2015 Health Insurance Information. We ve got you covered
|
|
- Vincent Holt
- 8 years ago
- Views:
Transcription
1 2015 Health Insurance Information We ve got you covered
2 or 30 years, United Personnel has been pleased to offer health insurance coverage to our employees. In 2015, our coverage options are changing as part of United s commitment to fully abide by the requirements of the Affordable Care Act (ACA). As part of this compliance, we are happy to inform you of your potential eligibility to participate in a new group insurance plan we ll be offering starting arch 1 st of this year. Under the ACA, employees working at least 30 hours per week, or 130 hours per month, are required to be offered compliant employer group medical coverage on the 90 th day of employment. United Personnel has decided to enhance this offering and make it available on the first of the month following 60 days of employment. ou are receiving this packet so that you have the information you need to make insurance decisions when you become eligible. In 2015, United will offer 4 health insurance plans through Health ew England. The most affordable coverage is Plan 1 (HO Wise Plus HDHP), which meets the ACA s affordability and minimum essential care and value requirements. or this plan, United Personnel will ensure 68% of the single premium ($ 2,866 annually). The total employee contribution for this single coverage on Plan 1 is $1334 annually. In addition, this plan comes with a $2000 deductible which must be paid out of pocket by the employee before insurance coverage begins. This means that you, as the covered employee, pay for all medical treatment/care/prescriptions, with the exception of preventive care visits with $0 copay, on your own until you reach a $2000 deductible. At that point, the insurance will help to pay for medical expense as outlined in the chart in this packet. If you chose to upgrade to one of the other 3 plans offered, Essential HO 500, 1500 or 2000, please refer to the chart in packet for plan description and cost. United s contribution to these premium rates remains $2,866 annually. If you achieve eligibility status and chose not to participate in this partially employer-paid plan, the ACA still requires all individuals over the federal poverty guidelines to purchase a policy referred to as inimum Essential Coverage. If you chose not to participate in any of these health plans and do not own a compliant policy through another source, you may owe up to 2% of your income when filing your 2015 individual income tax return under ACA rules.
3 UITED PERSOEL SERVICES edical Insurance Programs Underwritten by Health ew England Effective arch 1, 2015 Plan 1: HO Wise Plus HDHP Single Employee & Spouse Employee & Child(ren) amily Weekly Contribution $25.65 $ $94.30 $ Benefit Summary $0 Preventive Services Copay Plan ear Deductible $2,000 per Individual / $4,000 per amily ** PCP Office Visit: $25 Copay After Deductible Specialist Office Visit: $25 Copay After Deductible Chiropractic Services: $20 Copay After Deductible (12 visits per member per calendar year) Emergency Room: $100 Copay After Deductible Laboratory Services: $0 Copay After Deductible Radiological Services: $0 Copay After Deductible (Ultrasound, X-Ray, on-routine ammogram) Diagnostic Imaging: $75 Copay After Deductible (3 copays per year) (CT Scan, RI, RA, PET Scan, uclear Cardiac Imaging) Inpatient Hospital Admission: $500 Copay After Deductible Outpatient Surgery: $250 Copay After Deductible Prescription Drugs Subject to Plan ear Deductible Retail (30-Day Supply) : $15/$30/$50 After Deductible ail Order (90-Day Supply) : $30/$60/$150 After Deductible Out-of-Pocket aximum per Plan ear $5,000 per Individual / $10,000 per amily (The most you pay for cost sharing on Essential Health Benefits during a Plan ear before your Plan begins to pay 100% of the allowed amount.) **Once any individual on a family plan has paid $2,600 towards the family deductible, the plan will begin to pay benefits for that individual.
