2023 Benefits Guide Benefit plan year July 1, 2023- June 30, 2024
2023 Benefits Guide
Benefit plan year July 1, 2023- June 30, 2024
Benefit Plan Year July 1, 2023 – June 30, 2024 Insurance Agency Representatives / Contacts
Diane M Barber Consultant diane.barber@aleragroup.com (717) 506-33219 x 5626
Heather Murphy Senior Client Service Specialist heather.murphy@aleragroup.com (717) 506-3210 x 5632 Lindsay Miller Client Service Specialist lindsay.miller@aleragroup.com (717) 506-3209 x 5641
Benjamin Lerew Senior Account Manager benjamin.lerew@aleragroup.com (717) 482-0745 x 5616
Benefits Offered
Member Services Contact Number
Product
Carrier
Plan Name
Group Number
Medical / RX
United Healthcare
P6000i100LX21
TBD
866-414-1959
Health Reimbursement Arrangement (HRA)
BDS
N/A
N/A
888-273-7036
Dental Vision
Principal
Dental PPO Vision PPO
1160710
800-245-1522 800-432-4966
VBA
2713
NEW HIRE WAITING PERIOD
Newly hired employees are eligible to enroll effective 1 st of the month following Date of Hire (Class 1), First of the month following 60 days of full-time employment (Class II). BENEFITS TERMINATE
Benefits terminate as of the last day of the month.
ENROLLMENT OPPORTUNITIES
Federal legislation provides for enrollment onto a group-sponsored plan during the following periods:
Initial enrollment. When you are initially hired and become eligible for benefits as a newly hired employee. Annual enrollment. During the annual open enrollment period. An annual open enrollment period is typically the month prior to the benefit plan’s annual renewal. Special enrollment . Life changes may require you to make a change to your benefit enrollment. In the event of a life change, the enrollment change must be made within 30 calendar days of the life change. Life changes that might provide for a change in enrollment are: marriage, childbirth and adoption, death, legal separation and divorce.
HOW TO ENROLL
1. Review the plans offered and the related employee contributions. 2. Complete the enclosed consolidated enrollment form indicating your benefit election. 3. Return the completed enrollment form to Jason Smith.
UnitedHealthcare Level
Funded | Pennsylvania | Choice Plus | P6000i100LX21 | RX4 ADV
Choice Plus plan details, all in one place. Use this benefit summary to learn more about this plan’s benefits, ways you can get help managing costs and how you may get more out of this health plan.
Check out what’s included in the plan
Choice Plus
Network coverage only You can usually save money when you receive care for covered health care services from network providers. Network and out-of-network benefits You may receive care and services from network and out-of-network providers and facilities — but staying in the network can help lower your costs. Primary care physician (PCP) required With this plan, you need to select a PCP — the doctor who plays a key role in helping manage your care. Each enrolled person on your plan will need to choose a PCP. Referrals required You’ll need referrals from your PCP before seeing a specialist or getting certain health care services.
Preventive care covered at 100% There is no additional cost to you for seeing a network provider for preventive care.
Pharmacy benefits With this plan, you have coverage that helps pay for prescription drugs and medications.
Tier 1 providers Using Tier 1 providers may bring you the greatest value from your health care benefits. These PCPs and medical specialists meet national standard benchmarks for quality care and cost savings. Freestanding centers You may pay less when you use certain freestanding centers — health care facilities that do not bill for services as part of a hospital, such as MRI or surgery centers. Health savings account (HSA) With an HSA, you’ve got a personal bank account that lets you put money aside, tax-free. Use it to save and pay for qualified medical expenses.
This Benefit Summary is to highlight your Benefits. Don’t use this document to understand your exact coverage. If this Benefit Summary conflicts with the Summary Plan Description (SPD), that document governs. Review your SPD for an exact description of the services and supplies that are and are not covered, those which are excluded or limited, and other terms and conditions of coverage.
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Here's a more in-depth look at how Choice Plus works. Medical Benefits In Network
Out-of-Network
Annual Medical Deductible
Individual
$6,000
$12,000
Family
$12,000
$24,000
All individual deductible amounts will count toward the family deductible, but an individual will not have to pay more than the individual deductible amount. *After the Annual Medical Deductible has been met. You're responsible for paying 100% of your medical expenses until you reach your deductible. For certain covered services, you may be required to pay a fixed dollar amount - your copay. Annual Out-of-Pocket Limit
Individual
$8,150
$16,300
Family
$16,300
$32,600
All individual out-of-pocket maximum amounts will count toward the family out-of-pocket maximum, but an individual will not have to pay more than the individual out-of-pocket maximum amount. For the 2000X family plans, the out-of-pocket limit is capped at $6,550 for an individual and $8,000 for family. Once you’ve met your deductible, you start sharing costs with your plan - coinsurance. You continue paying a portion of the expense until you reach your out-of- pocket limit. From there, your plan pays 100% of allowed amounts for the rest of the plan year. What You Pay for Services
Copays ($) and Coinsurance (%) for Covered Health Care Services
Out-of-Network
Network
Preventive Care Services
Preventive Care Services
No copay
50%*
Certain preventive care services are provided as specified by the Patient Protection and Affordable Care Act (ACA), with no cost-sharing to you. These services are based on your age, gender and other health factors. UnitedHealthcare also covers other routine services that may require a copay, co-insurance or deductible. Includes services such as Routine Wellness Checkups, Immunizations, and Lab and X-ray services for Mammogram, Pap Smear, Prostate and Colorectal Cancer screenings. Office Services - Sickness & Injury
Primary Care Physician
All other covered persons
$25 copay
50%*
Covered persons less than age 19
No copay
50%*
Additional copays, deductible, or co-insurance may apply when you receive other services at your physician’s office. For example, surgery and lab work. Telehealth is covered at the same cost share as in the office.
