Beneﬁt Enrollment Guide - American Medical Plan · pregnant and nursing women. ... Rotavirus,...

2018Benefit Enrollment Guide

American Medical Plan

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.

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.

1)

2)

3)

IT IS OUR COMPANY POLICY THAT ALL EMPLOYEES COMPLETE THE ENROLLMENT PROCESS.

WHEN TO ENROLL

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!

Stay Compliant and Covered with our Minimum Essential Coverage Options

Understanding Your Minimum Essential Coverage Options

Option 1: MEC

We Offer THREE MEC Plans - Low, Medium and High (Choose ONE)

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.

MEDICAL BENEFIT

Employee OnlyEmployee + Child(ren)Employee + SpouseEmployee + Family

Weekly Deduction

$

$

$

$

15.7526.7526.2545.75

Option 2: MEC+Employee OnlyEmployee + Child(ren)Employee + SpouseEmployee + Family

Weekly Deduction

$

$

$

$

24.7536.0040.7552.25

Option 3: MEC ENHANCEDEmployee OnlyEmployee + Child(ren)Employee + SpouseEmployee + Family

Weekly Deduction

$

$

$

$

54.75102.25109.00149.75

MEC

Basic Plan Required by Law

18 Covered Services for Adults

26 Covered Services for Women

27 Covered Services for Children

All Covered MEC Services

Primary Care Office Visits

Specialist Office Visits

Urgent Care

Prescription Drug Benefit

MEC+

All MEC & MEC+ Services

Primary Care & Specialists

Basic Labs & X-Rays

Emergency Room Benefit

And More!

MEC ENHANCED

HOSPITAL and SURGERY INDEMNITY BENEFIT

Our Hospital Indemnity Benefit helps guard against the financial risk associated with paying for medical services to include; hospital stays, surgery, doctor visits, diagnostic labs and imaging, and more. Combined with one of the MEC Plus or MEC Enhanced options you have a greater level of coverage. The MEC option will cover your “day to day” doctor visits while the Indemnity program will help to cover greater expenses like hospital stays and surgery. Please review the Indemnity Schedule of Benefits.

Hospital Confinement Benefit

Hospital Admission Benefit

Inpatient Surgery Benefit

Outpatient Minor Surgery Benefit

Anesthesia Benefit

Physician Office / Urgent Care

Emergency Room

And more..

FIXED PAYMENT INDEMNITY PLAN

Employee OnlyEmployee + Child(ren)Employee + SpouseEmployee + Family

Weekly Deduction

$

$

$

$

20.4542.5033.2560.50

Monthly Deduction

$

$

$

$

81.80170.00133.00242.00

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) - https://www.multiplan.com/providers/valuepoint_faq.cfmKeep in mind; You will receive a separate Value Point Card.

Q1. What does the “Network Discount Card Applies” mean in the MEC Plus?

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. Please keep in mind all three MECs do not cover services like Physical Therapy, Behavior Health, Mental Health and Rehabilitation Services.

Q2. What is Minimum Essential Coverage and why are there 3 options?

Very simply put; the Hospital Indemnity Benefit puts money in your pocket when a claim is filed as per the schedule of benefits.

Q4. What is the Hospital Indemnity Benefit?

The MEC Plus and MEC Enhanced come with a prescription drug plan through SimpleSaveRX https://simplesaverx.com/default.pageSimpe 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 – 1.844.Save4RX

Q3. How does my prescription drug coverage work?

IMPORTANT INFORMATION ABOUT MY BENEFITS

Covered Preventive Services for Women, Including Pregnant Women

Covered Services for Children

Covered Preventive Services for Adults (ages 18 and older)

This list above summarizes some but not all services. Please reference the US Preventative Service Task Force website for the entire list.

1. Abdominal Aortic Aneurysm one time screening for age 65-752. Alcohol Misuse screening and counseling3. Aspirin use for men ages 45-79 and women ages55-79 to prevent CVD when prescribed by a physician4. Blood Pressure screening5. Cholesterol screening for adults6. Colorectal Cancer screening for adults starting at age 50limited to one every 5 years7. Depression screening8. Type 2 Diabetes screening9. Diet Counseling10. HIV Screening

11. Immunizations vaccines (Hepatitis A & B, Herpes Zoster, HumanPapillomavirus, Influenza (flu shot), Measles, Mumps, Rubella,Meningococcal, Pneumococcal, Tetanus, Diptheria, Pertussis, Varicella)12. Obesity screening and counseling13. Sexually Transmitted Infection (STI) prevention counseling14. Tobacco Use screening and cessation interventions15. Syphilis screening16. 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 atrisk for falling19. Hepatitis C screening for high risk individuals and a one timescreening for HCV infection if born between 1945-1965.

