WELCOME TO DAS!
2019 EMPLOYEE HANDBOOK AND BENEFITS GUIDE
TABLE OF CONTENTS
Human Resources Contact List Anonymous Fraud/Ethics Hotline Customer Service Pledge Student Loan Reimbursement
05 06 07 08
Health Insurance Marketplace Coverage Options
Using Your Health Plan
Voluntary Short-TermDisability Insurance
Voluntary Life Insurance
Flexible Spending Account Benefits
Medical Expense Reimbursement Claim Form Dependent Care Expense Reimbursement Claim Form
AFLAC SUPPLEMENTAL INSURANCE
Accident Plan Hospital Plan
45 46 47
Critical Illness Plan
EMPLOYEE STOCK OWNERSHIP PLAN (ESOP)
ALERUS 401K PLAN
Initial Enrollment Form
Company NMLS 227262
HUMAN RESOURCES CONTACT LIST
The HR Team is compromised of the following individuals who are dedicated to providing you with human support:
Jennifer Bell , HR Manager Jen oversees and manages all Human Resources department activities and functions.
JBell@dasacquisition.com (314) 628-2051
Carla Garcia , HR Coordinator Carla supports HQ and office brances in administering health and welfare benefits and on-boarding orientation.
firstname.lastname@example.org (314) 628-5055
Keith Graham , HR Specialist Keith supports HQ and offices branches for payroll and welfare benefits (401K and ESOP Program).
email@example.com (314) 628-2105
Riley Bell , HR Office Assistant Riley supports file maintenance, HR audits and other HR support functions within the Human Resources Team.
firstname.lastname@example.org (314) 628-5077
ANONYMOUS FRAUD/ETHICS HOTLINE
Without question, the largest threat to our organization is not any one of our competitors. It is not a retail bank, a mortgage bank or even the odd remaining mortgage broker. Our largest threat is potentially ourselves. We are a threat to ourselves anytime there is the potential use, threatened use, or actual use of fraud or unethical conduct in our daily business, our individual work, or within our family of employees. To continue our war against these potential crimes, DAS is excited to announce a new service to our team. In conjunction our accounting firm, Mueller Prost, we are implementing the Red Flag Reporting Hotline, a hotline to help protect our organization. Mueller Prost will host this service to provide anonymity when desired. The service is available to all employees for reporting any fraud and/or ethics issues anonymously. Anonymous fraud/ethics hotline service is available24/7/365 ByPhone: toll free: (877) 647-3335, client code3146282000 Employee webinars can be found on the Intranet.
The Hotline should be used to report: • Unauthorized or inappropriate use of employer’s assets • Falsification of time and expense reimbursement • Accepting inappropriate gifts from vendors • Operating a private business during work hours • Theft of employer’s assets, equipment or supplies • Other ethical breaches of employer’s policies and/or procedures
The Hotline should not be used to report: • Personality differences with co-workers • Annoying personal habits of co-workers • Opinions regarding management decisions that have already been made • Complaints about the quality of the office coffee
We encourage you to provide as much information as possible so that we can address any issues in a timely and ecient manner.
We will investigate all reports of possible ethical or legal misconduct as promptly as possible. We will keep details of investigations confidential to the maximum extent possible, consistent with resolution of the issue and in compliance with applicable laws.
Submissions to the hotline are handled internally, unless outside assistance is required. Retaliation against any individual making a report in good-faith to the hotline will not be tolerated. Confidentially of the reports, as well as the identity of those making the reports, if known, will remain confidential to the maximum extent possible. Reports may be made anonymously, however, if contact information is provided in the report, such information will be transcribed verbatim and provided to management. Contact information included in a report may be used to provide feedback on the incident or for follow-up with the complainant if further information is needed.
We are excited to take proactive steps to help you and our organization. Please let Jennifer Bell know if you have any questions about this program.
Thank you for being a part of the team and being an important part of making the company a better place to work!
CUSTOMER SERVICE PLEDGE
Acknowledge a problem. Apologize for it. Fix it. I will not be defensive nor aggressive, but always helpful. As a customer service representative for DAS, I will:
STUDENT LOAN REIMBURSEMENT PROGRAM 08
DAS Acquisition Company believes in the power of education. That’s why we offer the Student Loan Reimbursement Program.
• Employee must reach his or her 5th anniversary date with DAS.
• Each year, DAS employee will submit a statement from the student loan services.
• DAS will remit $1,000 per year for a maximum of 10 years.
• Benefit is for DAS employee’s student loans only. (Parent loans are not eligible for reimbursement.)
For more information:
Dee Franta Executive Administrative Assistant [O] 314.628.2161 email@example.com
Welcome to DAS Acquisition Company, LLC! Enclosed is your New Employee Packet detailing out your benefits. You will be eligible for coverage the first of the month following your start date. Please follow the instructions below to fill the paperwork out completely. Anthem Blue Cross/Blue Shield – DAS Acquisition Company, LLC offers medical coverage to the employee at a minimal fee per pay period. The following monthly rates are available. If rates change in the future, you will be notified. If you elect insurance, insurance will begin the first day of the month following your hire date. If you do not elect insurance, “ Waive ” when enrolling online. Health Savings HSA ($4000/$8000) BASE Deductible ($3000/$6000) BUYUP Deductible ($2000/$4000) Individual $205.30 – (102.65 PP) $ 254.86 - (127.43 PP) $ 343.05 - (171.53 PP) Employee + Spouse 760.50 – (380.25 PP) 869.87 - (434.93 PP) 1064.49 – (532.24 PP) Employee + Child 642.40 - (321.20 PP) 739.06 - (369.53 PP) 911.05 – (455.52 PP) Family 1,056.54 - (528.27 PP) 1,197.78 - (598.89 PP) 1,449.12 – (724.56 PP) Anthem Blue Cross/Blue Shield Vision- DAS Acquisition Company, LLC offers vision coverage at a minimal fee collected through payroll deduction. Individual Your monthly premium $ 6.73 - ( 3.37 PP) Employee + Spouse 12.75 - ( 6.38 PP) Employee + Children 14.96 - ( 7.48 PP) Family 21.04 - (10.52 PP) Anthem Blue Cross/Blue Shield Dental – DAS Acquisition Company, LLC offers dental insurance to the employee at a minimal fee per pay period. Individual Your monthly premium: $14.24 - ( 7.12 PP) Employee + Spouse 44.02 - (22.01 PP) Employee + Children 43.94 - (21.97 PP) Family 68.98 - (34.49 PP) Participation and Salary Reduction Agreement – This form allows any health and/or dental payroll deductions to be made before taxes. Authorization Agreement for Automatic Deposits – This form allows DAS Acquisition Company, LLC to direct deposit your payroll. Be sure to attach a voided or copy of your check or a savings deposit slip. When complete, send to Keith Graham, HR Specialist. Anthem Term Life Insurance – DAS Acquisition Company, LLC offers a policy through Anthem Blue Cross/Blue Shield at no cost to the employee. This covers a basic life insurance policy and beneficiary information MUST be completed. Voluntary Life Insurance/Disability - DAS Acquisition Company, LLC offers a Voluntary Life Insurance and short term disability plan through Lincoln Financial that you can apply for at cost to the employee through payroll deduction. Flex Spending – Employees may elect to payroll deduct on a pretax basis up to $1,500.00 annually for out of pocket medical expenses and $5,000.00 for Dependent care. AFLAC – DAS Acquisition Company, LLC through AFLAC offers the ability to choose valuable supplement benefits that meet your needs. The convenience of premiums payments through payroll deduction and the ability to take most coverag e’ s with you is available if you change jobs or retire. ESOP – DAS Acquisition Company, LLC offers an exemplary Retirement Plan. As a stockholder, you are an owner in the company by your efforts added to the efforts of all other eligible employees by contributing to the profitability and growth of the company and potentially increasing the value of Company Stock and your benefits. 401K – DAS Acquisition Company, LLC / USA Mortgage offers a 401K. You can enroll in the 401K plan and have a percentage of your payroll automatically deducted. NOTE: Be sure to complete the Beneficiary Designation Form and sign. Return to Keith Graham, HR Specialist.
