Download Enrollment Guide - Apollo Professional Solutions

Enrollment
Guide
5M
For the Employees of
Apollo Professional
Services
Medical Plan Options and Enrollment Information
Administered by Key Benefit Administrators, Inc
What is 5M?
A choice of options to fit your
healthcare needs
Minimum
Essential Coverage
MEC Heavy is a stronger version
of the MEC product that covers a
variety of outpatient services.
Minimum Essential Coverage (MEC) is designed
to satisfy your obligations under PPACA and avoid
individual tax penalties. The cost of this insurance is
100% paid by your employer.
MEC Heavy
The Minimum Value Plan is a bronze major medical plan that
provides comprehensive coverage for inpatient and outpatient
procedures. However, it has a high deductible and out-of-pocket
maximum ($6,500 for single coverage, $13,200 for families).
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Minimum
Value Plan
Minimum Essential Coverage
MEC
As outlined under the new healthcare law,
ACA, all individuals must have Minimum
Essential Coverage (MEC) beginning January
1, 2014, or pay a penalty tax. Employees can
prevent being taxed the “Individual Mandate”
penalty tax by purchasing Minimum Essential
Coverage through their employer.
If you don’t purchase Minimum Essential
Coverage (MEC) in 2015, you will face a tax
of the greater of 2% of adjusted household
income or $325 per adult plus $162.50 per
child. Thereafter, the tax will be the greater
of 2.5% of adjusted household income or
$695 per adult plus $347.50 per child.
There are preventive services covered at
100% under the required government list of
Preventive and Wellness Benefits when you
visit a network provider. The benefits drop to
40% if you use an out-of-network provider.
Services covered include immunizations,
blood pressure screenings, diabetes and
cholesterol screenings, prenatal visits for
pregnant women and more. A full list of
the covered services is included in this
information.
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 designed to
satisfy your individual mandate
under the new healthcare law.
Minimum Essential Coverage (MEC) provides
first dollar coverage with access to one
of the largest national preferred provider
organizations (PPO) available with great
discount savings for MEC benefits. The
network savings can also be used for
services not covered by the MEC. You will
have access to a simple-to-use web portal for
your local or out-of-town provider look up to
be sure your provider is in the PPO Network.
The MEC comes with a medical ID Card
that needs to be presented to your medical
provider at your time of service.
The cost of this insurance is detailed on page 17
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MEC Covered Preventive Services
Covered Preventive Services for Adults (ages 18 and older)
1. Abdominal Aortic Aneurysm one time
screening for age 65-75
2. Alcohol Misuse screening and counseling
3. Aspirin use for men ages 45-79 and women
ages 55-79 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
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- 55-80 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 onetime screening for HCV
infection if born between 1945-1965.
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
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
11. 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 60
18. 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
Covered Preventive 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 17
4. 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
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14. Hematocrit or Hemoglobin screening for children
15. Hemoglobinopathies or sickle cell screening for newborns
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 10
23. 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 5
27. Skin Cancer Behavioral Counseling – age 10-24 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.
Optional Hospital Indemnity Insurance
Underwritten by Transamerica Life Insurance Company
TransChoice® Advance: Group Limited Benefit Hospital Indemnity Insurance
Plan 1
Daily In-Hospital Indemnity Benefit
Pays per day, up to a max of 31 days per confinement
$200
Outpatient Physician Office Visit Indemnity Benefit
Pays per day, up to max days per calendar year per insured person
Outpatient Diagnostic X-Ray and Laboratory Indemnity Benefit
Pays benefit per day; 2 days per calendar year for Advanced Studies,
2 days per calendar year for Select Diagnostic tests, 3 days per calendar
year for Diagnostic Laboratory tests.
$60
6 day max
Advance Studies
Select Diagnostic
Diagnostic Laboratory
$200
$50
$10
Hospital Confinement
1 day of confinement per year
$1,000
Daily Inpatient Drug and Alcohol Indemnity Benefit
Pays per day, up to a max of 31 days per year
$200
Daily Inpatient Mental and Nervous Indemnity Benefit
Pays per day, up to a max of 31 days per year
$200
Off-the-Job Accidental Injury Benefit
Pays benefit per day of accident treatment (5 days per calendar year)
$200
Ambulance Service Daily Indemnity Benefit
Per trip in a ground ambulance, 3x benefit for air ambulance, up to 3 days per year
$100
Emergency Room Sickness Benefit
Per visit up to 4 days per calendar year per insured person
$100
Prescription Drug Indemnity Benefit
Per day a prescription is filled for up to 36 days per calendar year, per insured person
$15 Generic
$30 Brand
Critical Illness Indemnity Benefit and Subsequent Critical Illness Indemnity Benefit
Lump sum benefit for the initial diagnosis of a covered critical illness and an additional
lump-sum benefit of the same amount for subsequent and separate covered critical illness
$5,000
Additional Benefits
Group Term Life Insurance Policy with
Accidental Death and Dismemberment Rider (AD&D)
AD&D not available to dependent children
Employee
Spouse
Child(ren)
$5,000
$2,500
$2,500
Non-Insurance Benefits Included
Employee Discount Card - Offered by New Benefits, LTD
Provides access to a discount Vision plan, Nurses Hotline, Counseling Services, and discounts on Hearing Aids
Patient Advocacy - Offered by The Karis Group
Services that provide employees with unparalleled diligence and dedication to find the best solutions for resolving
their outstanding medical bills
This is a brief summary of TransChoice® Advance Group Limited Benefit Hospital Indemnity Insurance underwritten by Transamerica Life
Insurance Company, Cedar Rapids, IA. Policy form series CPGHI400 and CCGHI400. Forms and form numbers may vary. This insurance
may not be available in all jurisdictions. Limitations and exclusions apply. Refer to the policy, certificate and riders for complete details.
