If you have previously added dependents to your plan, you are not required to return a completed form.

Transcription

1 PHBP Producers Health Benefits Plan c/o Administrative Services Only, Inc. 303 Merrick Road, Suite 300 Lynbrook, NY P-(888)-345-PHBP F-(888) November 15, 2013 Dear Member: This serves as a reminder that we are in the open enrollment period for the Producers Health Benefits Plan (PHBP). Any member who was eligible for medical benefits through PHBP as of January 1, 2014, has the option of adding any dependent for whom they had previously waived coverage; (dependent coverage will begin on January 1, 2014 if procured prior to the cut off date of December 13, 2013). Once you opt for this coverage it will be effective until you, the member, are no longer eligible. The monthly cost to add a child or children is $329.33, to add a spouse/domestic partner is $ and to add a spouse/domestic partner and a child or children is $ For your convenience, enclosed please find a PHBP enrollment form and a breakdown of the monthly premium costs. If you wish to add any non-covered dependents to your insurance policy we will need to receive the completed enrollment form, proof of dependent status (marriage/birth certificate) and the monthly premium payment for January NO LATER THAN December 13, We have also enclosed an automatic withdrawal form. Payments can be withdrawn from a checking account on a monthly or quarterly basis. In order for the Plan to withdraw funds from your account we will need to receive the completed withdrawal form, a VOIDED check, and a completed enrollment form. If you have previously added dependents to your plan, you are not required to return a completed form. If you have any further questions or need any additional information please feel free to contact us at Very truly yours, Producers Health Benefits Plan

2 PHBP BENEFITS ENROLLMENT AND CHANGE FORM! Open Enrollment! New Enrollee! COBRA! Change Effective Date: *Qualifying Event: *Qualifying Event Date:! Cal COBRA Anthem PHBP Group Number: Anthem Medical PPO Dept Code (Staff CA):_M004_ Anthem Medical PPO Dept Code (Staff OOS): M010_ Anthem Medical PPO Dept Code (Freelance CA):_M001_ Anthem Medical PPO Dept Code (Freelance CA): M007_ Anthem Dental Group Number (ALL Staff and Freelance): COMPLETED FORMS MUST BE SUBMITTED TO ASO ONLY: BY MAIL (PHBP, C/O ASO, 303 Merrick Rd. Suite 300, Lynbrook, NY 11563) FAX ( ) OR YOUR SECURE SYSTEM EMPLOYEE INFORMATION (Please Print Clearly) - - Social Security Number Last Name First Name MI Maiden Name (if applicable) Job Title Sex Residential Address City State Zip Code! Single! Married! Divorced! Domestic Partner Mailing Address (if different from residential) City State Zip Code Employer Name (if applicable) ( ) ( ) Business Phone Home Phone Address Date of Hire Staff or Freelance Language Preference! English! Other Check box if additional sheet is attached to this application! ENROLLMENT INFORMATION First Name Last Name MI Social Security # Sex Date of Birth Age 26 Plans Decline Reason for declining coverage or older (Check One) SELF ANTHEM MEDICAL PPO AND ANTHEM DENTAL + VSP VISION! Covered by spouse's Plan! ENROLLED IN MEDICARE***! Carrier Name and ID# SPOUSE OR Medicare! DOM. PARTNER** ANTHEM MEDICAL PPO AND! Covered by Individual Plan!! Add ANTHEM DENTAL + VISION Enrolled in Tricare!! Delete ENROLLED IN MEDICARE***! Spouse Covered by Employer Plan! CHILD Enrolled in any other insurance plan! Carrier Name! Add! Yes ANTHEM MEDICAL PPO AND! Other!! Delete! No ANTHEM DENTAL + VSP VISION CHILD! Add! Yes ANTHEM MEDICAL PPO AND!! Delete! No ANTHEM DENTAL + VSP VISION CHILD! Add! Yes ANTHEM MEDICAL PPO AND!! Delete! No ANTHEM DENTAL + VSP VISION CHILD! Add! Yes ANTHEM MEDICAL PPO AND!! Delete! No ANTHEM DENTAL + VSP VISION *For COBRA or Cal COBRA **To be eligible as a Domestic Partner, the Subscriber and Domestic Partner must have properly filed a Declaration of Domestic Partnership with the California Secretary of State pursuant to the California Family Code, or have properly filed an equivalent document in accordance with the laws of another jurisdiction recognizing the creation of domestic partnerships. ***If you are eligible for Medicare, Anthem Blue Cross may not duplicate benefits. If you are adding yourself or your depenent outside the annual open enrollment period, you must submit this form along with the necessary documents (birth certificate, proof of prior coverage, marriage certificate, etc) within 30 days of the date of the change or no approval can be granted. If any dependent resides at another residence, please enter their information below: Dependent Name Relationship Address City ST ZIP DECLINITATION STATEMENT I acknowledge that the available coverages have been explained to me by my employer and I know that I have every right to apply for coverage. I have been given the chance to apply for this coverage and I have decided not to enroll myself and/or my dependent(s), if any. I have made this decision voluntarily, and no one has tried to influence me or put any pressure on me to decline coverage. BY DECLINING THIS GROUP MEDICAL COVERAGE (UNLESS EMPLOYEE AND/OR DEPENDENTS HAVE GROUP MEDICAL COVERAGE ELSEWHERE) I ACKNOWLEDGE THAT MY DEPENDENTS AND I MAY HAVE TO WAIT UP TO TWELVE (12) MONTHS TO BE ENROLLED IN THIS GROUP MEDICAL AND DENTAL GROUP LIFE INSURANCE PLAN. PRE-EXISTING CONDITIONS, WHEN ENROLLED IN THIS GROUP MEDICAL PLAN, MAY NOT BE COVERED FOR SIX (6) MONTHS. BY DECLINING THE GROUP VISION COVERAGE, I ALSO ACKNOWLEDGE THAT MY DEPENDENTS AND I WILL NOT HAVE ANY OPPORTUNITY IN THE FUTURE TO ENROLL IN THE PLAN UNLESS WE CAN SHOW PROOF OF LOSS OF OTHER VISION COVERAGE. Employee Signature (if declining coverage for employee and/or dependents) Date Page 1 of 2