1. Anemia screening on a routine basis for pregnant women2. Bacteriuria urinary tract or other infection screening forpregnant women3.BRCA counseling and genetic testing for women at higher risk4. Breast Cancer Mammography screenings every year forwomen age 40 and over5. Breast Cancer Chemo Prevention counseling for women6. Breastfeeding comprehensive support and counseling fromtrained providers, as well as access to breastfeeding supplies, forpregnant and nursing women.7. Cervical Cancer screening8. Chlamydia Infection screening9. Contraception: Food and Drug Administration-approvedcontraceptive methods, sterilization procedures, and patienteducation and counseling, not including abortifacient drugs10. Domestic and interpersonal violence screening andcounseling for all women

11. Folic Acid supplements for women who may become pregnantwhen prescribed by a physician12. Gestational diabetes screening13. Gonorrhea screening14. Hepatitis B screening for pregnant women15. Human Immunodeficiency Virus (HIV) screening and counseling16. Human Papillomavirus (HPV) DNA Test: HPV DNA testing everythree years for women with normal cytology results who are 30 or older17. Osteoporosis screening over age 6018. Rh Incompatibility screening for all pregnant women and follow-uptesting19. Tobacco Use screening and interventions and expandedcounseling for pregnant tobacco users20. Sexually Transmitted Infections (STI) counseling21. Syphilis screening22. Well-woman visits to obtain recommended preventive services23. Aspirin for Preeclampsia prevention*Includes routine prenatal visits for pregnant women

1. Alcohol and Drug Use assessments2. Autism screening for children limited to two screeningsup to 24 months3. Behavioral assessments for children limited to 5 assessmentsup to age 174. Blood Pressure screening5. Cervical Dysplasia screening6. Congenital Hypothyroidism screening for newborns7. Depression screening for adolescents age 12 and older8. Developmental screening for children under age 3, andsurveillance throughout childhood9. Dyslipidemia screening for children10. Fluoride Chemo Prevention supplements for children withoutfluoride in their water source when prescribed by a physician11. Gonorrhea preventive medication for the eyes of all newborns12. Hearing screening for all newborns13. Height, Weight and Body Mass Index measurements forchildren14. Hematocrit or Hemoglobin screening for children15. Hemoglobinopathies or sickle cell screening for newborns

16. HIV screening for adolescents17. Immunization vaccines for children from birth to age 18; doses,recommended ages, and recommended populations vary: Diphtheria,Tetanus, Pertussis, Hepatitis A & B, Human Papillomavirus, InactivatedPoliovirus, Influenza (Flu Shot), Measles, Mumps, Rubella,Meningococcal, Pneumococcal, Rotavirus, Varicella, Haemophilusinfluenzae type b18. Iron supplements for children up to 12 months when prescribed by aphysician19. Lead screening for children20. Medical History for all children throughout development ages: 0 to11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years21. Obesity screening and counseling22. Oral Health risk assessment for young children up to age 1023. Phenylketonuria (PKU) screening in newborns24. Sexually Transmitted Infection (STI) prevention counseling andscreening for adolescents25. Tuberculin testing for children26. Vision screening for all children under the age of 527. Skin Cancer Behavioral Counseling – age 10-24 for exposure to sun28. Tobacco intervention and counseling for children29. Fluoride varnish for primary teeth through age 5.

Group ID: EFOHE

P.O. Box 1807

Draper, Utah 84020

Emdeon Payor ID: 88067

Customer Service: 877-453-4201

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

Individual: None

Family: None

Individual: None

Family: None

Annual Co-pay and Co-Insurance

Out of Pocket Maximums

(Medical and Rx Co-pays apply to the annual out

of pocket maximums)

Individual $4,000

Family $7,500

Individual: Unlimited

Family: Unlimited

Office Visits - Primary Care

(exam or consultation)$20 Co-pay, Plan pays 100% No Benefit Limited to 3 visits annually.

Office Visits - Specialist

(exam or consultation)Network Discount Card applies No Benefit

Diagnostic Services - Basic labs/x-rays

(related to office visit, LabCorp, etc.)Network Discount Card applies No Benefit Included on 3 visits annually.

Diagnostic Services - Major (Facility Charges)

(MRI, CT, PET, Nuclear Medicine,etc.)Network Discount Card applies No Benefit

Diagnostic Services - Major (Physician Charges)

(MRI, CT, PET, Nuclear Medicine,etc.)Network Discount Card applies No Benefit

Diagnostic Services - Minor

(ultrasounds, bone density, ecography,etc)Network Discount Card applies No Benefit

Emergency Room Facilities Network Discount Card applies No Benefit

Emergency Room - All covered services other than

facility chargesNetwork Discount Card applies No Benefit

Urgent Care Center & 24 Hour Clinic $50 Co-pay, Plan pays 100% No Benefit Limited to 1 visit annually.

Wellness Office Visits and Lab Services Network Providers Non-Network Providers Benefit Limits

Office Visit Exam & Includes Services For: Plan pays 100% No Benefit Limited to preventive diagnosis only.

