Reference Manual - Staff Masters Inc
Transcripción
Reference Manual - Staff Masters Inc
Reference Manual Information for Branch Managers on Fixed Indemnity Medical Plan Contact Information...................................................................................3 Schedule of Benefits..................................................................................4 Questions with Answers ............................................................................6 Our Networks ............................................................................................7 Restock and Supplies Requests .................................................................8 New Hire Procedures.................................................................................9 Fax Cover Sheet ......................................................................................10 Sample Enrollment Form .........................................................................11 Change Forms .........................................................................................12 Temporary ID Card ..................................................................................14 STM Insurance Applications Group, Inc. v.18.2 Contact Information Branch Services: We have a single toll-free number and a single email address for you to use to submit your inquiries. Please contact the Essential StaffCARE Support Center at 1-844-262-6022 or via email at [email protected]. Representatives are available Monday – Friday from 8:30 a.m. – 5:00 p.m. ET. Secondary Contact: 704-637-0022 – Essential StaffCARE Account Management Use this contact in the event that the Primary Marketing Service Support Representative is unavailable and you are in need of immediate assistance. We ask that employees not call this number as it is reserved for management. Member Services: Essential StaffCARE Customer Service: 1-866-798-0803 Members will call this number for questions regarding their plan coverage, ID Card, claim status, policy booklets, and to cancel or change their coverage Customer Service Call Center hours are M-F 8:30am to 8:00pm EST Spanish Speaking representatives are available Interactive Voice Response (IVR): How To Make Changes and Cancel Coverage by Telephone After your initial enrollment form has been submitted, you may make changes or cancel coverage by telephone. Changes can be made within 30 days of completing your enrollment form. If you do not have an assignment during the first 30 days, you can make changes to your coverage within 30 days from the pay check date of your first assignment. You will be prompted to enter your PIN CODE plus the last four digits of your social security number. PIN CODE: 142 + _ _ _ _ (last four digits of your SSN) Call 1-800-269-7783 (toll free) to make changes or cancel coverage by telephone. You may cancel or reduce coverage at any time unless your deductions are pre-tax. Remember, it will take two to three weeks for the changes or cancellation to be reflected on your paycheck. Coverage will continue as long as you have a paycheck deduction and refunds will not be issued for this time period. 3 Fixed Indemnity Medical Benefits - Plan 1 Plan 1 Medical Network First Health Network Provider Must Accept Plan Yes Prescription Network Caremark Pre-Existing Condition Limitation None Wellness Care Wellness Care (one per year) $100 Inpatient Benefits Standard Care Intensive Care Unit Maximum $300 per day $400 per day 1 Inpatient Surgery $2,000 per day Anesthesiology $400 per day First Hospital Admission (1 per year) $250 Skilled Nursing (for stays in a skilled nursing facility after a hospital stay) $100 per day Outpatient Benefits 2 Annual Outpatient Maximum $2,000 Physician Office Visit $100 per day Diagnostic (Lab) $75 per day Diagnostic (X-Ray) $200 per day Ambulance Services $300 per day Physical Therapy, Speech Therapy, Occupational Therapy $50 per day Emergency Room Benefit - Sickness $200 per day Emergency Room Benefit - Accident $500 per day Outpatient Surgery $500 per day Anesthesiology $200 per day Prescription Drugs (via reimburesment) Annual Maximum $600 Generic Coinsurance 70% Brand Coinsurance 