3 A. Do any persons on this application intend to continue other group coverage if this application is accepted? Yes No If yes, name of person: Insurance company: B. Does any person applying for coverage currently have health insurance coverage? Yes No Has any person applying for coverage had health insurance coverage at any time in the past six months? Yes No If yes, applicant/family member name(s): Type of continuous coverage: Group Individual Other: Insurance company: Date coverage began: Date ended: C. Does any person applying for coverage currently have dental insurance coverage? Yes No If yes, applicant/family member name(s): Type of continuous coverage: Group Individual Other: Insurance company: Date coverage began: Date ended: D. Is any person applying for coverage eligible for Medicare or currently receiving Medicare benefits? Yes No NOTE: Failure to advise and provide proof of coverage may subject you or a family member to a six month pre-existing conditions clause. SIGNATURE I attest by signing below that I have reviewed the information provided on this application and to the best of my knowledge and belief, it is true and accurate with no omissions or misstatements. DEDUCTION AUTHORIZATION: If applicable, I authorize my employer to deduct from my wages the required subscription charges/premium. NON-PARTICIPATING PROVIDER: I understand that I am responsible for a greater portion of my medical costs when I use a non-participating provider. HIV TESTING PROHIBITED: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance. EFFECTIVE DATE: The effective date of coverage is subject to Anthem Blue Cross and VSP approval. COBRA/CAL-COBRA CONTINUATION COVERAGE: You may continue your health care coverage by: 1) completing the remainder of this form; 2) signing your name in the blank space below; 3) paying your Total Monthly Continuation Payment; and 4) mailing this form to Anthem Blue Cross, no later than sixty (60) days after the date you receive this notice. If you fail to choose COBRA Continuation Coverage within sixty (60) days after the date 1 The you date receive eligibility this for notice, COBRA your Continuation qualification Coverage for coverage ends, will or end. If you do choose COBRA Continuation Coverage, your current coverage will be continued until the earliest of the following dates: 2 The date you fail to make timely payments of your premium for COBRA Continuation Coverage, or 3 The date your employer discontinues coverage with Anthem Blue Cross, or 4 The date you become entitled to Medicare on the basis of age (65 years), or the date thirty (30) months after you become entitled to Medicare on the basis of end stage renal disease, or 5 The date you become covered under another group health plan as a result of employment, re-employment, remarriage, or otherwise, unless that other group health plan contains an exclusion or limitation for a pre-existing condition for which you are covered under your current coverage with Anthem Blue Cross. In such a case, the date on which you would lose eligibility for Continuation Coverage with Anthem Blue Cross is the date full coverage becomes available to you under the other plan, without limitations or exclusions for pre-existing conditions. If, at any time during the first sixty (60) days of your COBRA Continuation Coverage, you are determined under Title II or XVI of the United States Social Security Act to be disabled, you may be entitled to continue coverage while you are disabled for up to 29 months from the date you first qualified for Continuation Coverage under COBRA. Contact the Health Plan Administrator at your previous employer for full information. The Monthly Note: If you do not elect available COBRA Continuation of Medical Coverage, you will lose certain rights under federal law (HIPAA) to guaranteed issue individual coverage REQUIREMENT FOR BINDING ARBITRATION I understand that if my coverage is provided pursuant to an employer-sponsored benefit plan that is exempt from ERISA or if I have a dispute that is not governed by ERISA that I will be subject to the following binding arbitration provision: The following provision does not apply to class actions: IF YOU ARE APPLYING FOR COVERAGE, PLEASE NOTE THAT ANTHEM BLUE CROSS AND ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY AND VSP REQUIRE BINDING ARBITRATION TO SETTLE ALL DISPUTES INCLUDING BUT NOT LIMITED TO DISPUTES RELATING TO THE DELIVERY OF SERVICE UNDER THE PLAN/POLICY OR ANY OTHER ISSUES RELATED TO THE PLAN/POLICY AND CLAIMS OF MEDICAL MALPRACTICE, IF THE AMOUNT IN DISPUTE EXCEEDS THE JURISDICTIONAL LIMIT OF SMALL CLAIMS COURT. It is understood that any dispute including disputes relating to the delivery of services under the plan/policy or any other issues related to the plan/policy, including any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. THIS MEANS THAT YOU AND ANTHEM BLUE CROSS AND/OR ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY ARE WAIVING THE RIGHT TO A JURY TRIAL FOR BOTH MEDICAL MALPRACTICE CLAIMS, AND ANY OTHER DISPUTES INCLUDING DISPUTES RELATING TO THE DELIVERY OF SERVICE UNDER THE PLAN/POLICY OR ANY OTHER ISSUES RELATED TO THE PLAN/POLICY. I, the applicant, acknowledge that I have read and understood this application in its entirety and agree to the terms therin. Employee Signature (required) Date Page 2 of 2

