The WLRA Employee Benefit Plan and Trust is an exci<ng program designed specifically for your industry! Discover for yourself how a comprehensive employee benefit plan can…
v Help you aFract and retain employees v Offer you the flexibility you need, at a price you can
afford v Increase employee morale and loyalty to your company
Must have at least two employees par<cipa<ng. Other minimum par<cipa<on requirements may apply. Ask for details.
You can customize your plan by selec<ng from the following op<ons:
ü Six major medical plans ü Three dental plans ü Two vision plans ü Two limited benefit medical plans ü Group Life Insurance
MANY of these programs require NO employer contribu<on unless you opt to co-‐fund with the employee – they are voluntary and may be 100%
employee paid.
Benefits may be offered to: FULL-‐TIME; PART-‐TIME; SEASONAL;
TEMPORARY; H2B; SALARIED; or HOURLY… or almost any combina<on of the above.
Marketed to Members by:
For more informa<on, please contact: Ken Konicek, Account Execu9ve
PO Box 829 ● Pinedale, WY 82941 ● Toll-‐Free 1-‐800-‐438-‐2121 ● Phone: (307) 367-‐2154 ● Fax (307) 367-‐2632
Rev. November 22, 2013
Be Our Guest Check Out the Benefits
Wyoming Lodging & Restaurant Association
Benefit Plan & Trust Benefit Plan & Trust Rev. November 22, 2013
The WLRA Benefit Plan and Trust
provides group Medical, Dental and Vision
programs for eligible members of the
WLRA which are uniquely designed for this
industry.
Plan Descrip9on A Summary of the WLRA Welfare Benefit Plan
Ø A Welfare Benefit Plan which has been established under Internal Revenue Service code as well as
Department of Labor regula<ons. Ø Plan contribu<ons are held in a Trust that is directed by a Board of Trustees, chosen from the
member par<cipants of the Plan. Ø The Wyoming Lodging & Restaurant Associa<on Benefit Plan & Trust, the Plan Sponsor, and its Board
of Directors assigns a Plan Administrator, retains Legal Counsel, Accoun<ng & Audi<ng Services and other Administra<ve Services as needed for the management of the Plan, all working for the benefit of the par<cipants.
Ø Claims are paid by the contracted Claims Administrator (TPA) as directed by applicable State and Federal laws, the Trust Document, the Plan Declara<on, and the Summary Plan Descrip<on(s) of the benefit programs offered and administered by the Associa<on. Full copies of these documents are available upon request.
Ø The Trust contracts with insurance and/or reinsurance companies in order to ensure the overall financial stability of the Trust and the benefits offered. These contracts may change from <me to <me and are voted upon and approved by the Trust Board or its designee.
Ø The benefits offered by the Plan are reviewed annually to determine their viability for the members and par<cipants. The WLRA Benefit Associa<on, with available contracted counsel and advice may alter these benefits, remove a plan of benefits completely and/or add new plans for considera<on, without the consent of par<cipa<ng employers or par<cipa<ng employees.
Ø The Trust is par<cipant-‐owned along with any surplus or deficits incurred. Par<cipant employers are encouraged to review the applicable documents (Trust Document and Plan Declara<on) to ascertain applicable benefits and liability of becoming a par<cipant prior to applying for coverage.
Benefit Plan & Trust
Rev. November 22, 2013
Program Objec9ves ü More stability in insurance premiums, now and in the future ü Broader accessibility to health insurance and coverage op<ons within the
community ü Crea<on of a community-‐wide wellness mindset and culture ü Educa<on about access to a broader range of choices to promote beFer
healthcare decision making
Defined Contribu9on Healthcare IN A DEFINED CONTRIBUTION STYLE PLAN EMPLOYERS CHOOSE the amount of money to contribute toward a benefit plan… From the menu of benefit programs and associated pricing, the EMPLOYER decides how much of a premium to contribute per employee and/or employee with dependents. The amount of the actual rate increase is not based on the individual employer’s loss ra<o, but is based on the overall loss ra<o to the Trust and each benefit plan. EMPLOYEES CHOOSE the plan that best fits their need… From the same menu of benefit programs and associated pricing, the EMPLOYEE decides which benefit plan best meets his or her need. The employee’s applicable out-‐of-‐pocket premium cost is determined based on how much the employer contributes. If the employee chooses a plan which is more costly than the employer’s contribu<on, the difference is paid by the employee through payroll deduc<on. If the plan chosen by the employee is less costly than the employer’s contribu<on, the difference is contributed to a Health Reimbursement Arrangement (HRA) or Health Savings Account (HSA), depending on the benefit plan chosen. The employee may choose a new/different benefit program every year during the open enrollment period.
