HEALTH INSURANCE ENROLLMENT FORM
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1 HEALTH INSURANCE ENROLLMENT FORM Requirements You must complete the Enrollment Form as part of the New Hire Process. You must elect or decline coverage on the Enrollment Form. Return the Enrollment Form to your anager. Keep the Plan Information Packet for your. Esprit Benefits
2 Enroll Today and Avoid the IRS Tax Penalty! IRS enforces this penalty on your individual tax return. The IRS 2016, you WILL pay the higher of these two amounts: $695 per person ($ per child under 18). The maximum penalty per family using this method is $2, % of your yearly household income (only the amount of individual in 2014, is used to calculate the penalty. The maximum penalty is the national average premium for a Bronze plan.
3 Benefit Options Esprit Benefits MEC - Minimum Essential Coverage (Basic level of coverage required by law) Eliminates the personal IRS penalty under the Affordable Care Act Covers the required preventative services as outlined by the CMS Unlimited Telemedicine included-espritdoc Aetna Dental, Vision, Chiropractic, Hearing, and More Bundled Benefit Card for individual employee or the whole family-same price Valuable services and discounts
4 Frequently Asked Questions Your benefits will be effective on the 1st of the month following 30 days from your hire date. What is the tax penalty I keep hearing about? Coverage or pay a tax penalty. May I cover my dependents? Yes. On the enrollment form please select the coverage level you are enrolling in. Employee Only Employee + Spouse Employee + Children Employee + Family. *You may cover your children up to age 26 Can I make changes or cancel coverage? You status due to one of the following: Marriage or divorce Birth or adoption of a child(ren) Termination Medicare entitlement Loss or prior coverage Loss of dependent status
5 Benefit Election Form Please remit completed form to your employer Employer - Please Complete This Section: Requested Effective Date 01/01/2016 Date of Hire X Open Enrollment New Hire Life Status Change Employer Name BGI Staffing Group Number Employee: First Name DOB Address City Marital Status Spouse: First Name DOB Dependents (Additional Room on Back): Full Name DOB Full Name DOB Full Name DOB Last Name Social Security Number State Zip Phone Gender Male Female Last Name SSN Gender SSN Gender SSN Gender SSN Esprit Benefits
6 Benefit Election Form Esprit Benefits Please remit completed form to your employer Benefit Selection Coverage Two Deductions Per Month of: MEC Employee Only Employee + Spoue Employee + Child(ren) Family $38.08 $57.58 $86.30 $104.65
7 Benefit Election Form Esprit Benefits Refusal of Coverage I decline the Minimum Essential Coverage (MEC) and Minimal Value Plan (MVP) because I am currently enrolled in other creditable coverage: Spouse s Plan Other Government Sponsored Plan Tricare Other (Please specify) I do not have other creditable coverage and understand that I face tax penalties for not enrolling in my employer s sponsored Minimum Essential Coverage plan. Authorizations/Salary Reduction Agreement: I understand that in order to be eligible for the coverages I have elected, I must meet any applicable actively at work requirement as defined by the insurance contracts. I authorize any physician, medical practitioner, hospital, clinic, or medical related facility, insurance or reinsurance company, having information available as to diagnosis, treatment and prognosis with respect to any physical or mental condition and/or treatment of me or my minor children and any other non-medical information of me or my minor children to give to our Insurance Companies or their legal representative, any and all such information. I authorize the use and disclosure of my Social Security Number in the administration and provision of such benefits as may apply to me or my minor children. I understand Special Enrollment Rules may apply if I waive coverage for myself or my dependents when initially eligible, due to other health insurance coverage. If I do not qualify under the Special Enrollment Rules, enrollment will be restricted to once a year during the annual open enrollment period, subject to the pre-existing conditions limitations. I authorize the Company to reduce my regular compensation per pay period for all employee benefits which I have elected and deductions made for the purpose of recovering any ineligible benefit payments. This authorization shall remain in force for this Plan Year and each subsequent Plan Year, or until my participation in the employee benefit plan(s) terminates. By providing my address, I Authorize and Consent to the use of for communications regarding my employee benefits. I understand that my address is private and will be used solely for benefit administration purposes. I hereby authorize my employer to deduct from my paycheck the monthly premium agreed to on this application or a portion of it. I understand I can cancel at anytime with no obligation. X Signature Date
8 MEC MINIMUM ESSENTIAL COVERAGE SERVICE BENEFIT BENEFIT LIMITS PER CALENDAR YEAR Covered Preventive Serrvices rvices For: r Aspirin use for Men and W Ever - T disease - Varicella T r older T ion ser and r r
9 MEC MINIMUM ESSENTIAL COVERAGE SERVICE BENEFIT BENEFIT LIMITS PER CALENDAR YEAR Wr Well-W COVERED PREVENTIVE SERVICE FOR WOMEN - INCLUDING PREGNANT WOMEN r r - Cer Wr Wr r W r - r r r