1 3 3, 4 50% Pays in addition to standard care benefit All outpatient benefits are subject to the outpatient maximum Not subject to outpatient maximum 4 To file a claim, save your receipt and remit to Planned Administrators, Inc. 2 Weekly Premiums Medical Employee + 1 $40.54 Employee + Family $54.14 Employee Only 4 $19.98 Dental, Vision, Term Life, Short Term Disability, & Accidental Loss Benefits Accidental Loss of Life, Limb & Sight Employee Amount $20,000 Child Amount (6 mos to 26 yrs old) $5,000 Spouse Amount $20,000 Infant Amount (15 days to 6 mos) $2,500 Accidental Loss of Life, Limb & Sight is part of the Medical Benefits Dental Benefits Waiting Period Coinsurance Annual Maximum Benefit $750 Deductible $50 Coverage A None 80% Exams, Cleanings, Intraoral Films and Bitewings Coverage B 3 Months 60% Fillings, Oral Surgery, and Repairs for Crowns, Bridges and Dentures Coverage C 12 Months 50% Periodontics, Crowns, Bridges, Endodontics and Dentures Vision Benefits In-Network Out-of-Network Eye Examination for Glasses 1 (including dilation) Copay: $10, plan pays 100% Plan pays $35, you pay remainder Frames 2 Plan pays $110 allowance 4 Plan pays $55 Standard Plastic Lenses for Glasses 1 Copay: $25, plan pays 100% Copay: $0, plan pays $25-$55 3 Standard Contact Lens Fit 1 Plan pays up to $55 You pay 100% of the price Premium Contact Lens Fit 1 Plan pays 10% off the price You pay 100% of the price Contact Lenses or Disposable Lenses 1 Plan pays $110 allowance 4 Plan pays $88 Contact Lenses Medically Necessary 1 Plan pays 100% Plan pays $200 Term Life Benefits Employee Amount $10,000 (reduces to $7,500 at 65; $5,000 at 70) Child Amount (6 mos to 26 yrs old) $5,000 Spouse Amount $5,000 (terminates at age 70) Infant Amount (15 days to 6 mos) $1,000 Short-Term Disability Benefit 60% of Salary up to $150 per week Waiting Period/Maximum Benefit Period 7 days/26 weeks Once every 12 months 2 Once every 24 months 3 Single Vision: $25, Bifocal: $40, Trifocal: $55 4 Discount on balance above allowed amount; Frames: 20%, Conventional Contact Lenses: 15% 1 Weekly Premiums Dental Vision Term Life STD Employee + 1 $10.80 $4.92 $0.90 n/a Employee + Family $17.82 $6.56 $1.80 n/a Employee Only $5.40 $2.42 $0.60 $4.20 5 Questions & Answers Q: Do all employees have to complete an enrollment form? A: Yes. By obtaining acknowledgement of either an acceptance or declination from each employee completes new-hire paperwork, you are limiting the liability you and your employer face. We never want an employee or family member of your agency to come back to you and say they were discriminated against and never offered insurance. It is in your company’s best interest to make sure that all employees fill out the enrollment form and either elect or decline coverage. Q: When can an employee enroll for benefits? A: Employees may sign up for coverage during their first thirty (30) days of employment or during the company-wide open enrollment period. Employees who choose not to elect coverage during their own 30-day open enrollment period, or a company-wide open enrollment, will be asked to wait until the next company-wide open enrollment period before being allowed to elect coverage. Leaving one job assignment and immediately starting another does not constitute a “new” 30-day open enrollment period. If an employee has been terminated or laid off from an assignment and returns on a new assignment, after 6 or more weeks, he/she may re-enroll as a new hire. ESC/PAI considers an employee’s first day on a job assignment, regardless of length, the start of their personal 30-day open enrollment period. This is why we encourage you to make sure ALL employees filling out new-hire paperwork complete an Essential StaffCARE enrollment form. Q: Will an employee’s insurance be canceled if a premium payment is missed? A: No. Coverage cannot be cancelled until the employee has missed six consecutive premium deductions. In the event that an employee misses a deduction(s), the employee may make direct payments to PAI, as long as there has been at least one payroll deduction made through their employer. It is the employee’s responsibility to contact PAI to make arrangements