4 PHBP Producers Health Benefits Plan c/o Administrative Services Only, Inc. 303 Merrick Road, Suite 300 Lynbrook, NY P-(888)-345-PHBP F-(888) Payment of Monthly Premiums You may choose to make payments by regular mail or by Automatic Withdrawal. All payments are due by the 1 st of each month. For your convenience, premiums can be paid in three monthly installments or quarterly. The following is due each month to ensure uninterrupted Medical, Dental and Vision Coverage: Employee Only $ 0.00 Add Child(ren) $ Add Spouse/Domestic Partner $ Add Spouse/Domestic Partner & Child(ren) $ Option 1-Regular Mail If you wish to make a payment by regular mail, payments should be made payable and sent to: PRODUCERS HEALTH BENEFITS PLAN c/o Administrative Services Only, Inc. 303 Merrick Road, Suite 300 Lynbrook, NY Option 2-Automatic Withdrawal If you wish to have the monthly premiums automatically withdrawn from your Checking Account, please complete and return the Automatic Withdrawal Authorization Form below. Payments can be withdrawn monthly or quarterly. Terms of coverage, benefits and eligibility are governed by the Plan s Rules and Regulations, Insurance Policies and other Plan documents, and the decisions of its Trustees. Automatic Withdrawal Authorization Form Please enter your information about your checking account provided on the bottom of your check. You may only use a checking account. It can be from a bank, credit union or savings association. It can not be from a money market, line of credit or investment account. *Name on Bank Account: *Routing Number: *Bank Account #: I wish to have my account debited monthly I wish to have my account debited quarterly I certify that I have read and agree to abide by the Terms and Conditions. Money will be debited from my account at night on the day in which payment is due. Please be sure to include a VOIDED check with this form. Signature: Date: * Required Information