Abdominal Aortic Aneurysm Plan pays 100% No BenefitOne time screening for males of ages

65 to 75 who have ever smoked

Alcohol Misuse Screening and Counseling Plan pays 100% No Benefit

Aspirin use for Men and Women Plan pays 100% No BenefitOne Aspirin use consultation for women

ages 45 to 79 and men 55 to 79

Blood Pressure Screening Plan pays 100% No Benefit

One screening every two years for ages 18 to 39

One Screening per calendar year for ages 40 and over

Cholesterol Screening Plan pays 100% No Benefit

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

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

Coverage begins the 1st day of the month following 60 days of employment. Coverage ends the last day of the month following termination.

Limits are per person per calendar year

PPO Provider Network:

Minimum weekly hours for full time: 30 hours/130 per month

Covered Preventive Services for Adults as defined by CMS Preventive Services

Minimum Essential Coverage (MEC Plus) PlanSchedule of Medical Benefits

PHCS Specific Services Network

Colorectal Cancer Screening Plan pays 100% No Benefit Screening for adults over age 50

Depression Screening Plan pays 100% No Benefit

Type 2 Diabetes Screening Plan pays 100% No Benefit Screening for adults with high blood pressure only

Diet Counseling Plan pays 100% No Benefit Screening for adults at higher risk of chronic disease

Hepatitis B Screening Plan pays 100% No Benefit

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

Hepatitis C Screening Plan pays 100% No BenefitFor adults at increased risk, and one time for everyone

born between 1945 - 1965

HIV Screening Plan pays 100% No Benefit 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

Plan pays 100% No Benefit

Listed immunizations are once per calendar year.

Human Papillomavirus shots up to age 26.

Pneumococcal shots for adults 65 and older

Lung Cancer Screening Plan pays 100% No BenefitFor adults 55 - 80 at high risk for lung cancer because

they're heavy smokers or have quit in the past 15 years

Obesity Screening and Counseling Plan pays 100% No Benefit

Sexually Transmitted Infection (STI)

Screening and CounselingPlan pays 100% No Benefit Prevention counseling for adults at higher risk

Syphilis Screening Plan pays 100% No Benefit For all adults at higher risk

Tobacco Use Screening Plan pays 100% No BenefitScreenings for adults and cessation

interventions for tobacco users


Well-Women Visits Plan pays 100% No Benefit

Anemia Screening Plan pays 100% No Benefit For pregnant women

BRCA Counseling Plan pays 100% No Benefit Includes genetic test for women at high risk

Breast Cancer Mammography Screening Plan pays 100% No BenefitScreenings every 1 to 2 years

for women over 40 years old

Breast Cancer Chemoprevention Counseling Plan pays 100% No Benefit Counseling for women at high risk

Breastfeeding Consultations Plan pays 100% No Benefit

Comprehensive support and counseling from

trained providers, as well as access to breastfeeding

supplies, for pregnant and nursing women

Cervical Cancer Screening Plan pays 100% No Benefit

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

Chlamydia Infection Screening Plan pays 100% No Benefit For younger women and women at high risk

Contraception Plan pays 100% No BenefitIncludes birth control pills and devices, injections and

surgical sterilization (hospital, physician, anesthesia)

Covered Preventive Services for Women - Including Pregnant Women

Domestic and Interpersonal Violence Screening Plan pays 100% No Benefit

Folic Acid Supplements Plan pays 100% No Benefit For pregnant women

Gestational Diabetes Screening Plan pays 100% No BenefitFor women 24 to 28 weeks pregnant and/or

at high risk of developing gestational diabetes

Gonorrhea Screening Plan pays 100% No Benefit For all women at higher risk

Hepatitis B Screening Plan pays 100% No Benefit For pregnant women at their first prenatal visit

Human Immunodeficiency Virus (HIV)

Screening and counselingPlan pays 100% No Benefit For women sexually active

Human Paillomavirus (HPV) DNA Test Plan pays 100% No BenefitOne test every 3 years for woment with

normal cytology results who are 30 or older

Osteoporosis Screening Plan pays 100% No Benefit For women over age 60 or at high risk

Rh Incompatibility Screening Plan pays 100% No BenefitFor pregnant women and follow-up testing

for women at higher risk

Tobacco Use Screening and interventions Plan pays 100% No Benefit

Syphilis Screening Plan pays 100% No Benefit For all pregant woment or other women at increase risk

Sexually Transmitted Infection (STI) Screening and

Counseling.Plan pays 100% No Benefit For sexually active women

Urinary Tract or Other Infection Screening for

Pregnant WomenPlan pays 100% No Benefit


Alcohol and Drug Use Assessments Plan pays 100% No Benefit

Autism Screening Plan pays 100% No Benefit For children at 18 months to 24 months

Behavioral Assessments Plan pays 100% No Benefit For children to age 18

Blood Pressure Screening Plan pays 100% No Benefit For children to age 18

Cervical Dysplasia Screening Plan pays 100% No Benefit For sexually active females

Congenital Hypothyroidism Screening Plan pays 100% No Benefit For newborns

Depression Screening Plan pays 100% No Benefit For teenagers ages 12 to 18

Developmental Screening Plan pays 100% No BenefitFor children under age 3 and

surveillance throughout childhood

Dyslipidemia Screening Plan pays 100% No Benefit For children at high risk of lipid disorders

