2018 Temporary Employee Benefits Package

Transcription

1 2018 Temporary Employee Benefits Package Medical Insurance Options Third Party Administrator (TPA) - Tall Tree Health Tall Tree Customer Service - (877) PPO Provider Network PCHS Network through Multiplan Note: If you do not enroll/decline coverage within 30 days of the start of your assignment, you will be automatically enrolled in this plan. Basic Plan Required by Law - preventative care only 18 Covered Services for Adults 26 Covered Services for Women 27 Covered Services for Children MEC (Minimum Essential Coverage) All covered MEC Services Primary Care Office Visits Specialists Office Visits Urgent Care Prescription Drug Benefit Includes TeleMed MEC Plus All MEC and MECPlus Services Primary Care and Specialists Basic Labs and W-Rays Emergency Room Benefit Includes TeleMed MEC Enhanced All MEC and MECPlus Services $7,150 (individual) deductible Emergency Room and Inpatient Hospital Services Primary Care and Specialist visits Imaging, Laboratory Services, X-Rays and Diagnostic Imaging Certain Generic and Preferred Brand drugs Includes TeleMed MVP (Minimum Value Plan) Page 11 Pages Pages Pages Other Benefit Options Dental/Vision Discount This benefit offers discounted rates on dental, vision, labs, imaging and more through pre-negotiated cash prices at the time of service. This benefit is not insurance, has no utilization requirements and covers your entire family.

2 2018 Benefit Deduction Schedule Deductions are taken once a month as follows: Paycheck Date December 28, 2017 January 25, 2018 February 22, 2018 March 29, 2018 April 26, 2018 May 24, 2018 June 28, 2018 July 26, 2018 August 30, 2018 September 27, 2018 October 25, 2018 November 29, 2018 Pays For Benefits In January February March April May June July August September October November December Helpful Hints You will need to provide the birthday and the social security number for your spouse/dependents at the time of enrollment. If you end an assignment with Jacobson and begin a new assignment within 13 weeks, you will automatically be enrolled in your previous benefit selections. If you are not looking for coverage with Jacobson in 2018, you will need to actively OPT-OUT within the first 30 days of your assignment. If you take no action, you will be automatically enrolled in the MEC (employee only) for $73.00 per month. If you have any questions, please benefits@jacobsononline.com or call (800) and ask for HR. 2

3 2018 Benefit Costs All listed rates are monthly. Deductions are made on the last paycheck of the month to prepay for the following month s coverage. Employee Only Employee + Spouse Employee + Children Family Employee Only Employee + Spouse Employee + Children Family MEC MEC Plus $73.00 per month $ per month $ per month $ per month $ per month $ per month $ per month $ per month Employee Only Employee + Spouse Employee + Children Family MEC Enhanced $ per month $ per month $ per month $ per month Employee Only Employee + Spouse Employee + Children Family MVP * $ per month $ per month $ per month $1, per month *Full time employees making less than $32.50 per hour may qualify for an employer subsidy for the MVP plan. Dental/Vision Discount (Wellness Bundle) Employee + Family $15.95 per month * Applicable to employees making less than $32.50 per hour. Employees making more the $32.50 per hour will be responsible for the full cost of the plan. Tier rates: $ for single, $ for employee/spouse, $725.00for employee/children, and $1, for family. 3

4 EmployeeNavigator.com Benefit Enrollment Instructions We hope you find our online enrollment tool simple and easy to use. We ve broken the process down into five basic steps: 1. Receive your registration link 2. Register 3. Learn about your benefits and review your required tasks 4. Enter personal information, select your enrollees and select your benefits 5. Confirm your coverage and logout Step 1: Receive your registration link Within a week after your hire date you will receive a welcome from noreply@employeenavigator.com with a registration link and instructions. Step 2: Register You will need to create a username, password and confirm the last 4 of your Social Security Number. Use your personal address as your username. The Company Identifier is Jacobson. 4

5 Step 3: Learn about your benefits and review your required tasks Learn About Your Benefits: o Under the Compliance Documents header you will see a link that directs you to a summary of each benefit. Review Your Required Tasks o Click the go button next to review the company s Minimum Essential Coverage Policy Tasks Benefit Information Step 4: Enter personal information, select enrollees and select benefits You must have your spouse/dependents social security number(s) and birthday(s) to enroll. 1) Click Start Benefits link to begin 2) Add dependents 3) Select enrollees 4) Choose benefit 5) When enrolling spouse/dependents, be sure the circle next to their names are checked. 6) Click save and continue or don t want this benefit to decline. 5

6 Step 5: Confirm your coverage Once you have gone through the benefit election process, a confirmation screen will appear showing you the benefits you elected and the cost that will be deducted from your paycheck each week. Click Agree to confirm and finish. Questions? benefits@jacobsononline.com or call and ask for Human Resources. 6