THIS IS NOT MAJOR MEDICAL INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL INSURANCE. IT DOES NOT QUALIFY
AS MINIMUM ESSENTIAL HEALTH COVERAGE UNDER THE FEDERAL AFFORDABLE CARE ACT.
The cost of this insurance is detailed on page 17
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Optional Hospital Indemnity Insurance
Summary of Benefits for TransChoice® Advance: Group Limited Benefit Hospital Indemnity Insurance
underwritten by Transamerica Life Insurance Company
Daily In-Hospital Indemnity Benefit
When an insured person is confined in a hospital as a
result of an accident or sickness, this benefit pays the
benefit amount for each day the insured is confined in a
hospital, up to a maximum of 31 days per confinement.
Hospital Confinement
This benefit pays an additional benefit per insured
person per calendar year when he/she receives
treatment or surgery while confined to a hospital as an
inpatient as a result of a covered accident or sickness.
Outpatient Physician Office Visit Indemnity Benefit
This benefit pays the amount shown for the day of
a physician’s office visit as a result of a sickness or
accident. Benefits are payable for a maximum number
of days per calendar year per person.
Daily Inpatient Drug and Alcohol Indemnity Benefit
This benefit pays per day if an insured person is
confined as an inpatient in a rehabilitation facility for
substance abuse. The maximum benefit per covered
person per calendar year is 31 days. The lifetime
maximum for this benefit is $30,000.
Daily Inpatient Mental and Nervous Indemnity Benefit
This benefit pays per day if an insured person is
confined as an inpatient in a rehabilitation facility for a
mental or nervous condition. The maximum benefit per
covered person per calendar year is 31 days. The lifetime
maximum for this benefit is $30,000.
Prescription Drug Indemnity Benefit
This benefit pays the amount selected for a day when
a prescription is filled for prescription drugs prescribed
by a physician as a result of an accident or sickness.
There is a maximum of one brand and one generic
prescription per day.
Critical Illness Indemnity Benefits and Subsequent
Critical Illness Indemnity Benefit
When an insured person is diagnosed with a covered
critical illness, the selected amount will be paid. This
amount is payable up to two times for each insured
person, once under the Critical Illness Indemnity
Benefit and once under the Subsequent Critical Illness
Indemnity Benefit, and is paid in addition to any
other benefits paid by the TransChoice policy. The
Subsequent Critical Illness Indemnity Benefit is paid if
the insured person is diagnosed as having a subsequent
and seperate covered critical illness more than sixty
(60) days after the first covered illness.
For example: If an insured person is diagnosed for the
first time with a heart attack, and then is diagnosed
with a stroke for the first time more than sixty (60) days
later, he or she will receive the benefit amount selected
for each illness. This benefit is payable one time for
each insured person. The Subsequent Critical Illness
Indemnity Benefit is not payable for Skin Cancer or
Carcinoma in Situ.
100% of the benefit amount is payable for:
- Cancer (including leukemia and Hodgkin’s Disease,
except Stage 1 Hodgkin’s Disease)
- Heart Attack (diagnosis must be based on EKG
changes consisten with injury elevation of cardiac
enzymes, and confirmatory neuroimaging studies)
- Stroke (diagnosis must be based on documented
neurological deficits and confirmatory neuroimaging
studies)
- End Stage Renal Failure (chronic, irreversible failure
of the function of both kidneys, such that an insured
person must undergo regular hemodialysis or peritoneal
dialysis at least weekly)
- Major Organ Transplant (undergoing surgery as a
recipient of a transplant of a human heart, lung, liver,
kidney, or pancreas)
5% of the benefit amount is payable for:
- Skin cancer including basal cell epitheloma or
squamous cell carcinoma; does not include malignant
melanoma or mycosis fungoides
- Carcinoma In Situ (cancer that is confined to the site
of origin without having invaded neighboring tissue)
* Dependent insurance equal to 50% of this benefit
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EBD IB5MEG 0915
Optional Hospital Indemnity Insurance
Summary of Benefits for TransChoice® Advance: Group Limited Benefit Hospital Indemnity Insurance
underwritten by Transamerica Life Insurance Company
Ambulance Indemnity Benefit
This benefit pays per day of using an air or ground
ambulance. Treatment must be received within 72 hours
of the accident or onset of sickness, and must be provided
by a licensed ambulance company for benefits to be
payable.