4 UITED PERSOEL SERVICES edical Insurance Programs Underwritten by Health ew England Effective arch 1, 2015 HO Essential 500 HO Essential 1500 HO Essential 2000 Weekly Weekly Weekly Contribution Contribution Contribution Single $66.16 Single $47.30 Single $41.49 Employee & Spouse $ Employee & Spouse $ Employee & Spouse $ Employee & Child(ren) $ Employee & Child(ren) $ Employee & Child(ren) $ amily $ amily $ amily $ Benefit Summary Benefit Summary Benefit Summary $0 Preventive Services Copay $0 Preventive Services Copay $0 Preventive Services Copay $20 PCP Office Visit Copay ($20 Specialist Copay) $20 PCP Office Visit Copay ($20 Specialist Copay) $20 PCP Office Visit Copay ($20 Specialist Copay) $20 Chiropractic Copay $20 Chiropractic Copay $20 Chiropractic Copay (12 visits per member per calendar year) (12 visits per member per calendar year) (12 visits per member per calendar year) $150 Emergency Room Copay $150 Emergency Room Copay $150 Emergency Room Copay Laboratory Services Covered in ull Laboratory Services Covered in ull Laboratory Services Covered in ull Plan ear Deductible Plan ear Deductible Plan ear Deductible $500 per Individual / $1,000 per amily $1,500 per Individual / $3,000 per amily $2,000 per Individual / $4,000 per amily Radiological Services: $0 After Deductible Radiological Services: $0 After Deductible Radiological Services: $0 After Deductible (Ultrasound, X-Ray, on-routine ammogram) (Ultrasound, X-Ray, on-routine ammogram) (Ultrasound, X-Ray, on-routine ammogram) Diagnostic Imaging: $75 After Deductible (3 copays per year) Diagnostic Imaging: $100 After Deductible (3 copays per year) Diagnostic Imaging: $100 After Deductible (3 copays per year) (CT Scan, RI, RA, PET Scan, uclear Cardiac Imaging) (CT Scan, RI, RA, PET Scan, uclear Cardiac Imaging) (CT Scan, RI, RA, PET Scan, uclear Cardiac Imaging) Inpatient Hospital Admission: $0 After Deductible Inpatient Hospital Admission: $0 After Deductible Inpatient Hospital Admission: $0 After Deductible Outpatient Surgery: $0 After Deductible Outpatient Surgery: $0 After Deductible Outpatient Surgery: $0 After Deductible Prescription Drugs Prescription Drugs Prescription Drugs ot Subject to Plan ear Deductible ot Subject to Plan ear Deductible ot Subject to Plan ear Deductible Retail (30-Day Supply) : $15/$50/$75 Retail (30-Day Supply) : $15/$50/$75 Retail (30-Day Supply) : $15/$50/$75 ail Order (90-Day Supply) : $30/$100/$225 ail Order (90-Day Supply) : $30/$100/$225 ail Order (90-Day Supply) : $30/$100/$225 Out-of-Pocket aximum per Plan ear Out-of-Pocket aximum per Plan ear Out-of-Pocket aximum per Plan ear $5,000 per Individual / $10,000 per amily $5,000 per Individual / $10,000 per amily $5,000 per Individual / $10,000 per amily (The most you pay for cost sharing on Essential Health Benefits during a (The most you pay for cost sharing on Essential Health Benefits during a (The most you pay for cost sharing on Essential Health Benefits during a Plan ear before your Plan begins to pay 100% of the allowed amount.) Plan ear before your Plan begins to pay 100% of the allowed amount.) Plan ear before your Plan begins to pay 100% of the allowed amount.)
5 One onarch Place Suite 1500 Springfield, A Phone Enrollment ax hnewhizkidz.com hne.com enrollment /add /termination form PLEASE PRIT AD COPLETE ALL IORATIO EPLOEE AE (IRST, IDDLE, LAST) PCP IRST & LAST AE (does not apply to PPO) SS# GROUP/COPA AE PCP PROVIDER ID# (ound in the provider directory) IS THIS OUR DOCTOR OW? ES DOB OTH DA EAR GEDER ALE ADDRESS APT. O. STREET PO BOX CIT STATE ZIP TELEPHOE (HOE) TELEPHOE (WORK) EAIL ( ) ( ) ARITAL STATUS SIGLE ARRIED DIVORCED OTHER PRIAR LAGUAGE SPOKE OPTIO O EALE I OU VE EVER BEE A HE EBER, PLEASE LIST ORER AE (if applicable) AD ORER IDETIICATIO UBER WILL OU OR A EBER O OUR AIL BE COVERED THROUGH AOTHER HEALTH ISURACE? ES SUBSCRIBER S AE DATE O BIRTH POLIC #AE O ISURACE CO. EECTIVE DATE AES O COVERED IDIVIDUALS IS EPLOEE RETIRED? ES (provide copy of edicare card) O Are you or any of your dependents COVERED B medicare? ES O if yes, part A part b both a copy of your medicare card(s) must be attached O ETHICIT (Use codes from back of form.) 1 st 2 nd Other RACE (Use codes from back of form) each member UST select a Primary Care Physician. If a PCP is not chosen, HE A OT BE ABLE TO PROCESS OUR CLAIS (DOES OT APPL TO PPO). DEPEDET AE(S) ETHICIT RACE DATE O BIRTH IRST IDDLE LAST (if not same as employee) (Use codes from back of form) O DA R Spouse Other SEX SOCIAL SECURIT UBER PCP LAST IRST PROVIDER ID# IS THIS OUR DOCTOR OW? Dependent Dependent Dependent OR DEPEDET(S) AGED 21-26, I ATTEST TO THE OLLOWIG: (DEPEDET ELIGIBILIT RULES A VAR OR SEL-UDED PLAS.) DEPEDET AE(S) HE/SHE IS A