affected. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with your employer and don t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage Contact the person listed below for further information. NOTE: You ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through [Insert Name of Entity] changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage More detailed information about Medicare plans that offer prescription drug coverage is in the Medicare & You handbook. You ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the Medicare & You handbook for their telephone number) for personalized help Call MEDICARE ( ). TTY users should call If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at or call them at (TTY ). Date: November 16, 2015 Name of Entity/Sender: Boon Group Address: 6300 Bridgepoint Parkway Building 3, Suite 500 Austin, TX 78730

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