HEALTH INSURANCE MARKETPLACE COVERAGE OPTIONS
New Health Insurance Marketplace Coverage Options and Your Health Coverage
PART A: General Information ΈΙΖΟ͑ΜΖΪ͑ΡΒΣΥΤ͑ΠΗ͑ΥΙΖ͑ΙΖΒΝΥΙ͑ΔΒΣΖ͑ΝΒΨ͑ΥΒΜΖ͑ΖΗΗΖΔΥ͑ΚΟ͑ͣͥ͑͢͡͝ΥΙΖΣΖ͑ΨΚΝΝ͑ΓΖ͑Β͑ΟΖΨ͑ΨΒΪ͑ΥΠ͑ΓΦΪ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ : ͑ΥΙΖ͑ΖΒΝΥΙ͑ ͺΟΤΦΣΒΟΔΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͟΅Π͑ΒΤΤΚΤΥ͑ΪΠΦ͑ΒΤ͑ΪΠΦ͑ΖΧΒΝΦΒΥΖ͑ΠΡΥΚΠΟΤ͑ΗΠΣ͑ΪΠΦ͑ΒΟΕ͑ΪΠΦΣ͑ΗΒΞΚΝΪ͑͝ΥΙΚΤ͑ΟΠΥΚΔΖ͑ΡΣΠΧΚΕΖΤ͑ΤΠΞΖ͑ΓΒΤΚΔ͑ ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΥΙΖ͑ΟΖΨ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΖΞΡΝΠΪΞΖΟΥνΓΒΤΖΕ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͟
͑ What is the Health Insurance Marketplace?
΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΤ͑ΕΖΤΚΘΟΖΕ͑ΥΠ͑ΙΖΝΡ͑ΪΠΦ͑ΗΚΟΕ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΪΠΦΣ͑ΟΖΖΕΤ͑ΒΟΕ͑ΗΚΥΤ͑ΪΠΦΣ͑ΓΦΕΘΖΥ͑͟΅ΙΖ͑ ;ΒΣΜΖΥΡΝΒΔΖ͑ΠΗΗΖΣΤ͓͑ΠΟΖ͞ΤΥΠΡ͑ΤΙΠΡΡΚΟΘ͓͑ΥΠ͑ΗΚΟΕ͑ΒΟΕ͑ΔΠΞΡΒΣΖ͑ΡΣΚΧΒΥΖ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ΠΡΥΚΠΟΤ͑͟ΊΠΦ͑ΞΒΪ͑ΒΝΤΠ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ ΗΠΣ͑Β͑ΟΖΨ͑ΜΚΟΕ͑ΠΗ͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΒΥ͑ΝΠΨΖΣΤ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑ΣΚΘΙΥ͑ΒΨΒΪ͑͟ΡΖΟ͑ΖΟΣΠΝΝΞΖΟΥ͑ΗΠΣ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΓΖΘΚΟΤ͑ΚΟ͑ΔΥΠΓΖΣ͑ͣͤ͑͢͡ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΤΥΒΣΥΚΟΘ͑ΒΤ͑ΖΒΣΝΪ͑ΒΤ͑ͻΒΟΦΒΣΪ͑͑ͣͥ͑͢͢͟͝͡ Can I Save Money on my Health Insurance Premiums in the Marketplace? ΊΠΦ͑ΞΒΪ͑ΦΒΝΚΗΪ͑ΥΠ͑ΤΒΧΖ͑ΞΠΟΖΪ͑ΒΟΕ͑ΝΠΨΖΣ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑͝ΓΦΥ͑ΠΟΝΪ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΕΠΖΤ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͝ΠΣ͑ ΠΗΗΖΣΤ͑ΔΠΧΖΣΒΘΖ͑ΥΙΒΥ͑ΕΠΖΤΟ͘Υ͑ΞΖΖΥ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͟΅ΙΖ͑ΤΒΧΚΟΘΤ͑ΠΟ͑ΪΠΦΣ͑ΡΣΖΞΚΦΞ͑ΥΙΒΥ͑ΪΠΦ͘ΣΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑ΕΖΡΖΟΕΤ͑ΠΟ͑ ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ΚΟΔΠΞΖ͑͟ Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? ΊΖΤ͑͟ͺΗ͑ΪΠΦ͑ΙΒΧΖ͑ΒΟ͑ΠΗΗΖΣ͑ΠΗ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΗΣΠΞ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͝ΪΠΦ͑ΨΚΝΝ͑ΟΠΥ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΞΒΪ͑ΨΚΤΙ͑ΥΠ͑ΖΟΣΠΝΝ͑ΚΟ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͘Τ͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑͟ΠΨΖΧΖΣ͑͝ΪΠΦ͑ΞΒΪ͑ΓΖ͑ ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΒΥ͑ΝΠΨΖΣΤ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑͝ΠΣ͑Β͑ΣΖΕΦΔΥΚΠΟ͑ΚΟ͑ΔΖΣΥΒΚΟ͑ΔΠΤΥ͞ΤΙΒΣΚΟΘ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΕΠΖΤ͑ ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΪΠΦ͑ΒΥ͑ΒΝΝ͑ΠΣ͑ΕΠΖΤ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͟ͺΗ͑ΥΙΖ͑ΔΠΤΥ͑ΠΗ͑Β͑ΡΝΒΟ͑ΗΣΠΞ͑ΪΠΦΣ͑ ΖΞΡΝΠΪΖΣ͑ΥΙΒΥ͑ΨΠΦΝΕ͑ΔΠΧΖΣ͑ΪΠΦ͙͑ΒΟΕ͑ΟΠΥ͑ΒΟΪ͑ΠΥΙΖΣ͑ΞΖΞΓΖΣΤ͑ΠΗ͑ΪΠΦΣ͑ΗΒΞΚΝΪ͚͑ΚΤ͑ΞΠΣΖ͑ΥΙΒΟ͖͑ͪͦ͑͟ΠΗ͑ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ ΚΟΔΠΞΖ͑ΗΠΣ͑ΥΙΖ͑ΪΖΒΣ͑͝ΠΣ͑ΚΗ͑ΥΙΖ͑ΔΠΧΖΣΒΘΖ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΡΣΠΧΚΕΖΤ͑ΕΠΖΤ͑ΟΠΥ͑ΞΖΖΥ͑ΥΙΖ͓͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͓͑ΤΥΒΟΕΒΣΕ͑ΤΖΥ͑ΓΪ͑ΥΙΖ͑ ͲΗΗΠΣΕΒΓΝΖ͑ʹΒΣΖ͑ͲΔΥ͑͝ΪΠΦ͑ΞΒΪ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͟ ͢ ͑ ͿΠΥΖͫ͑ͺΗ͑ΪΠΦ͑ΡΦΣΔΙΒΤΖ͑Β͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΟΤΥΖΒΕ͑ΠΗ͑ΒΔΔΖΡΥΚΟΘ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ ΖΞΡΝΠΪΖΣ͑͝ΥΙΖΟ͑ΪΠΦ͑ΞΒΪ͑ΝΠΤΖ͑ΥΙΖ͑ΖΞΡΝΠΪΖΣ͑ΔΠΟΥΣΚΓΦΥΚΠΟ͙͑ΚΗ͑ΒΟΪ͚͑ΥΠ͑ΥΙΖ͑ΖΞΡΝΠΪΖΣ͞ΠΗΗΖΣΖΕ͑ΔΠΧΖΣΒΘΖ͑͟ͲΝΤΠ͑͝ΥΙΚΤ͑ΖΞΡΝΠΪΖΣ͑ ΔΠΟΥΣΚΓΦΥΚΠΟ͑͞ΒΤ͑ΨΖΝΝ͑ΒΤ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΖ͑ΔΠΟΥΣΚΓΦΥΚΠΟ͑ΥΠ͑ΖΞΡΝΠΪΖΣ͞ΠΗΗΖΣΖΕ͑ΔΠΧΖΣΒΘΖ͑͞ΚΤ͑ΠΗΥΖΟ͑ΖΩΔΝΦΕΖΕ͑ΗΣΠΞ͑ΚΟΔΠΞΖ͑ΗΠΣ͑ ͷΖΕΖΣΒΝ͑ΒΟΕ͑΄ΥΒΥΖ͑ΚΟΔΠΞΖ͑ΥΒΩ͑ΡΦΣΡΠΤΖΤ͑͟ΊΠΦΣ͑ΡΒΪΞΖΟΥΤ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΣΖ͑ΞΒΕΖ͑ΠΟ͑ΒΟ͑ΒΗΥΖΣ͞ ΥΒΩ͑ΓΒΤΚΤ͑͟ ͑ How Can I Get More Information? ͷΠΣ͑ΞΠΣΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͝ΡΝΖΒΤΖ͑ΔΙΖΔΜ͑ΪΠΦΣ͑ΤΦΞΞΒΣΪ͑ΡΝΒΟ͑ΕΖΤΔΣΚΡΥΚΠΟ͑ΠΣ͑ ΔΠΟΥΒΔΥ͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͟ ͑
΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΔΒΟ͑ΙΖΝΡ͑ΪΠΦ͑ΖΧΒΝΦΒΥΖ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΠΡΥΚΠΟΤ͑͝ΚΟΔΝΦΕΚΟΘ͑ΪΠΦΣ͑ΖΝΚΘΚΓΚΝΚΥΪ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑ ;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΚΥΤ͑ΔΠΤΥ͑͟ΝΖΒΤΖ͑ΧΚΤΚΥ͑ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ͑ΗΠΣ͑ΞΠΣΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑͝ΚΟΔΝΦΕΚΟΘ͑ΒΟ͑ΠΟΝΚΟΖ͑ΒΡΡΝΚΔΒΥΚΠΟ͑ΗΠΣ͑ΙΖΒΝΥΙ͑ ΚΟΤΦΣΒΟΔΖ͑ΔΠΧΖΣΒΘΖ͑ΒΟΕ͑ΔΠΟΥΒΔΥ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΗΠΣ͑Β͑ΖΒΝΥΙ͑ͺΟΤΦΣΒΟΔΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΟ͑ΪΠΦΣ͑ΒΣΖΒ͑͟
͑͢ ͲΟ͑ ΖΞΡΝΠΪΖΣ͞ΤΡΠΟΤΠΣΖΕ͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΞΖΖΥΤ͑ΥΙΖ͓͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͓͑ΚΗ͑ ΥΙΖ͑ΡΝΒΟ͘Τ͑ΤΙΒΣΖ͑ΠΗ͑ ΥΙΖ͑ΥΠΥΒΝ͑ΒΝΝΠΨΖΕ͑ΓΖΟΖΗΚΥ͑ΔΠΤΥΤ͑ΔΠΧΖΣΖΕ͑
ΓΪ͑ ΥΙΖ͑ΡΝΒΟ͑ΚΤ͑ ΟΠ͑ ΝΖΤΤ͑ΥΙΒΟ͑ͧ͑͡ΡΖΣΔΖΟΥ͑ΠΗ͑ ΤΦΔΙ͑ΔΠΤΥΤ͑͟
PART B: Information About Health Coverage Offered by Your Employer ΅ΙΚΤ͑ΤΖΔΥΚΠΟ͑ΔΠΟΥΒΚΟΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΒΟΪ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͟ͺΗ͑ΪΠΦ͑ΕΖΔΚΕΖ͑ΥΠ͑ΔΠΞΡΝΖΥΖ͑ΒΟ͑ ΒΡΡΝΚΔΒΥΚΠΟ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΚΟ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͝ΪΠΦ͑ΨΚΝΝ͑ΓΖ͑ΒΤΜΖΕ͑ΥΠ͑ΡΣΠΧΚΕΖ͑ΥΙΚΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑͟΅ΙΚΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΚΤ͑ΟΦΞΓΖΣΖΕ͑ ΥΠ͑ΔΠΣΣΖΤΡΠΟΕ͑ΥΠ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΡΡΝΚΔΒΥΚΠΟ͑͟