*After the Annual Medical Deductible has been met. ¹Prior Authorization Required. Refer to SPD.
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What You Pay for Services
Copays ($) and Coinsurance (%) for Covered Health Care Services
Out-of-Network
Network
Specialist
$75 copay
50%*
Additional copays, deductible, or co-insurance may apply when you receive other services at your physician’s office. For example, surgery and lab work. Telehealth is covered at the same cost share as in the office.
Urgent Care Center Services
$50 copay
50%*
Additional copays, deductible, or co-insurance may apply when you receive other services at the urgent care facility. For example, surgery and lab work.
Virtual Care Services
No copay
50%*
Network Benefits are available only when services are delivered through a Designated Virtual Network Provider. You can find a Designated Virtual Visit Network Provider by contacting us at myuhc.com® or the telephone number on your ID card. Access to Virtual Visits and prescription services may not be available in all states or for all groups. Emergency Care
Ambulance Services - Emergency Ambulance
Air Ambulance
No copay*
No copay*
Ground Ambulance
No copay*
No copay*
Ambulance Services - Non-Emergency Ambulance¹
Air Ambulance
No copay*
No copay*
Ground Ambulance
No copay*
50%*
Dental Services - Accident Only
No copay*
50%*
Emergency Health Care Services - Outpatient¹
You pay a $300 per occurrence copay per visit prior to and in addition to paying any Annual Deductible.*
You pay a $300 per occurrence copay per visit prior to and in addition to paying any Annual Deductible.*
Inpatient Care
Habilitative Services - Inpatient
The amount you pay is based on where the covered health care service is provided.
Hospital - Inpatient Stay¹
No copay*
50%*
Skilled Nursing Facility/Inpatient Rehabilitation Facility Services¹
No copay*
50%*
Limited to 60 days per year.
Outpatient Care
Acupuncture Services
$25 copay
50%*
Limited to 10 treatments per year.
*After the Annual Medical Deductible has been met. ¹Prior Authorization Required. Refer to SPD.
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What You Pay for Services
Copays ($) and Coinsurance (%) for Covered Health Care Services
Out-of-Network
Network
Habilitative Services - Outpatient
Manipulative treatment services
$25 copay
50%*
Other habilitative services
No copay*
50%*
Limits will be the same as, and combined with those stated under Rehabilitation Services - Outpatient Therapy and Manipulative Treatment.
Home Health Care¹
No copay*
50%*
Limited to 30 visits per year. One visit equals up to four hours of skilled care services. This visit limit does not include any service which is billed only for the administration of intravenous infusion.
Lab, X-Ray and Diagnostic - Outpatient - Lab Testing¹
No copay*
50%*
Limited to 18 Definitive Drug Tests per year. Limited to 18 Presumptive Drug Tests per year.
Lab, X-Ray and Diagnostic - Outpatient - X-Ray and other Diagnostic Testing¹
No copay*
50%*
Major Diagnostic and Imaging - Outpatient¹
No copay*
50%*
Physician Fees for Surgical and Medical Services
No copay*
50%*
Rehabilitation Services - Outpatient Therapy and Manipulative Treatment
Manipulative treatment services
$25 copay
50%*
Other rehabilitation services
No copay*
50%*
Limited to 20 visits of Manipulative Treatments per year. Limited to 30 combined visits of physical therapy, occupational therapy, speech therapy, cardiac therapy, post cochlear therapy, cognitive therapy and pulmonary therapy per year. Limits are combined with Habilitative Services - Outpatient.
Surgery - Outpatient¹
No copay*
50%*
Therapeutic Treatments - Outpatient¹
No copay*
50%*
Therapeutic treatments include, but are not limited to dialysis, intravenous chemotherapy, intravenous infusion, medical education services and radiation oncology. Supplies and Services
Diabetes Self-Management Items¹
The amount you pay is based on where the covered health care service is provided under Durable Medical Equipment (DME), Orthotics and Supplies or in the Prescription Drug Benefits Section.
