2017 Medical and Vision/Dental Insurance CHECK ONE BOX: NEW HIRE/ NEW ENROLLEE CHANGING COVERAGE COVERAGE EFFECTIVE DATE: Employee NAME: Last First Middle EMPLOYEE #: YOUR EMPLOYEE # CAN BE FOUND ON THE TOP RIGHT CORNER OF YOUR PAY STUB ADDRESS: HOME PHONE ( ) - CITY: STATE: ZIP CODE: Reason for Change BE SPECIFIC WHEN PROVIDING YOUR REASON FOR CHANGE BELOW: REASON FOR CHANGE (see instruction sheet, page 7): DATE OF EVENT: Indicate your choices MEDICAL PLAN TYPE (Check one box) Employee premiums listed on page 5. DECLINE MEDICAL COVERAGE EMPLOYEE ONLY EMPLOYEE ONLY EMPLOYEE ONLY EMPLOYEE + SPOUSE EMPLOYEE + SPOUSE EMPLOYEE + SPOUSE EMPLOYEE + DOMESTIC PARTNER EMPLOYEE + DOMESTIC PARTNER EMPLOYEE + DOMESTIC PARTNER EMPLOYEE + CHILD(REN) EMPLOYEE + CHILD(REN) EMPLOYEE + CHILD(REN) FAMILY FAMILY FAMILY FAMILY WITH DOMESTIC PARTNER FAMILY WITH DOMESTIC PARTNER FAMILY WITH DOMESTIC PARTNER HMO (Name of HMO) EMPLOYEE ONLY HMO EMPLOYEE + SPOUSE HMO EMPLOYEE + DOMESTIC PARTNER HMO EMPLOYEE + CHILD(REN) HMO FAMILY HMO FAMILY WITH DOMESTIC PARTNER HMO IF YOU DO NOT SELECT A BENEFIT PLAN DURING THE ANNUAL ENROLLMENT PERIOD, YOUR COVERAGE WILL AUTOMATICALLY ROLLOVER INTO THE SAME PLAN YOU ENROLLED IN FOR 2016 (including surcharges). YOU WILL BE REQUIRED TO REMAIN IN THAT PLAN FOR THE REMAINDER OF THE PLAN YEAR UNLESS YOU HAVE A QUALIFIED LIFE EVENT. (Does not apply to new hires or new enrollees.) Call the McDonald s Service Center for HMO application package HMO application must be returned to the McDonald s Service Center along with this form. Coverage not effective without HMO application. PLAN (Check one box) Employee premiums listed on page 5. DECLINE COVERAGE EMPLOYEE ONLY EMPLOYEE + SPOUSE EMPLOYEE + DOMESTIC PARTNER EMPLOYEE + CHILD(REN) FAMILY FAMILY WITH DOMESTIC PARTNER PLAN (Check one box only) Employee premiums are listed on page 5. DECLINE COVERAGE EMPLOYEE ONLY EMPLOYEE + SPOUSE EMPLOYEE + DOMESTIC PARTNER EMPLOYEE + CHILD(REN) FAMILY FAMILY WITH DOMESTIC PARTNER Healthcare Spending Account Dependent Care Spending Account HEALTHCARE SPENDING ACCOUNT: ELECT DECLINE INDICATE TOTAL AMOUNT TO BE DEDUCTED FOR THE YEAR: * (Any whole amount from $120 to $2,600) *The amount you choose will be divided equally and deducted from every paycheck beginning on the effective date and ending with the last paycheck this year. DEPENDENT CARE SPENDING ACCOUNT: ELECT DECLINE INDICATE TOTAL AMOUNT TO BE DEDUCTED FOR THE YEAR: * (Any whole amount from $600 to $5,000) *The amount you choose will be divided equally and deducted from every paycheck beginning on the effective date and ending with the last paycheck this year.