3. Employer name
4. Employer Identification Number (EIN)
5. Employer address
6. Employer phone number
9. ZIP code
10. Who can we contact about employee health coverage at this job?
11. Phone number (if different from above)
12. Email address
ΖΣΖ͑ΚΤ͑ΤΠΞΖ͑ΓΒΤΚΔ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΥΙΚΤ͑ΖΞΡΝΠΪΖΣͫ͑ x ͲΤ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͝ΨΖ͑ΠΗΗΖΣ͑Β͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΥΠͫ͑ ͲΝΝ͑ΖΞΡΝΠΪΖΖΤ͑͑͟ͶΝΚΘΚΓΝΖ͑ΖΞΡΝΠΪΖΖΤ͑ΒΣΖͫ͑
͑ ͑ ͑
͑ ͑ ΄ΠΞΖ͑ΖΞΡΝΠΪΖΖΤ͑͟ͶΝΚΘΚΓΝΖ͑ΖΞΡΝΠΪΖΖΤ͑ΒΣΖͫ͑͑
͑ ͑ ͑ ͑ ͑
͑ ͑ ͑ ͑
͑ ͺΗ͑ΔΙΖΔΜΖΕ͑͝ΥΙΚΤ͑ΔΠΧΖΣΒΘΖ͑ΞΖΖΥΤ͑ΥΙΖ͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͑͝ΒΟΕ͑ΥΙΖ͑ΔΠΤΥ͑ΠΗ͑ΥΙΚΤ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΪΠΦ͑ΚΤ͑ΚΟΥΖΟΕΖΕ͑ ΥΠ͑ΓΖ͑ΒΗΗΠΣΕΒΓΝΖ͑͝ΓΒΤΖΕ͑ΠΟ͑ΖΞΡΝΠΪΖΖ͑ΨΒΘΖΤ͑͟ ͑ ͛͛͑ ͶΧΖΟ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΚΟΥΖΟΕΤ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΓΖ͑ΒΗΗΠΣΕΒΓΝΖ͑͝ΪΠΦ͑ΞΒΪ͑ΤΥΚΝΝ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ ΕΚΤΔΠΦΟΥ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͟΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΨΚΝΝ͑ΦΤΖ͑ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ΚΟΔΠΞΖ͑͝ΒΝΠΟΘ͑ΨΚΥΙ͑ΠΥΙΖΣ͑ΗΒΔΥΠΣΤ͑͝ ΥΠ͑ΕΖΥΖΣΞΚΟΖ͑ΨΙΖΥΙΖΣ͑ΪΠΦ͑ΞΒΪ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ΕΚΤΔΠΦΟΥ͑͟ͺΗ͑͝ΗΠΣ͑ΖΩΒΞΡΝΖ͑͝ΪΠΦΣ͑ΨΒΘΖΤ͑ΧΒΣΪ͑ΗΣΠΞ͑ ΨΖΖΜ͑ΥΠ͑ΨΖΖΜ͙͑ΡΖΣΙΒΡΤ͑ΪΠΦ͑ΒΣΖ͑ΒΟ͑ΙΠΦΣΝΪ͑ΖΞΡΝΠΪΖΖ͑ΠΣ͑ΪΠΦ͑ΨΠΣΜ͑ΠΟ͑Β͑ΔΠΞΞΚΤΤΚΠΟ͑ΓΒΤΚΤ͚͑͝ΚΗ͑ΪΠΦ͑ΒΣΖ͑ΟΖΨΝΪ͑ ΖΞΡΝΠΪΖΕ͑ΞΚΕ͞ΪΖΒΣ͑͝ΠΣ͑ΚΗ͑ΪΠΦ͑ΙΒΧΖ͑ΠΥΙΖΣ͑ΚΟΔΠΞΖ͑ΝΠΤΤΖΤ͑͝ΪΠΦ͑ΞΒΪ͑ΤΥΚΝΝ͑ΦΒΝΚΗΪ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ΕΚΤΔΠΦΟΥ͑͟ ͑ ͺΗ͑ΪΠΦ͑ΕΖΔΚΕΖ͑ΥΠ͑ΤΙΠΡ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΚΟ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͝ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ ΨΚΝΝ͑ΘΦΚΕΖ͑ΪΠΦ͑ΥΙΣΠΦΘΙ͑ΥΙΖ ΡΣΠΔΖΤΤ͑͟ΖΣΖ͘Τ͑ΥΙΖ͑ ΖΞΡΝΠΪΖΣ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΪΠΦ͘ΝΝ͑ΖΟΥΖΣ͑ΨΙΖΟ͑ΪΠΦ͑ΧΚΤΚΥ͑ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ͑ΥΠ͑ΗΚΟΕ͑ΠΦΥ͑ΚΗ͑ΪΠΦ͑ΔΒΟ͑ΘΖΥ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΠ͑ΝΠΨΖΣ͑ΪΠΦΣ͑ ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞΤ͑͟ ͑
΅ΙΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΓΖΝΠΨ͑ΔΠΣΣΖΤΡΠΟΕΤ͑ΥΠ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ͶΞΡΝΠΪΖΣ͑ʹΠΧΖΣΒΘΖ͑΅ΠΠΝ͑͑͟ʹΠΞΡΝΖΥΚΟΘ͑ΥΙΚΤ͑ΤΖΔΥΚΠΟ͑ΚΤ͑ΠΡΥΚΠΟΒΝ͑ΗΠΣ͑ ΖΞΡΝΠΪΖΣΤ͑͝ΓΦΥ͑ΨΚΝΝ͑ΙΖΝΡ͑ΖΟΤΦΣΖ͑ΖΞΡΝΠΪΖΖΤ͑ΦΟΕΖΣΤΥΒΟΕ͑ΥΙΖΚΣ͑ΔΠΧΖΣΒΘΖ͑ΔΙΠΚΔΖΤ͑͟ ͑ 13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months? Yes (Continue) 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue) No (STOP and return this form to employee) ͑ 14. Does the employer offer a health plan that meets the minimum value standard*? Yes (Go to question 15) No (STOP and return form to employee) 15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly ͺΗ͑ΥΙΖ͑ΡΝΒΟ͑ΪΖΒΣ͑ΨΚΝΝ͑ΖΟΕ͑ΤΠΠΟ͑ΒΟΕ͑ΪΠΦ͑ΜΟΠΨ͑ΥΙΒΥ͑ΥΙΖ͑ΙΖΒΝΥΙ͑ΡΝΒΟΤ͑ΠΗΗΖΣΖΕ͑ΨΚΝΝ͑ΔΙΒΟΘΖ͑͝ΘΠ͑ΥΠ͑ΦΖΤΥΚΠΟ͑ͧ͑͢͟ͺΗ͑ΪΠΦ͑ΕΠΟ͘Υ͑ ΜΟΠΨ͑͝΄΅͑ΒΟΕ͑ΣΖΥΦΣΟ͑ΗΠΣΞ͑ΥΠ͑ΖΞΡΝΠΪΖΖ͑͟ ͑ 16. What change will the employer make for the new plan year? Employer won't offer health coverage Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)
a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month
ח ͑ͲΟ͑ΖΞΡΝΠΪΖΣ͞ΤΡΠΟΤΠΣΖΕ͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΞΖΖΥΤ͑ΥΙΖ͓͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͓͑ΚΗ͑ΥΙΖ͑ΡΝΒΟ͘Τ͑ΤΙΒΣΖ͑ΠΗ͑ΥΙΖ͑ΥΠΥΒΝ͑ΒΝΝΠΨΖΕ͑ΓΖΟΖΗΚΥ͑ΔΠΤΥΤ͑ΔΠΧΖΣΖΕ͑ΓΪ͑ ΥΙΖ͑ΡΝΒΟ͑ΚΤ͑ΟΠ͑ΝΖΤΤ͑ΥΙΒΟ͑ͧ͑͡ΡΖΣΔΖΟΥ͑ΠΗ͑ΤΦΔΙ͑ΔΠΤΥΤ͙͑΄ΖΔΥΚΠΟ͑ͤͧͳ͙Δ͚͙͚͙ͣʹ͚͙ΚΚ͚͑ΠΗ͑ΥΙΖ͑ͺΟΥΖΣΟΒΝ͑ΖΧΖΟΦΖ͑ʹΠΕΖ͑ΠΗ͚͑ͪͩͧ͑͢
TRIPLE OPTION PLAN COMPARISON WITH PAYROLL DEDUCTIONS
USA Mortgage Health Insurance Options Effective Date: March 1, 2019 Plan Name Plan Description
Anthem Blue Cross Triple Option
Buy Up Plan $2,000 Ded, 100% Blue Access Choice Blue Access
Base Plan $3,000 Ded, 80% Blue Access Choice Blue Access
HSA Plan $4,000 Ded, 90% Blue Access Choice Blue Access
In-Network Benefits Calendar Year Deductible & Coinsurance (Single/Family) Inpatient Hospitalization Outpatient Surgery / Services Hospital Copay- Inpatient / Outpatient
$2,000 / $4,000 then 100% Coinsurance
$3,000 / $6,000 then 80% Coinsurance
$4,000 / $8,000 then 90% Coinsurance
Lab / Diagnostic Testing
Office Visit - Primary Care / Specialist
Emergency Room (Waived if Admitted)
$10/$35/$60 Essential Formulary
$15/$45/$75 Essential Formulary
then $10/$35/$60 Essential Formulary
Rx- Tier 1/Tier 2/Tier 3 (30 day supply)
25% to $300 Max
25% to $300 Max
then 25% to $300 Max
ACA Preventive Services Other routine services may require an out-of-pocket expense.