Diabetes Self-Management and Training/Diabetic Eye Exams/Foot Care¹
The amount you pay is based on where the covered health care service is provided.
Durable Medical Equipment (DME), Orthotics and Supplies¹
No copay*
50%*
*After the Annual Medical Deductible has been met. ¹Prior Authorization Required. Refer to SPD.
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What You Pay for Services
Copays ($) and Coinsurance (%) for Covered Health Care Services
Out-of-Network
Network
Enteral Nutrition
No copay*
50%*
Hearing Aids
No copay*
50%*
Limited to $5,000 every 36 months. Benefits are further limited to a single purchase per hearing impaired ear including repair or replacement. For enrolled Dependent children under the age of 18: One hearing aid, per hearing impaired ear every 36 months.
Ostomy Supplies
No copay*
50%*
Pharmaceutical Products - Outpatient
No copay*
50%*
Depending on the pharmaceutical product prior authorization may be required. This includes medications given at a doctor's office, or in a covered person's home.
Prosthetic Devices¹
No copay*
50%*
Pregnancy
Pregnancy - Maternity Services¹
The amount you pay is based on where the covered health care service is provided except that an Annual Deductible will not apply for a newborn child whose length of stay in the Hospital is the same as the mother's length of stay.
Mental Health Care & Substance Related and Addictive Disorder Services
Inpatient
No copay*
50%*
Outpatient
$75 copay
50%*
Partial Hospitalization
No copay*
50%*
Limited to 60 days combined for residential treatment facility and skilled nursing facility per year. Other Services
Cellular and Gene Therapy
The amount you pay is based on where the covered health care service is provided.
For Network Benefits, Cellular or Gene Therapy services must be received from a Designated Provider.
Clinical Trials¹
The amount you pay is based on where the covered health care service is provided.
Gender Dysphoria¹
The amount you pay is based on where the covered health care service is provided or in the Prescription Drug Benefits Section.
Hospice Care¹
No copay*
50%*
Reconstructive Procedures¹
The amount you pay is based on where the covered health care service is provided.
Transplantation Services
No copay*
Not covered
Coverage is only available when services are performed at a Centers of Excellence facility, except for cornea transplants.
*After the Annual Medical Deductible has been met. ¹Prior Authorization Required. Refer to SPD.
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Pharmacy Benefits
Pharmacy Plan Details
Pharmacy Network
Standard Select
Prescription Drug List
Advantage
In Network
Annual Pharmacy Deductible
Individual
You do not have to pay a pharmacy deductible
Family
You do not have to pay a pharmacy deductible
Up to a 31-day supply
Up to a 90-day supply
Prescription Drug Product Tier Level
Mail Order Network Pharmacy**
Retail Network***
Out-of-Network Pharmacy
Tier 1 $ Tier 2 $$ Tier 3 $$$ Tier 4 $$$$
$10
$10
$25
$35
$35
$87.50
$75
$75
$187.50
$250
$250
$625
Mail Order Preferred Specialty Network Pharmacy**
Preferred Specialty Prescription Drug Product Tier Level
Preferred Specialty Retail Network
Preferred Specialty Out-of- Network Pharmacy
Tier 1 $ Tier 2 $$ Tier 3 $$$ Tier 4 $$$$
$10
$10
Not applicable
$150
$150
Not applicable
$350
$350
Not applicable
$500
$500
Not applicable
** Only certain Prescription Drug Products are available through mail order; please visit myuhc.com® or call Customer Care at the telephone number on the back of your ID card for more information. You will be charged a retail Copayment and/or Coinsurance for 31 days or 2 times for 60 days based on the number of days supply dispensed for any Prescription Order or Refills sent to the mail order pharmacy. To maximize your Benefit, ask your Physician to write your Prescription Order or Refill for a 90-day supply, with refills when appropriate, rather than a 30-day supply with three refills. ***Retail: up to a 90 day supply. You will be charged a retail Copayment and/or Coinsurance for 31 days, 2 times for 60 days, or 3 times for 90 days based on the number of days supply dispensed for any Prescription Order or Refills obtained at a retail pharmacy. Your Copayment and/or Coinsurance is determined by the tier to which the Prescription Drug List (PDL) Management Committee has assigned the Prescription Drug Product. All Prescription Drug Products on the Prescription Drug List are assigned to Tier 1, Tier 2, Tier 3 or Tier 4. If you are a member, you can find individualized information on your benefit coverage, determine tier status, check the status of claims and search for network pharmacies by logging into your account on myuhc.com® or calling the Customer Care number on your ID card. If you are not a member, you can view prescription information at welcometouhc.com > Benefits > Pharmacy Benefits.
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Here’s an example of how the plan’s costs come into play.
More ways to help manage your health plan and stay in the loop.