One benefit plan
DOES NOT fit all employee’s healthcare needs!
DEFINED CONTRIBUTION HEALTHCARE For years, employers have provided benefits for employees and planned for those benefits to meet the needs of those employees and their families. The challenge for employers is that healthcare has become much more specialized and variable while benefit programs have adhered to a more “one-‐size-‐fits-‐all” model. Due to the evolving benefit needs of employees and their families, benefit choices must be available for employees to choose from to fit their individual needs.
ENROLLMENT REQUIREMENTS/CONTINGENCIES v The employer must be a member of the Wyoming Lodging and Restaurant
Associa<on prior to applying. v Each employer must have a minimum of 70% of eligible employees
par<cipa<ng for groups of 5 or more, and 100% par<cipa<on for groups of 4 or less. Minimum group size is 2 employees (husband/wife teams are treated as 1 employee.)
v Completed Employee Enrollment/Waiver Applica<ons are required from each employee in order to qualify. The en<re employer group will either be accepted or denied coverage.
v The TRUST renewal date is July 1st of each calendar year. Regardless of when enrollment is completed, any changes to the TRUST rates and/or benefits will take place on July 1st. Open enrollment (the ability to add employees who waived coverage or dependents which had been previously waived) is during the month of June each year for each par<cipa<ng employer.
v Premium contribu<ons are made by the employer directly into the Trust Account and are used as described in the Trust Document, Summary Plan Descrip<on and Plan Declara<on. The Trust is governed by a Board of Trustees, elected as described in the Trust Document.
Rev. November 22, 2013
Group Medical Plans
All Loca/ons Plan 1 Plan 2 Plan 3 Plan 5 Plan 6 Value Plan
Calendar Year Deduc9ble
Single Family
$250 $500
$500 $1,000
$1,000 $2,000
$2,500 $5,000
HSA Qualified $2,500 $5,000
HSA Qualified $6,000 $12,000
In-‐Network Benefit Co-‐Insurance % Out-‐of-‐Pocket Maximum (incl. ded.)
Single Family
100%
$250 $500
70%
$1,700 $3,400
70%
$2,200 $4,400
70%
$4,300 $8,600
100%
$2,500 $5,000
100%
$6,000 $12,000
Out-‐of-‐Network Benefit Co-‐Insurance % Out-‐of-‐Pocket Maximum (incl. ded.)
Single Family
80%
$2,650 $5,300
50%
$2,500 $5,000
50%
$3,000 $6,000
50%
$5,500 $11,000
90%
$3,000 $6,000
90%
$7,000 $14,000
Doctor Office Visit (In-‐Network)
Primary Care Physician Specialist
Subject to ded. & co-‐insurance
$30 co-‐pay $65 co-‐pay
$30 co-‐pay $65 co-‐pay
$30 co-‐pay $65 co-‐pay
Subject to ded. &
co-‐insurance
Subject to ded. & co-‐insurance
Prescrip9on Drug Card Generic Preferred Brand Name Non-‐Preferred Brand
Name Specialty Mail Order Program Specialty Mail Order Out-‐of-‐Pocket Limit
$7.50 Co-‐Pay – 32 day supply $25 Co-‐Pay – 32 day supply $75 Co-‐Pay – 32 day supply
$75 Co-‐Pay + 10% to a max co-‐Pay of $250/fill $15/$50/$150 – 92 day supply
$150 + 10% to a max Co-‐Pay of $500/fill Co-‐Pays do not accumulate toward ded. or out-‐of-‐pocket
maximum
Subject to ded. & co-‐insurance
Subject to ded. & co-‐insurance
Accident Benefit Covered at 100% to $500 per person/per accident, then subject to deduc<ble & co-‐insurance
Subject to ded. & co-‐insurance
Subject to ded. & co-‐insurance
Emergency Room Co-‐pay $150 Co-‐Pay waived if admiFed Subject to ded. &
co-‐insurance Subject to ded. & co-‐insurance
Maternity Subject to deduc<ble & co-‐insurance Op<onal: Addi<onal $7,500 deduc<ble for groups under 15 lives
Subject to ded. & co-‐insurance
Subject to ded. & co-‐insurance
Preventa9ve Care 100%, Deduc<ble Waived, In-‐Network
Subject to Deduc<ble & Coinsurance, Out-‐of-‐Network