Covered in full
Covered in full
Covered in full
Max Out-of-Pocket (Single/Family)
$4,000 / $8,000
$6,000 / $12,000
$5,000 / $10,000
$6,000 / $12,000 then 70% Coinsurance
$9,000 / $18,000 then 50% Coinsurance
$9,000 / $18,000 then 60% Coinsurance
Calendar Year Deductible & Coinsurance (Single/Family)
Max Out-of-Pocket (Single/Family) (UCR- Benefits Based on Approved Charges) Semi-Monthly Payroll Deduction Amount
$12,000 / $24,000
$13,000 / $26,000
$10,000 / $20,000
Enriched $171.53 $532.24 $455.52 $724.56
HSA Plan $102.65 $380.25 $321.20 $528.27
$127.43 $434.93 $369.53 $598.89
Employee + Spouse Employee + Child(ren)
This is a brief summary of benefits. Please refer to your Certificate of Coverage or Summary of Benefits & Coverage (SBC) for complete detail of services.
USING YOUR HEALTH PLAN
Using your health plan How to get started with your plan and make the best of your benef ts i
Choose a doctor in your plan
Preventive care is covered at no extra cost
Avoid getting care from doctors outside of your plan; it will cost you more or your plan may not cover it at all. We’ve made it easy for you to f nd doctors in your plan. Just use i our Find a Doctor tool on anthem.com to look for a primary care doctor, hospitals, labs and other health care professionals in your plan.
Preventive care from a doctor in your plan is covered at 100%. Getting these regular checkups, screenings and shots can help you stay healthy and catch problems early – when they’re easier to treat. So, talk to your doctor about what preventive care you may need to protect your health.
Save emergency room visits for emergencies only
Use your ID card
Knowing where to go for care saves you time and money. So if you have a real emergency, head straight to the ER or call 911. Otherwise, visit your regular doctor or an urgent care center for minor medical issues.
You’ll be a member after you complete enrollment and your benef ts begin. Then, you’ll be able to use your ID card. i Don’t forget, it’s always available on the Anthem Anywhere mobile app. It’s like your passport to care since you’ll need to show it whenever you go to the doctor.
We’re here for you
When you become a member, you can get your questions answered in the way that works best for you. } By phone: Call the Member Services number on your mobile ID card. } Online: Register at anthem.com or download the Anthem Anywhere mobile app to chat with a team member.
Once your benef ts begin and you access your ID card, i register on anthem.com to get personalized information about your health plan. } Find a doctor. } Estimate your costs, before you step into the doctor’s off ce. i
Learn more at anthem.com/guidedtour .
7aNe your Eene¾tV wLth you when you traYel Your ID card, with the "PPO - in - a - suitcase" syPbol, is your key to getting your bene¾ts and saving Poney. By following the steps in the bo[ at the right, your PPO health care bene¾ts stay with you across the country. USING YOUR HEALTH PLAN 7aNe your Eene¾tV wLth you when you traYel Your ID card, with the "PPO - in - a - suitcase" syPbol, is your key to getting your bene¾ts and saving Poney. By following the teps in the bo[ at the right, your PPO health care bene¾ts st y with you across th country. Precerti¾cation tKe most important step Precerti¾cation is when you need approval froP us before receiving certain care and services. Precerti¾cation helps you to
:e¶re here to helS If you have questions or need help, please call CustoPer 6ervice. Our nuPber is on your ID card. We’re here to help you get the Post froP your health care bene¾ts. :e¶re here to helS If you have questions or need help, please call CustoPer 6ervice. Our nuPber is n your ID card. We’re here to help you get the Post froP your health care bene¾ts. Your steps to coast-to-coast care . $lways carry your current ID card. . When you need health care, call the nuPber on your ID card to ¾nd the nearest BlueCard PPO doctors or hospitals. . You Pust call us for precerti¾cation. 8se the phone nuPber on your ID card. . When you are at the doctor’s of¾ce or the hospital, show theP your ID card and the doctor or hospital will check to Pake sure you are a PePber and verify your bene¾ts. . $fter you get Pedical care, your claiP is sent to us electronically for processing. 6. Your in-network BlueCard PPO doctors and hospitals are paid directly, so you have less to worry about. You will norPally Your steps to coast-to-coast care . $lways carry your current ID card. . When you need health care, call the nuPber on your ID card to ¾nd the nearest BlueCard PPO doctors or hospitals. . You Pust call us for precerti¾cation. 8se the phone nuPber on your ID card. . When you are at the doctor’s of¾ce or the hospital, show theP your ID card and the doctor or hospital will check to Pake sure you are a PePber and verify your bene¾ts. . $fter you get Pedical care, your claiP is sent to us electronically for processing. 6. Y ur in-network BlueCar PPO doctors and hospitals are paid directly, so you have less to worry about. Y will norPally only need to pay for out-of- pocket costs (noncovered services, deductible, copayPent or coinsurance. We will send you a detailed ([planation of Bene¾ts ((OB that will show what you need to pay out of your pocket. only need to pay for out-of- pocket costs (noncovered services, ded ctible, copayPent or coinsurance. We will send you a detailed ([planation of Bene¾ts ((OB that will show what you need to pay out of your pocket.