Search the network to find doctors. You can go to providers in and out of our network — but when you stay in network, you’ll likely pay less for care. To get started: . Go to welcometouhc.com > Benefits > Find a Doctor or Facility. . Choose Search for a health plan. . Choose Choice Plus to view providers in the health plan’s network. Manage your meds. Look up your prescriptions using the Prescription Drug List (PDL). It places medications in tiers that represent what you’ll pay, which may make it easier for you and your doctor to find options to help you save money. . Go to welcometouhc.com > Benefits > Pharmacy Benefits. . Select Advantage to view the medications that are covered under your plan. Access your plan online. With myuhc.com®, you’ve got a personalized health hub to help you find a doctor, manage your claims, estimate costs and more. Get on-the-go access. When you’re out and about, the UnitedHealthcare® app puts your health plan at your fingertips. Download to find nearby care, video chat with a doctor 24/7, access your health plan ID card and more.
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Other important information about your benefits. Medical Exclusions Services your plan generally does NOT cover. It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
• Bariatric Surgery • Cosmetic Surgery • Dental Care (Adult) • Infertility Treatment • Long-Term Care • Non-emergency care when traveling outside the U.S. • Private-Duty Nursing • Routine Eye Care (Adult) • Routine Foot Care • Weight Loss Programs
Outpatient Prescription Drug Benefits For Prescription Drug Products dispensed at a retail Network Pharmacy, you are responsible for paying the lowest of the following: 1) The applicable Copayment and/or Coinsurance; 2) The Network Pharmacy’s Usual and Customary Charge for the Prescription Drug Product; and 3) The Prescription Drug Charge for that Prescription Drug Product. For Prescription Drug Products from a mail order Network Pharmacy, you are responsible for paying the lower of the following: 1) The applicable Copayment and/or Coinsurance; and 2) The Prescription Drug Charge for that Prescription Drug Product. For an out-of-Network Pharmacy, your reimbursement is based on the Out-of-Network Reimbursement Rate, and you are responsible for the difference between the Out-of-Network Reimbursement Rate and the out-of-Network Pharmacy’s Usual and Customary Charge. See the Copayment and/or Coinsurance stated in the Benefit Information table for amounts. We will not reimburse you for any non-covered drug product. For a single Copayment and/or Coinsurance, you may receive a Prescription Drug Product up to the stated supply limit. Some products are subject to additional supply limits based on criteria that we have developed. Supply limits are subject, from time to time, to our review and change. Specialty Prescription Drug Products supply limits are as written by the provider, up to a consecutive 31-day supply of the Specialty Prescription Drug Product, unless adjusted based on the drug manufacturer’s packaging size, or based on supply limits, or as allowed under the Smart Fill Program. Supply limits apply to Specialty Prescription Drug Products obtained at a Preferred Specialty Network Pharmacy, an out-of-Network Pharmacy, a mail order Network Pharmacy or a Designated Pharmacy. Certain Prescription Drug Products for which Benefits are described under the Prescription Drug Rider are subject to step therapy requirements. In order to receive Benefits for such Prescription Drug Products you must use a different Prescription Drug Product(s) first. You may find out whether a Prescription Drug Product is subject to step therapy requirements by contacting us at myuhc.com or the telephone number on your ID card. Before certain Prescription Drug Products are dispensed to you, your Physician, your pharmacist or you are required to obtain prior authorization from us or our designee to determine whether the Prescription Drug Product is in accordance with our approved guidelines and it meets the definition of a Covered Health Care Service and is not an Experimental or Investigational or Unproven Service. We may also require you to obtain prior authorization from us or our designee so we can determine whether the Prescription Drug Product, in accordance with our approved guidelines, was prescribed by a Specialist. If you require certain Prescription Drug Products, we may direct you to a Designated Pharmacy with whom we have an arrangement to provide those Prescription Drug Products. If you are directed to a Designated Pharmacy and you choose not to obtain your Prescription Drug Product from the Designated Pharmacy, the Prescription Drug Product is not eligible for benefits . Certain Preventative Care Medications may be covered at zero costshare. You can get more information by contacting us at myuhc.com or the telephone number on your ID card. Benefits are provided for certain Prescription Drug Products dispensed by a mail order Network Pharmacy . The Outpatient Prescription Drug Schedule of Benefits will tell you how mail order Network Pharmacy supply limits apply. Please contact us at myuhc.com or the telephone number on your ID card to find out if Benefits are provided for your Prescription Drug Product and for information on how to obtain your Prescription Drug Product through a mail order Network Pharmacy .
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Other important information about your benefits. Pharmacy Exclusions The following exclusions apply. In addition see your SPD for additional exclusions and limitations that may apply.
