2015 Health Insurance Information. We ve got you covered

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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

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