ULL-TIE STUDET? ES O ES O I WILL CLAI HI/HER AS A DEPEDET OR IRS TAX PURPOSES I THE CURRET CALEDAR EAR. ES O ES O BELOW SECTIO TO BE COPLETED B EPLOER I O, THE LAST EAR I CLAIED HI/HER AS A DEPEDET OR IRS TAX PURPOSES WAS I CALEDAR EAR: I UDERSTAD THAT B ACCEPTIG COVERAGE UDER THIS PLA, HE AD A HEALTH CARE PROVIDER A RECEIVE, USE AD DISCLOSE EDICAL IORATIO OR TREATET, PAET, HEALTH CARE OPERATIOS, AD A AD ALL OTHER USES ALLOWED B LAW. I HAVE READ AD UDERSTAD THE TERS O EROLLET O THE BACK O THIS OR. I CERTI THAT ALL IORATIO O THIS OR IS CORRECT AD COPLETE TO THE BEST O KOWLEDGE. X Employee Signature DATE EW EROLLET E. DATE REASO EW HIRE Part-time to ull-time AUAL OPE EROLLET OTHER LOSS O ISURACE (must attach documents) OVED ITO SERVICE AREA CHAGE TO CURRET POLIC E. DATE TERIATIO O POLIC ED DATE REASO CHAGE COVERAGE TPE ADD DEPEDET LISTED ABOVE TERIATE DEPEDET LISTED ABOVE TRASER TO COBRA AE/ADDRESS CHAGE LOSS O ISURACE (must attach documents) ARRIAGE OTHER REASO LET EPLOET VOLUTAR CACELLATIO OVED RO SERVICE AREA O LOGER ELIGIBLE DECEASED TPE O PLA: HO Advantage Plus (POS) PPO TPE O COVERAGE: IDIVIDUAL AIL OTHER DATE O HIRE: HE GROUP #: EPLOER SIGATURE: DATE: 4/15/ LE
6 Important: Please read these terms of EROLLET As an employee I understand that: 1. By submitting this form or accepting coverage under the plan, I agree, on behalf of myself and all enrolled dependents, to abide by the terms of the Health ew England (HE) Agreement, which includes this form as well as the applicable Explanation of Coverage or Summary Plan Description. RACE & Ethnicity Why are these questions being asked? The Commonwealth of A has established statewide goals for improving health care quality and reducing racial and ethnic disparities in health care. HE wants to do our part to remove any barriers to fair and unbiased treatment for all of our members. By collecting information about your race and ethnic background, we may be able to identify possible issues that affect the care or treatment you receive. HE will then be able to work with our provider community to address any issues. We appreciate your assistance in this effort. This information is designed for the purpose of data collection and will not be used for 2. embership will become effective upon acceptance by the Plan and that benefits under the Plan will be explained in a separate document (Explanation of Coverage or Summary Plan Description). 3. I may only enroll dependents subject to the guidelines outlined in my HE Agreement. 4. Whenever I seek treatment or services, I must identify myself as determining eligibility, rating or claim payment. Race Please choose from the following: ill in the code where indicated on the front of this form. Code R1 R2 R3 R4 Description American Indian/Alaska ative Asian Black/African American ative Hawaiian or other Pacific Islander R5 R9 UKOW White Other Race Unknown/not specified a HE member by presenting my HE Identification Card. 5. I must select a Primary Care Physician for myself and my dependents (does not apply to PPO). 6. If appropriate, I authorize my employer to deduct from my wages the rate required for the coverage selected. As an employer I understand that: 1. By submitting this form, I certify that the information provided on this form is accurate. Ethnic Group Please choose from the following: (ou may choose more than one.) ill in the code where indicated on the front of this form: Code Cuban Description Dominican exican, exican American, Chicano Puerto Rican Salvadoran Central American (not otherwise specified) South American (not otherwise specified) African African American AERC American Asian Asian Indian BRAZIL Brazilian Cambodian CVERD CARIBI Cape Verdean Caribbean Island Code Description Chinese Columbian European ilipino Guatemalan Haitian Honduran Japanese Korean Laotian iddle Eastern PORTUG RUSSIA EASTEU Portuguese Russian Eastern European Vietnamese OTHER Other Ethnicity UKOW Unknown/not specified
Northeastern University 2015 Medical Benefits
Northeastern University 2015 Medical Benefits Northeastern s 2015 Open Enrollment Effective Date: January 1, 2015 2015 Medical Plan Options Blue Choice New England Core POS Plan New Plan Blue Choice New
More informationSmall Business Employee Enrollment Form/Waiver of Coverage
California Small Business Employee Enrollment orm/waiver of Coverage Effective ay 1, 2011 Instructions Complete the information requested in each section according to the guidelines provided below. Please
More informationAnthem Blue Cross Life and Health Insurance Company Notice of Language Assistance
Anthem Blue Cross Life and Health Insurance Company tice of Language Assistance Anthem Blue Cross Language Assistance tice Enrollment orm with Life INSTRUCTIONS Please read carefully and provide all applicable