• A Pharmaceutical Product for which Benefits are provided in your Summary Plan Description. • A Prescription Drug Product with either: an approved biosimilar, a biosimilar and Therapeutically Equivalent to another covered Prescription Drug Product. • Any Prescription Drug Product to the extent payment or benefits are provided or available from the local, state or federal government (for example, Medicare). • Any product dispensed for the purpose of appetite suppression or weight loss. • Any product for which the primary use is a source of nutrition, nutritional supplements, or dietary management of disease, and prescription medical food products even when used for the treatment of Sickness or Injury, except as required by state mandate. • Certain New Prescription Drug Products and/or new dosage forms until the date they are reviewed and placed on a tier by our PDL Management Committee. • Certain Prescription Drug Products for tobacco cessation. • Certain Prescription Drug Products for which there are Therapeutically Equivalent alternatives available. • Certain Prescription Drug Products that are FDA approved as a package with a device or application, including smart package sensors and/or embedded drug sensors.
• Certain compounded drugs. • Diagnostic kits and products. • Drugs available over-the-counter. • Drugs which are prescribed, dispensed or intended for use during an Inpatient Stay.
• Durable Medical Equipment, including insulin pumps and related supplies for the management and treatment of diabetes, for which Benefits are provided in your Summary Plan Description. Prescribed and non-prescribed outpatient supplies. This does not apply to diabetic supplies and inhaler spacers specifically stated as covered. • Experimental or Investigational or Unproven Services and medications. • General vitamins, except Prenatal vitamins, vitamins with fluoride, and single entity vitamins when accompanied by a Prescription Order or Refill. • Medications used for cosmetic purposes. • Prescription Drug Products dispensed outside the United States, except as required for Emergency treatment. • Prescription Drug Products when prescribed to treat infertility. • Prescription Drug Products, including New Prescription Drug Products or new dosage forms, that we determine do not meet the definition of a Covered Health Care Service. • Publicly available software applications and/or monitors that may be available with or without a Prescription Order or Refill.
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UnitedHealthcare does not treat members differently because of sex, age, race, color, disability or national origin. If you think you weren’t treated fairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator: Online: UHC_Civil_Rights@uhc.com Mail: Civil Rights Coordinator You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m. You can also file a complaint with the U.S. Dept. of Health and Human Services. Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at: http://www.hhs.gov/ocr/office/file/index.html. Phone: Toll-free 1-800-368-1019 , 1-800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 UnitedHealthcare Civil Rights Grievance P.O. Box 30608, Salt Lake City, UT 84130 We provide free services to help you communicate with us such as letters in others languages or large print. You can also ask for an interpreter. To ask for help, please call the toll-free member phone number listed on your health plan ID card. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call the toll-free phone number listed on your identification card.
Administrative services provided by United HealthCare Services, Inc. or their affiliates, and UnitedHealthcare Service LLC in NY. Stop-loss insurance is underwritten by UnitedHealthcare Insurance Company or their affiliates, including UnitedHealthcare Life Insurance Company in NJ, and UnitedHealthcare Insurance Company of New York in NY. B2C EI1670806.1 4 /23 © 2023 United HealthCare Services, Inc. All Rights Reserved. 22-1665601
Medical Expense Reimbursement Program J. E. Smith Services, Inc. Effective July 1, 2023
Effective July 1, 2023 , the Company is offering a Medical Expense Reimbursement Program (aka Health Reimbursement Arrangement) to employees who are enrolled in the group health plan. The purpose of the HRA is to provide reimbursement for qualified medical expenses that are not paid by the insurance carrier. An HRA is an arrangement under which an employer establishes separate bookkeeping accounts for employees to pay for certain medical insurance coverage and welfare benefits. To the extent that an HRA is an employer-provided accident or health plan, coverage and reimbursements under the HRA of medical care expenses of an employee and his or her spouse and dependents are generally excludable from the employee’s gross income. HRA benefits must be paid for solely by the employer and not provided pursuant to a salary reduction contribution. Reimbursements are made on a tax-free basis for qualified medical expenses. Qualified medical expenses are defined as follows:
Carrier-approved medical charges applied towards the member’s in-network deductible
How it works:
Enrolled as:
Plan Deductible Member Responsibility
Company Will Reimburse
The first $2,500 in-network deductible
Employee Only $6,000
$3,500 in-network deductible
The first $2,500 in-network deductible per member, family maximum of $5,000
$3,500 in-network deductible per member, family maximum of $7,000
$6,000/member $12,000/family
Employee Plus Dependents
The plan year begins July 1, 2023 , and ends June 30, 2024 .
This program is being administered by Benefit Design Specialists (BDS). Prior to the beginning of the plan year, BDS will provide further information (plan document, summary plan description, claim form, claim submission instruction).
Helping You Understand Your Medicare Options
Help your employees understand their Medicare options As we age, quality healthcare is more important than ever. Often, employers make health insurance decisions for us, so determining what to do in retirement can be overwhelming. Our goal is to help you understand your Medicare health plan options so you can make a decision that improves your quality of life in retirement.
What is Medicare?