Fluoride Chemoprevention Supplements Plan pays 100% No Benefit For children without fluoride in their water sources

Gonorrhea Preventive Medicaiton for the Eyes of All

NewbornsPlan pays 100% No Benefit

Hearing Screenings Plan pays 100% No Benefit For all newborns

Height, Weight and Body Mass Index Measurements Plan pays 100% No Benefit For children to age 18

Hematocrit or Hemoglobin Screening Plan pays 100% No Benefit For children to age 18

Hemoglobinopathies of Sickle Cell Screening Plan pays 100% No Benefit For all newborns

HIV Screening Plan pays 100% No Benefit For sexually active children

Covered Preventive Services for Children

Hypothyroidism Screening for Newborns Plan pays 100% No Benefit

Immunizations

* Diphtheria, Tetanus, Petussis

* Haemophilus influenza type B

* Hepatitis A

* Hepatitis B


* Inactivated Poliovirus



* Meningococcal

* Pneumococcal

* Rotavirus

* Varicella

Plan pays 100% No Benefit For children to age 18

Iron Supplements Plan pays 100% No Benefit For children ages 6 to 12 months at risk of anemia

Lead Screening Plan pays 100% No Benefit For children at risk of exposure

Medical History Plan pays 100% No Benefit For all children throughout development

Obesity Screening and Counseling Plan pays 100% No Benefit For children to age 18

Oral Health Plan pays 100% No BenefitAt risk assessment for your children

ages newborn to age 10

Phenylketonuria (PKU) Screening Plan pays 100% No Benefit For genetic disorders in newborns


Screening and CounselingPlan pays 100% No Benefit

For children at higher risk, includes gonorrhea preventive

medication for newborn eyes

Tuberculin Testing Plan pays 100% No Benefit For children at higher risk of tuberculosis to age 18

Vision Screening Plan pays 100% No Benefit For children to age 18

Prescription Benefits

Covered Prescription Drugs - SimpleSaveRx


Rx Bin #: 018448

Rx PCN #: 66202303

Negotiated best price for drugs:

$0-$20 (Tier 1)

$20-$40 (Tier 2)

$40-$100 (Tier 3)

No Benefit

Specialty Medications: No Benefit

All prescriptions are limited to 31 day supply.

Plan pays costs above $100 up to $150 per family per

quarter.

Telemedicine

Sherpaa Go to www.sherpaa.com for more information.

Effective: 1/1/2018

We believe this coverage is a Non-Grandfathered health plan under the Patient Protection and Affordable Care Act. (PPACA)

Dependents covered to age 26 regardless of student or marital status.

Plan pays 100%

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.

Visit www.talltreehealth.com to view Schedule of Benefits, Plan Document, Enrollment information, claims history, link to the PPO Network and more.

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.

Group ID: EFOHE

P.O. Box 1807

Draper, Utah 84020

Emdeon Payor ID: 88067


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

Individual: None

Family: None

Individual $500

Family $1,000

Annual Co-pay and Co-Insurance

Out of Pocket Maximums

(Medical and Rx Co-pays apply to the annual out

of pocket maximums)

Individual $4,000

Family $7,500

Individual: Unlimited

Family: Unlimited

Office Visits - Primary Care

(exam or consultation)$20 Co-pay, Plan pays 100%

Deductible, Plan pays 60%

of allowed amount

Office Visits - Specialist

(exam or consultation)$40 Co-pay, Plan pays 100%


of allowed amount

Diagnostic Services - Basic labs/x-rays

(related to office visit, LabCorp, etc.)$50 Co-pay, Plan pays 100%


of allowed amount

Diagnostic Services - Major (Facility Charges)

(MRI, CT, PET, Nuclear Medicine,etc.)

$400 Co-pay, Plan pays 100%

of allowed amount

$400 Co-pay, Plan pays 60% of

allowed amount

Diagnostic Services - Major (Physician Charges)

(MRI, CT, PET, Nuclear Medicine,etc.)

Plan pays 100% of allowed

amount


of allowed amount

Diagnostic Services - Minor

(ultrasounds, bone density, ecography,etc)$50 Co-pay, Plan pays 100%


of allowed amount

Emergency Room Facilities $400 Co-pay, Plan pays 100%$400 Co-pay, Plan pays 100%

of allowed amount

Emergency Room - All covered services other than

facility charges$400 Co-pay, Plan pays 100% No Benefit

Urgent Care Center & 24 Hour Clinic $50 Co-pay, Plan pays 100%Deductible, Plan pays 60%

of allowed amount


Office Visit Exam & Includes Services For: Plan pays 100%Deductible, Plan pays 40% of

allowed amountLimited to preventive diagnosis only.

