How To Get Eye Care Insurance

Transcription

1 March 1 st begins our open enrollment period for Ameritas/Eye Med Vision Insurance. During this time, you will be allowed to elect changes such as new enrollments and cancellations as well as adding or deleting eligible dependents. The deadline to submit changes will be April 1, 2014 at 5pm. After that point, unless you have a qualifying event, you will not be able to make further changes until next year s open enrollment period. Please take some time to review the attached forms for more information on the plan coverage and complete the enrollment/change form to make your elections, should you have any. We will send out reminders as we get closer to the deadline. EyeMed Rates Per Pay Period Employee Only (EE) $3.56 EE + Spouse $6.87 EE + Children $5.78 EE + Spouse & Children $9.08

2 Newton County Board of Commissioners Eye Care Highlight Sheet ViewPointe SM Plan H Summary Effective Date: 04/01/2014 EyeMed Access Network Out of Network Deductibles Exam $10 No deductible Eye Glass Lenses $25 No deductible Annual Eye Exam Covered in full Up to $35 Lenses (per pair) Single Vision Covered in full Up to $25 Bifocal Covered in full Up to $40 Trifocal Covered in full Up to $55 Lenticular 20% discount No benefit Progressive See lens options NA Contacts Standard Standard: Member cost up to $55 No benefit Premium (Allowance) Premium: 10% off of retail No benefit Elective Up to $115 Up to $92 Medically Necessary Covered in full Up to $200 Frames $100 Up to $45 Frequencies (months) Exam/Lens/Frame 12/12/24 12/12/24 Based on date of service Based on date of service Lens Options (member cost) Please note that some lens options may only be partially covered by this plan and some may not be covered at all which may result in higher out of pocket costs. Additional charges may also apply for progressive and polycarbonate lenses. Ask your eye care provider for all available. EyeMed Network Out of Network Progressive Lenses No benefit Standard Standard: $65 + lens deductible Premium Premium: lens cost - 20% discount - $120 allowance + Standard Progressive cost Std. Polycarbonate $40 No benefit Tint (solid and gradient) $15 No benefit Scratch Resistant Coating $15 No benefit Anti-Reflective Coating $45 No benefit Ultraviolet Coating $15 No benefit Lasik or PRK Average discount of 15% off retail price or 5% off promotional price at US Laser Network participating providers. No benefit Rates Per Pay Period Employee Only (EE) $3.56 EE + Spouse $6.87 EE + Children $5.78 EE + Spouse & Children $9.08

3 Newton County Board of Commissioners Eye Care Highlight Sheet Additional ViewPointe SM H Features EyeMed In-Network Discounts 15% discount off the remaining balance in excess of the conventional contact lens allowance. 20% discount off the remaining balance in excess of the frame allowance. 20% discount on items not covered by the plan at network providers, which may not be combined with any other discounts or promotional offers. This discount does not apply to EyeMed Provider's professional services, or contact lenses. EyeMed In-Network Secondary Purchase Plan Members receive a 40% discount on a complete pair of glasses once the funded benefit has been exhausted. Members receive a 15% discount off the retail price on contact lenses once the funded benefit has been exhausted. Discount applies to materials only. Contact Lens Replacement by Mail Program After exhausting the contact lens benefit, replacement lenses may be obtained at significant discounts on-line. Visit EyeMedvisioncare.com for details. Eye Care Plan Member Service ViewPointe eye care from Ameritas Group features the money-saving eye care network of EyeMed Vision Care. Customer service is available to plan members through EyeMed's well-trained and helpful service representatives. Call or go online to locate the nearest EyeMed network provider, view plan benefit information and more. EyeMed Customer Care Center: Service representative hours: 8 a.m. to 11 p.m. ET Monday through Saturday, 11 a.m. to 8 p.m. ET Sunday Interactive Voice Response available 24/7 Locate an EyeMed provider at: ameritasgroup.com/provider View plan benefit information at: eyemedvisioncare.com Section 125 This plan is provided as part of the Policyholder's Section 125 Plan. Each employee has the option under the Section 125 Plan of participating or not participating in this plan. If an employee does not elect to participate when initially eligible, he/she may elect to participate at the Policyholder's next Annual Election Period. This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator.