for direct payments. PAI will NOT contact your employee if a premium payment is missed. Employees may not initiate coverage through a direct payment. If an employee chooses not to make payments for the week(s) they have a break, no benefit will be paid for claims incurred and submitted during the break in coverage. Payments must be received within 45 days of the date of the paycheck from which a premium deduction would have been made. If an employee comes back to work between one (1) and six (6) weeks, payroll deductions will automatically begin again and be applied on a going forward basis (the Monday following the next deduction). Deductions will only be taken weekly and will NOT be “caught up” by the employer or posted to back weeks. Q: When will an employee and his/her eligible dependents be eligible for COBRA? A: Employees become eligible to receive a COBRA offer if they have had at least one payroll deduction through their employer and have missed six consecutive premium payroll deductions. Once there is a six week break with no payroll premium reported, a COBRA letter is automatically generated and sent by PAI to the member’s home address. If the employee or dependent is eligible, he or she may elect COBRA within sixty days from the date of their letter and the applicable premium must be remitted in full to the address provided in their letter. COBRA participants or “qualified beneficiaries”, are not billed for their COBRA payment and must take responsibility to keep premium current. COBRA participants may generally stay on COBRA for up to 18 months from the date of a qualifying event that causes loss of coverage. A second qualifying event may allow extended COBRA coverage for up to 36 months. Qualifying events for COBRA are termination of employment, loss of coverage due to a reduction of hours, death of the employee, divorce or legal separation, change in status of a dependent, Medicare entitlement, retired employees, and for employer bankruptcy. Q: Who is considered an “eligible dependent”? A: Your eligible dependents are your spouse and your children under age 26. Q: When can an enrollee add coverage for himself/herself or dependents? A: An enrollee may add coverage for himself/herself during an annual open enrollment period or during a life changing event, such as birth, marriage, death, divorce, adoption, Medicare entitlement or loss of prior coverage. Proof of the event must be provided and enrollment or change must occur within thirty days of such event. 6 Our Networks Please utilize the web site addresses or phone numbers below to locate a physician, dentist, or vision provider. DO NOT call with questions about your health plan. The networks do not have any knowledge of your medical plan. Medical Network First Health Network www.firsthealth.com 1-800-226-5116 Prescription Network Caremark Pharmacy Network www.caremark.com 1-888-963-7290 Dental Network Dentemax www.dentemax.com 1-800-752-1547 Vision Network EyeMed Vision Care www.eyemedvisioncare.com 1-866-559-5252 7 Restock & Supply Requests Restock Your branch will receive a regular shipment of English Enrollment Forms (printed on white paper), Spanish Enrollment Forms (printed on blue paper), and Return Envelopes. The quantities of forms in the restock can be adjusted for each branch’s level of volume. The Spanish forms are in increments of 50 and the English forms are in increments of 100. Contact Essential StaffCARE to: • • • • Adjust the quantity of materials Change frequency of the shipments Stop the restock Order more materials Phone Number: 864-527-7929 Email: [email protected] Visit: www.essentialstaffcare.com/supplies Log on to essential.printtekonline.net to: • Stop the restock • Order more materials A stop request on the restock will only stop the next shipment. For example; if a stop order is placed in February then the March shipment would be canceled and the next shipment would be in May (if the restock occurs every two months). Any changes via email or phone in the quantity of materials or the frequency of shipments will remain in effect until notified to change. PrintTek Website – essential.printtekonline.net USER NAME: STM PASSWORD: password Supplies that can be ordered: Enrollment Forms Change Forms Reference Manuals Return Envelopes Posters Table Tents Essential StaffCARE welcomes all feedback and suggestions in reference to improving the enrollment materials. If you have specific recommendations, please contact your Account Manager. 