More informationSmall Business Health Options Program (SHOP)
Small Business Health Options Program (SHOP) Application for employees Complete this application to apply for SHOP health coverage from your employer. Go online Visit CoveredCA.com. You ll be able to see
More informationPatient Registration Form (ecw) (First) (MI) Previous Name. Address
Patient Registration Form (ecw) PATIENT INFORMATION (Please Print) Dr. Miss Mr. Mrs. Ms. Patient's Name (Last) (First) (MI) Previous Name Address City, State ZIP Check the best contact number q Home Phone
More informationIndividual Health Insurance
Individual Health Insurance Plans with a Wide Range of Options to it Your Budget Apply Today! Call us toll-free at 1-866-303-2583 Visit us on the web at bcbsok.com Contact your authorized independent Blue
More informationMassachusetts HIV Drug Assistance Program (HDAP) and Comprehensive Health Insurance Initiative (CHII) Application Form
Massachusetts HIV Drug Assistance Program (HDAP) and Comprehensive Health Insurance Initiative (CHII) Application Form Please print clearly and answer all questions. Review the attached instructions before
More informationPriority Health Medicare
Priority Health Medicare To enroll online please visit our website at prioritymedicare.com Enrollment instructions To avoid delays in processing your enrollment, please follow these helpful tips. Make
More informationGuide to MHBP and Medicare
Guide to MHBP and Medicare You ve Earned It... Go Get It! You ve Earned It You ll be eligible for Medicare soon. You owe it to yourself to take full advantage of these long-awaited benefits. Medicare Part
More informationSummary of Benefits and Coverage What this Plan Covers & What it Costs - 2015
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the plan document at www.mpiphp.org or by calling 1-855-275-4674. Important Questions Answers
More informationTRH HEALTH INSURANCE COMPANY APPLICATION FOR COVERAGE
TRH HEALTH INSURANCE COPANY APPLICATION OR COVERAGE PLEASE PRINT USING BLACK INK Section 1 Primary Applicant Information OICE USE ONLY irst Name I Last Name Phone No. ( ) - ay we leave a message? Yes No
More information$0 See the chart starting on page 2 for your costs for services this plan covers. Are there other deductibles for specific
This is only a summary. If you want more detail about your medical coverage and costs, you can get the complete terms in the policy or plan document at www.teamsters-hma.com or by calling 1-866-331-5913.
More informationHealth Insurance Matrix 01/01/16-12/31/16
Employee Contributions Family Monthly : $121.20 Bi-Weekly : $60.60 Monthly : $290.53 Bi-Weekly : $145.26 Monthly : $431.53 Bi-Weekly : $215.76 Monthly : $743.77 Bi-Weekly : $371.88 Employee Contributions
More informationInsurance Benefits For Employees C H E S T E R F I E L D C O U N T Y P U B L I C S C H O O L S
CCPS Insurance Benefits For Employees 2015 C H E S T E R F I E L D C O U N T Y P U B L I C S C H O O L S CHESTERFIELD COUNTY PUBLIC SCHOOLS BENEFITS DEPARTMENT Enrollment or Changes in Coverage 748-1226,
More informationSummary of Benefits and Coverage What this Plan Covers & What it Costs
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the plan document at www.mpiphp.org or by calling 1-855-275-4674. Important Questions Answers
More informationTeachers Retirement Insurance Program
Comparison of Illinois State Retiree Health Insurance Options with Traditional Medicare and Medicare Supplement (Medigap) Insurance Teachers Retirement Insurance Program Insuraprise, Inc. (C) Copyright
More informationKAISER PERMANENTE PLAN (Non-Medicare Eligible)
CEMENT MASONS HEALTH AND WELFARE TRUST FUND FOR NORTHERN CALIFORNIA RETIRED CEMENT MASONS AND THEIR ELIGIBLE DEPENDENTS EFFECTIVE JANUARY 1, 2015 GENERAL When You Can Change Plans Type of Plan, Service
More informationConsumer s Right to Know About Health Plans in Rhode Island
Consumer s Right to Know bout Health Plans in Rhode Island UnitedHealthcare Insurance Company n-differential PPO Consumer Disclosure Safe and Healthy Lives in Safe and Healthy Communities Consumer Disclosure
More informationPriority Health Medicare
Priority Health Medicare To enroll online please visit our website at prioritymedicare.com Enrollment instructions To avoid delays in processing your enrollment, please follow these helpful tips. Make
More informationHow To Buy Health Insurance. An Introduction To Healthcare Coverage
How To Buy Health Insurance An Introduction To Healthcare Coverage Table of Contents What Is Health Insurance? How Do I Get Health Insurance? When Can I Get Health Insurance? What Terms Should I Know?
