Download Enrollment Guide - Overview of plans

Employee Benefits Enrollment Guide
Plan Year: October 1, 2016 – September 30, 2017
Design © 2008-2014 Zywave, Inc. All rights reserved.
Who is Eligible?
If you are a full-time employee (working 35 or more hours per week)
you are eligible to enroll in the benefits described in this guide. The
following family members are eligible for medical, dental and vision
coverage: spouse and dependent children 26 years or younger.
How to Enroll
Complete an application form and return at least 15 days before
your effective date. You may elect medical, dental, and vision or
any of these separately. Once you have made your elections, you
will not be able to change them until the next open enrollment period
(October 1st each year) unless you have a qualified change in
status.
When to Enroll
You must enroll at least 15 days before the end of your 60-day
introductory period. The benefits you elect at this time will be
effective through September 30, 2017.
How to Make Changes
Unless you have a qualified change in status, you cannot make
changes to the benefits you elect until the next open enrollment
period. Qualified changes in status include, for example: marriage,
divorce, legal separation, birth or adoption of a child, change in
child’s dependent status, death of spouse, child or other qualified
dependent, change in residence, commencement or termination of
adoption proceedings, change in employment status or change in
coverage under another employer-sponsored plan.
What’s New for
2016
Bright Start offers plans through Innovation Health for the following lines of coverage:
 Medical
 Dental
 Vision
Medical and Prescription Drugs
Several changes have been implemented to our medical and prescription drug benefits for the
upcoming plan year October 1, 2016 to September 30, 2017. Our HMO plan is an open access plan
that allows you to select a primary care physician or secure a referral from one provider to another.
As a reminder, the plan does not provide coverage when you use out-of-network providers.
Innovation Health Silver Open HMO 2000 100%
Renewal
As of October 1, 2016
Services
Physician Visit
PCP - $45 Copay/Specialist - $75 Copay
Deductible
- Individual
- Family
$2,000
$4,000
Hospitalization
Deductible, then $500 Copay/admission
Preventive Care
No Charge based on age/frequency schedules
Emergency Room
$350 Copay
Out-of-Pocket Max
- Individual
- Family
$6,850
$13,700
Prescription Drugs
- Retail/Mail Order
- Generic
- Preferred
- Non-Preferred
Tier 1A preferred generic - $3/$7.50
Tier 1 – preferred generic - $15/$37.50
Preferred brand - $50/$125
Non preferred generic/brand - $100/$250
Specialty - $300 Copay
Your Cost in 2016-2017
EMPLOYEE BI-WEEKLY DEDUCTIONS
Employee Only
HMO
$68.41
Employee & Spouse
$136.82
Employee & Children
$133.40
Employee & Family
$201.81
Dental
The dental plan offered will be the Aetna PPO Max 1500 B which has both in/out of network benefits
and allows you to seek treatment from the dentist of your choice. Balance bill may apply to out of
network dentists.
Services
Amount You Pay
Preventive
Services
Exams, cleanings, x-rays – 100% in/out network
Deductible
Applies to basic and major services only – $50/$150
Basic Services
Fillings, simple extractions, root canal – Deductible applies. Coinsurance is 80/20 in/out
network
Major Services
Oral surgery, dentures, crowns – Deductible applies. Coinsurance is 50/50 in/out of network
Annual Maximum
$1,500
Bi-Weekly
Deduction
Employee only – $7.48
Employee & Spouse – $14.44
Employee & Child – $17.74
Family – $24.70
Vision
When you are enrolled in our medical plan you also eligible to participate in vision benefits. If you
utilize the services of a provider listed in the Preferred Provider Directory, your benefits include
routine vision exams for a $10 copay every 12 months, and preferred pricing on a large selection of
brand-name, designer frames, lenses, and lens options every 12 months. The frame allowance is
$130 and new frames are allowed every 12 months.
Bi-Weekly
Deduction
Employee only – $1.66
Employee & Spouse – $3.15
Employee & Child – $3.32
Family – $4.88
The information in this Enrollment Guide is presented for illustrative purposes and is based on
information provided by the employer. The text contained in this Guide was taken from various
summary plan descriptions and benefit information. While every effort was taken to accurately report
your benefits, discrepancies or errors are always possible. In case of discrepancy between the Guide
and the actual plan documents the actual plan documents will prevail. All information is confidential,
pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any questions
about your Guide, contact Human Resources.
Questions & Answers
Forms to be completed if you w ould like to enroll :


Medical & Dental Enrollment Form to add medical plans for you and any of your dependents
that you would like to enroll.
Vision Enrollment Form to enroll in the vision plan
Where do I find these forms?

All enrollment forms are on Bright Start’s website under the “For Employees” tab. You may
also see Kerri for a copy or for assistance with completing the enrollment form.
When are the forms due and w here do I return them?

All forms are due by 15 days before the end of your introductory period and must be
returned to Kerri Chase’s inbox in the office.
Who do I contact with questions?

Contact Kerri Chase with any questions you may have.