8 New Hire Procedures 1. All new hires who complete an I-9 and W-4 will need to complete the ESC enrollment form. Please incorporate the Essential StaffCARE (ESC) enrollment form into your New Hire paperwork. 2. Ask your employees to complete the form to the best of their knowledge. 3. Every new hire must check ‘Yes’ or ‘No’ on the enrollment application. 4. Don’t let employees take the application portion of the form home. 5. Check the form for completeness. We must have all personal information on the top portion of the application including: • Social Security Number • Date of Birth • First and Last Name • Home Phone Number • Address • Dependent information if dependent coverage is elected. • Signature and Date • Election of ‘Yes’ or ‘No’ 6. Any information left off of the top portion of the enrollment form may delay coverage for the employee. 7. Fax the completed forms to PAI’s secure fax at 1-803-264-0772. Please include a fax cover sheet alerting PAI how many applications are included in the fax transmission. You will find, enclosed, a fax cover template which includes important information to accompany your fax. Please feel free to use this version, or create your own. 8. If you prefer to mail your enrollment forms to PAI at least once a week, we will supply you with postage paid return envelopes. Ask your employees to fill out the Essential StaffCARE enrollment form to the best of their knowledge and hand the benefit election portion back to you. Do not allow this portion to leave your office. Your new hire employee may take the remainder of the form home with them. The take home portion contains valuable information about their plan and also how they can make changes until they receive their ID card and Summary Plan Description from Planned Administrators. Please do not let the benefit election portion of the enrollment form leave your office--- the chances of getting the form back within the eligibility period is slim and also leaves your company open for a liability. If an employee is unsure of the type of coverage they need, have them complete the top portion of the enrollment form with all personal information and check the box titled “No to all benefits” They can take the remaining portion home with them to discuss with family members. If the employee would like to change their initial election, the take home portion of the application will alert them on how this may be done. They can use our Interactive Voice Response (IVR) system, or they may call the Essential StaffCARE Customer Service line directly, and a customer service representative will assist them in making changes. Planned Administrators will do all the tracking of your employee’s eligibility through their systems. We are receiving weekly payroll files from your corporate office, therefore we are able to monitor when deductions and benefits will begin. That is why we must insist that the Essential StaffCARE enrollment form be completed at the time the new hire paperwork is done and faxed to PAI at 1-803-264-0772 no less than once a week. Enrollment forms are date stamped upon receipt at PAI and keyed into the system within 4 business days. Once an employee has received an assignment, PAI will communicate back to your corporate office as to when premium deductions will begin. 