10 MEC MINIMUM ESSENTIAL COVERAGE Basic Level of Care Required By Law SERVICE BENEFIT BENEFIT LIMITS PER CALENDAR YEAR Gestational Diabetes Screening Plan pays 100% of Allowable Charges For women 24 to 28 weeks pregnant and / or at high risk of developing gestational diabetes Hepatitis B Screening Plan pays 100% of Allowable Charges Osteoporosis Screening Plan pays 100% of Allowable Charges For women over age 60 or at high risk Plan pays 100% of Allowable Charges Screening and counseling Test Plan pays 100% of Allowable Charges Every 3 years for woment with normal cytolo - gy results who are age 30 or older Rh Incompatibility Screening Plan pays 100% of Allowable Charges For pregnant women follow-up testing for women at higher risk Tobacco Use Screening and interventions Plan pays 100% of Allowable Charges Urinary tract or other infection screening Plan pays 100% of Allowable Charges For pregnant women Sexually T - ing and Counseling, includes Gonorrhea & Syphilis Plan pays 100% of Allowable Charges
11 MEC MINIMUM ESSENTIAL COVERAGE SERVICE BENEFIT BENEFIT LIMITS PER CALENDAR YEAR COVERED PREVENTIVE SERVICE FOR CHILDREN Wr Cer r r r W- - V T r T TrT r
12 Some expenses are unavoidable. Other expenses are unnecessary. What if you could eliminate or reduce the cost of those expenses? Now that s smart. Check out the following EspritMed Healthy savings for healthy families. $15.95 per month Medical Bill Saver Experts who know the ins and outs of billing practices will attempt to negotiate a reduction in your outof-pocket medical expenses. Health Advocacy Your lifeline for healthcare and insurance help. Nurseline Rest assured highly trained registered nurses are on-call 24/7 to answer your questions. Vision Your eyes are the windows to your health. Save 10% to 60% on glasses, contacts, laser surgery, exams and more. Dental Smile brighter with big savings on dental services at thousands of locations nationwide. Chiropractic Back out of whack? Save 30% to 50% on X-rays, diagnostic services and treatments at chiropractors nationwide. Lab Testing Know your numbers! Help monitor your health with 10% to 80% off typical costs of routine lab work. MRI & CT Scans Save 50% to 75% on usual charges for MRI, CT Scans and more at thousands of credentialed radiology centers nationwide.* Hearing Aids Want to save big on hearing aids? You ll save 35% at retail locations nationwide. Diabetic Management Diabetes can be hard to manage big savings on supplies can make life easier. Start Saving TODAY!
13 DiscountMedicalPlan Application GroupNumber Company EmployeeID# DateofBirth Male Female FirstName MI LastName Address City State Zip Phone EspritMed $15.95permonth Thispackageincludes:HealthAdvocacy,MedicalBillSaver,Nurseline,Vision,Dental, Chiropractic,Hearing,LabTesting,MRI&CTScans,andDiabeticManagement Signupnowthroughpayrolldeduction! Iherebyauthorizemyemployertodeductfrommyearningssuchamountsasmaynowor hereafterbepayabletomeunderthediscountplanpurchasedthroughespritmed.intheeventof aratechange,iauthorizeacorrespondingchangeintheamountdeductedfrommyearnings.i alsoacknowledgeallratesaredeductedfrommypaycheckposttax. Yoursignature Date Yourmembershipiseffectiveupon / / If no date is populated above, your membership is effective upon receipt of membership materials. This plan is NOT insurance. The plan is not insurance coverage and does not meet the minimum creditable coverage requirements under the Affordable Care Act or Massachusetts M.G.L. c. 111M and 956 CMR This discount card program contains a 30 day cancellation period. Member shall receive a full refund of membership fees if membership is cancelled within the first 30 days after the effective date. Discount Medical Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box , Dallas, TX Discount Lab Work Benefit is not available to HI, MA, MD, ND, NJ, NY, RI or SD residents. Not available to residents of FL, KS, UT, VT, WA. Form#NB5727PD
14 Disclosures: This plan is NOT insurance. The plan is not insurance coverage and does not meet the minimum creditable coverage requirements under the Affordable Care Act or Massachusetts M.G.L. c. 111M and 956 CMR This plan provides discounts at certain healthcare providers for medical services. This plan does not make payments directly to the providers of medical services. The plan member is obligated to pay for all healthcare services but will receive a discount from those healthcare providers who have contracted with the discount plan organization. This discount card program contains a 30 day cancellation period. The range of discounts for medical or ancillary services provided under the plan will vary depending on the type of provider and medical or ancillary service received. Member shall receive a full refund of membership fees if membership is WA residents.
15 DiscountMedicalPlan Application Terms&Conditions 1. Member is defined as primary member, spouse, and all legal dependents. 2. Providers are subject to change without notice. Programs may vary in some states. Providers and locations may be removed from the network at any time. 3. This is a discount program only. The program may be cancelled or modified at anytime. You will receive notice if the plan is cancelled or materially modified. 4. Normal business hours are Monday through Friday, 7:00 am to 7:00 pm and Saturday, 8:00 am to 5:00 pm Central Time. 5. The discount company will not reimburse or pay any portion of any provider s fees. These benefits may not be used with any other discount plan or program. Listed or quoted prices are subject to change without notice. 6. Providers may offer products or services to the public at prices lower than the discounted prices. In such event, members will be charged the lower price. 7. Savings are based on the provider s normal fees. Actual savings will vary by location and the services or products purchased. 8. This discount program is a referral plan, and makes no warranties concerning the quality of care received. Providers are responsible for the professional advice and treatment provided to members. Form#NB5727PD
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