Abdominal Aortic Aneurysm Plan pays 100%Deductible, Plan pays 40% of

allowed amount

One time screening for males of ages

65 to 75 who have ever smoked

Alcohol Misuse Screening and Counseling Plan pays 100%Deductible, Plan pays 40% of

allowed amount

Aspirin use for Men and Women Plan pays 100%Deductible, Plan pays 40% of

allowed amount

One Aspirin use consultation for women

ages 45 to 79 and men 55 to 79

Blood Pressure Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amount

One screening every two years for ages 18 to 39

One Screening per calendar year for ages 40 and over

Cholesterol Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amount

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

Colorectal Cancer Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amountScreening for adults over age 50

Minimum Essential Coverage (Enhanced MEC) Plan

PPO Provider Network:

Minimum weekly hours for full time: 30 hours/130 per month

Claims Address

Coverage begins the 1st day of the month following 30 days of employment. Coverage ends the last day of the month following termination.

Covered Preventive Services for Adults as defined by CMS Preventive Services

Schedule of Medical Benefits

PHCS Specific Services Network

All benefits and accumulations are on a Calendar

Year.

This Plan provides Minimal Essential Coverage for Medical Care.

If the service is not listed on this Schedule of Benefits it is not covered.

Limited to 2 visits per year.

Maximum: $1,000

Depression Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amount

Type 2 Diabetes Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amountScreening for adults with high blood pressure only

Diet Counseling Plan pays 100%Deductible, Plan pays 40% of

allowed amountScreening for adults at higher risk of chronic disease

Hepatitis B Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amount

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

Hepatitis C Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amount

For adults at increased risk, and one time for everyone

born between 1945 - 1965

HIV Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amountScreening for adults at higher risk

Immunizations

* Hepatitis A

* Hepatitis B

* Herpes Zoster




* Meningococcal

* Pneumococcal

* Tetanus, Diphtheria, Pertussis

* Varicella

Plan pays 100%Deductible, Plan pays 40% of

allowed amount

Listed immunizations are once per plan year.

Human Papillomavirus shots up to age 26.

Pneumococcal shots for adults 65 and older

Lung Cancer Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amount

For adults 55 - 80 at high risk for lung cancer because

they're heavy smokers or have quit in the past 15 years

Obesity Screening and Counseling Plan pays 100%Deductible, Plan pays 40% of

allowed amount


Screening and CounselingPlan pays 100%

Deductible, Plan pays 40% of

allowed amountPrevention counseling for adults at higher risk

Syphilis Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amountFor all adults at higher risk

Tobacco Use Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amount

Screenings for adults and cessation

interventions for tobacco users


Well-Women Visits Plan pays 100%Deductible, Plan pays 40% of

allowed amount

Anemia Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amountFor pregnant women

BRCA Counseling Plan pays 100%Deductible, Plan pays 40% of

allowed amountIncludes genetic test for women at high risk

Breast Cancer Mammography Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amount

Screenings every 1 to 2 years

for women over 40 years old

Breast Cancer Chemoprevention Counseling Plan pays 100%Deductible, Plan pays 40% of

allowed amountCounseling for women at high risk

Breastfeeding Consultations Plan pays 100%Deductible, Plan pays 40% of

allowed amount

Comprehensive support and counseling from

trained providers, as well as access to breastfeeding

supplies, for pregnant and nursing women

Cervical Cancer Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amount

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

Chlamydia Infection Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amountFor younger women and women at high risk

Contraception Plan pays 100%Deductible, Plan pays 40% of

allowed amount

Includes birth control pills and devices, injections and

surgical sterilization (hospital, physician, anesthesia)

Covered Preventive Services for Women - Including Pregnant Women

Domestic and Interpersonal Violence Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amount

Folic Acid Supplements Plan pays 100%Deductible, Plan pays 40% of

allowed amountFor pregnant women

Gestational Diabetes Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amount

For women 24 to 28 weeks pregnant and/or

at high risk of developing gestational diabetes

Gonorrhea Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amountFor all women at higher risk

Hepatitis B Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amountFor pregnant women at their first prenatal visit

Human Immunodeficiency Virus (HIV)

Screening and counselingPlan pays 100%


allowed amountFor women sexually active

Human Paillomavirus (HPV) DNA Test Plan pays 100%Deductible, Plan pays 40% of

allowed amount

One test every 3 years for woment with

normal cytology results who are 30 or older

Osteoporosis Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amountFor women over age 60 or at high risk

Rh Incompatibility Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amount

For pregnant women and follow-up testing

for women at higher risk

Tobacco Use Screening and interventions Plan pays 100%Deductible, Plan pays 40% of

