CERTIFICATE FOR GROUP MEDICAL INSURANCE MINIMUM ESSENTIAL COVERAGE (MEC) PLUS LIMITED THIS INSURANCE PLAN IS A QUALIFIED HEALTH PLAN THAT MEETS THE STANDARDS OF MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE CARE ACT Your Coverage This Certificate explains benefits provided under the self-insured plan offered by your employer, further referred to as the Plan Sponsor. Please read this document carefully to understand your coverage. This certificate includes a Schedule of Benefits, information pertaining to Member Eligibility, Plan Exclusions, Limitations and Definitions; and additional information regarding Premiums, Claims and Termination of Coverage. TABLE OF CONTENTS Eligibility, Enrollment and Termination....2-3 Schedule of Benefits.4-6 Exclusions, Limitations and Definitions 7-8 Premiums and Claims.9 1
ELIGIBLITY, ENROLLMENT & TERMINATION Eligible Members: All full-time individuals contracted for employment by the Plan Sponsor are eligible for the Plan. Fulltime employment is defined by the Affordable Care Act (ACA) and Internal Revenue Service (IRS) as working at least 30 hours per week or 130 hours per month on average. Employees who meet these criteria should be offered benefits based on the Plan Sponsor s new-hire waiting period. For employees who choose to participate in the Plan, coverage will begin the first day of the month following the waiting period which is not to exceed 90 days from the date of hire. Eligible Dependents: Members may also enroll their eligible dependents in the Plan. Eligible dependents are as follows: Spouse - defined as any individual lawfully married to you in any state, whether the spouse is of the same or opposite sex as the member Dependent children - defined as individuals under the legal guardianship of the member including adopted individuals and adult dependents up to age 26 Enrollment: As a requirement of enrollment in the Plan, members must provide Staff Benefits Management and Administrators, further referred to as the Plan Administrator, with demographic information including their full legal name, date of birth, social security number (or other tax identification number) and mailing address. The same information is required to enroll eligible dependents. This information is usually collected by the Plan Sponsor at the time of hire and is provided by the Plan Sponsor to the Plan Administrator at the time of enrollment. Eligible employees are restricted in opportunities to enroll themselves, and eligible dependents, under the following circumstances: You, and your eligible dependents, may enroll on the first day of the month following your Plan Sponsor s new-hire waiting period You, and your eligible dependents, may enroll in, change or cancel coverage during the Plan Sponsor s Annual Open Enrollment Period You, and your eligible dependents, may enroll in or make changes to your coverage if you become eligible for a Qualifying Event. 2
Qualifying Event: Certain circumstances may occur during the plan year that allow members to make changes to their coverage or allow them to enroll in coverage if they previously waived coverage during one of the opportunities listed above. These circumstances are referred to as Qualifying Events and are defined as follows: Marriage, divorce, legal separation, annulment or death of spouse Eligibility for an alternative health plan including Medicare and Medicaid Birth, adoption or placement for adoption Loss of other health coverage Change in your dependent s eligibility status because of age, marital status, or other change in existing or alternative coverage. Termination of Coverage: There are many circumstances which may lead to a termination of coverage. The Plan provides coverage for the full month of eligibility and termination of coverage will take effect the first day of the month following the member s change in eligible status. Termination of coverage may occur in any of the following circumstances: Employee ceases to be eligible due to a change in employment status which may include termination of employment or a reduction in hours A member may terminate coverage if they become eligible for a Qualifying Event (refer to list of Qualifying Events above) Eligible dependents may be terminated if they reach the age of 26; coverage will terminate the first day of the month following the date of the members 26 th birthday Eligible dependents may be terminated if they have a Qualifying Event including, marriage or eligibility for an alternative health plan The Plan Sponsor terminates the Plan The Plan Administrator terminates the Plan (usually due to a lack of premium payment by the Plan Sponsor In most circumstances, upon termination of coverage, members, and their covered dependents, will become eligible for COBRA continuation coverage. Please refer to the General Notice of Your Rights- Group Health Continuation Coverage Under COBRA for additional information. 3