7 2018 Benefit Enrollment Guide 7

8 YOUR BENEFITS ARE GETTING AN Upgrade We Now Offer THREE Versions of the Minimum Essential Coverage Plan: MEC, MEC Plus and MEC Enhanced. There is no change to the MEC. The MEC Plus and MEC Enhanced come with upgraded benefits. One of the main upgrades in the MEC Plus and MEC Enhanced is the Prescription Drug Plan. * Please see the following pages for a summary and the additional pages after that which list a detailed explanation. 8

9 2018 ENROLLMENT We are very excited about our 2018 employee benefit package that is being offered to all eligible employees. The plan offers meaningful benefits including a Preventive Care Plan (Minimum Essential Coverage), which satisfies your obligation to maintain coverage under the individual mandate as required by The Affordable Care Act, the new health care reform law. IN ADDITION TO YOUR HEALTH INSURANCE WE OFFER A RANGE OF VOLUNTARY BENEFITS TO HELP PROTECT YOU AND YOUR FAMILY. WHEN TO ENROLL 1) 2) 3) You can enroll during your employer s open enrollment period, during your new hire window or during a qualifying event. If you are a new hire YOU MUST complete the enrollment process within 30 days from your hire date. You can only make changes to your enrollment if you experience a qualifying event. A qualifying event is defined as a change in your status due to one of the following: marriage, divorce, birth or adoption, termination, loss of dependent and loss of prior coverage. IT IS OUR COMPANY POLICY THAT ALL EMPLOYEES COMPLETE THE ENROLLMENT PROCESS. 9

10 MEDICAL BENEFIT Stay Compliant and Covered with our Minimum Essential Coverage Options Understanding Your Minimum Essential Coverage Options The Health Care Reform Laws mandate you are covered by Minimum Essential Coverage (MEC) or pay a fine. Our MEC benefit package covers 100% of eligible preventative services when performed in-network. That means you pay nothing. Our MEC PLUS covers even more! We Offer THREE MEC Plans - Low, Medium and High (Choose ONE) Option 1: MEC Employee Only Employee + Child(ren) Employee + Spouse Employee + Family MONTHLY $ $ $ $ Option 2: MEC PLUS Employee Only Employee + Child(ren) Employee + Spouse Employee + Family MONTHLY $ $ $ $ Option 3: MEC ENHANCED Employee Only Employee + Child(ren) Employee + Spouse Employee + Family MONTHLY $ $ $ $ MEC MEC+ MEC ENHANCED Basic Plan Required by Law All Covered MEC Services All MEC & MEC+ Services 18 Covered Services for Adults Primary Care Office Visits Primary Care & Specialists 26 Covered Services for Women Specialist Office Visits Basic Labs & X-Rays 27 Covered Services for Children Urgent Care Emergency Room Benefit Prescription Drug Benefit And More! 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. 10

11 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 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 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 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 one time screening for HCV infection if born between 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 follow-up 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 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 11

12 Group ID: EFOHE Insurance Staffers Minimum Essential Coverage (MEC Plus) Plan Schedule of Medical Benefits Option ID: CR18I This Plan provides Minimal Essential Coverage for Medical Care. If the service is not listed on this Schedule of Benefits it is not covered. Claims Address P.O. Box 1807 PPO Provider Network: Draper, Utah PHCS Specific Services Network Emdeon Payor ID: Customer Service: Coverage begins the 1st day of the month following 60 days of employment. Coverage ends the last day of the month following termination. Minimum weekly hours for full time: 30 hours/130 per month Lifetime Max: None Network Providers Non-Network Providers Benefit Limits Per Calendar Year Annual Deductibles Does not include Co-pays. In-network and Out-of-network are separate accumulations and do not cross apply Annual Co-pay and Co-Insurance Out of Pocket Maximums (Medical and Rx Co-pays apply to the annual out of pocket maximums) Individual: None Family: None Individual: $7,150 Family: $14,300 Individual: None Family: None Individual: Unlimited Family: Unlimited Limits are per person per calendar year Office Visits - Primary Care (exam or consultation) $20 Co-pay, Limited to 3 visits annually. Office Visits - Specialist (exam or consultation) Network Discount Card applies Diagnostic Services - Basic labs/x-rays (related to office visit, LabCorp, etc.) Network Discount Card applies Included on 3 visits annually. Diagnostic Services - Major (Facility Charges) (MRI, CT, PET, Nuclear Medicine,etc.) Diagnostic Services - Major (Physician Charges) (MRI, CT, PET, Nuclear Medicine,etc.) Diagnostic Services - Minor (ultrasounds, bone density, ecography,etc) Network Discount Card applies Network Discount Card applies Network Discount Card applies Emergency Room Facilities Network Discount Card applies Emergency Room - All covered services other than facility charges Network Discount Card applies Urgent Care Center & 24 Hour Clinic $50 Co-pay, Limited to 1 visit annually. Covered Preventive Services for Adults as defined by CMS Preventive Services Wellness Office Visits and Lab Services Network Providers Non-Network Providers Benefit Limits Office Visit Exam & Includes Services For: Limited to preventive diagnosis only. Abdominal Aortic Aneurysm One time screening for males of ages 65 to 75 who have ever smoked Alcohol Misuse Screening and Counseling Aspirin use for Men and Women Blood Pressure Screening Cholesterol Screening One Aspirin use consultation for women ages 45 to 79 and men 55 to 79 One screening every two years for ages 18 to 39 One Screening per calendar year for ages 40 and over One screening per calendar year for men 35 and older. Men under 35 who have heart disease or risk factors for heart disease or women who have heart disease or risk factors for heart disease 12