Outpatient Diagnostic X-Ray and
Laboratory Indemnity Benefit
This benefit pays the amount shown per testing day for
tests performed for the purpose of diagnosis of a covered
sickness or accident as indicated by symptoms that would
suggest an injury or sickness had occured. The benefit is
limited to a number of days of testing per calendar year
per covered person and is not payable while the insured is
confined in a hospital (i.e. it applies to outpatient services
only).
Off-the-Job Accidental Injury Benefit
This benefit pays the selected amount per day accident
(maximum of 5 days per insured person per calendar
year), for x-rays used to diagnose an accidental injury
and for treatment of a covered accident by a physician
in the physician’s office, clinic, urgent care facility, or
hospital emergency room. Treatment must be received
within 96 hours of the accident for benefits to be
payable.
Emergency Room Sickness Benefit
This benefit will pay for each sickness visit to the
emergency room for a number of days per calendar year
per insured person. Emergency room visits for accidents
are not covered under this benefit, they would be
covered under the Off-the-Job Accident Benefit.
Group Term Life Insurance Policy with Accidental Death and Dismemberment Rider
Policy Form Series CP100200 and CP100400
This policy pays the benefit amount shown upon the death of the insured, subject to any limitations/exclusions. The
AD&D benefit amount will match the amount of group term life insurance.
Exclusions
We will not pay any benefits if the loss, directly or indirectly,
results from any of the following, even if the means or cause of
the loss is accidental:
- suicide or intentionally self-inflicted injury, while sane or insane;
- commission of or attempt to commit an assault or felony;
- sickness or mental illness, disease of any kind, or medical or
surgical treatment for any sickness, illness or disease;
- injuries received while under the influence of alcohol, a
controlled substance or other drugs as defined by the laws of
the State where the accident occurs, except as prescribed by a
doctor;
- any poison or gas voluntarily taken, administered, absorbed, or
inhaled (except in the course of employment);
- flight in any kind of aircraft, except as a fare paying passenger
on a regularly scheduled commercial aircraft;
- any bacterial or viral infection;
- declared or undeclared war, or any act of war; and
- taking part in an insurrection.
Age Reduction
Death benefits automatically reduce to the following percentages,
or flat amount, on the Group Master policy Anniversary Date that
follows the applicable birthday, as follows:
Schedule
Birthday
65% of pre-age 65 death benefit
65th
50% of pre-age 65 death benefit
70th
25% of pre-age 65 death benefit
75th
The lesser of $5,000 or 25% of
pre-age 65 death benefit
80th
Under the AD&D Rider, when a covered accident results in any of
the following losses, benefits are paid for the following specified
percentages of the coverage amount subject to any limitations
and exclusions.
Loss
Percentage
Paid
Loss of life or loss of two or more members
(hand, foot, sight of an eye)
100%
Quadriplegia
(total and permanent paralysis of both upper
and lower limbs)
100%
Loss of speech AND hearing in both ears
100%
Paraplegia (loss or paralysis of both lower limbs)
75%
Loss of one member, or loss of speech, or loss of
hearing in both ears
50%
Hemiplegia (total and permanent paralysis
of the upper and lower limbs of one side of the
body)
50%
Loss of hearing of one ear, or loss of thumb
and index finger of same hand
25%
Only one such amount will be paid as a result of a single
covered accident This Rider stops on the Employee’s/member’s
70th birthday.
This is a brief summary of Group Term Life Insurance
underwritten by Transamerica Life Insurance Company,
Cedar Rapids, Iowa 54299. Policy form series CP100200
and CC100400; Rider form series CR101100. Forms and
form numbers may vary. Coverage may not be available in
all jurisdictions. Limitations and exclusions apply. Refer to
the policy, certificate, and riders for complete details.
EBD IB5MEG 0915
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Optional Hospital Indemnity Insurance
Non-Insurance Benefits
Employee Discount Card
This discount card is provided by New Benefits, LTD.
It offers Employees access to a discount Vision Plan,
a Nurses Hotline, Counseling Services and benefits for
Hearing Aids. This is not an insurance plan. The discount
Vision Plan through the Coast to Coast network allows
the Employee to receive discounts of 20% to 60%
on eyeglasses, non-prescription sunglasses, contact
lenses (including disposables) and frames from over
10,000 independent retail optical locations nationwide.