More informationBlue Care Elect Saver with Coinsurance Northeastern University HDHP Coverage Period: on or after 01/01/2016
Blue Care Elect Saver with Coinsurance Northeastern University HDHP Coverage Period: on or after 01/01/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual
More information$500 member / $1,000 family Self- Referred. Does not apply to emergency room, emergency transportation, or acupuncture services.
Blue Choice New England Plan 2 MIT Choice Coverage Period: on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Ind.+Spouse, Ind.+Child(ren)
More informationBrookhaven Science Associates, LLC. 2016 Guide To: Medical Programs Health Savings Account Health Care Reimbursement Account
Brookhaven Science Associates, LLC 2016 Guide To: Medical Programs Health Savings Account Health Care Reimbursement Account 1 2 Here s What You ll Find In This Booklet ITEM PAGE # OVERVIEW... 5 MEDICAL
More informationTop Echelon Contracting 2015 Health Insurance Benefit Summary
Top Echelon Contracting 2015 Health Insurance Benefit Summary Top Echelon Contracting offers employees health insurance through Aetna ( one of the largest and most nationally recognized health care companies
More informationHarvard University 2015 Medical Benefits. High Deductible Health Plan with Health Savings Account Introduction
Harvard University 2015 Medical Benefits High Deductible Health Plan with Health Savings Account Introduction Topics for Discussion High Deductible Health Plan (HDHP) Why Consider? High Deductible Health
More informationMedical and Dental Plan Application for Individuals and Families
Medical and Dental Plan Application for Individuals and Families Please be sure to complete ALL information below to avoid delays in processing. Please print clearly using blue or black ink. Section 1
More informationGEHA 2014. Health Savings AdvantageSM High-deductible health plan with a health savings account (HSA) (800) 821-6136 geha.com
GEHA 2014 Health Savings AdvantageSM High-deductible health plan with a health savings account (HSA) (800) 821-6136 geha.com CODE Self Only 341 Self + Family 342 Enrollment checklist 1. Research health
More informationPolicy Holder Name Relationship to Patient SSN DOB
Orthopedic Today s Date Patient s SSN# Legal First Name Last Name M.I. DOB Gender Parent/Guardian Name (for pediatrics) DOB Address City State Zip Home Phone Cell Phone Work Phone Email Have any members
More informationApplication for Health Insurance
TM Application for Health Insurance Your destination for affordable health insurance, including Medi-Cal See Inside Things to know 1 Application 2 19 Attachments A F 20 28 Frequently Asked 29 33 Questions
More informationSmall Employer Health Insurance Survey South Carolina State Planning Grant
Small Employer Health Insurance Survey South Carolina State Planning Grant So that we can ensure our survey sample is geographically representative of the state, it is very important that you provide the
More informationHealth Insurance Marketplace in Illinois Plan Comparison Charts
2015 Independent Authorized Agent for An Independent Licensee of the Blue Cross Blue Shield Association Health Insurance Marketplace in Illinois Plan Comparison Charts preventive services and maternity
More informationCommunity HealthEssentials. 2014 Guide
Community HealthEssentials 2014 Guide Community HealthEssentials - Summary Community HealthEssentials is the new name for Community Health Plan of Washington s (CHPW) individual commercial products offered
More informationHealth and Dental Insurance Questions/Answers for Retirees
Health and Dental Insurance Questions/Answers for Retirees What happens with my health insurance if I continue to work full-time beyond age 65? As an active full-time employee working beyond the age of
More informationMAYFLOWER MUNICIPAL HEALTH GROUP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PPO REVIEW OF BENEFITS
Fiscal Year 2015 2016 MAYFLOWER MUNICIPAL HEALTH GROUP ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PPO REVIEW OF S ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
More informationMedicare Advantage Election Form
Serving select counties Medicare Advantage Election Form Serving select counties Serving select counties Already a Blue Cross of Idaho Care Plus Medicare member? Please check the box below: o I have a
More informationBoston College Student Blue PPO Plan Coverage Period: 2015-2016
Boston College Student Blue PPO Plan Coverage Period: 2015-2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family Plan Type: PPO This is only a
More informationPriority Health Medicare
Priority Health Medicare To enroll online please visit our website at prioritymedicare.com Enrollment instructions To avoid delays in processing your enrollment, please follow these helpful tips. Make
More information2014 Individual Application
2014 Individual Application Directions: Please complete this application in its entirety using blue or black ink. You may select one plan per family unless applying separately. Your signature is required
More informationNew Group Submission Checklist HARVARD PILGRIM HEALTH CARE Best Buy HSA PPO Plans
hsainsurance.com New Group Submission Checklist HARVARD PILGRIM HEALTH CARE Best Buy HSA PPO Plans To ensure your application is processed as quickly and accurately as possible, follow these steps: 1.
