Group Voluntary Supplemental Insurance for Part-Time and Hourly Workers

Transcription

1 Group Voluntary Supplemental Insurance for Part-Time and Hourly Workers This product is (a) not a substitute for minimum essential health coverage under the Affordable Care Act (ACA); and (b) does not qualify as minimum essential coverage under the ACA.

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3 What is Framework SM? Framework is a creative benefits program that is designed to provide supplemental and ancillary coverage to employees who are not offered qualifying coverage through their employer. Our benefits will not satisfy the employer or individual mandates, but they are designed to help employees reduce their out-of-pocket expenses or provide extra money when they are hospitalized or injured in an accident. Framework provides employers with a wide array of group insurance options that will help reduce turnover and improve retention. For more than 20 years, we have been designing and supporting fixed indemnity supplemental health benefit programs for employers ranging in size from 5 50,000 lives. With the implementation of the Affordable Care Act, we have re-designed our program to meet the new needs of part-time and hourly workers. Building upon our experience and reputation, we continue to grow and invest in our business to better serve our clients through superior customer service and competitive pricing. Creating Value for Employees & Employers Employees: Framework helps employees with day-to-day health care costs and creates value because it doesn t have the barriers to coverage that other plans have. Guaranteed issue, no medical questions asked at enrollment & no pre-existing condition limitations No deductibles or co-insurance (except dental and vision) Freedom to choose your own providers or use a network provider Custom employee communication materials Benefits can be assigned to a provider or paid to the employee Affordable dependent coverage Employers: Framework creates value for employers because it s affordable and has the flexibility to meet almost any budget and our flexible billing cycles make operating a benefit plan simple and easy. Benefits can complement a plan from the Health Insurance Marketplaces Plans can be 100% employee paid no employer contribution requirements Attract and retain employees reducing turnover costs Waiting period determined by the employer Missed premium strategy 1

4 Traditional Plans Employers can choose from a pre-packaged array of benefits and offer a plan suited to their specific needs. Depending upon group size, employers can offer from one to three plans with access to a prescription drug program, PPO network, discount benefits including Teladoc, and other benefits to complement the insured benefits. Traditional plans are available to groups with eligible lives. Plan 1 Plan 2 Plan 3 Hospital Admission Not Included $500 single sum $500 single sum Daily In-Hospital Indemnity (500 day lifetime maximum) Intensive Care Mental Illness Substance Abuse Skilled Nursing Inpatient Miscellaneous (60 day calendar year maximum) Surgical Indemnity Benefit Daily Inpatient Surgical Daily Outpatient Surgical Daily Outpatient Minor Outpatient Benefit $200 per day $300 per day $200 per day $50 per day $50 per day $50 per day (up to 60 days) $400 per day (up to 60 days) $600 per day $150 per day $150 per day $150 per day (up to 60 days) Not Included Not Included Not Included $500, $250 $50 Maximum amount payable is limited to 1 day per calendar year $1,000, $500 $100 Maximum amount payable is limited to 1 day per calendar year $1,500, $750 $150 Maximum amount payable is limited to 1 day per calendar year Anesthesia Benefit 30% of surgical 30% of surgical 30% of surgical Daily Outpatient Surgical Facility Not Included Not Included Not Included Doctor s Office Benefit Outpatient Diagnostic X-ray Outpatient Diagnostic Lab Outpatient Diagnostic Advanced Studies Preventive Care Accident Expense Emergency Room Indemnity Benefit for Illness Only $50 per day 6 days per calendar year $75 per testing day $75 per testing day Not Included $50 per day Not Included $75 per day 4 days per calendar year $60 per day 6 days per calendar year $85 per testing day $75 per day $300 max per occurrence $75 per day 4 days per calendar year $75 per day 6 days per calendar year $125 per testing day $200 per testing day $500 max per occurrence Life/AD&D Insurance $5,000 $5,000 $10,000 Discount Health Savings Program* Teladoc Health Advocacy Neighborhood Pharmacy Program Included Included Included 2 days per calendar year Voluntary Rates Monthly Weekly Monthly Weekly Monthly Weekly Employee Only $52.60 $12.12 $86.49 $19.94 $ $26.61 Employee + Child(ren) $89.03 $20.52 $ $34.59 $ $46.14 Employee + Spouse $ $27.56 $ $47.11 $ $62.93 Family $ $29.62 $ $51.71 $ $ *These benefits are not underwritten by Nationwide Life Insurance Company.