Medicare is the federal health insurance program for people 65 or older, or younger people with certain disabilities or end stage renal disease.
We can help you answer the following questions:
Q: Do I need Medicare when I'm first eligible?
Q: How do I get enrolled in Medicare?
Q: How much does Medicare cost?
Q: Once enrolled in Medicare, how do I know which coverage option is right for me?
Please contact me, your certified Medicare consultant, to learn more about when to enroll in Medicare and what plan option is right for you.
Bob Pease, Jr. Medicare Consultant
C:717-574-2448 D:717-506-3214 Bob.Pease@aleragroup.com AIA.AleraGroup.com
Policyholder: JESSINC Group voluntary dental insurance
Benefit Summary for all eligible employees Effective date: 07/01/202 3
What's available to me? Dental insurance helps pay for all, or a portion, of the costs associated with dental care, from routine cleanings to root canals.
Eligibility Eligible employees
All active, full-time employees Calendar-year deductible
Coinsurance your policy pays
In-network
Out-of-network
In-network
Out-of-network
$0
$0
100%
100%
Preventive
$50 $50
$50 $50
80% 50%
80% 50%
Basic Major
Additional provisions Family deductible
2 times the per person deductible amount Combined deductible Your deductibles that are in and out-of-network for basic and major services are combined. Combined maximum Maximums for preventive, basic, and major procedures are combined. In-network calendar year maximums are $1,000 per person or non-networkcalendar year maximums are $1,000 per person. Maximum accumulation Included Plantype Scheduled Who can buy coverage? • You may buy coverage if you're an active, full-time employee. Seasonal, temporary, or contract employees can't purchase. o If you’re on regularly scheduled day off, holiday, vacation day, jury duty, funeral leave, or personal time off, you’re still considered actively at work, as long as you’re fulfilling your regular duties and were working the day immediately prior to your time off. o You must enroll within 31 days of being eligible. If you don’t, you’ll have to wait until the next open enrollment period, or qualifying event. Additional eligibility requirements may apply.
Which procedures are covered, and how often? Preventive Routine exams Twice per calendar year
Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392 04052210597 - 6 Page 1 of 4
Twice per calendar year
Routine cleanings
Once per calendar year
Bitewing X-rays
Once every 60 months
Full mouth X-rays
Once per calendar year (covered only for dependent children under age 14)
Fluoride
Basic Sealants
Covered only for dependent children under age 14; once per tooth each 36 months
Emergency exams Subject to routine exam frequency limit Periodontal maintenance If three months have passed since active surgical periodontal treatment; subject to routine cleaning frequency limit Fillings Replacement fillings every 24 months Composite (tooth colored) Covered on posterior teeth Simple endodontics Root canal therapy for anterior teeth Complex endodontics Root canal therapy for molar teeth
Non-surgical periodontics, including scaling and root planning
Once per quadrant per 24 months
Periodontal surgical procedures
Once per quadrant per 36 months
Harmfulhabit appliance Covered only for dependent children under age14
Major Oral surgery
Simple and complex
General anesthesia / IV sedation (covered only for specific procedures)
Covered only for specific procedures
Each 120 months per tooth if tooth cannot be restored by a filling
Crowns
Each 120 months per tooth
Core buildup
120 months old (initial placement / replacement)
Bridges
Dentures
60 months old (initial placement / replacement)
Additional benefits Scheduled / MAC design In and out-of-network claim payments are based on the amounts agreed to by network dentist, known as a negotiated fee schedule.
Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392 04052210597 - 6 Page 2 of 4
Maximum accumulation Some of your unused annual benefit maximum can be carried over to the next year. To qualify, you must have had a dental service performed within the calendar year and used less than the maximum threshold. The threshold is equal to the lesser of 50% of the out-of-network maximum benefit or $1,000. If the qualification is met, 50% of the threshold is carried over to next year's maximum benefit. Individuals with fourth quarter effective dates will start qualifying for rollover at the beginning of the next calendar year. You can accumulate no more than four times the carry over amount. The entire accumulation amount will be forfeited if no dental service is submitted within a calendar year Emergency services If you have a dental emergency and you can't see an in-network provider in a reasonable amount of time, your claim may be paid if you see an out-of-network provider. Participating provider services If you require treatment and you can’t see an in-network provider in a reasonable amount of time, your claim may be paid if you see an out-of-network provider. Periodontal program If you’re pregnant or have diabetes or heart disease, you may receive scaling and root planing covered at 100% (if dentally necessary), or one additional cleaning (routine or periodontal) subject to deductible and coinsurance. Second opinion program You may be eligible for second opinions from dental providers at 100%. This program makes sure you get the best advice to make an informed decision about your care. Cancer treatment oral health program If you have cancer and are undergoing chemotherapy or head/neck radiation therapy, you may receive up to three fluoride treatments every 12 months covered at 100% plus one additional routine cleaning. How do I find a network dentist? When you receive services from a dentist in our network, your cost may be lower. Network dentists agree to lower their fees for dental services and not charge you the difference. You’ll have access to the Principal Plan Dental network, with more than 117,000 dentists nationwide. Visit principal.com/dentist to find a dentist or call 800-247-4695. What if my dentist isn't in the network? You can refer your dentist to our network. Please submit the dentist’s name and information by calling 800-247-4695, or submitting a form at principal.com/refer-dental-provider. What are the limitations and exclusions of my coverage? • Missing tooth –The initial placement of bridges, partials, and dentures to replace teeth missing before this coverage starts won’t be covered. If this policy replaces coverage with another carrier, continuous coverage under the prior plan may be applied to the missing tooth provision requirement. This doesn’t apply to pediatric essential benefits. • Frequency limitations for services are calculated to the month and exact date from the last date of service or placement date. There are additional limitations to your coverage. Please review your booklet for more information.