Providers include independent practitioners, regional
chains, department store opticals, and the largest chains
in the U.S. Some of these providers are LensCrafters,
Pearle Vision, Sears Optical and JC Penney Optical
(among others).*
The Nurses Hotline allows access to experienced
registered nurses 24 hours a day, 7 days a week, 365
days a year. These hotline nurses are an immediate,
reliable and caring source of health information,
education and support. Services provided by this plan
include:
o
o
o
o
o
o
General information on all types of health concerns
Information based on physician-approved guidelines
Answers about medication usage and interaction
Information on non-medical support groups
Translation services for non-English speaking callers
Full time medical director on staff
The Counseling Services benefit allows the Employee
to speak with a counselor 24 hours a day, 7 days a
week regarding any personal problems they may be
facing. In addition, if the Employee is referred to one of
the 27,000 counseling providers nationwide, they will
receive discounts of 25% to 30% off the normal billing
charges from those providers.*
The Hearing Aid benefit provides savings of up to
15% off the retail cost on over 70 models of hearing
aids, and a free hearing test when utilizing one of the
1,200 participating Beltone® locations nationwide. Or,
the Employees can realize savings of up to 50% off
suggested retail price on over 90 models of hearing aids
in over 1,000 locations nationwide.*
Information on how to access the benefits of the
Employee Discount card will be included in the
fulfillment package that each insured Employee receives
from KBA.
* Discounts on professional services are not available
where prohibited by law.
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EBD IB5MEG 0915
Patient Advocacy
Even with exceptional PPO discounts and rich
reimbursement schedules, employees of limited benefit
medical plans may be left with unpaid medical bills in
years when medical bills approach $3,500 or more.
For these individuals, Karis’ Patient Advocacy service
becomes the critical missing piece and an invaluable
benefit for customers. Since we treat each employee,
locality and provider as a unique combination of
variables that leads to a customized solution for
each employee, Karis delivers a customized and
comprehensive solution that goes far beyond the
benefits of a one size fits all PPO network discount.
When reimbursement limits are reached, our services
kick in and provide employees with unparalleled
diligence and dedication to find the best solutions for
resolving their outstanding medical bills.
For employees who find themselves unable to
pay bills that exceed Limited Benefit Medical plan
reimbursements, Karis can come alongside to advocate
on their behalf, working with every provider to find a
mutually agreeable solution. Karis’ highly trained and
experienced “Employee Advocates” guide employees
through the tangled maze of medical billing. Initially,
we research the availability of entitlement or financial
assistance programs in an effort to locate outside
funding sources to help pay their bills. If an employee
qualifies for such programs, their Employee Advocate
will hold their hand throughout what can be a lengthy
process and will do everything for the employee from
acquiring necessary paperwork to chasing decision
makers. If an employee does not qualify for entitlement
or financial assistance programs, their Employee
Advocate will try to negotiate a reduced settlement or
reduced/extended payment plan with providers that is
acceptable to all parties.
ID Cards
You will receive a separate ID card for the
Transamerica product. Claims administration and
customer service will be provided by Key Benefit
Administrators. An explanation of benefits (EOB)
will be provided on each claim to explain how it
was processed.
Optional Hospital Indemnity Insurance
Limitations and Exclusions for TransChoice® Advance: Group Limited Benefit Hospital Indemnity Insurance
underwritten by Transamerica Life Insurance Company
Confinement for the same or related condition within 30 days of discharge will be treated as a continuation of the prior confinement.
Successive confinements separated by more than 30 days will be treated as a new and separate confinement.
No benefits under this contract will be payable as the result of the following:
• Suicide or attempted suicide, whether while sane or insane.
• Intentionally self-inflicted injury.
• Rest care or rehabilitative care and treatment.
• Immunization shifts and routine examinations such as: physical examinations, mammograms, Pap smears, immunizations, flexible
sigmoidoscopy, prostate-specific antigen tests and blood screenings (unless Wellness Indemnity Benefit Rider is included).
• Any pregnancy of a dependent child including confinement rendered to her child after birth.
• Routine newborn care (unless Wellness Indemnity Benefit Rider is included).
• An insured person’s abortion, except for medically necessary abortions performed to save the mother’s life
• Treatment of mental or emotional disorder (unless Inpatient Mental and Nervous Disorder Indemnity Benefit Rider is included).
• Treatment of alcoholism or drug addiction (unless Inpatient Drug and Alcohol Addiction Indemnity Benefit Rider is included).
• Participation in a felony, riot, or insurrection.
• Any accident caused by the participation in any activity or event, including the operation of a vehicle, while under the influence of
a controlled substance (unless administered by a physician or taken according to the physician’s instructions) or while intoxicated
(intoxicated means that condition as defined by the law of the jurisdiction in which the accident occurred).