In addi<on, the following services will be covered as Preven<ve Care: evidence-‐based items or services that have in effect a ra<ng of "A" or "B" in the current recommenda<ons of the United States Preven<ve Services Task Force; and immuniza<ons that are recommended from the Advisory CommiFee on Immuniza<on
Prac<ces of the Centers for Disease Control and Preven<on with respect to the Member or Dependent involved; and preven<ve care and screenings for infants, children, and adolescents, according to guidelines supported by the Health Resources and Services Administra<on; and in addi<on to the benefits or services listed above, addi<onal preventa<ve care and screening for women
according to the guidelines supported by the Health Resources and Services Administra<on.
Annual Maximum $2,000,000/covered par<cipant
Rev. November 22, 2013
Limited Health Benefit Plans
Benefits Plan 7 Plan 8
Overall Per Person Calendar Year Max $55,000 $25,000
Calendar Year Deduc9ble $0 $0
Wellness Benefit – Max Benefit of $150 Per Person Per Calendar Year $50 per Visit $50 per Visit
Physician Office Visits General Office Visits – 6 Visits Per Person Calendar Year Max Emergency Room – Sickness – Included in Office Visit Max
$75 $60
$50 $35
Emergency Room – Accident For treatment in an emergency room if performed within 72 hours of the accident
$500 (per occurrence)
$200 (per occurrence)
Lab & X-‐Ray Outpa9ent Outpa<ent X-‐Ray and Lab -‐ $450 Calendar Year Max Benefit $150/Test $50/Test
Surgery and Anesthesia – Scheduled Benefit Indemnity Inpa<ent – Calendar Year Max Per Person Outpa<ent – Calendar Year Max Per Person Anesthesiology
$2,500 $1,500
25% of surgery benefit
$1,000 $500
25% of surgery benefit
Daily Hospital Confinement Indemnity Calendar Year Maximum is 30 days per person $1,000 Per Day
1st Day $500, $250 Per Day Thereawer
Intensive Care Confinement Paid in addi<on to Daily Hospital Confinement Benefits Calendar Year Maximum is 30 days Per Person
$500 Per Day $250 Per Day
Outpa9ent Prescrip9on Drug Benefit Member pays 100% of discounted price for drugs
100% Co-‐Pay Discount Card
100% Co-‐Pay Discount Card
Life Insurance -‐ Employee Only $15,000 $15,000
Limited Benefits Plan LIMITED BENEFITS PLANS are designed specifically for: **Entry level **Part-‐<me workers **Seasonal workers These benefits are not intended to be comprehensive medical benefit plans, not to replace a major medical plan, but to provide employers with ability to provide benefits for those who may not have any benefits available. Plan are administered along with the major medical programs and dental programs of the Trust.
Rev. November 11, 2011
The Affordable Care Act prohibits health plans from applying arbitrary dollar limits for coverage for key benefits. This year, if a plan applies a dollar limit on the coverage it provides for key benefits in a year, that limit must be at least $750,000. Your health insurance coverage, offered by Wyoming Lodging and Restaurant Associa<on, does not meet the minimum standards required by the Affordable Care Act described above. Instead, it puts an annual limit of: $55,000 on Plan 7 and $25,000 on Plan 8 for all covered benefits. In order to apply the lower limits described above, your health plan requested a waiver of the requirement that coverage for key benefits be at least $750,000 this year. That waiver was granted by the U.S. Department of Health and Human Services based on your health plan’s representa<on that providing $750,000 in coverage for key benefits this year would result in a significant increase in your premiums or a significant decrease in your access to benefits. This waiver is valid for one year. If the lower limits are a concern, there may be other op<ons for health care coverage available to you and your family members. For more informa<on, go to: www.HealthCare.gov. If you have any ques<ons or concerns about this no<ce, contact Wyoming Lodging and Restaurant Associa<on at 307-‐634-‐8816.