NOTE: Employee Dependent for Medical and Vision Supplement/ Dental Plan You must sign and submit pages 1-4 of this form in order for your elections to be processed even if you have no dependents or are declining coverage. Documentation is required when adding or removing all dependents. A complete list of acceptable documents is listed on page 6. Availability of Summary Health : You can find a Summary of Benefits & Coverage (SBC) that describes the important provisions (deductible, copay, etc.) of each option available to you under your plan online at Addinitupforme.com, then click on Programs, then Reference, and then SBCs. You can also request a paper copy by calling the McDonald s Service Center at 877-623- 1955. NAME: Last First Middle DEPENDENT NAME Last name, first name middle initial SOCIAL SECURITY NUMBER DATE OF BIRTH mm/dd/yyyy EMPLOYEE #: YOUR EMPLOYEE # CAN BE FOUND ON THE TOP RIGHT CORNER OF YOUR PAY STUB SPOUSE, DOMESTIC PARTNER* OR CHILD MALE OR FEMALE Please indicate: Yes or No Dental Vision Medical If child age 26 or older: Handicapped? Please indicate: Yes or No Dependents Your eligible Dependents under the McDonald s Plans (HMO eligibility may differ) are: Your Spouse or Domestic Partner* (with completed Affidavit of Domestic Partnership/Dependent Tax Certification -form 3838), after meeting domestic partner eligibility criteria.) Fiancées are not eligible. If you listed a Domestic Partner last year but are legally married, change it to Spouse and send in your marriage certificate to the Service Center. Children: Your child under age 26 (older if handicapped and dependent on you for support) who is your natural child, adopted child, step child, foster child, or a child for whom you are the legal guardian. Children or dependents, such as grandchildren or parents, should not be listed even if they are your IRS dependents, except in the case of children for whom you are the legal guardian. These same rules apply for the child(ren) of your spouse or domestic partner*. * See Note at bottom of page 5 below. Please read the following before you sign the form If electing an HMO, in addition to this form, you must fill out an HMO enrollment form, which can be obtained from the McDonald s Service Center and must be returned to the McDonald s Service Center. You will not be covered without submitting both the HMO form and this form to the McDonald s Service Center. A qualifying life event change allows you to request a change in your Medical and Vision Supplement/Dental coverage category (i.e., employee + spouse, family) and McDonald s Medical Plan option or your Healthcare Spending Account or Dependent Care Spending Account within 60 days (31 days for HMO plans) of the event. If you do not submit a change by that date you will have to wait until the next annual enrollment period to do it.
Signature I have reviewed the above insurance, Healthcare Spending Account and Dependent Care Spending Account elections and understand the following: Where I have not made an election or selected Decline Coverage, I have rejected coverage. For Annual Enrollment, I will reference the Annual Enrollment materials for the deadline to make elections. For Daily Enrollment (as a new hire/newly eligible employee), I have until prior to the first day of the month that coverage could begin to make this election. After that date, I will not be able to change the coverage elected or to enroll for any coverage until McDonald s next annual enrollment period or within 60 days (31 days for HMO plans) of a qualifying life event. Acceptance of the requested insurance change may depend on approval based on acceptance by an HMO. If applicable, I certify that this request is consistent with my life event change. I am responsible for paying each premium for the group insurance or HMO coverage I elect. I elect to pay my premiums and Healthcare/Dependent Care salary reductions by payroll deductions under the McDonald s Premium Payment Plan, the McDonald s Healthcare Spending Account and the McDonald s Dependent Care Spending Account, for coverage that I elect. Failure to do so may result in termination of my coverage. My PPO medical election will rollover in the next year if I do not re-enroll. My HMO and Healthcare/Dependent Care elections will remain in effect from year to year unless I change them during annual enrollment or due to a life event. I must recertify each year to avoid spouse and tobacco surcharges on my medical insurance. My Healthcare and Dependent Care Spending Account balances remaining after all eligible expenses for the calendar year, including the grace period, have been reimbursed will be forfeited to those Plans. I certify that I will only submit eligible medical/dental/vision expenses to the Healthcare Spending Account and eligible Dependent Care expenses to the Dependent Care Spending Account and that I will not have those expenses reimbursed from any other source. For Hawaii employees only: I understand that if I separate from employment after McDonald s has prepaid my share of the premiums, McDonald s will deduct one-half of the premium cost from my final pay. EMPLOYEE SIGNATURE: DATE:
SURCHARGE AFFIDAVITS for Annual Enrollment Employee NAME: Last First Middle EMPLOYEE #: YOUR EMPLOYEE # CAN BE FOUND ON THE TOP RIGHT CORNER OF YOUR PAY STUB Tobacco Use: Complete only if you elect medical coverage TOBACCO USE AFFIDAVIT A tobacco use surcharge is being added to the medical premium for tobacco users. Complete the affidavit below to certify whether or not the surcharge should apply to you. IF YOU DO NOT COMPLETE THE AFFIDAVIT AND FINISH YOUR ANNUAL ENROLLMENT, YOU WILL AUTOMATICALLY PAY THE SURCHARGE if you re enrolled in a McDonald s medical plan for 2017. You will not be able to change this surcharge until annual enrollment for 2018 (unless you complete the medical plan s smoking cessation program). Remember, use of a tobacco product means any use (even one time) of a tobacco product, including cigarettes, chewing tobacco, cigars, pipes or any other product that contains tobacco. ---- CERTIFICATION -------- By checking a box below, I agree that the statement I check is true and accurate to the best of my knowledge. I understand that if I am being purposefully dishonest, my coverage could be terminated back to January 1, I could be required to repay claims and I could be subject to disciplinary action up to and including termination of employment. I certify I and all of my covered dependents have not used any tobacco products during the past 90 days or more, or have completed the medical plan s smoking cessation program since August 1, 2016. (Surcharge does not apply.) OR I or at least one of my covered dependents have used a tobacco product within the past 90 days and have not completed the medical plan s smoking cessation program since August 1, 2016. (Surcharge applies.) Spouse coverage: Complete only if medical coverage category is Employee + Spouse or DP or Family with Spouse or DP Check here if you are not covering a SP or DP AFFIDAVIT REGARDING SPOUSE ACCESS TO OTHER COVERAGE A spousal surcharge is added to the medical plan premium for employees whose covered spouse or domestic partner also has access to comprehensive medical coverage through his or her employer (other than McDonald s). IF YOU DO NOT COMPLETE THE AFFIDAVIT AND FINISH YOUR ANNUAL ENROLLMENT, YOU WILL AUTOMATICALLY PAY THE SURCHARGE if you cover a spouse or domestic partner on your McDonald s medical plan for 2017. Remember, comprehensive coverage means the insurance covers a wide variety of health care services (including doctor visits, hospital stays, surgery and rehabilitation). Medicare is not considered comprehensive coverage. ---- CERTIFICATION -------- By checking a box below, I agree that the statement I check is true and accurate to the best of my knowledge. I understand that if I am being purposefully dishonest, my coverage could be terminated back to January 1, I could be required to repay claims and I could be subject to disciplinary action up to and including termination of employment. I also understand that the spousal surcharge, once applied for the year, can only be removed due to either the death or divorce of a spouse/dp, except during annual enrollment. I certify OR My covered spouse or domestic partner does not have access to comprehensive medical coverage through his or her employer (or he/she is a McDonald s staff or McOpCo restaurant employee). (No surcharge.) My covered spouse or domestic partner has access to comprehensive medical coverage through his or her employer (other than McDonald s). (Surcharge applies.) About the Surcharges The surcharge amount is the same for tobacco use and spouse/domestic partner coverage. If both surcharges apply to you (you and/or a covered family member use tobacco and you cover a spouse/domestic partner who has access to another employer s coverage), then the extra cost you pay each month is two times the number below. For 2017, the surcharge for McDonald s Gold, Silver, Bronze and HMO plans is: $20 per month for Full-time Crew $33 per month for Restaurant employees and Staff in the Associate and Coordination bands $46 per month for Staff above the Coordination band $63 per month for Officers Take note: The tobacco use surcharge is only applies once, regardless of how many family members use tobacco. EMPLOYEE SIGNATURE: DATE:
Annual Premium Rates The premium rates shown in this chart are annual pre-tax* amounts. To determine the amount deducted from each pay check, divide the annual amount by 24 if you are paid semi-monthly, by 26 if you are paid bi-weekly or by 52 if you are paid weekly. If you are covering a Domestic Partner refer to the note* below. Full-time Crew - (averaging at least 30 hours per week over a 1 year measurement period) Restaurant Certified Swing, Primary Maintenance, and Salaried Restaurant Management Full time Staff Home Office and Regional Associate and Coordination Bands Part time Staff Home Office and Regional Associate and Coordination Bands (working at least 20 hours per week) EMPLOYEE ONLY $ 1,111.80 $ 833.88 $ 312.00 $ 95.40 $134.28 EMPLOYEE + SPOUSE OR DOMESTIC PARTNER* $ 2,334.84 $ 1,751.04 $ 660.00 $190.80 $282.24 EMPLOYEE + CHILD(REN) $ 2,112.36 $ 1,584.36 $ 600.00 $171.84 $255.24 FAMILY OR FAMILY WITH DOMESTIC PARTNER* $ 3,335.40 $ 2,501.52 $ 948.00 $262.44 $403.20 Full time Staff Home Office and Regional Specialist, Supervisor, Manager, and Director Bands Part time Staff Home Office and Regional Specialist, Supervisor, Manager, and Director Bands (working at least 20 hours per week) EMPLOYEE ONLY $1,556.52 $1,167.36 $ 441.00 $ 95.40 $134.28 EMPLOYEE + SPOUSE OR DOMESTIC PARTNER* $3,268.68 $2,451.48 $ 926.16 $190.80 $282.24 EMPLOYEE + CHILD(REN) $2,957.40 $2,217.96 $ 837.96 $171.84 $255.24 FAMILY OR FAMILY WITH DOMESTIC PARTNER* $4,669.44 $3,502.20 $ 1,323.00 $262.44 $403.20 Full time Officers Home Office and Regional Part time Officers Home Office and Regional (working at least 20 hours per week) EMPLOYEE ONLY $2,112.36 $1,584.36 $ 598.56 $ 95.40 $134.28 EMPLOYEE + SPOUSE OR DOMESTIC PARTNER* $4,436.04 $3,327.00 $ 1,256.88 $190.80 $282.24 EMPLOYEE + CHILD(REN) $4,013.64 $3,010.20 $ 1,137.12 $171.84 $255.24 FAMILY OR FAMILY WITH DOMESTIC PARTNER* $6,337.20 $4,752.84 $1,795.56 $262.44 $403.20 EMPLOYEE ONLY $ 958.68 $ 680.76 $ 252.00 $ 95.40 $134.28 EMPLOYEE + SPOUSE OR DOMESTIC PARTNER* $2,013.24 $1,429.56 $ 528.00 $190.80 $282.24 EMPLOYEE + CHILD(REN) $1,821.60 $1,293.36 $ 480.00 $171.84 $255.24 FAMILY OR FAMILY WITH DOMESTIC PARTNER* $2,876.04 $2,042.16 $ 756.00 $262.44 $403.20 * Note: If you cover a domestic partner, the portion of your premium for your partner and any children is deducted from your pay after taxes, and you pay taxes on the value of the company s contribution for their coverage unless you complete an Affidavit of Domestic Partnership/Dependent Tax Certification form to certify the family members that qualify as your dependents for federal income tax purposes. The Affidavit is available online through the annual enrollment web site or from the Service Center by calling (877) 623-1955. NOTE: Refer to page 4 for additional Surcharge costs that may apply.
DEPENDENT ELIGIBILITY Here is what you ll need to provide Note: Photocopies are acceptable forms of documentation TO ADD A DEPENDENT Proof of Marital Status: - Copy of Marriage Certificate Proof of Domestic Partnership: - Signed Affidavit of Domestic Partnership Proof of Birth, Adoption or Placement for Adoption of a Dependent or other adding of children (the child previously had been on the spouse s plan). Only one of the following is required Birth Certificate Hospital Certificate Adoption and/or Legal Guardianship Paperwork You must include proof of Social Security Number for any dependent that you are adding. Proof of Social Security Number can be verified by the 1st page of your tax return or by calling the Service Center at 877-623-1955. TO REMOVE A DEPENDENT Proof of Divorce only one of the following is required Copy of Divorce Decree Judgment Proof of Ended Domestic Partnership: Signed Termination Affidavit of Domestic Partnership Deceased Dependent- only one of the following is required Death Certificate Funeral Home Record Obituary All submitted documentation must include Employee s name and relationship to dependent. If you do not provide documentation within 60 days from the date you enroll, your dependent s coverage will be terminated. However, you will remain in the same coverage level and pay the same premiums until the next annual enrollment, unless you experience a life event. If we do not receive the documentation our plan coverage report to the federal government will show that your dependent did not have health coverage under the McDonald s Plan for 2017 regardless of premiums paid. You will then be subject to a penalty by the IRS in 2018 when you file your taxes. See next page for life event details. If your dependents are dropped due to non-certification, they will not be eligible for COBRA.benefits.