5 Terms and Conditions for Automatic Withdrawal SCOPE OF AGREEMENT: This Agreement covers your participation in the Automatic Withdrawal Program offered by Administrative Services Only, Inc (the "Program"). In this Agreement, the words "you" and "your" refer to the Basic Participant (that is, the person primarily responsible for repayment of the account) and also includes all Additional Participants who have applied to participate in the Program. The words "we," "our" and "us" refer to Administrative Services Only, Inc. The words "your account" refer to the account held by a bank, securities firm or other financial institution from which payment will be made when you make transactions under the Program. The words "your bank" mean the bank, securities firm or other financial institution that holds your account. PAYMENT FOR CASH OR CHECKS: Each time you initiate a transaction, you authorize us or our agent to draw a check or draft or initiate an automated clearing house (ACH) or depository transfer check (DTC) debit in your name to the financial account you specify in the amount you request, payable to us or to our agent, in the amount of the transaction. CHARGES: For each transaction your bank may assess its customary per-check or item-handling charge, if any. You also agree to pay us a service charge for each dishonored check or draft to reimburse us for any costs of collection. Your bank may also assess its customary charge for such items. DISHONORED REQUESTS FOR PAYMENTS: If any transaction (check or draft drawn by us or our agent in connection with the Program) is not honored by your bank, we have the right to charge the amount of any such transaction to your bank account or to collect the amount from you in some other way. If this happens, we may cancel your right to participate in the Program. HOW TO CONTACT US: If for any reason you wish to contact us about the automatic withdrawals or, if you believe someone has transferred or may transfer money from your account without your permission call PHBP (7427). Or write: Producers Health Benefits Plan (PHBP) Administrative Services Only, Inc. 303 Merrick Road, Suite 300 Lynbrook, NY OUR LIABILITY FOR IMPROPER TRANSACTIONS OR PAYMENTS: If a transaction is not completed as you have directed or if we do not complete a transfer to or from your account on time in the correct amount, we will be liable for your losses or damages. However, there are some exceptions. We will not be liable to you in the following instances: - If, through no fault of ours, your account does not contain enough money to complete the transaction; - If the funds in your account are subject to legal process or other encumbrance restricting the transaction; - If circumstances beyond our control (such as fire or flood) prevent the transaction, despite reasonable precautions that we have taken. BUSINESS DAY: For purposes of this Agreement, our business days are Monday through Friday. Holidays are not included. DISCLOSURE OF ACCOUNT INFORMATION TO THIRD PARTIES: To protect your privacy, we will not disclose any information about your transactions to any person, except as follows: 1. as necessary to complete transactions; 2. to comply with government agency or court orders; 3. to our employees, auditors, service providers, attorneys, or collection agents in the course of their

6 duties; 4. to persons authorized by law in the course of their official duties; or 5. if you give us your written permission. IN CASE OF ERRORS OR QUESTIONS ABOUT YOUR TRANSACTIONS: Write or call us at the number or address given above as soon as you can if you think your receipt is wrong or if you need more information about a transaction listed on your receipt. We must hear from you no later than 60 days from when the problem occurred. 1. Tell us your name and Social Security number. 2. Describe the error or the transaction you are unsure about, and explain as clearly as you can why you believe it is an error or why you need more information. 3. Tell us the dollar amount of the suspected error. If you tell us orally we may require that you send us your complaint or question in writing within 10 business days from the date you notified us. We will tell you the results of our investigation within 10 business days* after we hear from you and we will correct any error promptly. If we need more time, however, we may take up to 45 calendar days to investigate your complaint or question. If we decide to do this we will ensure that your bank re-credits your account within 10 business days* for the amount you think is in error, so that you will have the use of the money during the time it takes us to complete our investigation. If we ask you to put your complaint or question in writing and we do not receive it within 10 business days* following your oral notification, we may not re-credit your account. For transactions initiated outside the U.S. (and in the event there are transfers resulting from any point of sale debit card transactions), we will have 20 business days instead of 10 business days, and 90 calendar days instead of 45 calendar days, unless otherwise required by law. If we determine that there was no error, we will send you a written explanation within 3 business days after we finish our investigation. Upon your request we will provide you with copies of the documents that we used in our investigation. If we have provisionally re-credited your account during the investigation and determine that there was no error, we will notify you of the date on which we will redebit your account, and the amount to be debited. You should make certain that your account contains sufficient funds to cover this debit. If this happens, we may cancel your right to participate in the Program. Please be sure to check the next day to confirm that the transaction completed successfully. Terms of coverage, benefits and eligibility are governed by the Plan s Rules and Regulations, Insurance Policies and other Plan documents, and the decisions of its Trustees.