| Get care in the right place Precerti¾cation tKe most important step
| Meet your plan’s rules for what is medically necessary care
Have your provider call us if precerti¾cation is required. Prior to the procedure, Pake sure you call the 0ePber 6ervice nuPber on the back of your ID card to con¾rP the precerti¾cation has been applied. Precerti¾cation is when you need approval froP us before receiving certain care and services. Precerti¾cation helps you to | Get care in the right place
| Meet your plan’s rules for what is medically necessary care
Precerti¾cation is not required for ePergency treatPent or adPissions. However, authorization is still required. You or a faPily PePber Pust tell us within hours hours for PePbers in Indiana, or as soon as reasonably possible. If you do not let us know, we will not pay for services that we ¾nd are not Pedically necessary. Have your provider call us if precerti¾cation is required. Prior to the procedure, ak sure you call the 0ePber 6ervic nuPber on the back of your ID card to con¾rP the precerti¾cation has been applied. Precerti¾cation is not required for ePergency treatPent or adPissions. However, authorization is still required. You or a faPily PePber Pust tell us within hours hours for PePbers in Indiana, or as soon as reasonably possible. If you do not let us know, we will not pay for services that we ¾nd are not Pedically necessary. For more information or to determine if your service or equipment requires precerti¾cation pOease caOO tKe 0emEer 6ervice numEer on tKe EacN of your memEer ,' card For more information or to determine if your service or equipment requires precerti¾cation pOease caOO tKe 0emEer 6ervice numEer on tKe EacN of your memEer ,' card Emergency care
Blue Cross and Blue 6hield $ssociation, About the Blue Cross and Blue Shield Association (accessed 0ay bcbs.coPabout
For Administrative Services Only accounts, Anthem Blue Cross and Blue Shield Srovides administrative claims Sayment services only and does not assume any ¾nancial risN or oEliJation Zith resSect to claims. 7his Slan overvieZ is intended to Ee a ErieI outline oI coveraJe and is not a contract. ,n case oI any con¿ict EetZeen this overvieZ and the Slan document, the Srovisions oI the Slan document Zill Srevail.
Anthem Blue Cross and Blue Shield is the trade name oI ,n Colorado and Nevada RocNy Mountain +osSital and Medical Service, ,nc. ,n Connecticut Anthem +ealth 3lans, ,nc. ,n *eorJia Blue Cross and Blue Shield oI *eorJia, ,nc. ,n ,ndiana Anthem ,nsurance ComSanies, ,nc. ,n .entucNy Anthem +ealth 3lans oI .entucNy, ,nc. ,n Maine Anthem +ealth 3lans oI Maine, ,nc. ,n Missouri e[cludinJ 30 counties in the .ansas City area RiJhtC+O,CE ManaJed Care, ,nc. R,7, +ealthy Alliance /iIe ,nsurance ComSany +A/,C, and +MO Missouri, ,nc. R,7 and certain aI¾liates administer non+MO Eene¾ts underZritten Ey +A/,C and +MO Eene¾ts underZritten Ey +MO Missouri, ,nc. R,7 and certain aI¾liates only Srovide administrative services Ior selIIunded Slans and do not underZrite Eene¾ts. ,n NeZ +amSshire Anthem +ealth 3lans oI NeZ +amSshire, ,nc. ,n Ohio Community ,nsurance ComSany. ,n 9irJinia Anthem +ealth 3lans oI 9irJinia, ,nc. trades as Anthem Blue Cross and Blue Shield in 9irJinia, and its service area is all oI 9irJinia e[ceSt Ior the City oI FairIa[, the 7oZn oI 9ienna, and the area east oI State Route 123. ,n :isconsin Blue Cross Blue Shield oI :isconsin ³BCBS:i´, Zhich underZrites or administers the 33O and indemnity Solicies ComScare +ealth Services ,nsurance CorSoration ³ComScare´, Zhich underZrites or administers the +MO Solicies and ComScare and BCBS:i collectively, Zhich underZrite or administer the 3OS Solicies. ,ndeSendent licensees oI the Blue Cross and Blue Shield Association. AN7+EM is a reJistered trademarN oI Anthem ,nsurance ComSanies, ,nc. 7he Blue Cross and Blue Shield names and symEols are reJistered marNs oI the Blue Cross and Blue Shield Association. Blue Cross and Blue 6hield $ssociation, About the Blue Cross and Blue Shield Association (accessed 0ay bcbs.coPabout For Administrative Services Only accounts, Anthem Blue Cross and Blue Shield Srovides administrative claims Sayment services only and does not assume any ¾nancial risN or oEliJation Zith resSect to claims. 7his Slan overvieZ is intended to Ee a ErieI outline oI coveraJe and is not a contract. ,n case oI any con¿ict EetZeen this overvieZ and the Slan document, the Srovisions oI the Slan document Zill Srevail.
13273ANMENABS Rev. 9/11 F0023247
Take care of yourself. Use your preventive care benefits.
Getting regular checkups and exams can help you stay well and catch problems early. It may even save your life. Our health plans offer the services listed in this preventive care flier at no cost to you. 1 When you get these services from doctors in your plan’s network, you don’t have to pay anything out of your own pocket. You may have to pay part of the costs if you use a doctor outside the network. Preventive versus diagnostic care What’s the difference? Preventive care helps protect you from getting sick. Diagnostic care is used to find the cause of existing illnesses. For example, say your doctor suggests you have a colonoscopy because of your age when you have no symptoms. That’s preventive care. On the other hand, say you have symptoms and your doctor suggests a colonoscopy to see what’s causing them. That’s diagnostic care.