13 Colorectal Cancer Screening Screening for adults over age 50 Depression Screening Type 2 Diabetes Screening Screening for adults with high blood pressure only Diet Counseling Screening for adults at higher risk of chronic disease Hepatitis B Screening Hepatitis C Screening For members at high risk, including members in countries with 2% or more Hepatitis B prevalence, and U.S. Born people not vaccinated as infants and with at least on parent born in a region with 8% or more Hepatitis B prevalence For adults at increased risk, and one time for everyone born between HIV Screening Screening for adults at higher risk Immunizations * Hepatitis A * Hepatitis B * Herpes Zoster * Human Papillomavirus * Influenza (Flu Shot) * Measles, Mumps, Rubella * Meningococcal * Pneumococcal * Tetanus, Diphtheria, Pertussis * Varicella Listed immunizations are once per calendar year. Human Papillomavirus shots up to age 26. Pneumococcal shots for adults 65 and older Lung Cancer Screening For adults at high risk for lung cancer because they're heavy smokers or have quit in the past 15 years Obesity Screening and Counseling Sexually Transmitted Infection (STI) Screening and Counseling Prevention counseling for adults at higher risk Syphilis Screening For all adults at higher risk Screenings for adults and cessation Tobacco Use Screening interventions for tobacco users Covered Preventive Services for Women - Including Pregnant Women Wellness Office Visits and Lab Services Network Providers Non-Network Providers Benefit Limits Well-Women Visits Anemia Screening For pregnant women BRCA Counseling Includes genetic test for women at high risk Breast Cancer Mammography Screening Screenings every 1 to 2 years for women over 40 years old Breast Cancer Chemoprevention Counseling Counseling for women at high risk Breastfeeding Consultations Comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women Women ages 21 to 29 pap test every 3 years Cervical Cancer Screening Women ages 30 to 65 every 3 years if you only have a pap test Every 5 years if you have both a pap test and an HPV test Women age 66 and older consult your doctor Chlamydia Infection Screening For younger women and women at high risk Contraception Includes birth control pills and devices, injections and surgical sterilization (hospital, physician, anesthesia) 13

14 Domestic and Interpersonal Violence Screening Folic Acid Supplements For pregnant women Gestational Diabetes Screening For women 24 to 28 weeks pregnant and/or at high risk of developing gestational diabetes Gonorrhea Screening For all women at higher risk Hepatitis B Screening For pregnant women at their first prenatal visit Human Immunodeficiency Virus (HIV) Screening and counseling For women sexually active Human Paillomavirus (HPV) DNA Test One test every 3 years for woment with normal cytology results who are 30 or older Osteoporosis Screening For women over age 60 or at high risk Rh Incompatibility Screening For pregnant women and follow-up testing for women at higher risk Tobacco Use Screening and interventions Syphilis Screening For all pregant woment or other women at increase risk Sexually Transmitted Infection (STI) Screening and Counseling. For sexually active women Urinary Tract or Other Infection Screening for Pregnant Women Covered Preventive Services for Children Wellness Office Visits and Lab Services Network Providers Non-Network Providers Benefit Limits Alcohol and Drug Use Assessments Autism Screening For children at 18 months to 24 months Behavioral Assessments For children to age 18 Blood Pressure Screening For children to age 18 Cervical Dysplasia Screening For sexually active females Congenital Hypothyroidism Screening For newborns Depression Screening For teenagers ages 12 to 18 Developmental Screening For children under age 3 and surveillance throughout childhood Dyslipidemia Screening For children at high risk of lipid disorders Fluoride Chemoprevention Supplements For children without fluoride in their water sources Gonorrhea Preventive Medicaiton for the Eyes of All Newborns Hearing Screenings For all newborns Height, Weight and Body Mass Index Measurements For children to age 18 Hematocrit or Hemoglobin Screening For children to age 18 Hemoglobinopathies of Sickle Cell Screening For all newborns HIV Screening For sexually active children 14