Dental & Vision Benefit Plans
DENTAL Plan 1 Plan 2 Plan 3
Calendar Year Deduc9ble Single Family
$100 $300
$50 $150
$50 $150
Preven9ve & Diagnos9c Services 80%; ded waived 100%; ded waived 100%, ded waived
Basic Services Ded, then 50% Ded, then 80% Ded, then 80%
Major Services (Subject to a 6 month wai<ng period) Ded, then 50% Ded, then 50% Ded, then 50%
Orthodon9c Services For children to age 19 (Subject to a 6 month wai<ng period)
Not Covered Not Covered $50 ded ($150/family), then 50%
Orthodon9c Life9me Maximum N/A N/A $1,000
Annual Maximum Benefit $750 $1,000 $1,000
Sec/on 125 – Sec<on 125 of the Internal Revenue Code allows for the premiums paid by employees for employer provided group benefits to be withheld from employee pay on a pre-‐tax basis. The WLRA Benefit Plan qualifies as an employer sponsored group benefit plan that could be offered under an employer’s Sec9on 125 plan. However, before an employer can offer pre-‐tax premium payments for his or her employees, the employer must adopt a separate “Sec9on 125 Plan” and allow employees the right to choose whether they wish to par9cipate. The claims administrator for the WLRA Benefit Plan has sample documents and/or administra<on op<ons an employer may need, in order to adopt a pre-‐tax Sec<on in consulta<on with the employer’s tax counsel.
Rev. November 22, 2013
VISION Plan B Plan C
Eye Exam $10 co-‐pay Every 12 months
$10 co-‐pay Every 12 months
Prescrip9on Glasses $25 co-‐pay $25 co-‐pay
Lenses Every 12 months Every 12 months
Frames Every 24 months; $130 allowance plus 20% off amount over allowance
Every 12 months; $130 allowance plus 20% off amount over allowance
Contact Lenses (in lieu of prescrip<on glasses)
Every 12 months $130 allowance
Every 12 months $130 allowance
Coverage with Non-‐VSP Providers
Eye Exam – up to $45 Single Vision Lenses – up to $30 Lined Bifocal Lenses – up to $50 Lined Trifocal Lenses – up to $65
Frames – up to $70 Contacts – up to $105
Benefits available…but NOT limited to: Acupuncture for anesthesia purposes
Allergy tests and allergy injec<ons Ambulatory/Outpa<ent Surgery Facility Care
Anesthesia charges Assistant surgeon charges
(if required due to surgical aspects) Birthing Center
Blood and blood related products Cardiac Rehabilita<on
Chemotherapy for treatment of a malignancy Chiroprac<c Manipula<on or adjustment of the spinal column
Colonoscopy (Diagnos<c) Diabetes Educa<on Equipment and supplies for persons with
diabetes Durable Medical Equipment
(purchase of rental up to the purchase price) Elec<ve Steriliza<on
Emergency Room Hospital inpa<ent or outpa<ent services
Laboratory Services Mastectomy due to diagnosed breast cancer
Mental Health and Substance Use (to plan limits)
Nursing Services Occupa<onal Therapy Orthopedic braces Oxygen & the equipment for its administra<on Pathological Services Physical Therapy Prescrip<on drugs requiring a prescrip<on under federal law Professional ambulance service if medically necessary (includes air ambulance) Prosthe<c/Ortho<cs Radia<on Therapy Respiratory/Inhala<on Therapy Services of Physicians a) Hospital visits b) Doctor’s office calls c) Doctor’s office surgery Speech Therapy (only to restore speech abili<es lost due to illness or injury) Surgery charges Vision Care following covered medical procedure to the eye Wig -‐ up to 1 per life<me due to administra<on of cancer treatment X-‐ray Services
This is a par<al lis<ng of the benefits provided under the medical plan and is NOT intended to provide complete details of benefits and limita<ons. Please refer to the Summary Plan Descrip<on (SPD) for details of benefits, limita<ons and the applicability of these benefits to each situa<on.