• Dental care or treatment, except for such care or treatment due to accidental injury to sound natural teeth within 12 months of the
accident and except for dental care or treatment necessary due to congenital disease or anomaly.
• Sex change, reversal of tubal ligation or reversal of vasectomy.
• Artificial insemination, in vitro fertilization, and test tube fertilization, including any related testing, medications or physician’s services,
unless required by law.
• Committing, attempting to commit, or taking part in a felony or assault, or engaging in an illegal occupation.
• Traveling in or descending from any vehicle or device for aerial navigation, except as a fare-paying passenger in an aircraft operated
by a commercial airline (other than a charter airline) on a regularly scheduled passenger trip.
• Any loss incurred on active duty status in the armed forces. (If you notify us of such active duty, we will refund any premiums paid for
any period for which no insurance is provided as a result of this exception.)
• An accident or sickness arising out of or in the course of any occupation for compensation, wage or profit or for which benefits may
be payable under an Occupational Disease Law or similar law, whether or not application for such benefits has been made.
• Involvement in any war or act of war, whether declared or undeclared
Termination of Insurance
The insurance terminates on the earliest of:
• The insured’s death.
• The premium due date when we fail to receive a premium,
subject to the grace period.
• The date of written notice to cancel insurance.
• The date the policy terminates, subject to the portability option.
• The date the insured ceases to be eligible for insurance.
Dependent insurance ends on the earliest of:
• The date the insured’s insurance terminates for any of the
reasons above.
• The date the dependent no longer meets the definition of a
dependent.
• The premium due date when we fail to receive a premium,
subject to the grace period.
• The date of written notice to cancel insurance.
• The date the policy is modified so as to exclude dependent
insurance.
The insurance company has the right to terminate the insurance
of any insured who submits a fraudulent claim. Termination will
not impact any claim which begins before the date of termination.
Extension of Benefits
Whenever termination of insurance under this section occurs
due to termination of Your employment or membership, such
termination will be without prejudice to:
1. Any Hospital Confinement which commenced while
insurance was in force, with respect to Daily In-Hospital
Indemnity Benefits; or,
2. Any covered treatment or service for which benefits would
be provided and which commenced while insurance was
in force; provided, however, that the Insured Person is and
continues to be Hospital Confined or Disabled.
Such Extension of Benefits will continue for up to the earlier of:
1. 30 days; or
2. The date on which the Insured Person is no longer disabled.
Massachusetts Residents: This product DOES
NOT MEET MINIMUM CREDITABLE COVERAGE
STANDARDS and WILL NOT SATISFY the
Massachusetts individual mandate that you have
health insurance.
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MEC Heavy
As outlined under the new healthcare law, ACA, all individuals must have Minimum Essential
Coverage (MEC) or pay a penalty tax. Employees can prevent being taxed the “Individual
Mandate” penalty tax by purchasing Minimum Essential Coverage through their employer.
Because the MEC plan covers specific preventative services we also offer the MEC Heavy™
plan that provides meaningful benefits for those looking for a more encompassing MEC plan.
The MEC Heavy™ plan covers the required MEC preventative services in addition to
Emergency Room Services, Primary Care and Specialist visits, Imaging (CT, PET Scans,
MRI’s), Laboratory Services, X-Ray and Diagnostic Imaging and Prescription Drugs. The
MEC Heavy™ includes our acclaimed Chronic Disease management program along with the
RealTime Health Diabetic Program and the RealTime Choices Price Transparency tool.
Covered Benefit Categories for
the MEC Heavy™ Plans:
- Emergency Room Services
- Primary Care Visit to Treat
an Injury or Illness
- Specialist Visit
- Imaging (CT, PET Scans, MRIs)
- Preventative Care, Screening,
& Immunization (MEC Services)
- Laboratory Outpatient
and Professional Services
- X-Rays and Diagnostic Imaging
- Prescription Drugs
- Chronic Disease Services under
the AHDI CDM Benefit
As a MEC Heavy™ member, you will receive a
medical ID Card that needs to be presented to
your medical provider at your time of service.
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The MEC Heavy™ offers a Co-Pay
plan design with a $2,500 single
Out-of-Pocket Maximum.
Out-of-Network benefits are
covered with a $500 single /
$1,000 family deductible with a
40% coinsurance and no out of
pocket maximum.