9 ENROLLMENT FORMS FAX COVER SHEET GROUP #251200-STM NUMBER OF PAGES BEING FAXED (INCLUDING COVER PAGE) YOUR NAME YOUR PHONE NUMBER Please Fax to ONE of the following. Indicate which fax line you are using by checking the box below. PAI’s FAX NUMBERS: 1-803-264-0772 1-803-264-8571 1-803-264-8739 1-803-870-8060 VSI LOCATION ____________ OFFICE USE ONLY Rehire Date __ __ /__ __ /__ __ __ __ ENROLLMENT FORM ESC S P1 v18.2 A. REQUIRED EMPLOYEE INFORMATION PRINT USING BLACK or BLUE INK (Must Be Filled Out) Name Social Security # Home Phone Address Sex M F E L Apt. # City State Zip B. DO YOU OR ANY OF YOUR DEPENDENTS RECEIVE MEDICARE BENEFITS? Medicare Health Insurance Claim Number (HICN) Name of Covered Person (s): 1. Date of Birth / Yes / No. If Yes, please continue. Medicare Effective Date 2. P 3. C. LIMITED BENEFITS PLAN SELECTION Payroll Deducted Weekly Rates You MUST enroll in the Fixed Indemnity Medical Insurance Plan before adding any additional benefits in Section C. Your coverage level for the additional benefits in Section C will be identical to your fixed indemnity medical plan selection. This plan is underwritten by BCS Insurance Company. FIXED INDEMNITY MEDICAL 1 1 M DENTAL VISION TERM LIFE SHORT-TERM DISABILITY 2 $4.20 Employee Only $19.98 $5.40 $2.42 $0.60 Employee + 1 $40.54 $10.80 $4.92 $0.90 Employee + Family $54.14 $17.82 $6.56 $1.80 NO to ALL Benefits Yes A S No Yes No Yes No Yes No This coverage is not available to residents of NH, HI, or PR. 2 STD is not available to persons who work in CA, HI, NJ, NY, or RI. For Term Life / Accidental Loss of Life, Limb & Sight, please write in your beneficiary information. Accidental Loss of Life, Limb & Sight is part of the Fixed Indemnity Medical Benefit. Name Relationship D. REQUIRED DEPENDENT INFORMATION Name Name Name Name E. REQUIRED SIGNATURE Social Security # Date of Birth Sex / / M F Relationship Child Spouse Domestic Partner Social Security # Date of Birth Sex / / M F Relationship Spouse Child Domestic Partner Social Security # Date of Birth Sex / / M F Relationship Child Spouse Domestic Partner Social Security # Date of Birth Sex / / M F Relationship Spouse Child Domestic Partner YOU MUST SIGN AND DATE, EVEN IF YOU DECLINE COVERAGE I have read the benefit packet and understand its limitations. I understand that open enrollment is only available for a limited time and I understand that making no benefit selection is a declination of coverage. DATE __ __ /__ __ /__ __ __ __ SIGNATURE PLAN 1 - CHANGE FORM Essential StaffCARE Mail / Fax to: Planned Administrators, Inc. PO Box 6702 Columbia, SC 29260 251200-STM Telephone (866) 798-0803 Fax (803) 264-0772 Underwritten by BCS Insurance Company Oakbrook Terrace, IL Fill out this form ONLY if you are making changes in your coverage or terminating coverage. A. REASON FOR THE CHANGE Address Change Name Change Add Dependent(s) Coverage Change Terminate Coverage B. REQUIRED EMPLOYEE INFORMATION MUST BE FILLED OUT Address/Name Change Name Social Security # Home Phone Address City State Employer Sex Zip Hire Date / M F Apt. # Date of Birth / / / Add/Change Dependent Information Name Social Security # Date of Birth Gender / / M F Relationship M F M F C. INDEMNITY PLAN CHANGES - Select the change you wish to make for each benefit Weekly Rates You MUST enroll in the Fixed Indemnity Medical Insurance Plan before adding any additional benefits in Section C. Your coverage level for the additional benefits in Section C will be identical to your fixed indemnity medical plan selection. FIXED INDEMNITY MEDICAL 1 1 DENTAL VISION TERM LIFE SHORT-TERM DISABILITY 2 $4.20 Employee Only $19.98 $5.40 $2.42 $0.60 Employee + 1 $40.54 $10.80 $4.92 $0.90 Employee + Family $54.14 $17.82 $6.56 $1.80 Terminate Plan Enroll Enroll Enroll Enroll No Change Cancel Cancel Cancel Cancel No Change No Change No Change No Change This coverage is not available to residents of NH, HI, or PR. STD is not available to persons who work in CA, HI, NJ, NY, or RI. 2 Add/Change Life/Accidental Loss of Life, Limb and Sight Beneficiary Primary Relationship Secondary Relationship D. REQUIRED SIGNATURE I hereby authorize my employer to deduct the required premium contributions from my payroll earnings. If cancelling coverage, I understand that I have been offered an opportunity to become covered under the Essential StaffCARE plan, and I have chosen NOT to take advantage of this offer. I understand that deductions may continue under my old elections until this form is received and processed by PAI. Deductions will not be refunded. DATE __ __ /__ __ /__ __ __ __ Form: ESC S P1 v.18.2 SIGNATURE PLAN 1 - FORMULARIO DE CAMBIOS Essential StaffCARE Enviar por correo/fax a: Planned Administrators, Inc. PO Box 6702 Columbia, SC 29260 Teléfono (866) 