allowed amount

Syphilis Screening Plan pays 100%Deductible, Plan pays 40% of

allowed amountFor all pregant woment or other women at increase risk

Sexually Transmitted Infection (STI) Screening and

Counseling.Plan pays 100%


allowed amountFor sexually active women

Urinary Tract or Other Infection Screening for

Pregnant WomenPlan pays 100%


allowed amount


Alcohol and Drug Use Assessments Plan pays 100%Deductible, Plan pays 40%

of allowed amount

Autism Screening Plan pays 100%Deductible, Plan pays 40%

of allowed amountFor children at 18 months to 24 months

Behavioral Assessments Plan pays 100%Deductible, Plan pays 40%

of allowed amountFor children to age 18

Blood Pressure Screening Plan pays 100%Deductible, Plan pays 40%


Cervical Dysplasia Screening Plan pays 100%Deductible, Plan pays 40%

of allowed amountFor sexually active females

Congenital Hypothyroidism Screening Plan pays 100%Deductible, Plan pays 40%

of allowed amountFor newborns

Depression Screening Plan pays 100%Deductible, Plan pays 40%

of allowed amountFor teenagers ages 12 to 18

Developmental Screening Plan pays 100%Deductible, Plan pays 40%

of allowed amount

For children under age 3 and

surveillance throughout childhood

Dyslipidemia Screening Plan pays 100%Deductible, Plan pays 40%

of allowed amountFor children at high risk of lipid disorders

Fluoride Chemoprevention Supplements Plan pays 100%Deductible, Plan pays 40%

of allowed amountFor children without fluoride in their water sources

Gonorrhea Preventive Medicaiton for the Eyes of All

NewbornsPlan pays 100%


of allowed amount

Hearing Screenings Plan pays 100%Deductible, Plan pays 40%

of allowed amountFor all newborns

Height, Weight and Body Mass Index Measurements Plan pays 100%Deductible, Plan pays 40%


Hematocrit or Hemoglobin Screening Plan pays 100%Deductible, Plan pays 40%


Hemoglobinopathies of Sickle Cell Screening Plan pays 100%Deductible, Plan pays 40%

of allowed amountFor all newborns

HIV Screening Plan pays 100%Deductible, Plan pays 40%

of allowed amountFor sexually active children

Covered Preventive Services for Children

Hypothyroidism Screening for Newborns Plan pays 100%Deductible, Plan pays 40%

of allowed amount

Immunizations

* Diphtheria, Tetanus, Petussis

* Haemophilus influenza type B

* Hepatitis A

* Hepatitis B


* Inactivated Poliovirus



* Meningococcal

* Pneumococcal

* Rotavirus

* Varicella

Plan pays 100%Deductible, Plan pays 40%


Iron Supplements Plan pays 100%Deductible, Plan pays 40%

of allowed amountFor children ages 6 to 12 months at risk of anemia

Lead Screening Plan pays 100%Deductible, Plan pays 40%

of allowed amountFor children at risk of exposure

Medical History Plan pays 100%Deductible, Plan pays 40%

of allowed amountFor all children throughout development

Obesity Screening and Counseling Plan pays 100%Deductible, Plan pays 40%


Oral Health Plan pays 100%Deductible, Plan pays 40%

of allowed amount

At risk assessment for your children

ages newborn to age 10

Phenylketonuria (PKU) Screening Plan pays 100%Deductible, Plan pays 40%

of allowed amountFor genetic disorders in newborns


Screening and CounselingPlan pays 100%


of allowed amount

For children at higher risk, includes gonorrhea preventive

medication for newborn eyes

Tuberculin Testing Plan pays 100%Deductible, Plan pays 40%

of allowed amountFor children at higher risk of tuberculosis to age 18

Vision Screening Plan pays 100%Deductible, Plan pays 40%


Covered Prescription Drugs - SimpleSaveRx


Rx Bin #: 018448

Rx PCN #: 66202303

Negotiated best price for drugs:

$0-$20 (Tier 1)

$20-$40 (Tier 2)

$40-$100 (Tier 3)

No Benefit

Specialty Medications: No Benefit

All prescriptions are limited to 31 day supply

Plan pays costs above $100 up to $150 per family per

quarter.

Sherpaa Go to www.sherpaa.com for more information.

Effective: 1/1/2018

Telemedicine

Plan pays 100%

Prescription Benefits

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)

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.

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.

Visit www.talltreehealth.com to view Schedule of Benefits, Plan Document, Enrollment information, claims history, link to the PPO Network and more.

____________________________________________________________________________________________________________________________

Beazley includes the issuing company of Beazley Insurance Company, Inc., 30 Batterson Park Rd, Farmington, CT 06032.For more information, visit http://www.beazley.com/accident&health. Administrative services are provided by HealthPlan Services (HPS).

Schedule of Benefits

GLI Voluntary

Plan features Benefit options

Plan Design Guarantee Issue

Benefit Year Calendar Year 1/1 - 12/31

Eligibility Employee Status: All Permanent EmployeesEmployee Hours: Working 15 hours or more per week and actively in service

Early Retiree Eligibility No

Hospital Confinement Benefit Benefit Amount Day 1: $100 per Insured, per dayBenefit Amount Day 2: $100 per Insured, per dayBenefit Amount Day 3: $100 per Insured, per dayBenefit Amount Day 4: $100 per Insured, per dayBenefit Amount Day 5: $100 per Insured, per dayMaximum per Benefit Year: 5 days per Insured

Hospital Admission Benefit Benefit Amount: $1,500 per Insured, per dayMaximum per Benefit Year: 1 day per Insured