Child preventive care Preventive physical exams Screening tests:
} Behavioral counseling to promote a healthy diet } Blood pressure } Cervical dysplasia screening } Cholesterol and lipid level } Depression screening } Development and behavior screening } Type 2 diabetes screening } Hearing screening } Height, weight and body mass index (BMI) } Hemoglobin or hematocrit (blood count) } HPV screening (female)
} Lead testing } Newborn screening } Screening and counseling for obesity } Counseling for those ages 10–24, with fair skin, about ways to lower their risk for skin cancer } Oral (dental health) assessment when done as part of a preventive care visit } Screening and counseling for sexually transmitted infections } Tobacco use: related screening and behavioral counseling } Vision screening 2 when done as part of a preventive care visit
} Diphtheria, tetanus and pertussis (whooping cough) } Haemophilus influenza type b (Hib)
} Meningococcal (meningitis) } Pneumococcal (pneumonia) } Polio } Rotavirus } Varicella (chickenpox)
} Hepatitis A and Hepatitis B } Human papillomavirus (HPV) } Influenza (flu) } Measles, mumps and rubella (MMR)
Women’s preventive care: } Well-woman visits
} Counseling related to genetic testing for women with a family history of ovarian or breast cancer } HPV screening 5 } Screening and counseling for interpersonal and domestic violence } Pregnancy screenings: includes, but is not limited to, gestational diabetes, hepatitis, asymptomatic bacteriuria, Rh incompatibility, syphilis, iron deficiency anemia, gonorrhea, chlamydia and HIV 5 } Pelvic exam and Pap test, including screening for cervical cancer
} Breast cancer, including exam, mammogram, and, including genetic testing for BRCA 1 and BRCA 2 when certain criteria are met 3 } Breast-feeding: primary care intervention to promote breast-feeding support, supplies and counseling (female) 4,5 } Contraceptive (birth control) counseling } FDA-approved contraceptive medical services provided by a doctor, including sterilization } Counseling related to chemoprevention for women with a high risk of breast cancer
The preventive care services listed are recommendations as a result of the Affordable Care Act (ACA, or health care reform law). The services listed may not be right for every person. Ask your doctor what’s right for you, based on your age and health condition(s). This sheet is not a contract or policy with Anthem Blue Cross and Blue Shield. If there is any difference between this sheet and the group policy, the provisions of the group policy will govern. Please see your combined Evidence of Coverage and Disclosure Form or Certificate for Exclusions and Limitations.
43199MUMENABS Rev. 12/14
Live life to the fullest – without paying full price
Save money with discounts at anthem.com Saving money is good. Saving money on things that are good for you — that’s even better. With SpecialOffers@Anthem SM , you can get discounts on products and services that help promote better health and well-being.* It’s just one of the perks of being a member. Check out how much you can save:
Vision and hearing
Fitness and health Jenny Craig ® — Join Jenny Craig and get a 30-day trial at no additional cost and 50% off enrollment. Lindora ® — Save 20% on weight-loss programs. SelfHelpWorks — Choose one of the online Living programs and get a 40% discount to help you lose weight, stop smoking, manage stress or face an alcohol problem. GlobalFit ™ — Save on gym memberships, home fitness equipment and GlobalFit’s Virtual Gym. ChooseHealthy ™ — Get preferred pricing on fitness club memberships and a one-week free trial. Enjoy discounts on acupuncture, chiropractors and massage — plus 40% off certain wellness products. FitOrbit ® — Get your own personal trainer for less than $2 a day. Fitness legend Jake Steinfeld (Body by Jake ® ) created FitOrbit — giving everybody the ability to afford a personal trainer. Performance Bicycle — Get $20 off a purchase of $80 or more in store or online.
Glasses.com TM — Get the latest, brand-name frames for just a fraction of the cost at typical retailers — every day. Plus, you get an additional $20 off orders of $100 or more, free shipping and free returns. Premier LASIK — Save 15% on LASIK with all in-network providers. Prices are as low as $695 per eye with select providers. Amplifon — Get a low-price guarantee with the seven top companies that work with Amplifon. Save $50 on one hearing aid or $125 on two. Plus, get a three-year repair/loss/damage warranty and a free two-year supply of batteries. Beltone ™ — Get hearing screenings and in-home service at no additional cost, and up to 50% off all Beltone hearing aids. 1-800 CONTACTS ® — Get contact lenses quick and easy — plus discounts only available to Anthem members, like $20 off when you spend $100 or more and free shipping.
Check out more SpecialOffers@Anthem SM on the other side.
MANSH1231A VPOD Rev. 02/15
for taking care of your health
Online Wellness Toolkit Getting healthier can get easier — with a little help from the Online Wellness Toolkit. Sign up and take a private Health Assessment to find out what’s going on with your health. The results can help you set goals and show you areas to focus on and actions you can take to improve your health. ConditionCare With ConditionCare, you can get help managing diabetes, asthma, heart disease or chronic obstructive pulmonary disease (COPD). A nurse coach offers expert advice and support so you can follow your doctor’s care plan and learn how to take care of your health. Future Moms Future Moms is a maternity program that offers resources to help you have a healthy pregnancy and a healthy baby. Call a toll-free number 24/7 to talk to a nurse coach about pregnancy topics. Get prenatal goodies, including a book about pregnancy and weekly tracking tools. Take advantage of these programs to help you and your family take care of your health: Your health plan gives you access to health and wellness programs that don’t cost you anything extra. From online resources at anthem.com to personal attention from nurses, these programs can help you make better health care decisions. Of course, better health is your greatest reward, but extra incentives can help, too.
Rewards are waiting for you } Sign up and use the Online Wellness Toolkit — up to $150 } Enroll in ConditionCare — $100 } Graduate from ConditionCare — $200 } Complete the Future Moms program — up to $200
57043MUMENABS VPOD Rev. 01/17
How to sign up
How to earn rewards
1. Complete your health assessment by answering questions and reporting your biometric results like blood pressure, weight and cholesterol. You get points after doing this. 2. You can also collect points by setting and completing health goals using the Health Assistant, signing up for challenges and connecting f tness i devices. 3. You’ll receive a $50 reward (gift card) when you reach the 100-, 200- and 300-point milestones. Each time you redeem a reward, your point value will reset to zero.
Log in at anthem.com .
Online Wellness Toolkit
1. Enroll in ConditionCare. Reward: $100 gift card 2. Graduate from ConditionCare. Reward: $200 gift card
Call the number on your ID card.
1. Enroll and get assessment no later than 183 days before the baby’s birth. Reward: $100 gift card 2. Complete second assessment between 1 to 97 days before the baby’s birth. Reward: $50 gift card 3. Complete postpartum assessment no later than 56 days after the baby’s birth. Reward: $50 gift card
Call the number on your ID card.
Check your activities and rewards
1. Log in at anthem.com and go to Health and Wellness .
2. Select Get my rewards . You can check available activities and your reward status. Any rewards earned will automatically appear on the rewards site.
How to get your rewards
Once you've earned a reward, you'll get information in the mail with instructions on how to redeem for a gift card.
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain aff liates administer non-HMO benef ts underwritten by HALIC and HMO benef ts underwritten by HMO Missouri, Inc. RIT and certain aff liates only provide administrative services for self-funded plans and do not underwrite benef ts. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. i i i i i HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
Your plan details
In this next section, you’ll find more information about your plan.
Out-of-Network Your Summary of Benefits DAS Acquisition Company LLC dba USA Mortgage - 03/01/2019 Anthem Blue Cross and Blue Shield Dental Complete WELCOME TO YOUR DENTAL PLAN! This benefit summary outlines how your dental plan works and provides you with a quick reference of your dental plan benefits. For complete coverage details, please refer to your certificate of coverage. Dental coverage you can count on Your Anthem Blue Cross and Blue Shield (Anthem) dental plan lets you visit any licensed dentist or specialist you want – with costs that are normally lower when you choose one within our large network. Savings beyond your dental plan benefits – you get more for your money. You pay our negotiated rate for covered services from in-network dentists even if you exceed your annual benefit maximum. YOUR DENTAL PLAN AT A GLANCE In-Network Out-of-Network Annual Benefit Maximum – (Calendar Year) Per insured person Diagnostic & Preventive Services are applied to the Annual Benefit Maximum Annual Maximum Carryover $1,250 Yes $1,250 Yes Orthodontic Lifetime Benefit Maximum Per eligible insured child $1,000 $1,000 Annual Deductible – (Calendar Year) Out-of-Network $1,250 Yes $1,000 $1,250 Yes $1,000
of your dental plan benefits. For complete f your dental plan benefits. For complete
r specialist you want – with costs that are normally specialist you want – with costs that are normally
annual benefit maximum. nnual benefit maximum.