Benefits Exclusion: Abor<on
Acupuncture Charges for acupuncture or acupressure therapy
Adop<on or surrogate expenses Behavioral Counseling expenses
Biofeedback Therapy Blood handling and storage charges
Cosme<c surgery Chela<on Therapy
(except for heavy metal poisoning) Contracep<ves Devices
Correc<ve footwear Cosme<c services
Court ordered treatment Custodial care
Dental & Dental Implants Developmental delays
Discount Preferred Provider discount amounts or “cash discounts”
Educa<onal or voca<onal tes<ng Excess charges
Exercise Experimental or inves<ga<onal
Eyelid or Eyebrow Surgery Failure to keep appointments
Felonious Acts Charges resul<ng from or caused during the commission of a felony
Food Foot Care
Foreign medical care or Government provided services
Hair loss Hearing aids & exams Hypno<sm Liposuc<on Mailing expenses Marital counseling Massage therapy No obliga<on to pay No physician recommenda<on Non-‐prescrip<on items Not appropriate or not medically necessary Obesity Occupa<onal Personal comfort of convenience items Providing medical informa<on Rela<ve giving services Riot Sales tax Self-‐Inflicted, if not related to a medical condi<on Services before or awer coverage Sex changes Smoking cessa<on Surgical steriliza<on reversal Third Party liability Travel or accommoda<ons Unwanted hair Vision Care Visual training or orthop<cs War or Acts of War Worker’s Compensa<on
This is a par<al lis<ng of limita<ons and exclusions. A complete lis<ng, as well as suppor<ng details, is provided in the Summary Plan Descrip<on (SPD) supplied to each par<cipant.
Rev. November 22, 2013
BridgeHealth Surgery Benefit & Teladoc
BRIDGEHEALTH SURGERY BENEFITTM There are hospitals and physicians who through training and quality control measures perform their services to the very best levels. Many of these providers also contract with benefit plans for very aggressive pricing. When care is sought at these facili<es, for certain diagnosed condi<ons the Plan will alter the structure of how benefits are paid and include a travel allowance for the par<cipant and companion.
Benefit Plan & Trust
Teladoc physicians diagnose rou<ne, non-‐emergency medical problems via telephone, recommend treatment and prescribe medica<on when appropriate. You can access this service from anywhere. Simply log in to your Teladoc account or make a phone call to the 800 number. Teladoc consul<ng physicians treat illnesses that arise quickly and tend to run a brief course typically 5-‐10 days. Consul<ng physicians address acute episodes, and minor illnesses as approved chronic condi<ons such as hypertension, epilepsy or diabetes. and Teladoc can be used to treat problems such as: Teladoc Benefits Teladoc addresses key challenges facing healthcare today…below are just a few ways you can benefit from Teladoc Significant Cost Savings
Ø No need to take <me off to see a doctor Ø Access to care for rural residents and those who travel Ø Consult with physicians who diagnose medical problems and prescribe
medica<on when appropriate Ø Access to a physician within three hours or the consulta<on is free Ø Physician consults at a frac<on of the cost of a physician office, urgent care or ER
visit Ø Access to personal, portable and free electronic health record using HIPAA
compliant secure services Ø Teladoc fees are FSA & HSA eligible expenses
When to Use Teladoc Call Teladoc whenever you need non-‐emergency medical assistance and cannot reach a primary care physician (Teladoc physicians do not replace the primary care physicians)
Ø Your primary care physician’s office is closed Ø Are on vaca<on or a business trip Ø Need a recurring prescrip<on filled and don’t have <me to go to the doctor’s
office (short term refills only) Ø Need medical aFen<on that might be resolved without seeing a primary care
physician or visi<ng the ER Ø Have medical ques<ons, medical issues or concerns and would like to discuss
these with a physician Ø Need a second opinion
Note: Teladoc consul<ng physicians do not prescribe DEA controlled medica<ons Teladoc does not replace the exis<ng primary care physician rela<onship Members must be at least 10 years of age to use the service (effec<ve 11/1/2008) Teladoc is not an insurance product or prescrip<on fulfillment warehouse