798-0803 Fax (803) 264-0772 251200-STM Con el aval de BCS Insurance Company Oakbrook Terrace, IL Llene este formulario SÓLO si va a hacer cambios a la cobertura o a cancelarla. A. RAZÓN DEL CAMBIO Cambio de dirección Cambio de nombre Agregar dependiente(s) Cambio de cobertura B. INFORMACIÓN REQUERIDA DEL EMPLEADO CONTESTAR TODO Nombre # de Seguro Social Teléfono Dirección Ciudad Estado Cancelar la cobertura Cambio de dirección/nombre Empleador H M Sexo Código Zip Fecha de contratación / / Apt. # Fecha de nacimiento / / Agregar/cambiar información de dependientes Nombre # de Seguro Social Nacimiento / / Sexo H M Relación H M H M C. CAMBIOS AL PLAN DE COMPENSACIÓN FIJA - Elija el cambio que quiere en cada beneficio Pagos semanales DEBE registrarse en el Plan de seguro médico de compensación fija (Fixed Indemnity Medical) antes de agregar más beneficios en la Sección C. El nivel de cobertura de sus beneficios adicionales de la Sección C será idéntico a su selección del plan médico de compensación fija. PLAN MÉDICO DE COMPENSACIÓN FIJA 1 1 PLAN DENTAL PLAN DE LA VISTA SEGURO DE VIDA DISCAPACIDAD A CORTO PLAZO 2 $2.42 $0.60 $4.20 Solo empleado $19.98 $5.40 Empleado + 1 $40.54 $10.80 $4.92 $0.90 Empleado + Familia $54.14 $17.82 $6.56 $1.80 Cancelar el plan Registrarse Registrarse Registrarse Registrarse Sin cambio Cancelar Cancelar Cancelar Cancelar Sin cambio Sin cambio Sin cambio Sin cambio Cobertura no disponible a residentes de NH, HI o PR. Beneficios de discapacidad a corto plazo no disponibles a trabajadores de CA, HI, NJ, NY o RI. 2 Agregar/cambiar al beneficiario del seguro de vida y del seguro por pérdida de la vida, de un miembro o de la vista por accidente Primario Relación Secundario Relación D. REQUIRED SIGNATURE Por medio del presente autorizo a mi empleador a deducir los aportes de las primas requeridas de mis ingresos por nómina. Si estoy cancelando mi cobertura, entiendo que se me ha ofrecido la oportunidad de obtener cobertura bajo el plan Essential StaffCARE, y yo he elegido NO aprovechar esta oferta. Entiendo que las deducciones pueden continuar bajo mis antiguas selecciones hasta cuando este formulario sea recibido y procesado por PAI. Las deducciones no serán devueltas. FECHA __ __ /__ __ /__ __ __ __ Formulario: ESC S P1 v.18.2 FIRMA Enrollee Letter Dear Enrollee: Welcome to the Essential StaffCARE Benefit Plan! Included you will find a temporary ID Card that will allow you access to Essential StaffCARE Benefits until you receive your permanent ID Card. You should receive your permanent ID Card within a few weeks of your coverage effective date. Your member ID number is your Social Security Number. 251200-STM ID Card - Cut on the dotted lines and then fold down the middle Q: After I sign up, when will my coverage go into effect? A: Your coverage goes into effect the Monday following your first payroll deduction. Coverage can not be initiated with a prepayment. Q: How do I find an in-network physician or hospital? A: While your medical plan does not impose an in-network restriction, you may realize additional savings by utilizing an innetwork medical provider. First Health Network - www.firsthealthnetwork.com - 1-800-226-5116 Q: Is there a phone number my doctor can call to get a list of my benefits? A: Yes, your provider may call the Essential StaffCARE Customer Service number 1-866-798-0803 for scheduled benefits and benefit maximums. Q: What if I need to have a prescription filled? A: For generic and brand prescriptions, present your ID card at a participating pharmacy to receive discounts. Generic and brand prescriptions are payable based on the schedule of benefits up to the annual prescription drug maximum. To file a claim for reimbursement, save your receipt and remit to Planned Administrators, Inc. Prescription drug coverage is not provided for drugs administered during a physician office visit or hospital stay. Q: Where can I get claim forms? A: Medical and Dental claim forms may be obtained by calling our customer service line at 1-866-798-0803 or you may download claim forms from our website – www.paisc.com. Be sure to click on Essential StaffCARE on the welcome page. Q: What if I want to cancel