More informationSECTION I. Answer the questions in Section I to determine if application needs to be completed for person needing help with medical bills.
N.C. Department of Health and Human Services Division of Medical Assistance Breast and Cervical Cancer Medicaid Application SECTION I. Answer the questions in Section I to determine if application needs
More informationCost Sharing Definitions
SU Pro ( and ) Annual Deductible 1 Coinsurance Cost Sharing Definitions $200 per individual with a maximum of $400 for a family 5% of allowable amount for inpatient hospitalization - or - 50% of allowable
More informationName of Employer: Your Work Address:
TIE INSURANCE COPANY GEORGIA GROUP INSURANCE EPLOYEE ENROLLENT OR Instructions for completing this enrollment form 1) Each eligible employee enrolling for any coverage offered must complete the entire
More informationCoverage Period : 01/01/2014-12/31/2014
Coventry Health and Life Insurance Company: Silver Integrated $10 Co-pay PPO Exchange Summary of Benefits and Coverage: What this Plan Covers & What it Costs This is only a summary. If you want more detail
More informationPATIENT REGISTRATION Date:
PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN
More informationRETIREE GUIDE TO FY 2016 OPEN ENROLLMENT PERIOD
GUIDE TO FY 2016 OPEN ENROLLMENT PERIOD Highlights Inside: Open Enrollment for non-medicare eligible retirees and their dependents begins on May 6, 2015 and ends May 22, 2015. Open enrollment is generally
More informationBlue Care Elect Preferred Amherst College Coverage Period: on or after 07/01/2014
Blue Care Elect Preferred Amherst College Coverage Period: on or after 07/01/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family Plan Type:
More informationCompass Rose Health Plan: High Option Coverage Period: 01/01/2015 12/31/2015
This is only a summary. Please read the FEHB Plan RI 72-007 that contains the complete terms of this plan. All benefits are subject to the definitions, limitations, and exclusions set forth in the FEHB
More informationImportant Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?
: VIVA HEALTH Access Plan Coverage Period: 01/01/2015 12/31/2015 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document
More informationBlueCHiP for Medicare 2016 Plan Selection Form
2016 Plan Selection Form Date: c c / c c / c c c c Instructions: Complete the following sections 1. Provide Demographics 2. Choose your Medical Plan 3. Choose your Optional Supplemental Dental Plan 4.
More informationHOSPITAL AND AMBULATORY SURGICAL CENTER FAX REPORTING OF INCIDENTS AND ABUSE
HOSPITAL AND AMBULATORY SURGICAL CENTER FAX REPORTING OF INCIDENTS AND ABUSE GENERAL INSTRUCTIONS: 1. These instructions apply to reporting all hospital and ASC incidents, and suspected abuse, neglect,
More informationPPO Schedule of Payments (Maryland Large Group) Qualified High Deductible Health Plan National QA2000-20
PPO Schedule of Payments (Maryland Large Group) Qualified High Health Plan National QA2000-20 Benefit Year Individual Family (Amounts for Participating and s services are separated in calculating when
More informationHealth Insurance Overview
Spotsylvania County Open Enrollment August 10 to 28, 2015 Plan Year: October 1, 2015 to September 30, 2016 Health Insurance Overview All Full Time employees are eligible to participate in the County Health
More informationHigh Deductible Health Plan (HDHP) with Health Savings Account (HSA) FREQUENTLY ASKED QUESTIONS
High Deductible Health Plan (HDHP) with Health Savings Account (HSA) FREQUENTLY ASKED QUESTIONS Part I HIGH DEDUCTIBLE HEALTH PLAN (HDHP) Q. What is the HDHP? A. The High Deductible Health Plan (HDHP)
More informationMedical Benefit Highlights for Employees. All Ages and Retirees Under Age 65* Plan Year 2013 September 1, 2012 August 31, 2013
HealthSelectSM of Texas Medical Benefit Highlights for Employees All Ages and Retirees Under Age 65* Plan Year 2013 September 1, 2012 August 31, 2013 www.healthselectoftexas.com * Also applies to return-to-work
More informationApplication for Health Insurance
TM Application for Health Insurance Your destination for affordable health insurance, including Medi-Cal Covered California is the place where individuals and families can get affordable health insurance.