Inpatient Surgery Benefit Benefit Amount: $2,500 per Insured, per dayMaximum per Benefit Year: 1 day per Insured

Outpatient Major SurgeryBenefit

Benefit Amount: $1,000 per Insured, per dayMaximum per Benefit Year: 1 day per Insured

Outpatient Minor SurgeryBenefit

Benefit Amount: $75 per Insured, per dayMaximum per Benefit Year: 2 days per Insured

Anesthesia Benefit Benefit Amount: $750 per Insured, per dayMaximum per Benefit Year: 1 day per Insured

Physician Office/Urgent CareFacility Benefit


Emergency Room - Injury Benefit Benefit Amount: $500 per Insured, per dayMaximum per Benefit Year: 1 day per Insured

Outpatient Diagnostic LabBenefit


Outpatient X-Ray Benefit Benefit Amount: $75 per Insured, per dayMaximum per Benefit Year: 2 days per Insured

Outpatient Major DiagnosticTesting Benefit

Benefit Amount: $500 per Insured, per dayMaximum per Benefit Year: 1 day per Insured

Termination Unlimited Age for Active Employees

Rate Guarantee 1 year

* For definitions of Underwriting options, refer to Rates and Assumptions page. For full description, please request the Master Policydefinitions from the agent/broker.

http://www.beazley.com/accident&health

____________________________________________________________________________________________________________________________

Beazley includes the issuing company of Beazley Insurance Company, Inc., 30 Batterson Park Rd, Farmington, CT 06032.For more information, visit http://www.beazley.com/accident&health. Administrative services are provided by HealthPlan Services (HPS).

GLI Voluntary Definitions

• Actively in Service: An employee or member who is performing in the usual manner, all of the Material and Substantial Duties ofhis/her job for the regularly scheduled number of hours at a place of business where he/she normally performs such duties.

• Early Retiree: A person who is a retiree of the Policyholder, under age 65 and who is not eligible for or covered by Medicare.

• Hospital Confinement Benefit: Pays out a benefit if an Insured is confined and receiving treatment in a hospital due to sickness orinjury for a period of 23 or more continuous hours, on the advice of a Physician.

• Hospital Admission Benefit: Pays out a benefit if an Insured is admitted and confined to a hospital due to sickness or injury.

• Inpatient Surgery Benefit: Pays out a benefit if an Insured incurs charges for inpatient surgery due to sickness or injury.

• Outpatient Major Surgery Benefit: Pays out a benefit if an Insured incurs charges for outpatient surgery due to sickness or injuryin a Hospital, Outpatient Surgical Center or other similar medical facility for surgery. The surgery must be an eligible CPT code.Outpatient Major Surgery does not include the CPT codes for which Outpatient Minor Surgery benefits are payable.

• Outpatient Minor Surgery Benefit: Pays out a benefit if an Insured incurs charges for outpatient surgery due to sickness or injuryin a Hospital, Outpatient Surgical Center or similar medical facility. The surgery must be an eligible CPT code.

• Anesthesia Benefit: Pays out a benefit if an Insured incurs charges for and receives general anesthesia administered by ananesthesiologist or a Certified Registered Nurse Anesthetist (CRNA) during a surgical procedure for which a benefit is payable.

• Physician Office/Urgent Care Facility Benefit: Pays out a benefit when an Insured incurs charges for and requires servicesrendered by a Physician at a Physician's office or urgent care facility.

• Emergency Room - Injury Benefit: Pays out a benefit when an Insured incurs charges for and receives treatment rendered in anEmergency Room due to injury, as defined in the Policy/Certificate of Insurance.

• Outpatient Diagnostic Lab Benefit: Pays out a benefit when an Insured incurs charges for and undergoes any type of outpatientdiagnostic laboratory testing that is ordered by a Physician and performed on an outpatient basis in a Hospital, Physician's office,Urgent Care Facility, Emergency Room or other appropriately licensed stand-alone healthcare facility that provides diagnosticservices.

• OutPatient X-Ray Benefit: Pays out a benefit when an Insured incurs charges for and undergoes outpatient X-rays that are orderedby a Physician and performed on an outpatient basis in a Hospital, Physician's office, Urgent Care Facility, Emergency Room or otherappropriately licensed stand-alone healthcare facility that provides diagnostic services.

• Outpatient Major Diagnostic Testing Benefit: Pays out a benefit when an Insured incurs charges for and undergoes an outpatientmajor diagnostic test that is ordered by a Physician and performed on an outpatient basis in a Hospital, Physician's Office, UrgentCare Facility, Emergency Room or other appropriately licensed stand-alone healthcare facility that provides diagnostic services.Outpatient Major Diagnostic tests include an MRI, an MRA, a CT scan, or a PET scan.

These definitions are not intended to replace definitions contained in the Master Policy. For full description, please request the masterpolicy definitions from the agent/broker.

http://www.beazley.com/accident&health

More and more employers are adopting consumer-driven healthcare programs to replace or complement their

traditional insurance benefit plans. ValuePoint by MultiPlan® is a medical access card program designed to help you reach

this growing population of consumers. Participating providers have specifically agreed to extend their MultiPlan Network contracted discounts to your eligible members in exchange for payment in full by the member at the point of service.