SCHEDULE OF BENEFITS Coverage Information: The following services are covered 100% as mandated by the Affordable Care Act (ACA). Covered Services for Adults 1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked 2. Alcohol Misuse screening and counseling 3. Aspirin use to prevent cardiovascular disease 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 7. Depression screening for adults 8. Diabetes (Type 2) screening for adults with high blood pressure 9. Diet counseling for adults at higher risk for chronic disease 10. Hepatitis C screening for adults at increased risk, and one time for everyone born 1945 1965 11. HIV screening for everyone ages 15 to 65, and other ages at increased risk 12. Immunization vaccines for adults doses, recommended ages, and recommended populations vary: Hepatitis A, Hepatitis B, Herpes Zoster, Human Papillomavirus, Influenza (Flu Shot), Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Tetanus, Diphtheria, Pertussis, Varicella 13. Lung cancer screening for adults 55-80 at high risk for lung cancer because they re heavy smokers or have quit in the past 15 years 14. Obesity screening and counseling for all adults 15. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk 16. Syphilis screening for all adults at higher risk 17. Tobacco Use screening for all adults and cessation interventions for tobacco users Covered Services for Women 1. Anemia screening on a routine basis for pregnant women 2. Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for breast cancer 3. Breast Cancer Mammography screenings every 1 to 2 years for women over 40 4. Breast Cancer Chemoprevention counseling for women at higher risk 5. Breastfeeding comprehensive support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women 6. Cervical Cancer screening for sexually active women 7. Chlamydia Infection screening for younger women and other women at higher risk 8. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt religious employers. 9. Domestic and interpersonal violence screening and counseling for all women 10. Folic Acid supplements for women who may become pregnant 11. Gestational diabetes screening for women 24 to 28 months pregnant and those at high risk of developing gestational diabetes 12. Gonorrhea screening for all women at higher risk 13. Hepatitis B screening for pregnant women at their first prenatal visit 14. HIV screening and counseling for sexually active women 15. Human Papillomavirus (HPV) DNA Test every 3 years for women with normal cytology results who are 30 or older 16. Osteoporosis screening for women over age 60 depending on risk factors 17. Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk 18. Sexually Transmitted Infections counseling for sexually active women 19. Syphilis screening for all pregnant women or other women at increased risk 20. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users 21. Urinary tract or other infection screening for pregnant women 22. Well-woman visits to get recommended services for women under 65 4
Covered Services for Children 1. Alcohol and Drug Use assessments for adolescents 2. Autism screening for children at 18 and 24 months 3. Behavioral assessments for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 4. Blood Pressure screening for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 5. Cervical Dysplasia screening for sexually active females 6. Depression screening for adolescents 7. Developmental screening for children under age 3 8. Dyslipidemia screening for children at higher risk of lipid disorders at the following ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 9. Fluoride Chemoprevention supplements for children without fluoride in their water source 10. Gonorrhea preventive medication for the eyes of all newborns 11. Hearing screening for all newborns 12. Height, Weight and Body Mass Index measurements for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 13. Hematocrit or Hemoglobin screening for children 14. Hemoglobinopathies or sickle cell screening for newborns 15. HIV screening for adolescents at higher risk 16. Hypothyroidism screening for newborns 17. Immunization vaccines for children from birth to age 18 - doses, recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis, Hemophilus influenzae type b, Hepatitis A, Hepatitis B, Human Papillomavirus, Inactivated Poliovirus, Influenza (Flu Shot), Measles, Meningococcal, Pneumococcal, Rotavirus, Varicella 18. Iron supplements for children ages 6 to 12 months at risk for anemia 19. Lead screening for children at risk of exposure 20. Medical History for all children throughout development at the following 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 Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years. 23. Phenylketonuria (PKU) screening for this genetic disorder in newborns 24. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk 25. Tuberculin testing for children at higher risk of tuberculosis at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 26. Vision screening for all children. Benefits are not limited to the schedule above. For more information on covered services visit: https://www.healthcare.gov/coverage/preventive-care-benefits/ 5
Additional Coverage Information: Annual deductible - $0 Out-of-pocket maximum - $1,850 individual / $3,700 family Additional Covered Services Primary care visits - (limit 3 per plan year at a $15 copay then subject to a network discount* for subsequent visits) Specialist visits - (limit 3 per plan year at a $15 copay then subject to a network discount* for subsequent visits) Urgent care (limit 1 per plan year at a $50 copay then subject to a network discount* for subsequent visits) Laboratory services - (limit 3 per plan year at a $50 copay then subject to a network discount* for subsequent visits) X-rays - (limit 3 per plan year at a $50 copay then subject to a network discount* for subsequent visits) *In-network services are repriced through the Multiplan PHCS network and provide discounts on covered services. Discounts vary based on provider contracts with the network. Members will be responsible for paying the remaining allowable balance after the network discount is applied. 6