Yes
U1P 1
Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392 04052210597 - 6 Page 3 of 4
Save money while improving your life Discounts and services Looking for ways to help improve your life—financially, mentally, and physically? These discounts and services are available through your group benefits from Principal ® . These discounts are not insurance.
Laser Vision Correction
Imagine your life free from glasses and contacts. You, your spouse, and dependent children save $800 off LASIK through the National Lasik Network, administered by LCA-Vision, Inc. principallasik.com | 888-647-3937 Protect your hearing health to improve your quality of life. You, your spouse, children, parents, and grandparents can get exclusive discounts up to 48% off on hearing aids, including rechargeable and Bluetooth options, with a 60-day trial to ensure your full satisfaction. You can also receive a free hearing consultation at any of their 3,000+ locations nationwide. principal.com/hearingbenefits/ahb | 877-890-4694 Get help when you’re feeling overwhelmed or need support. You, your spouse, and dependent children can call this free, confidential support line 24 hours a day, 7 days a week to reach licensed behavioral health clinicians who will provide emotional support, tips for healthy coping, and referrals to local resources. If your employer offers an Employee Assistance Program (EAP), use those resources instead. 800-424-4612
Hearing Aid Program
Emotional health support line
Available with your dental insurance
Dental Health Edge SM
Get the information you need to make better decisions about oral health care. Youcango online and submit a dental care question and get a response from a dentist in one business day. A dental cost estimator shows approximate costs in a ZIP code. And you can access articles about dental health topics plus get information about how dental coverage works. http://c3.go2dental.com/scontent/
GP58554C-16 (Dental, Disability, Life, Vision, VTL) (SP1285C-16)
VBA# 2713
Alera Group (Plan D Frequency)
$0 Exam / $0 Materials Copay Dependent Age: 26 (EOBM)
Frequency Type: Last Date of Service
Employee
Spouse
Children
Vision Exam
12 Months 12 Months 12 Months
12 Months 12 Months 12 Months
12 Months 12 Months 12 Months
Lenses Frames
VBA Participating Provider Amount Covered/Benefit (Zero Copay)
Out-of-Network Max Reimbursement (Zero Copay)
Benefits: Employee Can Select Either
Vision Exam (Glasses or Contacts) Clear Standard Lenses (Pair): Single Vision
Covered in Full
$40
Covered in Full Covered in Full Covered in Full Covered in Full Partially-Covered Covered in Full
$40 $50 $50 $75 $75
Bifocal
Blended Bifocal
Trifocal
Progressives
Lenticular
$100
Covered in Full for Persons Up to Age 19
Polycarbonate
N/A
Basic Scratch Coating
Covered in Full
N/A $50
Frame (Wholesale Allowance)
Up to $ 50
-OR- Elective Contacts (in lieu of eyeglass benefits) Material Allowance Elective Fitting Fee and Evaluation -OR- Medically Necessary Contacts Low Vision Aids (Per 24 Months. No Lifetime Max)
Up to $ 110 A 15% off UCR
$110
N/A
Covered in Full B
$320 $650
N/A
-AND- Lasik Surgery (once every 8 years)
N/A $125 Where an “allowance” is shown above, the Member is responsible for paying any charges in excess of the allowance less any applicable copay. Benefits and participation may vary by location, including, but not limited to, Costco® Optical, Pearle Vision, LensCrafters®, Target Optical® and Boscov’s™ A The allowance is applied to all services/materials associated with contact lenses, including, but not limited to, contact fitting, dispensing, cost of the lenses, etc. No guarantee the allowance will cover the entire cost of services and materials. B Requires prior approval. May only be selected in lieu of all other material benefits listed herein. Cost Per Employee Per Month Employee Only Employee + Family $8.70 $17.40
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Limitations
This plan is designed to cover your visual needs rather than cosmetic options. Additional Charges You may incur out-of-pocket charges when selecting any of the following: • Tinted Lenses • Photochromic/Polarized Lenses • Polycarbonate (covered under age 19) • Hi-index Lenses • Progressive (available starting at $29) • The coating of the lens or lenses (except Basic Scratch Coating) • A frame that costs more than the plan allowance