5 Plan 4 Plan 5 Plan 6 Hospital Admission $500 single sum $1,000 single sum $1,500 single sum Daily In-Hospital Indemnity (500 day lifetime maximum) Intensive Care Mental Illness Substance Abuse Skilled Nursing $500 per day $1,000 per day $1,500 per day $1,000 per day $250 per day $250 per day $250 per day (up to 60 days) $2,000 per day $500 per day (up to 10 days) $500 per day $500 per day (up to 60 days) $3,000 per day $750 per day (up to 10 days) $750 per day $750 per day (up to 60 days) Inpatient Miscellaneous (60 day calendar year maximum) Not Included $200 per day Surgical Indemnity Benefit Daily Inpatient Surgical Daily Outpatient Surgical Daily Outpatient Minor Outpatient Benefit $2,000, $1,000 $200 Maximum amount payable is limited to 1 day per calendar year $3,000, $1,500 $300 Maximum amount payable is limited to 1 day per calendar year $4,000, $2,000 $400 Maximum amount payable is limited to 1 day per calendar year Anesthesia Benefit 30% of surgical 30% of surgical 30% of surgical Daily Outpatient Surgical Facility Doctor s Office Benefit Outpatient Diagnostic X-ray Outpatient Diagnostic Lab Outpatient Diagnostic Advanced Studies Preventive Care Accident Expense Emergency Room Indemnity Benefit for Illness Only $250 per day 1 per calendar year $90 per day 6 days per calendar year $200 per testing day 4 days per calendar year $300 per testing day $500 max per occurrence $500 per day 1 per calendar year 6 days per calendar year $200 per testing day 4 days per calendar year $500 per testing day $150 per day $1,000 max per occurrence $150 per day 2 days per calendar year $1,000 per day 1 per calendar year $125 per day 6 days per calendar year $200 per testing day 4 days per calendar year $500 per testing day $300 per day 2 days per calendar year $2,500 max per occurrence Life/AD&D Insurance $5,000 $5,000 $10,000 Discount Health Savings Program* Teladoc Health Advocacy Neighborhood Pharmacy Program Included Included Included $150 per day 2 days per calendar year Voluntary Rates Monthly Weekly Monthly Weekly Monthly Weekly Employee Only $ $33.26 $ $49.81 $ $69.07 Employee + Child(ren) $ $58.57 $ $88.36 $ $ Employee + Spouse $ $80.41 $ $ $ $ Family $ $87.64 $ $ $ $ *These benefits are not underwritten by Nationwide Life Insurance Company. If an employer pays 50% or more of the employee only premium, a discount may be provided. 3

6 Packages Package plans are available to groups with 250+ eligible lives. Inpatient Plan The inpatient plan helps cover expenses associated with an inpatient hospital stay and surgical procedures. If an insured has major medical coverage, it can help cover deductibles and other out-of-pocket expenses. Benefits can be paid directly to the insured so they can use it to replace income, purchase groceries or help cover housing expenses. High Plan Hospital Admission $1,500 single sum $800 single sum Inpatient Miscellaneous (10 day calendar year maximum) Surgical Indemnity Benefit Daily Inpatient Surgical Daily Outpatient Surgical Daily Outpatient Minor Outpatient Benefit $500 per day $300 per day $1,000, $500 $100 Maximum amount payable is limited to Anesthesia Benefit 30% of surgical 30% of surgical Low Plan $500, $250 $50 Maximum amount payable is limited to Voluntary Rates Monthly Weekly Monthly Weekly Employee Only $60.41 $13.93 $33.24 $7.67 Employee + Child(ren) $ $25.07 $59.83 $13.81 Employee + Spouse $ $34.85 $83.10 $19.18 Family $ $40.58 $96.58 $