7 Anthem Blue Cross Modified Classic PPO 500 Medical Plan In-Network Benefits Non-Network Benefits Annual Deductible $500 per Person / $1,000 per Family $1,000 per Person / $2,000 per Family Annual Out-of-Pocket Maximum $2,000 per Person / $4,000 per Family (excludes deductibles & co-pays) Lifetime Maximum Benefit Unlimited Unlimited $4,000 per Person / $8,000 per Family (excludes deductibles & co-pays) Primary Office Visits $20 co-pay Deductible & Coinsurance Specialist Office Visits $20 co-pay (no referral required) Deductible & Coinsurance Emergency Room Co-pay $150 $150 Urgent Care Center $20 co-pay Deductible & Coinsurance Hospitalization Deductible & Coinsurance Deductible & Coinsurance + $500 co-pay Outpatient Surgery Deductible & Coinsurance Deductible & Coinsurance Outpatient Lab & X-Ray No co-pay Deductible & Coinsurance Rx Drugs Retail (30 Day Supply) Rx Drugs Mail Order (90 Day Supply) Dependent Children Domestic Partners Prior Notification Required for Certain Services Female Oral Contraceptives Generic and Single-Source Brand Name No co-pay Preventive Immunizations Administered at a Pharmacy No co-pay Tier 1 - $10 co-pay Tier 2 - $30 co-pay Tier 3 - $50 co-pay Tier 4-30% co-pay Female Oral Contraceptives Generic and Single-Source Brand Name No co-pay Tier 1 - $ 10 co-pay Tier 2 - $ 60 co-pay Tier 3 - $100 co-pay Tier 4-30 % co-pay Employee pays the full retail price of the prescription drug and submits claim form to us for reimbursement. We will reimburse 50% of the remaining prescription drug maximum allowed amount less any pharmacy deductible (if applicable), the above retail pharmacy co-pay & costs in excess of the prescription drug maximum allowed amount. Employee pays the full retail price of the prescription drug and submits claim form to us for reimbursement. We will reimburse 50% of the remaining prescription drug maximum allowed amount less any pharmacy deductible (if applicable), the above retail pharmacy co-pay & costs in excess of the prescription drug maximum allowed amount. Children are eligible up to age 26 regardless of student status* * Provided they are not eligible for other employer-sponsored coverage due to their own employment. Same sex Domestic Partners are eligible with proper verification Hospitalizations and many other services require prior notification to Anthem. You should contact Anthem s member services beforehand to confirm if prior notification is required. Some examples of services that require prior notification include hospital stays, maternity, home health care, hospice care, skilled nursing, rehabilitation, transplants, substance abuse and mental health services. Refer to your insurance certificate for a detailed list of services requiring prior notification. Failure to give prior notification may result in a loss or reduction of benefits. This summary is intended only to highlight your benefits and should not be relied upon to fully determine your coverage. This benefit plan may not cover all of your health care expenses. More complete descriptions of benefits and the terms under which they are provided are contained in the Certificate of Coverage that you will receive upon enrolling in the Plan. If this benefit summary conflicts in any way with the Policy issued, the Policy shall prevail. Insurance coverage provided by Anthem Blue Cross Insurance Company and affiliated insurance companies.

8 Anthem Blue Cross Dental PPO Plus VSP Vision Anthem Blue Cross Dental In-Network Benefits Non-Network Benefits Deductible (Indv/Fam)* $50/150 Maximum Allowance $1,500 Preventive Services 100% 100% Basic or General 80% 80% Major Services 50% 50% Child Ortho Not Covered Not Covered Payment Basis Negotiated Fee Schedule 90% of UCR *Waived for Preventive Care VSP Vision In-Network Benefits Non-Network Benefits Deductible (Exam/Materials) $10/25 $10/25 Exam 12 mo., Covered in full 12 mo., $45 allowance Lenses: Single 12 mo., Covered in full 12 mo., $30 allowance Bi-Focal 12 mo., Covered in full 12 mo., $50 allowance Tri-Focal 12 mo., Covered in full 12 mo., $65 allowance Lenticular 12 mo., Covered in full 12 mo., $70 allowance Frames 12 mo., $175 allowance 12 mo., $70 allowance Elective Contacts 12 mo., $175 allowance 12 mo., $105 allowance Required Contacts 12 mo., Covered in full 12 mo., $210 allowance This summary is intended only to highlight your benefits and should not be relied upon to fully determine your coverage. This benefit plan may not cover all of your dental and vision care expenses. More complete descriptions of benefits and the terms under which they are provided are contained in the Certificate of Coverage that you will receive upon enrolling in the Plan. If this benefit summary conflicts in any way with the Policy issued, the Policy shall prevail. Insurance coverage provided by Anthem Blue Cross Insurance Company and affiliated insurance companies and Vision Service Plan (VSP) and affiliated companies.