MEC Heavy
MEC Heavy™ Plan Design
In-Network
Out-of-Network
$0 / $0
$500 / $1,000
You pay 0%
You pay 60%
$2,500 / $13,200
Deductible & Coinsurance
In-Network
Out-of-Network
$400 copay, then 100%
up to $7,500 per day
$400 copay, then 100%
up to $7,500 per day
$400 copay, then 100%
up to $2,500 per day
$400 copay, then 100%
up to $2,500 per day
Primary Care Visits to Treat an Injury
or Illness
$15 copay
Deductible & Coinsurance
Specialist Visit
$25 copay
Deductible & Coinsurance
$400 copay
Deductible & Coinsurance
Laboratory Outpatient and
Professional Services
$50 copay
Deductible & Coinsurance
X-rays and Diagnostic Imaging
$50 copay
Deductible & Coinsurance
Preventative Care, Screening, &
Immunization (Minimum Essential
Coverage)
100% covered
Deductible & Coinsurance
Chronic Disease Management (CDM)
100% covered
Deductible & Coinsurance
Generic Drugs
$15 copay
Deductible & Coinsurance
Preferred Brand Drugs
$25 copay
Deductible & Coinsurance
Non-Preferred Brand Drugs
$75 copay
Deductible & Coinsurance
$10,000
$10,000
Deductible
Coinsurance
Out-of-Pocket Maximum
Covered Benefits
Emergency Room Services
(Facility Charges)
Emergency Room Services
(Physician Charges)
Imaging (CP, PET Scans, MRIs)
Prescription Drugs
Life Insurance with AD&D
The Following Services are NOT COVERED: Inpatient Hospital Services,
Mental/Behavioral Health and Substance Abuse Disorder Outpatient
Services, Rehabilitative Speech Therapy, Rehabilitative Occupational
and Rehabilitative Physical Therapy, Outpatient Facility Fees, Outpatient
Surgery Physician/Surgical Services, Specialty Drugs & Compounds
The cost of this insurance is detailed on page 17
11
Optional Hospital Indemnity Insurance
Underwritten by Transamerica Life Insurance Company
TransChoice® Advance: Group Limited Benefit Hospital Indemnity Insurance
Plan 2
Daily In-Hospital Indemnity Benefit
Pays per day, up to a max of 31 days per confinement
$400
Hospital Confinement
1 day of confinement per year
$500
Intensive Care Indemnity Benefit
Pays per day, up to a max of 30 days per year
$500
Critical Illness Indemnity Benefit and Subsequent Critical Illness Indemnity Benefit
Lump sum benefit for the initial diagnosis of a covered critical illness and an additional
lump-sum benefit of the same amount for subsequent and separate covered critical illness
$5,000
Non-Insurance Benefits Included
Employee Discount Card - Offered by New Benefits, LTD
Provides access to a discount Vision plan, Nurses Hotline, Counseling Services, and discounts on Hearing Aids
This is a brief summary of TransChoice® Advance Group Limited Benefit Hospital Indemnity Insurance underwritten by Transamerica Life
Insurance Company, Cedar Rapids, IA. Policy form series CPGHI400 and CCGHI400. Forms and form numbers may vary. This insurance
may not be available in all jurisdictions. Limitations and exclusions apply. Refer to the policy, certificate and riders for complete details.
THIS IS NOT MAJOR MEDICAL INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL INSURANCE. IT DOES NOT QUALIFY
AS MINIMUM ESSENTIAL HEALTH COVERAGE UNDER THE FEDERAL AFFORDABLE CARE ACT.
12
The cost of this insurance is detailed on page 17
EBD IB5MEG 0915
Optional Hospital Indemnity Insurance
Summary of Benefits for TransChoice® Advance: Group Limited Benefit Hospital Indemnity Insurance
underwritten by Transamerica Life Insurance Company
Daily In-Hospital Indemnity Benefit
When an insured person is confined in a hospital as a
result of an accident or sickness, this benefit pays the
benefit amount for each day the insured is confined in a
hospital, up to a maximum of 31 days per confinement.
Hospital Confinement
This benefit pays an additional benefit per insured
person per calendar year when he/she receives
treatment or surgery while confined to a hospital as an
inpatient as a result of a covered accident or sickness.
Intensive Care Indemnity Benefit
This benefit pays per day for confinement in an
intensive care unit, for a maximum of 31 days per
insured person per calendar year. This benefit is paid in
addition to the Daily In-Hospital Indemnity Benefit.
Critical Illness Indemnity Benefits and Subsequent
Critical Illness Indemnity Benefit
When an insured person is diagnosed with a covered
critical illness, the selected amount will be paid. This
amount is payable up to two times for each insured
person, once under the Critical Illness Indemnity
Benefit and once under the Subsequent Critical Illness
Indemnity Benefit, and is paid in addition to any
other benefits paid by the TransChoice policy. The
Subsequent Critical Illness Indemnity Benefit is paid if
the insured person is diagnosed as having a subsequent
and seperate covered critical illness more than sixty
(60) days after the first covered illness.
For example: If an insured person is diagnosed for the
first time with a heart attack, and then is diagnosed
with a stroke for the first time more than sixty (60) days
later, he or she will receive the benefit amount selected
for each illness. This benefit is payable one time for
each insured person. The Subsequent Critical Illness
Indemnity Benefit is not payable for Skin Cancer or
Carcinoma in Situ.