Reason for Change Instruction Sheet To make an insurance change based on a qualifying life event, you must notify the McDonald s Service Center by completing the attached election form within 60 days (31 days for HMO plans) of your qualifying life event date. If it is past that date, changes cannot be processed. Life Event Changes When Coverage Begins Note: Because pre-tax dollars are used for Plan contributions, the IRS requires that changes in elections for these contributions be made only on an annual basis (effective January 1 st ) unless you have one of the following qualifying life event changes: Marriage, divorce, or annulment.* (Submit first and last page of divorce decree along with this application.) Applies to all Plans. Death of Spouse or Dependent.* Applies to all Plans. Birth, adoption, or placement for adoption of a Dependent.* Applies to all Plans. Beginning or termination of employment for you, your spouse or your Dependent.* Applies to all Plans. Change in employment-related eligibility for the Plan or another health or Healthcare/Dependent Care Spending Account Plan by you, your spouse or Dependent.* Applies to all Plans. Change in eligibility status of your spouse or your Dependent under the Plan or another health or Healthcare/Dependent Care Spending Account Plan.* Applies to all Plans. Beginning or returning from an unpaid leave of absence by you, your spouse or Dependent (subject to the Unpaid Leave" rules).* Applies to all Plans. Strike or lockout involving you, your spouse or your Dependent.* Applies to all Plans. You, your spouse or your Dependent becomes entitled to Medicare, Medicaid or the Child Health Insurance Program (CHIP). Applies to Health Plans and Healthcare Spending Account Plan. You have a reduction in hours and you and your covered family members are eligible for and intend to enroll in another health plan that provides minimum essential coverage. Your Dependent s coverage under a Qualified Medical Child Support Order. Applies to Health Plans and Healthcare Spending Account. Loss of coverage under another health plan that qualifies you or your Dependents for special enrollment under the Plan or another health plan. Applies to Health Plans only. Refer to Summary Plan Description. Certain significant increases or decreases in cost of a health, vision supplement or dental option under the Plan, as determined by the Plan Administrator. Applies to Health Plans only. Significant decrease in coverage provided under a health, vision supplement or dental option under the Plan, as determined by the Plan Administrator. Applies to Health Plans only. Your change in residence due to a job transfer that is at least 30 miles from your previous job location, if the change in location causes you to lose coverage under an HMO under the Plan. Applies to Health Plans only. Change in election under your spouse s or Dependent s medical, dental or vision supplement or Dependent Care Spending Account Plan if that change is allowed under the IRS rules or that plan has a different enrollment period and the change in election under this Plan is consistent with and corresponds to the change in election under the other plan. Applies to Health Plans and Dependent Care Spending Account Plan. Change in Dependent Care provider or rate changed by Dependent Care provider. Applies to Dependent Care Spending Account Plan only. *Your change of election must be consistent with the life event change. Changes marked by an * are allowed only if the life event change causes you, your spouse, or Dependent to lose or gain eligibility for coverage under the Plan or another health, healthcare spending account or dependent care spending account plan, as applicable. The life event changes also apply to your domestic partner, but only for the medical, vision supplement and dental plans. New Hires/Newly Benefit Eligible Employees: Your Employee coverage starts on the first day of the month following the end of your waiting period (first of the month following the date you enroll for Full-Time Crew), assuming you have enrolled for that coverage prior to that date. Refer to your Summary Plan Description. Enrolled Dependents (other than certain Special Enrollments): The date you become covered, or The first day of the following month, unless you enroll the Dependent on the first day of the month in which you acquire the Dependent. Special Enrollments due to marriage or adding domestic partner, birth or adoption and eligibility for CHIP or Medicaid Must elect coverage within 60 days (31 days for HMO plans of the special event; in that case, coverage begins: For marriage, adding domestic partner or eligibility for CHIP or Medicaid, the first day of the month following the special event. For birth, adoption or placement of adoption, the date of the special event. Premiums are due the first day of the month for which coverage begins (even though, in the case of birth or adoption, coverage begins on the date of the event in that month.)