EXCLUSIONS, LIMITATIONS & DEFINITIONS Exclusions: Abortion Acupuncture/spinal manipulation and chiropractic care Biofeedback Brand name prescription drugs Chemical dependency treatment Chemotherapy/radiation Childbirth/delivery facility services and professional services Cochlear implants Cosmetic surgery Dental care Diabetic supplies including insulin injectors and pumps Diagnostic imaging including CT/PET scans, MRIs and ultrasounds Diagnostic mammograms (preventive mammograms are covered) Dialysis Durable medical equipment including boots, canes, crutches, splints, prosthetics, orthotics, hospital beds, oxygen equipment, sleep apnea machines, walkers, wheelchairs and scooters Emergency room care and transportation including ambulance Experimental drugs, procedures or studies including sleep studies Eye care Foot care Generic prescription drugs Genetic testing including breast cancer (BRCA) Habilitation services Hearing aids Home health care, hospice, skilled nursing care and long-term care Hospice Services Hospitalization including facility fees and physician/surgeon fees Infertility treatment Mental health/behavioral health services Naturopathic services Nutritional supplies, vitamins or supplements Occupational therapy Out-of-network services including care outside the United States Pathology Private duty nursing Rehabilitation services including substance abuse and physical therapy Sexual dysfunctional services including drugs, supplies and therapy Sex change services including drugs, supplies, therapy and surgery Specialty prescription drugs Strength and performance services including devices and drugs Surgical procedures including transplants and outpatient surgery, facility fees, physician/surgeon fees and anesthesia TMJ and orthognathic services Weight loss drugs, procedures (including gastric bypass surgery and lap banding), programs and supplies 7
Limitations: Birth control implants including intrauterine devices (IUD) insertion/removal limit 1 per plan year unless due to medical necessity Breast cancer genetic testing (BRCA) counseling only no testing Preventive breast cancer mammography screening limit 1 per plan year Routine preventive/wellness visits (men, woman and children) limit 1 per plan year Primary care and Specialist visits are limited to 3 per plan year each at a $15 copay; subsequent visits are subject to the network discount (see schedule of benefits for additional information) Urgent care is limited to 1 per plan year at a $50 copay; subsequent visits are subject to the network discount (see schedule of benefits for additional information) Laboratory services and X-rays are limited to 3 per plan year each at a $50 copay; subsequent visits are subject to the network discount (see schedule of benefits for additional information) Definitions: Counseling providing patients with advice or education about a condition or disease and the potential treatment options available Screening a method of identifying a medical condition or disease without the existence of any signs or symptoms Testing a process or procedure performed to detect, diagnose or monitor a condition or disease based on a patient s illness, injury or symptoms 8
PREMIUMS & CLAIMS Premiums: For members paying for their medical coverage, premiums will be payroll deducted in accordance with your employer s payroll schedule. The Plan Sponsor will remit payment premiums on your behalf on a monthly basis. For Qualify Events, premiums will be changed upon the effective date of the Qualifying Event and the Plan Sponsor is responsible for updating the amount of payroll deduction. The Plan Administrator is not responsible for payroll deductions. Refunds of premiums will not be issued by the Plan Administrator. Any refund requests should be made directly to the Plan Sponsor. Coverage may be suspended or terminated in the event the Plan Sponsor does not remit premium payment to the Plan Administrator in accordance with the Associated Service Agreement between the Plan Sponsor and Plan Administrator. Coverage will be reinstated immediately upon receipt of premium payment by the Plan Administrator. Claims: Claims for medical services must be submitted by the provider via a Health Insurance Claim Form. Submission of invoices from providers will be rejected. Approved claims will be paid on the patient s behalf. Denied claims must be paid by the patient directly to the provider. Patients will receive an Explanation of Benefits (EOB). EOB s are not bills. No payments for claims should ever be remitted to the Plan Administrator directly. Approved claims will be paid within 30-45 days from the date of receipt of the claim by the Plan Administrator. Appeals of denied claims must be submitted in writing within 30 days from the processed date listed on the EOB. Please include a copy of the EOB for reference and mail the appeal to the Plan Administrator at the address below: Staff Benefits Management & Administrators Attention: Member Appeals 2307 Fenton Parkway # 107-126 San Diego, CA 92108 Prescription drug coverage is a discount program only. For Healthcare Reform approved prescription drugs, member must pay for the drugs out of pocket and submit a MEC Prescription Drug Claim Form. This form may be found at http://sbmabenefits.com/rxreimbursement. Healthcare Reform approved prescription drugs will be reimbursed 100%. 9