100% of the benefit amount is payable for:
- Cancer (including leukemia and Hodgkin’s Disease,
except Stage 1 Hodgkin’s Disease)
- Heart Attack (diagnosis must be based on EKG
changes consisten with injury elevation of cardiac
enzymes, and confirmatory neuroimaging studies)
- Stroke (diagnosis must be based on documented
neurological deficits and confirmatory neuroimaging
studies)
- End Stage Renal Failure (chronic, irreversible failure
of the function of both kidneys, such that an insured
person must undergo regular hemodialysis or peritoneal
dialysis at least weekly)
- Major Organ Transplant (undergoing surgery as a
recipient of a transplant of a human heart, lung, liver,
kidney, or pancreas)
5% of the benefit amount is payable for:
- Skin cancer including basal cell epitheloma or
squamous cell carcinoma; does not include malignant
melanoma or mycosis fungoides
- Carcinoma In Situ (cancer that is confined to the site
of origin without having invaded neighboring tissue)
* Dependent insurance equal to 50% of this benefit
EBD IB5MEG 0915
13
Optional Hospital Indemnity Insurance
Non-Insurance Benefits
Employee Discount Card
This discount card is provided by New Benefits, LTD.
It offers Employees access to a discount Vision Plan,
a Nurses Hotline, Counseling Services and benefits for
Hearing Aids. This is not an insurance plan. The discount
Vision Plan through the Coast to Coast network allows
the Employee to receive discounts of 20% to 60%
on eyeglasses, non-prescription sunglasses, contact
lenses (including disposables) and frames from over
10,000 independent retail optical locations nationwide.
Providers include independent practitioners, regional
chains, department store opticals, and the largest chains
in the U.S. Some of these providers are LensCrafters,
Pearle Vision, Sears Optical and JC Penney Optical
(among others).*
The Nurses Hotline allows access to experienced
registered nurses 24 hours a day, 7 days a week, 365
days a year. These hotline nurses are an immediate,
reliable and caring source of health information,
education and support. Services provided by this plan
include:
o
o
o
o
o
o
General information on all types of health concerns
Information based on physician-approved guidelines
Answers about medication usage and interaction
Information on non-medical support groups
Translation services for non-English speaking callers
Full time medical director on staff
The Counseling Services benefit allows the Employee
to speak with a counselor 24 hours a day, 7 days a
week regarding any personal problems they may be
facing. In addition, if the Employee is referred to one of
the 27,000 counseling providers nationwide, they will
receive discounts of 25% to 30% off the normal billing
charges from those providers.*
The Hearing Aid benefit provides savings of up to
15% off the retail cost on over 70 models of hearing
aids, and a free hearing test when utilizing one of the
1,200 participating Beltone® locations nationwide. Or,
the Employees can realize savings of up to 50% off
suggested retail price on over 90 models of hearing aids
in over 1,000 locations nationwide.*
Information on how to access the benefits of the
Employee Discount card will be included in the
fulfillment package that each insured Employee receives
from KBA.
* Discounts on professional services are not available
where prohibited by law.
14
EBD IB5MEG 0915
ID Cards
You will receive a separate ID card for the
Transamerica product. Claims administration and
customer service will be provided by Key Benefit
Administrators. An explanation of benefits (EOB)
will be provided on each claim to explain how it
was processed.
Limitations & Exclusions Apply.
See page 9 for details
Minimum Value Plan
The Minimum Value Plan (MVP) is a high deductible plan offering very limited coverage.
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 $6,500 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 outlined below.
The MVP offers a very limited benefit plan design
excluding the following major service categories:
- Mental/Behavioral Health and Substance
Abuse Disorder Outpatient Services
- Rehabilitative Speech Therapy
- Rehabilitative Occupational and Rehabilitative
Physical Therapy
- Skilled Nursing Facility
- Outpatient Facility Fees.
- Outpatient Surgery Physician/Surgical Services
- Non-Preferred Brand Drug.
- Specialty Drugs (including compound drugs)
- Drugs related to mental health such as ADHD
MVP
The MVP offers a plan design with a $6,500
single deductible and a $13,200 family
deductible. The Coinsurance responsibility is
40% paid by the enrolled. The out-of-pocket
maximum is $6,500 for single and $13,200 for
a family.
Note: Because almost every benefit category is
subject to the deductible it is important that you
budget for the $6,500 deductible which comes
out to be $541 a month in addition to your
maximum premium contribution.
As a MVP member, you will
receive a medical ID Card that
needs to be presented to your
medical provider at your time
of service.