• Rimless Frames • Anti-Reflective Additionally, costs for contact lenses/services in excess of the plan’s scheduled reimbursement allowances are the responsibility of the patient. Not Covered The contract gives VBA the right to waive any of the plan limitations if, in the opinion of our optometric consultants, it is necessary for the patient’s welfare. VBA provides no benefit for professional services or materials connected with the following: • Orthoptics or vision training • Non-prescription lenses • Two pair of glasses in lieu of bifocals • Medical or surgical treatment of the eyes • An eye examination, or corrective eyewear, required by an employer as a condition of employment • Services of materials provided as result of any Worker’s Compensation Law or similar legislation • Glasses and contacts during the same eligibility period Lenses and frames furnished under this program which are lost or broken will not be replaced except at the normal intervals when services are otherwise available. Additional Terms and Conditions Frame allowance is based on wholesale pricing at non-retail locations. Frame allowance, contact lens pricing and policies vary by location. Contact your provider before requesting services. Benefits may only be used for contact lenses when selected in lieu of eyeglasses (spectacle lenses and frames). If purchased at the same time from a single provider, your plan will cover up to $110 towards the cost of contact fitting fees and contact lenses. Any provider contact lens charges that exceed this amount shall be the responsibility of the member. Members may be required to pay contact fitting fees out of pocket at some locations. Benefits and participation may vary by location and where prohibited by state law. LASIK benefits may be limited to no more than 50% per eye. A 15% discount off the provider's usual, customary and reasonable contact lens fitting fee may be available in some locations. Void where prohibited by law. Benefits may only be used for medically necessary contact lenses when selected in lieu of all other materials. Additional terms and conditions apply. Contact VBA at 412-881-4900 for more information.
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J E Smith Services, Inc. dba JESSINC CONSOLIDATED ENROLLMENT, TERMINATION & CHANGE FORM Effective July 1, 2023 through June 30, 2024
EMPLOYEE INFORMATION
Effective Date:
Social Security Number
Date of Birth
Date of Hire
Last Name
First Name
Middle Initial
Address
Change q
City
State
Zip
County
q M q F
Gender
Phone (home or cell)
Phone (work)
Employment Class (if applicable)
Salary or Hourly Rate
# Hours worked/week
# of Pay Periods
q Single
q Full Time q Part Time q Variable
q Class 1 q Class 2 q Other
q Divorced/Separated
Marital Status
Employment Status
Job Description:
q Married q Widowed
q Other
EMPLOYEE AND DEPENDENT INFORMATION / ELECTIONS
Medical
Dental
Vision
Last Name
First Name
MI
Gender
Date of Birth
Social Security Number
United Healthcare
Principal
VBA
Option # (CBC Only)
o Enroll o Term o Waive o Enroll o Term o Waive o Enroll o Term o Waive o Enroll o Term o Waive o Enroll o Term o Waive
o Enroll o Term o Waive o Enroll o Term o Waive o Enroll o Term o Waive o Enroll o Term o Waive o Enroll o Term o Waive
o Enroll o Term o Waive o Enroll o Term o Waive o Enroll o Term o Waive o Enroll o Term o Waive o Enroll o Term o Waive
Please indicate action to right for employee listed above
Employee
o Female o Male
Spouse/Partner
o Female o Male
Son/Dau
o Female o Male
Son/Dau
o Female o Male
Son/Dau
WAIVER OF COVERAGE (Not Enrolling) ACKNOWLEDGEMENT I have been given the opportunity to participate in the group health and welfare benefits offered by my employer. The benefits and enrollment eligibility guidelines have been explained. I understand if I choose to waive (not enroll) for myself and eligible dependents, the next opportunity to enroll would be at annual open enrollment or if I experience a qualifying life status event.
q Other Coverage (please circle applicable type and provide copy of ID card)
q Other (please describe below)
Reason for waiving:
spouse, parent, Medicare, Medicaid
(Bi-Weekly Employee Contributions)
Coverage Tier
Vision
Medical
Dental
Employee
$20.91 $276.34 $256.53 $506.02
$23.09 $26.91 $40.58 $11.29
$4.02 $8.03 $8.03 $8.03
Employee/spouse Employee/child(ren)
Employee/family
EMPLOYEE SIGNATURE By signing here, I authorize the above action as indicated and the pre-tax salary reductions from my wages for the coverage(s) elected above. The benefits and enrollment eligibility guidelines have been explained. I understand if I choose to not enroll (opt out or waive coverage) for myself and/or eligible dependents, the next opportunity to enroll will be at the next open enrollment. Exceptions include qualified life status events. I understand by checking "waiving coverage" above, I do not wish to enroll in those products at this time.
Employee name (print)
Signature
Date
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