7 Outpatient Plans If an insured has a high deductible plan, these benefits can help reduce out-of-pocket costs. It can also help pay for a limited amount of basic procedures, if there is no other coverage. Doctor s Office Benefit Outpatient Diagnostic X-ray Outpatient Diagnostic Lab Outpatient Diagnostic Advanced Studies Full Plan Plus 6 days per calendar year $200 per testing day 4 days per calendar year $500 per testing day Full Plan $60 per day 6 days per calendar year $85 per testing day $500 per testing day Daily Outpatient Surgical Facility $500 per day, $500 per day, Discount Health Savings Program* Teladoc Health Advocacy Prescription Drug* Included $10 generic / $30 preferred brand / Discount non preferred brand / $250 monthly maximum Included Neighborhood Pharmacy Program Discount Only Voluntary Rates Monthly Weekly Monthly Weekly Employee Only $85.81 $19.80 $51.29 $11.84 Employee + Child(ren) $ $34.43 $88.62 $20.46 Employee + Spouse $ $45.52 $ $27.70 Family $ $51.35 $ $29.75 Doctor s Office Benefit Outpatient Diagnostic X-ray Outpatient Diagnostic Lab Outpatient Diagnostic Advanced Studies Lite Plan Plus $60 per day 2 days per calendar year $85 per testing day 2 days per calendar year $500 per testing day Lite Plan $60 per day 2 days per calendar year $85 per testing day 2 days per calendar year $500 per testing day Daily Outpatient Surgical Facility $500 per day, $500 per day, Discount Health Savings Program* Teladoc Health Advocacy Prescription Drug* Included $10 generic / $30 preferred brand / Discount non preferred brand / $250 monthly maximum Included Neighborhood Pharmacy Program Discount Only Voluntary Rates Monthly Weekly Monthly Weekly Employee Only $52.97 $12.22 $37.28 $8.60 Employee + Child(ren) $90.08 $20.79 $63.40 $14.63 Employee + Spouse $ $26.57 $84.95 $19.60 Family $ $30.89 $91.09 $21.02 *These benefits are not underwritten by Nationwide Life Insurance Company. 5

8 These benefits provide financial protection employees need if faced with a serious medical condition or death. Critical Illness, Accident and Life/AD&D Insurance Plan High Plan Low Plan Life/AD&D Insurance $20,000 (employee only) $10,000 (employee only) Dependent Life Insurance $10,000 spouse $5,000 child $800 infant $5,000 spouse $2,500 child $400 infant Critical Illness First ever occurrence $10,000 $5,000 Accident Expense $2,500 max per occurrence $1,000 max per occurrence Voluntary Rates Monthly Weekly Monthly Weekly Employee Only $29.00 $6.69 $14.88 $3.44 Employee + Child(ren) $45.48 $10.49 $23.41 $5.41 Employee + Spouse $54.26 $12.52 $28.19 $6.52 Family $65.53 $15.12 $33.91 $7.82 Short Term Disability High Plan Weekly Maximum $250 lump sum 50% up to $125 Waiting Period Accident Sickness Benefit Period 7 days 7 days 14 days 14 days 26 weeks Low Plan Voluntary Rates Monthly Weekly Monthly Weekly Employee Only $21.66 $5.00 $15.17 $3.50 Dental and Vision High Plan Dental $50 deductible $50 deductible Low Plan Benefit Maximum $1,000 per calendar year $500 per calendar year Co-Insurance Type 1 Type 2 Type 3 Waiting Period Type 1 Type 2 Type 3 Orthodontia 80% 60% 50% None 3 months 12 months Not Included Vision 80% to $150 calendar year max Voluntary Rates Monthly Weekly Monthly Weekly Employee Only $35.26 $8.14 $29.24 $6.75 Employee + Child(ren) $63.44 $14.64 $52.62 $12.14 Employee + Spouse $88.17 $20.35 $73.16 $16.88 Family $98.08 $22.63 $78.98 $