15
Minimum Value Plan
MVP Plan Design
In-Network
Out-of-Network
$6,500 / $13,200
Not Covered
You pay 40%
Not Covered
$6,500 / $13,200
Not Covered
Covered Benefits
In-Network
Out-of-Network
Inpatient Hospital Services
Deductible
Not Covered
Emergency Room Services
Deductible
Not Covered
Primary Care Visits to
Treat an Injury or Illness
$50 copay +
40% Coinsurance
Not Covered
Specialist Visit
$70 copay +
40% Coinsurance
Not Covered
Imaging (CP, PET Scans, MRIs)
Deductible
Not Covered
Laboratory Outpatient and
Professional Services
Deductible
Not Covered
X-rays and Diagnostic Imaging
Deductible
Not Covered
Preventative Care, Screening, &
Immunization (Minimum Essential Coverage)
100% covered
Not Covered
Chronic Disease Management (CDM)
100% covered
Not Covered
Generic Drugs
Deductible
Not Covered
Preferred Brand Drugs
Deductible
Not Covered
Deductible
Coinsurance
Out-of-Pocket Maximum
Prescription Drugs
The Following Services are NOT COVERED: Mental/Behavioral Health and Substance
Abuse Disorder Outpatient Services, Rehabilitative Speech Therapy, Rehabilitative
Occupational and Rehabilitative Physical Therapy, Outpatient Facility Fees,
Outpatient Surgery Physician/Surgical Services, Specialty Drugs & Compounds
The cost of this insurance is detailed on page 17
16
Rate Sheet
Weekly Cost
Employee
EE + Spouse
EE + Child(ren)
Family
MEC
$0.00
$9.17
$23.54
$32.71
Weekly Cost
Employee
EE + Spouse
EE + Child(ren)
Family
MEC Heavy
$30.30
$69.63
$67.92
$109.39
Optional TransChoice® Advance:
Group Limited Benefit Hospital Indemnity Insurance
underwritten by Transamerica Life Insurance Company
Weekly Cost
Employee
EE + Spouse
EE + Child(ren)
Family
TransChoice
Advance
Plan 1
$20.90
$42.21
$32.79
$49.73
Weekly Cost
Employee
EE + Spouse
EE + Child(ren)
Family
TransChoice
Advance
Plan 2
$10.71
$21.36
$15.00
$23.95
If you choose to purchase both KeySolution MEC or MEC Heavy and
TransChoice® Advance Hospital Indemnity Insurance, your total cost will be
Weekly Cost
Employee
EE + Spouse
EE + Child(ren)
Family
MEC+
$20.90
$51.38
$56.33
$82.44
Weekly Cost MEC Heavy+
Employee
$41.00
EE + Spouse
$90.99
EE + Child(ren)
$82.92
Family
$133.35
Weekly Cost
Employee
EE + Spouse
EE + Child(ren)
Family
MVP
9.5% of your
income
+ $75.98
+ $129.67
+ $181.70
17
Notes
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Notes
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19
Frequently Asked Questions
How Can You Participate?
All employees scheduled for 30 hours or
more per week are eligible to enroll on
the first of the month following 30 days of
employment. Eligible dependents include
spouses and children or stepchildren,
under age 26.
How Are Premium Payments Made?
Premiums will be taken through payroll
deduction. If you miss a payroll deduction
as a result of absence or lack of work,
insurance will be terminated and you
will not be eligible to re-enroll until the
next open enrollment period unless you
experience a qualifying event.
When Will My Insurance End?
Your insurance will end when you no
longer qualify for the insurance or when
your premium payments end, whichever
comes first. Insurance on dependents
ends on either the date they no longer
meet the definition of a dependent or, the
date your insurance terminates, whichever
comes first.
What Is An Indemnity Benefit?
It means that the insurance company will
pay a set amount each time the insured
receives a covered service. The same
amount is paid regardless of the fees
charged by the provider.
Is my doctor in the network?
To check if your provider is in the
network, go to www.multiplan.com
or speak to a representative at
1-866-680-7427.
What if I do not enroll?
Group health benefits have been offered
to you through an open enrollment. If you
do not affirmatively elect benefits during
this open enrollment, you will be unable
to elect such insurance until the next open
enrollment period unless you experience
a change in status that entitles you to a
special enrollment period.
This plan offering prevents an otherwise
qualified individual from obtaining
a premium tax credit through the
HealthCare Marketplace.
Can I Sign Up For Insurance At Any Time?
No. You must sign up for insurance in the
first 30 days of becoming eligible. If you
do not elect to enroll in the first 30 days,
you will not be able to enroll until the
next open enrollment period unless you
experience a qualifying event.
Can I Cancel My Insurance At Any Time?
Premiums are paid with pre-tax dollars
through payroll deductions as part of a
Section 125 Savings Plan. You will not be
able to change these elections until the
next annual enrollment period, unless you
have a qualifying event.
When can I expect to receive
the Member Kit?
The member kit will typically be mailed
to you approximately 7-10 business days
after your first payroll deduction. Please
allow three weeks for this kit to arrive in
your mailbox.
EBD IB5MEG 0915