4 Group Enrollment / Change or Waiver Form POLICY AND DIV. # 010- NAME AND ADDRESS OF EMPLOYER (Policyholder) 1. TO ENROLL EYE CARE ONLY TERMINATE COVERAGE EMPLOYEE INFORMATION: MARITAL STATUS SINGLE MARRIED SOCIAL SECURITY NUMBER DEPT.# EMPLOYEE S LAST NAME, FIRST, MI DATE OF BIRTH MALE FEMALE FULL TIME DATE OF HIRE REHIRE - REHIRE DATE OCCUPATION HOURS WORKED EACH WEEK ARE YOUR EARNINGS PAID: HOURLY OR SALARIED STREET ADDRESS CITY STATE ZIP ARE YOU COVERED UNDER ANOTHER EYE CARE INSURANCE PLAN? EMPLOYEE: YES NO DEPENDENTS: YES NO DEPENDENT COVERAGE INFORMATION. LIST ALL ELIGIBLE DEPENDENTS TO BE ADDED OR DELETED. (Employee must be enrolled to cover dependents) PRINT FULL LEGAL NAME (LAST, FIRST, M) ADD DROP RELATIONSHIP SEX DATE OF BIRTH SOCIAL SECURITY NUMBER PLEASE SIGN (EMPLOYEE / POLICYHOLDER SIGNATURES) As an employee, I hereby apply for, or waive (if indicated), group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct premiums from my salary. THE FOLLOWING APPLIES ONLY TO SECTION 125 FLEXIBLE BENEFITS PLANS: I am signing up for coverage until the next enrollment period except in the case of a life event. This information was explained in the plan s solicitation materials which I have read and understand. I represent that the information I have provided is complete and accurate. The policyholder certifies the date of employment, job title, hours worked and salary information are correct according to the Policyholder s records. X X Employee Signature (Do Not Print) Date Policyholder Signature Date In several states, we are required to advise you of the following: Any person who knowingly and with intent to defraud provides false, incomplete, or misleading information in an application for insurance, or who knowingly presents a false or fraudulent claim for payment of a loss or benefit, is guilty of a crime and may be subject to fines and criminal penalties, including imprisonment. In addition, insurance benefits may be denied if false information provided by an applicant is materially related to a claim. (State-specific statements on back.) EMPLOYEE LATE ENTRANT DATE DEPENDENT LATE ENTRANT DATE 2. TO CHANGE NAME CHANGE NEW NAME Effective Date OLD NAME Class Dep. Code ADD DEPENDENT COVERAGE IF DUE TO MARRIAGE, WHAT IS THE DATE OF MARRIAGE? IF DUE TO BIRTH/ADOPTION OF A CHILD, WHAT IS THE DATE OF EVENT? IF DUE TO LOSS OF COVERAGE, DATE AND REASON: OTHER, THE DATE OF EVENT AND PLEASE EXPLAIN: DROP DEPENDENT COVERAGE NUMBER OF DEPENDENTS STILL COVERED: DUE TO DIVORCE DUE TO DEATH DUE TO ANNUAL ELECTION PERIOD OTHER: PLEASE EXPLAIN: EFFECTIVE DATE OF DROP: 3. TO WAIVE IF YOU DO NOT WANT COVERAGE, COMPLETE THE WAIVER SECTION. THE WAIVER MAY NOT BE ALLOWED FOR THIS PLAN, CHECK WITH YOUR EMPLOYER. I have been given an opportunity to apply for Group Insurance offered by my employer, and have decided not to accept the offer for: myself (does not apply to TRUST policies) spouse only child(ren) only spouse and child(ren) because Name of Insurance Co. & Employer of Dependent Should I desire to apply for this group insurance in the future, I realize that a late entrant penalty may be applied. GR 875 Rev COBRA - If the individual is a continuee: Qualifying Event Date of Event CERT.# MAILING ADDRESS: P.O. BOX 81889, LINCOLN, NE / FAX: L

