Election Forms
Employee Insurance Rates 2021/2022 Plan Year Effective October 1, 2021
J & L Ventures, LLC Employee Insurance Rates effective 10/01/2021 are shown below.
It is now Open Enrollment for J & L Ventures, LLC. Open Enrollment is an opportunity for you to review your current benefit plan elections to ensure they continue to meet your needs and those of your family. New enrollments and changes will become effective October 1 st .
If you do not enroll, or make any necessary changes during Open Enrollment, you will not be able to enroll again until the next annual open enrollment period unless you experience a Qualifying Event (QE).
Examples of a QE include: Open Enrollment, Other insurance, Marriage, Divorce, or legal separation, Adoption or birth of a child, Death of a spouse or child or Involuntary loss of coverage
ALL rates are shown on a weekly basis . **NOTE – Coverage for spouse is not allowed if insurance is available through spouse’s employer.
Group Health Insurance – High Benefit Plan Option $1,500 Individual / $4,500 Family Deductible 80% In Network Coinsurance $7,150 Individual / $14,300 Out of Pocket $25 PCP Copay / $50 SCP Copay $300 Individual / $600 Family Non-Generic Rx Deductible $5/$20/$45/$80/25% Rx Copays
I elect this benefit (please check)
Current Per Pay Period Costs
Employee Only
$ 68.00 $140.00 $130.00 $218.00
Employee + Spouse Employee + Child(ren)
Family
Group Health Insurance – Low Benefit Plan Option $2,500 Individual / $7,500 Family Deductible 70% In Network Coinsurance $7,150 Individual / $14,300 Out of Pocket $45 PCP Copay (4 Visit Max) $1,000 Individual / $2,000 Family Non-Generic Rx Deductible $5/$20/20% Rx Copays
I elect this benefit (please check)
Current Per Pay Period Costs
Employee Only
$ 53.00 $110.00 $ 99.00 $167.00
Employee + Spouse Employee + Child(ren)
Family
I Decline Medical Coverage
_____________
***No Medical Coverage***
12 J&L Ventures, LLC 2022 Enrollment Guide
Made with FlippingBook flipbook maker