15 Hypothyroidism Screening for Newborns Immunizations * Diphtheria, Tetanus, Petussis * Haemophilus influenza type B * Hepatitis A * Hepatitis B * Human Papillomavirus * Inactivated Poliovirus * Influenza (Flu Shot) * Measles, Mumps, Rubella * Meningococcal * Pneumococcal * Rotavirus * Varicella For children to age 18 Iron Supplements For children ages 6 to 12 months at risk of anemia Lead Screening For children at risk of exposure Medical History For all children throughout development Obesity Screening and Counseling For children to age 18 Oral Health At risk assessment for your children ages newborn to age 10 Phenylketonuria (PKU) Screening For genetic disorders in newborns Sexually Transmitted Infection (STI) Screening and Counseling For children at higher risk, includes gonorrhea preventive medication for newborn eyes Tuberculin Testing For children at higher risk of tuberculosis to age 18 Vision Screening For children to age 18 Prescription Benefits Covered Prescription Drugs - SimpleSaveRx Customer Service: Rx Bin #: Rx PCN #: Negotiated best price for drugs: $0-$20 (Tier 1) $20-$40 (Tier 2) $40-$100 (Tier 3) Specialty Medications: All prescriptions are limited to 31 day supply. Plan pays costs above $100 up to $150 per family per quarter. Telemedicine Sherpaa Go to for more information. Effective: 1/1/2018 Dependents covered to age 26 regardless of student or marital status. Timely Filing: Claims must be filed within 12 months from the date the service incurred. Rural Area is defined as 30 miles. If preventive services are not available within 30 miles of your residence the provider will be paid in network. Coordination of Benefits: Non duplicating, Plan does not pay in excess of what the plan would have paid without other coverage. We believe this coverage is a Non-Grandfathered health plan under the Patient Protection and Affordable Care Act. (PPACA) Visit to view Schedule of Benefits, Plan Document, Enrollment information, claims history, link to the PPO Network and more. All claims are subject to Plan provisions at the time of service. Any benefits quoted telephonically or in writing is not a guarantee of payment. Claims are determined upon receipt of the claim and any additional information required to make a benefit determination. 15

16 Insurance Staffers Minimum Essential Coverage (Enhanced MEC) Plan Schedule of Medical Benefits Option ID: CR18C Group ID: EFOHE This Plan provides Minimal Essential Coverage for Medical Care. If the service is not listed on this Schedule of Benefits it is not covered. Claims Address P.O. Box 1807 PPO Provider Network: Draper, Utah PHCS Specific Services Network Emdeon Payor ID: Customer Service: Coverage begins the 1st day of the month following 30 days of employment. Coverage ends the last day of the month following termination. Minimum weekly hours for full time: 30 hours/130 per month Lifetime Max: None Network Providers Non-Network Providers Benefit Limits Per Calendar Year Annual Deductibles Does not include Co-pays. In-network and Out-of-network are separate accumulations and do not cross apply Annual Co-pay and Co-Insurance Out of Pocket Maximums (Medical and Rx Co-pays apply to the annual out of pocket maximums) Individual: None Family: None Individual $7,150 Family $14,300 Individual $500 Family $1,000 Individual: Unlimited Family: Unlimited All benefits and accumulations are on a Calendar Year. Office Visits - Primary Care (exam or consultation) $20 Co-pay, Deductible, Plan pays 60% of Office Visits - Specialist (exam or consultation) $40 Co-pay, Deductible, Plan pays 60% of Diagnostic Services - Basic labs/x-rays (related to office visit, LabCorp, etc.) $50 Co-pay, Deductible, Plan pays 60% of Diagnostic Services - Major (Facility Charges) (MRI, CT, PET, Nuclear Medicine,etc.) $400 Co-pay, of $400 Co-pay, Plan pays 60% of Diagnostic Services - Major (Physician Charges) (MRI, CT, PET, Nuclear Medicine,etc.) of allowed amount Deductible, Plan pays 60% of Diagnostic Services - Minor (ultrasounds, bone density, ecography,etc) $50 Co-pay, Deductible, Plan pays 60% of Emergency Room Facilities $400 Co-pay, $400 Co-pay, of Limited to 2 visits per year. Emergency Room - All covered services other than facility charges $400 Co-pay, Maximum: $1,000 Urgent Care Center & 24 Hour Clinic $50 Co-pay, Deductible, Plan pays 60% of Covered Preventive Services for Adults as defined by CMS Preventive Services Wellness Office Visits and Lab Services Network Providers Non-Network Providers Benefit Limits Office Visit Exam & Includes Services For: Limited to preventive diagnosis only. Abdominal Aortic Aneurysm Alcohol Misuse Screening and Counseling Aspirin use for Men and Women Blood Pressure Screening Cholesterol Screening Colorectal Cancer Screening One time screening for males of ages 65 to 75 who have ever smoked One Aspirin use consultation for women ages 45 to 79 and men 55 to 79 One screening every two years for ages 18 to 39 One Screening per calendar year for ages 40 and over One screening per calendar year for men 35 and older. Men under 35 who have heart disease or risk factors for heart disease or women who have heart disease or risk factors for heart disease Screening for adults over age 50 16