ValuePoint by MultiPlan

®

Imagine more…

Imagine the best of an insurance-based PPO network tailored for non-insurance programs.

What It Offers Who Should Use It How It Works

• Provider Choice

o 1,300 hospitals

o 60,000 ancillary facilities

o 450,000 practitioner locations

• Savings

o National average savings of 39%for practitioner claims

o National average savings of 28%for ancillary facilities

o National average hospital savingsof 22% for inpatient claims, 21% for outpatient claims

• Programs like shopping clubs thatmay want to partially subsidize fees

• Employers who want a fully orpartially funded alternative totraditional plans

• Employers who want to complementa limited benefit plan

• Employers who want to complementa consumer-directed health plan witha fund or account like an FSA, HRA or HSA

• Member chooses a provider fromonline or telephone directory

• You confirm member eligibility withID card, letter or phone call

• Member presents his/her memberID card featuring the ValuePoint logoat appointment

• If needed, provider calls thenumber on the ID card to obtain thecontractual reimbursement amountfor the service

• The provider collects the discountedamount in full from the member orestablishes payment schedule

Applicable Markets

multiplan.com

MultiPlan, Inc. 115 Fifth Avenue, New York, NY 10003 • multiplan.com© 2016 MultiPlan, Inc. All rights reserved. MKT5096 10/2016

For more information call 1-866-750-7427 or email [email protected].

ValuePoint by MultiPlan® Participating Providers

The table below represents the number of locations by provider type and state as of October 2016. Note that there may be

overlap in the location counts for primary care physicians (PCPs) and specialists.

State Facilities Practitioners

Hospital Ancillary Primary Specialist

Alabama 44 970 2,440 6,620

Alaska 12 163 201 848

Arizona 67 2,287 1,386 4,835

Arkansas 38 576 634 2,719

California 162 5,408 8,115 27,579

Colorado 23 1,195 1,189 5,256

Connecticut 5 694 1,484 5,854

Delaware 2 187 182 864

Dist. of Columbia 2 71 270 693

Florida 34 5,032 7,314 23,203

Georgia 32 2,186 2,298 10,705

Hawaii 4 77 177 1,044

Idaho 14 230 329 1,726

Illinois 24 2,640 1,600 8,172

Indiana 34 1,427 1,458 6,933

Iowa 15 724 618 2,878

Kansas 16 722 869 3,491

Kentucky 9 891 1,255 5,646

Louisiana 46 1,399 1,902 6,684

Maine 10 188 708 1,952

Maryland 18 1,239 2,544 8,002

Massachusetts 8 1,002 1,535 10,603

Michigan 30 1,701 2,182 7,377

Minnesota 27 839 671 2,514

Mississippi 28 617 658 2,444

Missouri 26 1,581 2,138 6,778

StateFacilities Practitioners

Hospital Ancillary Primary Specialist

Montana 3 128 105 488

Nebraska 12 428 251 1,178

Nevada 9 758 1,324 5,183

New Hampshire 8 181 345 1,678

New Jersey 11 1,834 6,610 15,052

New Mexico 15 458 501 2,715

New York 71 3,596 13,884 49,093

North Carolina 15 1,491 1,722 12,097

North Dakota 4 77 112 399

Ohio 39 2,904 2,695 10,371

Oklahoma 31 846 756 3,249

Oregon 17 628 891 6,402

Pennsylvania 46 3,107 5,608 18,285

Rhode Island 7 188 701 1,643

South Carolina 10 870 1,929 6,673

South Dakota 10 109 265 1,183

Tennessee 31 1,827 1,745 8,856

Texas 146 6,106 8,314 29,619

Utah 15 406 2,639 9,663

Vermont 2 62 241 644

Virginia 6 1,206 2,359 6,460

Washington 26 1,048 3,581 16,944

West Virginia 10 359 807 2,406

Wisconsin 34 930 1,576 7,362

Wyoming 3 84 168 370

Unique Totals 1,311 63,677 103,286 383,433

®

MINIMUM VALUE PLAN (MVP)

Our Minimum Value Plan is an affordable way to help you meet the individual mandate required by the government

Understand the Value

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 $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.

PROVIDER NETWORKS &CONTACT INFORMATION

Understanding Your Provider Networks and Who to Contact

MedicalNetwork: PHCS Network through Multiplanwww.multiplan.com

Once enrolled: For Questions Please call your Plan Administrator Tall Tree Administrators1-877-453-4201

Hospital Indemnity

Carrier: Beazley - www.Beazley.comTo File a Claim: 1.888.222.1123

Beneﬁt Enrollment Guide - American Medical Plan · pregnant and nursing women. ... Rotavirus,...

Documents

Transcript of Beneﬁt Enrollment Guide - American Medical Plan · pregnant and nursing women. ... Rotavirus,...