The Plan provides you and your eligible Dependents with an op<on to receive certain surgical procedures through the BridgeHealth Surgery Benefit when a trea<ng Physician recommends certain Covered Expenses and you or your eligible Dependent elects to receive treatment at certain medical providers par<cipa<ng in the BridgeHealth network (“BridgeHealth Providers”). Surgeries may include, but are not limited to: Joint procedures (knees, hips, shoulders and others) Heart surgeries (bypasses, valves, pacemakers and others) Spinal surgeries (fusions, discectomies and others) General surgeries: (prostate, thyroid, hysterectomy, and others) Addi<onal procedures are offered. Please call to learn more. Covered Expenses include all medical costs incurred under the BridgeHealth Surgery Benefit, with no Copay, Deduc<ble or Coinsurance applied, as well as transporta<on, lodging, meals and incidentals for the Covered Person and one (1) companion. (1) Transporta9on and lodging includes round trip transporta<on for the pa<ent and one (1) companion between the pa<ent’s home loca<on and the loca<on of the BridgeHealth Provider where treatment is to be performed; and hotel accommoda<ons near the BridgeHealth Provider. Hotel accommoda<ons are limited to one (1) room to be shared by the pa<ent and companion. All transporta<on and lodging must be reserved and scheduled through BridgeHealth Medical, Inc. (2) Meals and incidentals include a daily allowance calculated for the number of days the pa<ent and companion are at the des<na<on and is intended to cover incidental and “out-‐of-‐pocket” expenses incurred by the pa<ent in connec<on with his/her treatment. The meals and incidentals allowance shall be established and payable at ini<a<on of the travel associated with such treatment.
Teladoc (Plans 4, 5 & 6 Only) In an effort to provide par<cipants with the very best access to quality medical advice, the Teladoc program allows par<cipants to speak with a licensed physician in their State of Residence regarding certain diagnosis and health condi<on issues.
For addi<onal details regarding the benefits and limita<ons of these programs, please consult the Summary Plan Descrip<on.
Teladoc Services Teladoc for Plans 4-‐ 6 Teladoc is a network of state licensed, board cer<fied primary care physicians providing cross coverage consulta<ons 24 hours a day, 7 days a week, and 365 days a year.
Rev. November 22, 2013
• Respiratory infec<ons • Bronchi<s • Gastroenteri<s
• Urinary Tract infec<ons • Pharyngi<s Sinusi<s • Allergies RX Refill (short term only)
Benefit Plan & Trust
Submission Checklist To apply for coverage with the WLRA Benefit Plan and Trust, the following forms need to be submiFed: ü Employer Applica9on: Completed in full and dated no more than 60 days prior to the requested effec<ve
date ü Employee Applica9on: Completed in full. Any employee correc<ons must be ini<ated by the employee.
All medical ques<ons must be answered, details given, and, if requested, a ques<onnaire asking addi<onal details provided. Applica<ons must be dated no more than 60 days from the requested effec<ve date. Employee must complete waiver form for any eligible dependents who are not signing up for coverage.
ü Unemployment Report: A copy of the employer’s most recent Quarterly Unemployment Report as filed for SUI, itemized by employee, must be included.
ALL FORMS MUST BE COMPLETED AND SIGNED FOR VERIFICATION.
Once the applica<on set is complete, it is forwarded to the Trust underwriter. The underwriter makes the decision whether the en<re group is accepted into the Trust or declined. If employer is approved, the following forms and informa<on is requested: ü Acceptance Form: This form shows that the group has been accepted along with the names of the
employees who applied, the benefit plan chosen, the billed rates for that plan, and the group’s total premium per month. This form must be signed and returned by the employer within 1 week.
ü First Month’s Premium: The first month’s premium must be submiFed (check made out to the Trust). Available bill payment op<ons are included (invoicing with either check payment, ACH payment or EFT payment).
ü Adop9on Agreement: This contract outlines the obliga<ons of the Plan and the Employer, for the dura<on of the benefit plan. Two copies must be signed and returned. Both will be countersigned and one returned to the employer.
Rev. November 22, 2013
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