17 Depression Screening Type 2 Diabetes Screening Diet Counseling Hepatitis B Screening Hepatitis C Screening HIV Screening Screening for adults with high blood pressure only Screening for adults at higher risk of chronic disease For members at high risk, including members in countries with 2% or more Hepatitis B prevalence, and U.S. Born people not vaccinated as infants and with at least on parent born in a region with 8% or more Hepatitis B prevalence For adults at increased risk, and one time for everyone born between Screening for adults at higher risk Immunizations * Hepatitis A * Hepatitis B * Herpes Zoster * Human Papillomavirus * Influenza (Flu Shot) * Measles, Mumps, Rubella * Meningococcal * Pneumococcal * Tetanus, Diphtheria, Pertussis * Varicella Listed immunizations are once per plan year. Human Papillomavirus shots up to age 26. Pneumococcal shots for adults 65 and older Lung Cancer Screening Obesity Screening and Counseling For adults at high risk for lung cancer because they're heavy smokers or have quit in the past 15 years Sexually Transmitted Infection (STI) Screening and Counseling Prevention counseling for adults at higher risk Syphilis Screening For all adults at higher risk Tobacco Use Screening Screenings for adults and cessation interventions for tobacco users Covered Preventive Services for Women - Including Pregnant Women Wellness Office Visits and Lab Services Network Providers Non-Network Providers Benefit Limits Well-Women Visits Anemia Screening BRCA Counseling Breast Cancer Mammography Screening Breast Cancer Chemoprevention Counseling Breastfeeding Consultations Cervical Cancer Screening Chlamydia Infection Screening Contraception For pregnant women Includes genetic test for women at high risk Screenings every 1 to 2 years for women over 40 years old Counseling for women at high risk Comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women Women ages 21 to 29 pap test every 3 years Women ages 30 to 65 every 3 years if you only have a pap test Every 5 years if you have both a pap test and an HPV test Women age 66 and older consult your doctor For younger women and women at high risk Includes birth control pills and devices, injections and surgical sterilization (hospital, physician, anesthesia) 17

18 Domestic and Interpersonal Violence Screening Folic Acid Supplements Gestational Diabetes Screening Gonorrhea Screening Hepatitis B Screening For pregnant women For women 24 to 28 weeks pregnant and/or at high risk of developing gestational diabetes For all women at higher risk For pregnant women at their first prenatal visit Human Immunodeficiency Virus (HIV) Screening and counseling For women sexually active Human Paillomavirus (HPV) DNA Test Osteoporosis Screening Rh Incompatibility Screening Tobacco Use Screening and interventions Syphilis Screening One test every 3 years for woment with normal cytology results who are 30 or older For women over age 60 or at high risk For pregnant women and follow-up testing for women at higher risk For all pregant woment or other women at increase risk Sexually Transmitted Infection (STI) Screening and Counseling. For sexually active women Urinary Tract or Other Infection Screening for Pregnant Women Covered Preventive Services for Children Wellness Office Visits and Lab Services Network Providers Non-Network Providers Benefit Limits Alcohol and Drug Use Assessments of Autism Screening Behavioral Assessments Blood Pressure Screening Cervical Dysplasia Screening Congenital Hypothyroidism Screening Depression Screening Developmental Screening Dyslipidemia Screening Fluoride Chemoprevention Supplements of of of of of of of of of For children at 18 months to 24 months For children to age 18 For children to age 18 For sexually active females For newborns For teenagers ages 12 to 18 For children under age 3 and surveillance throughout childhood For children at high risk of lipid disorders For children without fluoride in their water sources Gonorrhea Preventive Medicaiton for the Eyes of All Newborns of Hearing Screenings Height, Weight and Body Mass Index Measurements Hematocrit or Hemoglobin Screening Hemoglobinopathies of Sickle Cell Screening HIV Screening of of of of of For all newborns For children to age 18 For children to age 18 For all newborns For sexually active children 18