$50 3x single member deductible Yes $50 3x single member deductible Yes Per insured person Family maximum Out-of-NetworkReimbursement
$50 3x single member deductible
$50 3x single member deductible
Deductible Waived for Diagnostic/Preventive Services
Maximum Allowed Amount Out-of-Network Anthem Pays: aximum Allowed Amount Out-of-Network Anthem Pays: 100% coinsurance 100% coinsurance
Maximum Allowed Amount
Waiting Period No waiting period Waiting Period No waiting period
In-Network Anthem Pays: 100% coinsurance
Out-of-Network Anthem Pays: 100% coinsurance
Dent l Services
Waiting Period No waiting period
Diagnostic and Preventive Services Periodic oral exam Teeth cleaning (prophylaxis) Bitewing X-rays (once in 12 mos. for all ages) Periapical X-rays
90% coinsurance 90% coinsuranc
No waiting period No waiting period
Basic Services Amalgam (silver-colored) filling Front composite (tooth colored) filling Back composite (tooth colored) filling, alternated to amalgam allowance Simple extractions
No waiting period
90% coinsurance 90% coinsurance 90% coinsurance 90% coinsurance 90% coinsurance 90% coinsurance 50% coinsurance 50% coinsurance 50% coinsuranc 50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance
No waiting period No waiting period No waiting period No waiting period No waiting period No waiting period No waiting period No waiting period No waiting period No waiting period
Endodontics Root canal
No waiting period
Periodontics Scali g and root planing Oral Surgery Surgical extractions
No waiting period
No waiting period
Major Services Crow s
No waiting period
No waiting period No waiting period ProstheticRepairs/Adjustments No waiting period Prosthodontics Dentures Bridges Dental implants (not covered)
No waiting period
50% coinsurance 50% coinsurance
50% coinsurance 50% coinsurance
No waiting period No waiting period
ABCBS_IN_KY_MO_OH_WI_PCLG_FI-Custom s, exclusions, terms d provisions of your certificate of certificate will prevail. must have been banded between the ages of eight and 19 in been banded before age 19. ions, exclusions, terms and provisions of your certificate of e certificate will prevail. ild must have been banded between the ages of eight and 19 in ve been banded before age 19. Orthodontic Services D pendent ch ldren only* No waiting period
This is not a contract; it is a partial listing of benefits and services. All covered services are subject to the conditions, limitations, exclusions, terms and provisions of your certificate of coverage. In the event of a discrepancy between the information in this summary and the certificate of coverage, the certificate will prevail. Remove if no child ortho: *Child orthodontic coverage begins at age eight and runs through age 18.This means that the child must have been banded between the ages of eight and 19 in order to receive coverage. If children are dependents until age 19, they can continue to receive coverage, but they must have been banded before age 19.
Blue View Vision SM DAS Acquisition Company LLC Effective 03/01/2019
Welcome to your Blue View Vision plan! You have many choices when it comes to using your benefits. As a Blue View Vision plan member, you have access to one of the nation’s largest vision networks. You may choose from many private practice doctors, local optical stores, and national retail stores including LensCrafters®, Target Optical®, Sears Optical®, JCPenney® Optical and most Pearle Vision® locations. You may also use your in-network benefits to order eyewear online at Glasses.com and ContactsDirect.com. To locate a participating network eye care doctor or location, log in at anthem.com , or from the home page menu under Care, select Find a Doctor . You may also call member services for assistance at 1-866-723-0515 . Out-of-Network – If you choose to, you may instead receive covered benefits outside of the Blue View Vision network. Just pay in full at the time of service, obtain an itemized receipt, and file a claim for reimbursement up to your maximum out-of-network allowance.
YOUR BLUE VIEW VISION PLAN BENEFITS
Routine Eye Exam A comprehensive eye examination
Once every 12 months
Up to $42 allowance
$130 allowance, then 20% off any remaining balance
Once every 24 months
One pair of eyeglass frames
Up to $45 allowance
Eyeglass Lenses (instead of contact lenses) One pair of standard plastic prescription lenses:
Single vision lenses Bifocal lenses Trifocal lenses
$10 copay $10 copay $10 copay
Up to $40 allowance Up to $60 allowance Up to $80 allowance
Once every 12 months
Eyeglass Lens Enhancements When obtaining covered eyewear from a Blue View Vision provider, you may choose to add any of the following lens enhancements at no extra cost.
$0 copay $0 copay $0 copay
No allowance when obtained out-of-network
Lenses (for a child under age 19)
Same as covered eyeglass lenses
} Standard polycarbonate (for a child under age 19) } Factory scratch coating
Contact Lenses (instead of eyeglass lenses) Contact lens allowance will only be applied toward the first purchase of contacts made during a benefit period. Any unused amount remaining cannot be used for subsequent purchases in the same benefit period, nor can any unused amount be carried over to the following benefit period.
} Elective conventional (non-disposable) OR
Up to $125 allowance
$125 allowance, then 15% off any remaining balance $125 allowance (no additional discount) Covered in full
Once every 12 months
Up to $125 allowance
Up to $210 allowance
Non-elective (medically necessary)
This is a primary vision care benefit intended to cover only routine eye examinations and corrective eyewear. Blue View Vision is for routine eye care only. If you need medical treatment for your eyes, visit a participating eye care doctor from your medical network. Benefits are payable only for expenses incurred while the group and insured person’s coverage is in force. This information is intended to be a brief outline of coverage. All terms and conditions of coverage, including benefits and exclusions, are contained in the member’s policy, which shall control in the event of a conflict with this overview. This benefit overview is only one piece of your entire enrollment package. EXCLUSIONS & LIMITATIONS (not a comprehensive list – please refer to the member Certificate of Coverage for a complete list) Combined Offers. Not to be combined with any offer, coupon, or in-store advertisement. Excess Amounts. Amounts in excess of covered vision expense. Lost or Broken Lenses or Frames. Any lost or broken lenses or frames are not eligible for replacement unless the insured person has reached his or her normal service interval as indicated in the plan design. Non-Prescription Lenses. Any non-prescription lenses, eyeglasses or contacts. Plano lenses or lenses that have no refractive power. Orthoptics. Orthoptics or vision training and any associated supplemental testing. Sunglasses. Plano sunglasses and accompanying frames. Safety Glasses. Safety glasses and accompanying frames. Not Specifically Listed. Services not specifically listed in this plan as covered services.
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