9 Benefit Descriptions Life/Accidental Death and Dismemberment Insurance The Life Insurance Benefit is reduced by 35% of the original amount upon attainment of Age 65, and by an additional 35% each five-year period thereafter. Daily In-Hospital Indemnity Benefit Benefit payable per day. Up to a lifetime maximum of 500 days of confinement (does not apply for Substance Abuse, Mental Illness Disorder, and In-patient Skilled Nursing Facility confinement). Intensive Care Unit Double the Daily In-Hospital Benefit will be paid, up to a maximum of 30 days per calendar year. Mental Illness Disorder 50% of the Daily In-Hospital Benefit will be paid, up to a maximum of 30 days per calendar year. Lifetime maximum $30,000. Substance Abuse 50% of the Daily In-Hospital Benefit will be paid, up to a maximum of 30 days per calendar year. Lifetime maximum $30,000. In-Patient Skilled Nursing Facility 50% of the Daily In-Hospital Benefit will be paid. Maximum benefit per covered person per period of confinement is 60 days. The confinement is covered only if it follows a covered hospital stay of at least 3 days. Anesthesia Indemnity Benefit amount will equal 30% of the amount paid for the covered surgical procedure. Benefit is paid once per surgical session. Doctor s Office Indemnity Benefit (due to illness, accident or medical emergency). Benefit payable per day per covered person. Routine exams, medical treatment, immunizations and injections are not covered under this benefit. Outpatient Diagnostic X-Ray Indemnity Benefit Benefit is payable per testing day per covered person, when hospital confinement is not required. Routine exams are not covered under this benefit. Outpatient Diagnostic Lab Indemnity Benefit Benefit is payable per testing day per covered person, when hospital confinement is not required. Routine exams are not covered under this benefit. Inpatient, Outpatient or Outpatient Minor Surgical Indemnity Benefit Daily Inpatient Surgical Indemnity Benefit Benefit is payable per covered person to a maximum of. Daily Outpatient Surgical Indemnity Benefit Benefit is payable per covered person. Daily Outpatient Minor Surgical Indemnity Benefit Benefit is payable per covered person. The amount payable for the Outpatient Benefit is limited to a maximum of 1 day per covered person per calendar year. Outpatient Diagnostic Advanced Studies Indemnity Benefit Benefit is payable per testing day, per covered person for tests ordered or performed by a doctor, when hospital confinement is not required. Routine exams are not covered under this benefit. Covered procedures are limited to: Angiograms, Arteriograms, CT Scans, MRI s and other advanced studies tests. Benefit includes the cost of reading the Advanced Studies. 7

10 Daily Outpatient Surgical Facility Indemnity Benefit Benefit will be paid for a covered surgical procedure, per covered person, per calendar year. A covered surgery must be performed at a free-standing outpatient surgical center or a hospital outpatient surgical facility. No benefits will be payable for surgeries performed in a doctor s office. Inpatient Miscellaneous Indemnity Benefit Benefits payable per day. Up to 60 days per calendar year (reduced benefits apply to Mental Illness Disorder and Substance Abuse). Benefits include non-professional facility charges associated with a hospital inpatient stay and are paid in addition to the Daily In-Hospital Indemnity Benefit. Mental Illness Disorder 50% of the daily Inpatient Miscellaneous Indemnity Benefit will be paid, up to a maximum 30 days per calendar year. Substance Abuse 50% of the daily Inpatient Miscellaneous Indemnity Benefit will be paid, up to a maximum of 30 days per calendar year. Emergency Room Indemnity Benefit for Illness Only Benefit is payable per day. Limited to 1 day per ER Visit. Non-Occupational Weekly Disability Income Benefit Maximum amount of insurance is $500 per week. Maximum period of disability is 26 weeks. Hospital Admission Single Sum Benefit Single Sum Benefit payable only once during any period of confinement. The amount is equal to the Daily In-Hospital Benefit for other than Intensive Care. Vision Care Benefit Covered vision care expenses are paid at 80%. Maximum benefit per person per calendar year applies. Dependent Life Insurance Spouse; Child (from 6 months to 26 years); and Child (from 10 days to 6 months). Critical Illness Benefit Benefit payable on the first occurrence of End-Stage Renal Failure, Heart Attack, Life-Threatening Cancer, Major Organ Transplant, or a Stroke as defined by the plan. Dental Benefit Eligible regular or preventive dental expenses are covered at a maximum of 80%. Special dental benefits are covered at 50%. Pre-Certification is recommended for dental claims exceeding $250. Preventive Care Indemnity Benefit Benefit payable per day per covered person. Routine exams, medical treatment and immunizations are covered under this benefit. Accident Expense Benefit Up to 100% of charges incurred are payable within 90 days of an accidental bodily injury. Benefit is per accident. 68