19 Hypothyroidism Screening for Newborns of Immunizations * Diphtheria, Tetanus, Petussis * Haemophilus influenza type B * Hepatitis A * Hepatitis B * Human Papillomavirus * Inactivated Poliovirus * Influenza (Flu Shot) * Measles, Mumps, Rubella * Meningococcal * Pneumococcal * Rotavirus * Varicella of For children to age 18 Iron Supplements Lead Screening Medical History Obesity Screening and Counseling Oral Health Phenylketonuria (PKU) Screening of of of of of of For children ages 6 to 12 months at risk of anemia For children at risk of exposure For all children throughout development For children to age 18 At risk assessment for your children ages newborn to age 10 For genetic disorders in newborns Sexually Transmitted Infection (STI) Screening and Counseling of For children at higher risk, includes gonorrhea preventive medication for newborn eyes Tuberculin Testing Vision Screening Prescription Benefits of of For children at higher risk of tuberculosis to age 18 For children to age 18 Covered Prescription Drugs - SimpleSaveRx Customer Service: Rx Bin #: Rx PCN #: Negotiated best price for drugs: $0-$20 (Tier 1) $20-$40 (Tier 2) $40-$100 (Tier 3) Specialty Medications: All prescriptions are limited to 31 day supply Plan pays costs above $100 up to $150 per family per quarter. Telemedicine Sherpaa Go to for more information. Effective: 1/1/2018 Dependents covered to age 26 regardless of student or marital status. Timely Filing: Claims must be filed within 12 months from the date the service incurred. Rural Area is defined as 30 miles. If preventive services are not available within 30 miles of your residence the provider will be paid in network. Coordination of Benefits: Non duplicating, Plan does not pay in excess of what the plan would have paid without other coverage. We believe this coverage is a Non-Grandfathered health plan under the Patient Protection and Affordable Care Act. (PPACA) Visit to view Schedule of Benefits, Plan Document, Enrollment information, claims history, link to the PPO Network and more. All claims are subject to Plan provisions at the time of service. Any benefits quoted telephonically or in writing is not a guarantee of payment. Claims are determined upon receipt of the claim and any additional information required to make a benefit determination. 19

20 IMPORTANT INFORMATION ABOUT MY BENEFITS Q1. What does the Network Discount Card Applies mean in the MEC Plus? The MEC Plus does not cover services that state Network Discount Card Applies We still wanted to provide some type of benefit so we incorporated the Value Point program through Multiplan. The Value Point program allows you to access the Multiplan Network (same network in your MEC Plus) for the discounted provider rate. You get to pay the discounted provider rate I.E. The contractual rate your provider (Doctor) has with the network (Multiplan) - Keep in mind; You will receive a separate Value Point Card. Q2. What is Minimum Essential Coverage and why are there 3 options? Minimum Essential Coverage (MEC) is the coverage level every American must have as defined by the Affordable Care Act. Because a basic MEC doesn t cover that much we enhanced the offering with two other MEC s that cover more; MEC Plus and MEC Enhanced. Q3. How does my prescription drug coverage work? The MEC Plus and MEC Enhanced come with a prescription drug plan through SimpleSaveRX Simpe Save RX has what is a rapidly growing practice in the industry known as pass through or transparent pricing. Every pharmacy you go to can offer their drugs at a different price depending on how much they acquire their drugs for. With Simple Save you can go to virtually any pharmacy and pay a co-pay depending on the pass through cost. For information on which pharmacies have a cheaper price you can call Simple Save RX directly Save4RX 20

21 MINIMUM VALUE PLAN (MVP) Understand the Value The Minimum Value Plan (MVP) is a high deductible plan. 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 $7,150 (individual) 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 * Please note: If you elect the MVP a Personal Health Questionnaire is required. 21