5 Note for California Residents: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage. Note for Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Note for Florida Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Note for New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Note for Georgia, Oregon and Virginia Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud against insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law. Note for Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. TIPS FOR FILLING OUT THIS FORM TO ENROLL Missing, incomplete or illegible information can cause delays in adding new employees to the system and could create errors in billing. To ensure proper handling of your enrollment forms, please make sure the following areas are completed: Policy Name and Group Number to make sure plan members are added to the correct group. Department/Division Numbers so plan members are added in the proper locations, and appear in the appropriate section on the billing if the group has multiple departments or divisions. Social Security Numbers the most important identifier for plan members when calling in with claims or administrative questions. Please double check to make sure your social security number is accurate and written clearly. Full-time Employment Date needed so the correct effective date is calculated for new members. Class Number needed when the plan has more than one class of employees. TO CHANGE Changing Dependent Codes When adding or dropping dependents, please note whether this change is because of a life event or for some other reason. (Examples of life events: marriage, birth of a child, divorce... ) Please remember to include the date of the event. Late entrant status will be applied if a life event is not included. Be specific when changing status so all dependents who are still eligible will be covered. IMAGING In order to provide better service, our administration system utilizes image technology. In the image environment, we scan your enrollment forms into our system, making them easier and faster to access. Better quality forms help us to process your enrollments faster. Unfortunately, certain forms are difficult or impossible to scan. The following list of helpful hints will make your forms easier to scan: Do: 1) submit clear, legible enrollment forms. 2) underline or circle important information. 3) use blue or black ink. Don t: 1) submit dark copies as they appear black on imaging. 2) highlight, which blackens the area so it cannot be read. 3) write on the top or bottom margins. This information is not always captured on the image system. GR 875 Rev L

6 Professional Providers Near You Not all providers offer all services. Discounts on non-covered services, like the additional pair discount, may not be available in all states. When making your appointment, please confirm all discounts and services are offered. PREMIER OPHTHALMOLOGY LLC 7170 HWY 278STE B (770) Miles PEARLE VISION 1192 DOGWOOD DR SE CONYERS, GA (770) Miles DR JAMES D BARBER 5165 COOK ST (770) Miles SEARS OPTICAL MALL AT STONECREST 8020 MALL PKWY LITHONIA, GA (678) Miles GEORGIA OPHTHALMOLOGISTS LLC 4167 HOSPITAL DR (770) Miles JCPENNEY OPTICAL 8040 MALL PKWY LITHONIA, GA (770) Miles ANDREA WASHINGTON OD 4106 MILL STSTE A (678) Miles THE MALL AT STONECREST 2929 TURNER HILL RDSTE 2500 LITHONIA, GA (678) Miles COVINGTON VISION CENTER 4124 HIGHWAY 278 (770) Miles 4002 STONE MOUNTAIN HWYSTE 100 SNELLVILLE, GA (770) Miles EYE DEAL OPTICAL 5125 HWY 278 NW (770) Miles PEARLE VISION 1708 SCENIC HWY SNELLVILLE, GA (770) Miles

7 EAST METRO EYECARE PC 1013 E FREEWAY DR CONYERS, GA (770) Miles JCPENNEY OPTICAL 1380 WEST HWY 20 MCDONOUGH, GA (770) Miles R WAYNE BAKER OD 1455 OLD MCDONOUGH RD CONYERS, GA (770) Miles THE AVENUES OF WEBB GIN 1250 SCENIC HWYSTE 1268 LAWRENCEVILLE, GA (678) Miles MILAMS COMMUNITY EYE CARE 805 COMMERCE DR SOUTHWESTSTE A CONYERS, GA (770) Miles SHERWIN WILLIAMS PAVILION 1363 MT ZION RD MORROW, GA (770) Miles ARATI D PANDYA MD 1309 MILSTEAD RD NORTHEAST CONYERS, GA (770) Miles SEARS OPTICAL SOUTHLAKE MALL 1300 SOUTHLAKE MALL MORROW, GA (770) Miles MONROE OPTICAL INC 1311 W SPRING ST MONROE, GA (770) Miles PEARLE VISION 1281 SOUTHLAKE CIRCLE MORROW, GA (770) Miles WALTON EYE CARE INC 517 GREAT OAKS DRSTE 101 MONROE, GA (770) Miles MACYS OPTICAL 1500 SOUTHLAKE MALL MORROW, GA (770) Miles