More informationImportant Questions Answers Why this Matters: In-network: $2,000 Single / $4,000 Family Out-of-network: $3,000 Single / $6,000 Family
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.independenthealth.com or by calling 1-800-501-3439. Important
More informationHow To Get A Plan From Avmed
Small Group Plan Benefits Proposal Prepared for: Bill's Pest Control 3/5/2015 Prepared for: Bill's Pest Control Effective date: 3/15/2015 Thank you for your interest in AvMed. Attached are the preliminary
More informationImportant Questions Answers Why this Matters:
Anthem Blue Cross Life and Health Insurance Company Unify: PPO Coverage Period: 01/01/2015 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family
More informationYou can see the specialist you choose without permission from this plan.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.cvtrust.org or by calling 1-800-288-9870. Important Questions
More informationBlue Care Elect Preferred 90 Copay Coverage Period: on or after 09/01/2015
Blue Care Elect Preferred 90 Copay Coverage Period: on or after 09/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual Only Plan Type: PPO This is only
More informationMedicare Plans Enrollment Request Form
Medicare Plans Enrollment Request Form STEP 1. To enroll, please provide the following information: First name: Last name: Middle initial: Birth date (mm/dd/yyyy): / / Sex: M F Permanent residence street
More informationDivision of Insurance
Division of Insurance COLORADO UNIOR EPLOYEE APPLICATION OR SALL GROUP HEALTH BENEIT PLANS This form is designed for an employee s initial application for coverage. Please contact your agent or the carrier
More informationImportant Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling 1-888-990-5702. Important Questions Answers Why this
More informationState Retiree Medicare Advantage Plans
State Retiree Medicare Advantage Plans October/November 2015 Copyright 2013 by The Segal Group, Inc. All rights reserved. Your 2016 Retiree Benefits www.cms.illinois.gov/thetrail 2 Eligibility Who is Required
More informationMCPHS University Health Insurance Program Information
MCPHS University Health Insurance Program Information Beginning September 1, 2014 Health Services MCPHS University students on the Boston campus have access to the Massachusetts College of Art and Design
More informationPLUMBERS LOCAL 24 WELFARE FUND
PLUMBERS LOCAL 24 WELFARE FUND Quick Reference Guide for JOURNEYMEN Effective January 1, 2015 Important Notice: This is an outline of the principal plan provisions of the Plumbers Local 24 Welfare Plan
More informationYour employees want and need help with health care coverage. Now there s a way to provide it. Colonial Health AdvantageSM
Your employees want and need help with health care coverage. Now there s a way to provide it. Colonial Health AdvantageSM Now affordable health care coverage is within reach for you and your employees.
More informationFee-for-Service. Medicare Supplemental Retiree Health Plans
Sheet Metal Workers Health Plan of Southern California, Arizona & Nevada April 2011 Summary Comparison Of Benefits Available under the Fee-for-Service and Medicare Supplemental Retiree Health Plans Important:
More informationINDIVIDUAL POLICY CHANGE APPLICATION
INDIVIDUAL POLICY CHANGE APPLICATION Instructions: Please complete all applicable areas of this application. Please print using black ink. WPS/Delta Dental of Wisconsin/WPS Health Plan, Inc. d/b/a Arise
More informationInformational Series. Community TM. Glossary of Health Insurance & Medical Terminology. (855) 624-6463 HealthOptions.
Informational Series Glossary of Health Insurance & Medical Terminology How to use this glossary This glossary has many commonly used terms, but isn t a full list. These glossary terms and definitions
More informationNEVADA GROUP INSURANCE EMPLOYEE ENROLLMENT FORM
NEVADA GROUP INSURANCE EPLOYEE ENROLLENT OR Instructions for completing this enrollment form 1) Each eligible employee enrolling for any coverage offered must complete the entire enrollment form, except
More informationApplication for Free Home Repairs
Application for Free Home Repairs Name of Homeowner: Date of Birth: Gender Male Female Is this a female headed household? Is this a grandparent headed household? Street Address: City: County: Zip Marital
More informationHealth Insurance 101. A brief overview of health insurance 10/15/09
Health Insurance 101 A brief overview of health insurance 10/15/09 Health Care vs. Health Insurance Health Care is Provision of Medical Services by Private Physicians and Hospitals (private pay or insurance)
More informationCoventry Health and Life Insurance Company: Silver $10 Co-pay PPO KC Exchange Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coventry Health and Life Insurance Company: Silver $10 Co-pay PPO KC Exchange Summary of Benefits and Coverage: What this Plan Covers & What it Costs This is only a summary. If you want more detail about
More informationBlueSelect Silver ValueTwo for Individuals
BlueSelect Silver ValueTwo for Individuals Coverage Period: 1/1/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single Plan Type: PPO This is only
More informationInsurance 101 for Students
Insurance 101 for Students Health Care in the United States The U.S. does not offer free medical care to the general public Medical care is very expensive Doctor office visit: $150 - $200 Annual asthma
More informationBanner Health - Choice Plus Coverage Period: 1/1/2015-12/31/2015
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the plan document at www.bannerbenefits.com by clicking on the Resources tab and then Plan
More informationhealth plan meets Minimum Creditable Coverage standards and will satisfy the individual mandate that you have health insurance.
health plan meets Minimum Creditable Coverage standards and will satisfy the individual mandate that you have health insurance. This Massachusetts Requirement to Purchase Health Insurance: As of January
More informationBronze HSA 3250 Coinsurance 50
Bronze HSA 3250 Coinsurance 50 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning on or after 01/01/2016 Coverage for: Individual and Individual + Family
More informationImportant Questions Answers Why this Matters: Network: $500 Individual / $1,500 Family;
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthscopebenefits.com or by calling 1-866-208-4281.