22 Group ID: SFFHT Insurance Staffers Basic Minimum Value (Basic MVP) & Preventative Services Coverage Plan Schedule of Medical Benefits * Pre-Certification: Arizona Foundation - FoundationUM (AZF) Claims Address: Option ID: CR18F This Plan provides Minimal Value Coverage for Medical Care. If the service is not listed on this Schedule of Benefits it is not covered. P.O. Box 1807 PPO Provider Network: Draper, Utah Physicians: PHCS- Specific Services Network Emdeon Payor ID: Facilities: 150% of Medicare Customer Service: Coverage begins the 1st day of the month following 60 days of employment. Coverage ends the last day of the month following termination. Minimum weekly hours for full time: 30 hours/130 per month Lifetime Max: None Network Providers Non-Network Providers Benefit Limits Per plan year Annual Deductibles Does not include Co-pays. In-network and Out-of-network are separate accumulations and do not cross apply Deductible applies to Out of Pocket Annual Co-pay and Co-Insurance Out of Pocket Maximums (Medical and Rx Co-pays apply to the annual out of pocket maximums) Deductible applies to Out of Pocket Individual: $7,150 Family: $14,300 Individual: $7,150 Family: $14,300 Individual $14,300 Family $28,600 Individual: Unlimited Family: Unlimited All benefits and accumulations are on a calendar year. Office Visits - Primary Care (exam or consultation) Office Visits - Specialist (exam or consultation) $50 Co-pay, Plan pays 60% $70 Co-pay, Plan pays 60% once Deductible is met for in-network providers. Office Services - basic services with exam (does not include pain management, chemo, surgical services) Plan pays 60% Wellness Care - Adult Wellness Care - Children Wellness Care includes, but not limited to: pap smear, mammogram, prostate screening, gynecological exam, routine physical exam, routine vision screening for children, routine hearing screening for children, immunizations and related laboratory blood tests, colonoscopies. Other preventive services as identified by the Patient Protection and Affordable Care Act (PPACA) will be covered. Covered services incurred at a facility will be allowed at the Data isight amount. Ambulance Birth Control / IUD Breast Pumps One per delivery. Purchase Breast Pump at a local retail store and submit the receipt for reimbursement AZF * Chemical Dependency - Inpatient Chemical Dependency Inpatient - All covered services other than facility charges Chemical Dependency - Outpatient Chemotherapy / Radiation Therapy Chiropractic Services Colonoscopy (For Medical Reasons) Deductible, up to 150% of Medicare allowed amount Deductible, ** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment Diagnostic Services - Basic labs/x-rays (related to office visit, LabCorp, etc.) Deductible, Diagnostic Services - Major (Facility Charges) (MRI, CT, PET, Nuclear Medicine,etc.) Deductible, up to 150% of Medicare allowed amount Diagnostic Services - Major (Physician Charges) (MRI, CT, PET, Nuclear Medicine,etc.) Deductible, Diagnostic Services - Minor (Facility Charges) (ultrasounds, bone density, ecography,etc) Deductible, up to 150% of Medicare allowed amount Diagnostic Services - Minor (Physician Charges) (ultrasounds, bone density, ecography,etc) Deductible, ** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment Diabetic Education Dialysis 22

23 Durable Medical Equipment (includes orthotics & prosthetics) Emergency Room Facilities Deductible, up to 150% of Medicare allowed amount ** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment Emergency Room - All covered services other than facility charges Gastric Bypass Surgery / Lap Banding Home Health Care Hospice Care of allowed amount AZF * Hospital Facility and Inpatient Services Deductible, up to 150% of Medicare allowed amount ** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment Attending Physician, Surgeon and Anesthesiologist charges during an inpatient hospital confinement Deductible, plan pays 100% Hospital - Outpatient Services (any charge billed from a hospital) Infertility Services Maternity - Prenatal Office Visits Only (billed separately from total delivery) Prenatal office visit is covered for all females covered under the plan Maternity (Labs, x-rays, ultrasounds and related covered services) AZF * Maternity - Facility and Inpatient Services Deductible, Deductible, up to 150% of Medicare allowed amount ** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment Percertifiation required if stay is in excess of 48 hours (or 96 hours) Attending Physician, Surgeon and Anesthesiologist charges during an inpatient hospital confinement Deductible, Medical Supplies (Including but not limited to: Insulin, Diabetic test strips, Insulin pumps, etc.) These supplies may also be covered under Prescription Benefit. AZF * Mental Health - Inpatient Mental Health Inpatient - All covered services other than facility charges Mental Health - Outpatient Outpatient Therapy Physical, Speech and Occupational Deductible, up to 150% of Medicare allowed amount Deductible, ** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment Outpatient Surgery performed in an office or urgent care facility Included with office visit or urgent care Co-pay Maximum of $300 per visit Skilled Nursing Sleep Studies Sterilization for Women Sterilization for Men TMJ and Orthognathic AZF * Transplant Facility Deductible, up to 150% of Medicare allowed amount Transplant Services Limited to Inpatient hospitalization only ** Patient may be balance billed if provider does not accept 150% of Medicare Allowable Payment Attending Physician, Surgeon and Anesthesiologist charges during an inpatient hospital confinement Deductible, Urgent Care Center & 24 Hour Clinic $70 Co-pay, Plan pays 60% Prescription Benefits Covered Prescription Drugs - SimpleSaveRx Customer Service: Rx Bin #: Rx PCN #: Negotiated best price for drugs: $0-$20 (Tier 1) $20-$40 (Tier 2) $40-$100 (Tier 3) Specialty Medications: All prescriptions are limited to 31 day supply Plan pays costs above $100 up to $150 per family per quarter. Telemedicine Sherpaa Go to for more information. Effective: 1/1/