8 JOE H DEW OD 428 W HIGHLAND AVE MONROE, GA (770) Miles JCPENNEY OPTICAL 4840 BRIARCLIFF RD NE ATLANTA, GA (770) Miles SVS VISION 3552 HIGHWAY 138 SW STOCKBRIDGE, GA (770) Miles 1173 NORTHLAKE MALL 4800 BRIARCLIFF RD NE ATLANTA, GA (770) Miles STONECREST EYE EXPERTS 8225 MALL PARKWAYSTE 210 LITHONIA, GA (678) Miles SEARS OPTICAL NORTHLAKE MALL 2201 HENDERSON MILL ATLANTA, GA (770) Miles LEWIS FREY OD PC 4495 ATLANTA HWYSTE 300 LOGANVILLE, GA (770) Miles TARGET OPTICAL 3935 VENTURE DRIVE DULUTH, GA (678) Miles FRED R HOWELL OD 4380 LAWRENCEVILLE RD LOGANVILLE, GA (770) Miles SEARS OPTICAL GWINNETT PLACE MALL 2100 PLEASANT HILL DULUTH, GA (770) Miles EAST LAKE EYE CARE PC 2145 HIGHWAY 155 N MCDONOUGH, GA (770) Miles GWINNETT PLACE MALL 2100 PLEASANT HILL RDSTE 254 DULUTH, GA (770) Miles

9 THE SPECTACLE SHOPPE 1410 EATONTON RD MADISON, GA (706) Miles MACYS OPTICAL GWINNETT MALL PLACE 2100 PLEASANT HILL RD DULUTH, GA (770) Miles ADVANCED EYE CARE OF MADISON 223 S MAIN ST MADISON, GA (706) Miles PEARLE VISION GEORGIA SQUARE 3700 ATLANTA HWY ATHENS, GA (706) Miles GEORGIA OPHTHALMOLOGISTS LLC 2151 EATONTON RDSTE H2 MADISON, GA (706) Miles SEARS OPTICAL GEORGIA SQUARE MALL 3700 ATLANTA HIGHWAY ATHENS, GA (706) Miles ROBERT L ELWELL JR OD 673 W WASHINGTON ST MONTICELLO, GA (706) Miles ATHENS PROMENADE 3654B ATLANTA HWY ATHENS, GA (706) Miles SOUTHPOINT EYECARE 5900 HILLANDALE DRSTE 345 LITHONIA, GA (678) Miles NORTH DRUID HILLS 2370 N DRUID HILLS RD NE ATLANTA, GA (404) Miles MCDONOUGH VISION CARE 183 KEYS FERRY STSTE A MCDONOUGH, GA (770) Miles PEARLE VISION MILL CREEK WALK SHOPPING CTR 3264 BUFORD DRSTE 100-A BUFORD, GA (678) Miles

10 AKSTEIN EYE CARE CENTER PC 102 ATLANTA ST MCDONOUGH, GA (770) Miles MACYS OPTICAL MALL OF GEORGIA 3333 BUFORD DR BUFORD, GA (770) Miles EAGLE EYE & MEDICAL CLINIC 237 ATLANTA ST MCDONOUGH, GA (770) Miles MALL OF GEORGIA 3333 BUFORD DRSTE 2002 BUFORD, GA (678) Miles GEORGIA OPHTHALMOLOGISTS LLC 170 MACON RD JACKSON, GA (770) Miles JCPENNEY OPTICAL 3379 A BUFORD DR BUFORD, GA (770) Miles STONE MOUNTAIN EYE CLINIC 7184 ROCKBRIDGE RDSTE 301 STONE MOUNTAIN, GA (678) Miles MACYS OPTICAL LENOX MALL 3393 PEACHTREE RD NORTHEAST ATLANTA, GA (404) Miles RICHARD CARLIN MD PC 2377 LENORA CHURCH RD SNELLVILLE, GA (770) Miles LENOX SQUARE 3393 PEACHTREE RD NORTHEASTSTE B128 ATLANTA, GA (404) Miles ENVISION FAMILY EYECARE 414 HWY 155 SOUTH MCDONOUGH, GA (770) Miles FAYETTE PAVILLION 160 PAVILLION PKWY FAYETTEVILLE, GA (770) Miles Not all providers offer all services. Please confirm the services available at the provider when making your appointment.

11 Always call ahead to confirm their participation in your plan, and identify yourself as an EyeMed member to ensure you receive your maximum benefits. Eye exams are available by Independent Doctors of Optometry at or next to LensCrafters, Pearle Vision, Sears Optical and Target Optical in most states. Doctors in some states are employed by the location. In California, optometrists are not employed by LensCrafters, Sears Optical and Target Optical, which do not provide eye exams. For LensCrafters, eye exams are available from optometrists employed by EYEXAM of California, a licensed vision health care service plan. For Sears Optical and Target Optical, eye exams are available from self-employed doctors who lease space inside the store. This list does not include laser vision correction surgeons. For laser vision correction providers, please call LASER6 or visit