More informationBlue Dental. Personal Blue Dental SM Personal Blue Dental Plus SM
Blue Dental S s m i l e, y o u ' r e c o v e r e d Personal Blue Dental S Personal Blue Dental Plus S Quality dental care from the Blues Blue Cross Blue Shield of ichigan dental plans are backed by the
More informationA Guide to Health Insurance
A Guide to Health Insurance Your health matters. A healthier you makes a healthier Cleveland! Healthy Cleveland Insurance Guide Dial Dial Acknowledgements On behalf of the City of Cleveland Department
More informationMedicare + GEHA. Protect yourself from unexpected health care expenses
Medicare + GEHA Protect yourself from unexpected health care expenses Table of contents Facts about Medicare 5 Medicare Part A 6 Medicare Part B 6 Medicare Part C 7 Medicare Part D 8 GEHA + Medicare 10
More informationImportant Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling 1-888-990-5702. Important Questions Answers Why this
More informationImportant Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Summary Plan Description (SPD) or Plan Document at www.pebtf.org or by calling 1-800-522-7279.
More informationPhysicians Plus Insurance Corporation Coverage Period: 01/01/2016 12/31/2016
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.pplusic.com or by calling 1-800-545-5015. Important Questions
More informationCoverage Period : 01/01/2014-12/31/2014
Coventry Health and Life Insurance Company: Silver Integrated $10 Co-pay PPO KC Exchange Summary of Benefits and Coverage: What this Plan Covers & What it Costs This is only a summary. If you want more
More informationCoverage for: Individual, Family Plan Type: PPO. Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bbsionline.com or by calling 1-866-927-2200. Important
More informationSilver Basic Plus: QCA Health Plan, Inc. Coverage Period: Beginning on or after 01/01/2014
Silver Basic Plus: QCA Health Plan, Inc. Coverage Period: Beginning on or after 01/01/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family Plan
More informationOpen Enrollment 2015 November 12 November 26
Open Enrollment 2015 November 12 November 26 November 4 & 6, 2014 1 Brief Review of Affordable Care Act (ACA) What You Need to Know What you Need to do by November 26 What s New or Changing in 2015 Do
More informationUniversity of Southern California USC. USC Senior Care. A Supplemental Plan to Medicare
Senior Care A Supplemental Plan to Medicare What is Senior Care and Who is Eligible? A sponsored supplemental plan to Medicare for former employees of the University of Southern California, their spouses,
More informationImportant Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.etf.wi.gov or by calling 1-877-533-5020. Important Questions
More informationOperating Engineers Public Employees Health and Welfare Trust Fund Plan D vs PERS CHOICE and PERS SELECT PPO Plan
Calendar Year Deductible $500 Individual / $1,000 Family per calendar year Does not apply to PPO physician office visits, PPO preventive care or hospital emergency room charges for an emergency medical
More informationName: Location: Phone:
Welcome to our practice. Please complete all sections below. The signature of the patient, the custodial parent, or the legally responsible party is required. Please print all information. PATIENT INFORMATION:
More informationAdvanced Women's HealthCare, SC Registration Form
Patient Full Name Address Advanced Women's HealthCare, SC Registration Form Street Account # Provider Last First Middle Maiden(0ther) Apt/Suite# City State Zip Code Phone # (Please circle preferred contact
More informationMassachusetts Application for Health and Dental Coverage and Help Paying Costs
Massachusetts Application for Health and Dental Coverage and Help Paying Costs THINGS TO KNOW HOW TO APPLY Use this application to see what coverage choices you may qualify for. Who can use this application?
More informationApply faster online at Compass.ga.gov.
GEORGIA DEPARTMENT OF HUMAN SERVICES Division of Family and Children Services Application for Health Coverage & Help Paying Costs Form Approved OMB No. 0938-1191 Use this application to see what coverage
More informationThis guide was designed for employees in the University System of Georgia Indemnity HealthCare plan who reside abroad
University System of Georgia Guide for GA TECH Employees Residing Abroad This guide was designed for employees in the University System of Georgia Indemnity HealthCare plan who reside abroad. Frequently
More informationTVA-Tennessee Valley Authority 80% PPO Plan Coverage Period: 01/01/2015-12/31/2015
TVA-Tennessee Valley Authority 80% PPO Plan Coverage Period: 01/01/2015-12/31/2015 Summary of Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family* Plan Type: PPO This is
More information