24 * Pre Certification Required. Failure to obtain Pre Certification may result in a reduction of $250 or denial of benefits. ** Payment will be capped at 150% of the Medicare Allowable Payment. If provider does not accept the Medicare Allowable Amount, patient may be balance billed. Note: Any non-allowed or not covered amounts or services are the responsibility of the patient and are not included in the Out-of-Pocket Maximum. Dependents are covered to age 26 regardless of student or marital status. Timely Filing - Claims must be filed within 12 months from the date of service. Coordination of benefits - Non duplicating meaning this Plan will not pay in excess of the normal plan benefit in absence of other insurance. Rural Area is defined as 30 miles. If covered services are not available in the network within 30 miles the provider will be paid in network. No Pre-existing for employees or dependents. Out of Country services will be paid as a in-network for covered medical emergencies only, to a maximum of $15,000 of billed charges. We believe this coverage is a non grandfathered health plan under the Patient Protection and Affordable Care Act. (PPACA) Visit to view the Plan Document, Schedule of Benefits, enrollment information, your claims history, link to the PPO network and more. All claims are subject to Plan provisions at the time of service. Any benefits quoted telephonically or in writing is not a guarantee of payment. Claims are determined upon receipt of the claim and any additional information required to make a benefit determination. 24

25 PROVIDER NETWORKS & CONTACT INFORMATION Understanding Your Provider Networks and Who to Contact Medical Network: PHCS Network through Multiplan Once enrolled: For Questions Please call your Plan Administrator Tall Tree Administrators 25

26 Three reasons to use your dental discount You ll smile brighter with big savings at over 161,000* available dental practice locations nationwide. Just present your card with the Aetna Dental Access logo and pay the discounted price at the time of service. In most instances, you save 15% to 50% per visit. ** Use your card over and over again to keep your teeth sparkling clean! NO LIMITS Most dental plans limit the number of exams, cleanings and x-rays that are covered each year. You can use the dental discount through the Consumerism Card as often as you like! FAMILY DISCOUNTS Some dental plans exclude orthodontia, such as braces, or limit to plan members under the age of 19. You can use the dental discount to save money on orthodontia for yourself and your immediate family. REDUCE OUT-OF-POCKET EXPENSES Dental plans generally limit the amount of dollars that can be spent towards your dental care. Once you reach that maximum, you pay out-of-pocket for any additional dental care. This is the perfect time to use your dental discount! Visit MyMemberPortal.com to find a participating dentist! Visit MyMemberPortal.com *As of September **Actual costs and savings vary by provider, service and geographical area. The Consumerism Card provides access to the Aetna Dental Access network. This network is administered by Aetna Life Insurance Company (ALIC). Neither ALIC nor any of its affiliates offers or administers the Dental/Vision Discount. Neither ALIC nor any of its affiliates is an affiliate, agent, representative or employee of Esprit Benefits Group. Dental providers are independent contractors and not employees or agents of ALIC or its affiliates. ALIC does not provide dental care or treatment and is not responsible for outcomes. Disclosures: This plan 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 discount card program contains a 30 day cancellation period. Member shall receive a reimbursement of all periodic membership fees if membership is cancelled within the first 30 days after the effective date. Discount Medical Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box , Dallas, TX , Website to obtain participating providers: MyMemberPortal.com. Not available to KS, UT, VT or WA residents. 26

27 Some expenses are unavoidable. Others are unnecessary. What if you could eliminate or reduce the cost of those expenses? Now that s smart. Check out the following time and money-saving benefits. Medical Bill Saver TM Experts who know the ins and outs of billing practices will attempt to negotiate a reduction in your out-of-pocket medical expenses. Health Advocacy Your lifeline for healthcare and insurance information. Nurseline TM Rest assured - highly trained registered nurses are on-call 24/7 to answer your questions. Vision Your eyes are the windows to your health. Save 10% to 60% on glasses, contacts, laser surgery, exams and more. Diabetic Management Diabetes can be hard to manage. Big savings on supplies can make life easier. Dental Smile brighter with big savings on dental services at thousands of locations nationwide. Chiropractic Back out of whack? Save 30% to 50% on x-rays, diagnostic services and treatment at chiropractors nationwide. Lab Testing Know your numbers! Help monitor your health with 10% to 80% off typical costs of routine lab work. MRI & CT Scans Save 50% to 75% on usual charges for MRI, CT Scans and more at thousands of credentialed radiology centers nationwide. Hearing Aides Want to save big on hearing aides? You ll save 35% at retail locations nationwide. Start Saving Today! 2016 Esprit Benefits Group, LLC. All rights reserved. info@espritbenefits.com 27

28 2015 Esprit Benefits Group, LLC. All rights reserved S. 35th St. C10 Phoenix, AZ Disclosures: This plan 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. Discount Medical Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box , Dallas, TX , Website to obtain participating providers: MyMemberPortal.com. Not available to FL, KS, UT, VT or WA residents. Discount Lab Work Benefit is not available to HI, MA, MD, ND, NJ, NY, RI or SD residents. *Savings may vary based on geographic location, provider and procedure performed. Available services may vary by provider. 28