11 Discount Health Savings Program Discount benefits administered by New Benefits, Ltd. Teladoc Teladoc provides employees with 24/7 access to a national network of U.S. board-certified physicians who can diagnose and treat many medical issues over the telephone. Teladoc physicians can even prescribe routine medication if warranted. There is no consult fee for members and their dependents to access this service and the average physician call back time is 16 minutes Teladoc, Inc. All rights reserved. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services. Teladoc phone consultations are available 24 hours, 7 days a week while video consultations are available during the hours of 7am to 9pm, 7 days a week. Lab and Imaging Lab With DirectLabs, members save 10% to 80% off typical lab costs. The lab tests promote early detection of possible serious medical conditions such as heart disease, prostate cancer, diabetes, and thyroid disease. The lab network portion of this benefit is not available in MA, MD, ND, NE, NJ, NY, RI or SD. Imaging Members receive discounts of 50% to 75%* off usual charges for MRI and CT procedures while utilizing credentialed radiology providers. These radiologists deliver tests and test interpretations which lead to appropriate diagnosis and effective treatment. *Savings may vary based on geographic location, provider selected and procedure performed. Health Advocate Services Medical Bill Saver The Health Advocate Medical Bill Saver benefit can lower outof-pocket costs on medical bills not covered by insurance. Advocates will work with healthcare providers and attempt to lower the balance on any uncovered medical or dental bill over $400. Medical Health Advisor The services are organized around Personal Health Advocates, typically registered nurses, supported by a team of medical directors and administrative experts, who assist individuals in getting the most value from their healthcare benefits. One call to Medical Health Advisor and we ll help members resolve insurance claims and billing issues. Nurseline TM Nurseline TM offers toll-free access to experienced registered nurses, 24 hours a day, 365 days per year. Hotline nurses are an immediate, reliable and caring source of health information, education and support. Health Advocate does not replace health insurance, provide medical care or recommend treatment. Vision Care* Coast to Coast Vision (CTC) has over 12,000 eye care locations nationwide. Members save on eyeglasses, contacts and laser surgery. The CTC provider network is the most thorough in the U.S. It includes ophthalmologists, optometrists, independent optical centers and most national chains. 9

12 Additional Benefits Include: Vitamins and Diabetic Supplies Hearing Telephonic Counseling Chiropractic Care* Durable Medical Equipment Dental* * Not Available in VT or WA. Neighborhood Pharmacy Program Discount pharmacy benefit administered by New Benefits, Ltd. The neighborhood pharmacy discount program assures members the lowest price on prescription drugs, saving 10% to 85% on most short-term, acute care prescriptions such as antibiotics and painkillers. Long-term prescriptions may be purchased at the local pharmacy. It s simple to use. The member simply presents the membership card to the pharmacist with the prescription. The pharmacist calculates the discount and the member pays the discounted price. No other forms required. Online Drug Price Check Utility ( provides members the ability to find the price of their prescriptions at participating locations in their zip code. Over 60,000 participating locations, including independent, national and regional chain pharmacies nationwide. Pharmacy discounts are NOT insurance, and are NOT intended as a substitute for insurance. The discount is only available at participating pharmacies. 10 8

13 Disclosures The Discount Health Savings Program 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, excluding registration fee, if membership is cancelled within the first 30 days after the effective date. AR and TN residents: A refund of all fees will be issued if membership is cancelled within the first 30 days. Discount Medical Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box Dallas, TX , Website to obtain participating providers: MyMemberPortal.com. First Health Network The First Health Network provides access to one of the nation s largest and most respected networks. By going to a First Health provider members can reduce out- ofpocket expenses and stretch their benefit dollars. Access to more than 490,000 provider locations across all 50 states and the District of Columbia First Health logo on the insurance ID card for fast and easy recognition by the provider Re-priced Claims will be assigned directly to the provider to simplify the claims process To find a provider online, visit Members retain the ability to choose any doctor they wish and have those claims assigned. All benefits will be paid as specified in the benefit provisions of the policy regardless of the provider chosen. 11

14 Contact Us Framework SM Anderson Mill Road, Ste. 401 Austin, Texas Toll Free: Local: Website: Plan Administration Experience Plan Benefit Services, Inc. is experienced in administering high-turnover and payroll cycle based benefit plans; the employer is left with little administrative work. Our approach limits the burden of administrative work for the employer. Services Include: Full service in-house administration COBRA Administration at no additional cost to the employer Free replacement identification cards Experienced live customer service representatives who work exclusively with this product Online enrollment capabilities and data exchange Plans are subject to state availability. State restrictions may apply. This brochure is for Broker use only and does not include a full description of the benefits or plan exclusions and limitations. For additional information contact Framework. 12

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16 Framework is part of the Fringe Benefit Group. Since 1983, we have helped part-time and hourly workers get the most out of their benefits. As a privately held company, and a third party administrator, we are able to provide clients with the hardest working A rated carriers. With over 90 employees and 30 years of experience, we have established ourselves as the model business in providing part-time and hourly workers with the insurance they need. Underwritten by Nationwide Life Insurance Company P.O. Box , Columbus, OH , Nationwide Mutual Insurance Company. All rights reserved. Nationwide and the Nationwide framemark are federally registered service marks of Nationwide Mutual Insurance Company. SHR-0141AO