or make changes to my coverage? A: Coverage may be canceled or reduced at any time, unless your employer takes premium deductions pre-tax. To make changes or cancel coverage by telephone call (800) 269-7783 within 30 days of the date of your first paycheck. You will be prompted to enter your PIN CODE plus the last four digits of your Social Security number (SSN). PIN CODE: 142 14 + _ _ _ _ (last four digits of your SSN) Toll Free Customer Service Hotline: 1-866-798-0803 8:30 a.m. to 8:00 p.m. EST Limited Benefits Enrollment Form Complete the Enrollment Form to Elect or Decline Coverage 1. You MUST complete the Enrollment Form as part of your New Hire Process. 2. Elect or decline all benefits on the Enrollment Form. 3. You MUST Sign and Date the bottom of the form, even if you decline coverage. 4. Return the Enrollment Form to your Branch Manager. 5. Keep the Benefits at a Glance page for your records. This plan does not qualify as minimum essential coverage as defined under the Affordable Care Act (ACA). This plan is a supplement to health insurance and is not a substitute for major medical coverage. Lack of major medical coverage (or other minimum essential coverage) may result in an additional payment with your taxes. ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF INSURANCE FRAUD AND WILL BE PROSECUTED. The Essential StaffCARE Fixed Indemnity Medical, Prescription Drug, Accidental Loss of Life, Limb & Sight, Dental and Vision Plans are underwritten by BCS Insurance Company, Oakbrook Terrace, Illinois under Policy Series Numbers 25.1204, 26.1214, 26.212, and 26.213. The Term Life and Short-Term Disability Plans are underwritten by 4 Ever Life Insurance Company, Oakbrook Terrace, Illinois under Policy Series Number 62.200. For questions or assistance, please call Essential StaffCARE Customer Service at 1-866-798-0803. STM ESC S P1 v18.2 251200-STM VSI LOCATION ____________ OFFICE USE ONLY Rehire Date __ __ /__ __ /__ __ __ __ ENROLLMENT FORM ESC S P1 v18.2 A. REQUIRED EMPLOYEE INFORMATION PRINT USING BLACK or BLUE INK (Must Be Filled Out) Name Social Security # Home Phone Sex Address M F Apt. # City State Zip B. DO YOU OR ANY OF YOUR DEPENDENTS RECEIVE MEDICARE BENEFITS? Date of Birth / / Medicare Health Insurance Claim Number (HICN) Yes No. If Yes, please continue. Medicare Effective Date Name of Covered Person (s): 1. 3. 2. C. LIMITED BENEFITS PLAN SELECTION Payroll Deducted Weekly Rates You MUST enroll in the Fixed Indemnity Medical Insurance Plan before adding any additional benefits in Section C. Your coverage level for the additional benefits in Section C will be identical to your fixed indemnity medical plan selection. This plan is underwritten by BCS Insurance Company. FIXED INDEMNITY MEDICAL 1 1 DENTAL VISION TERM LIFE SHORT-TERM DISABILITY 2 $4.20 Employee Only $19.98 $5.40 $2.42 $0.60 Employee + 1 $40.54 $10.80 $4.92 $0.90 Employee + Family $54.14 $17.82 $6.56 $1.80 NO to ALL Benefits Yes No Yes No Yes No Yes No This coverage is not available to residents of NH, HI, or PR. STD is not available to persons who work in CA, HI, NJ, NY, or RI. 2 For Term Life / Accidental Loss of Life, Limb & Sight, please write in your beneficiary information. Accidental Loss of Life, Limb & Sight is part of the Fixed Indemnity Medical Benefit. Name Relationship D. REQUIRED DEPENDENT INFORMATION Name Name Name Name E. REQUIRED SIGNATURE Social Security # Date of Birth Sex / / M F Relationship Child Spouse Domestic Partner Social Security # Date of Birth Sex / / M F Relationship Child Spouse Domestic Partner Social Security # Date of Birth Sex / / M F Relationship Spouse Child Domestic Partner Social Security # Date of Birth Sex / / M F Relationship Child Spouse Domestic Partner YOU MUST SIGN AND DATE, EVEN IF YOU DECLINE COVERAGE I have read the benefit packet and understand its limitations. I understand that open enrollment is only available for a limited time and I understand that making no benefit selection is a declination of coverage. DATE __ __ /__ __ /__ __ __ __ SIGNATURE This is an Essential StaffCARE Enrollment Form. Policy Number LIMITED BENEFITS SUMMARY 251200-STM FIXED INDEMNITY MEDICAL BENEFIT The Fixed Indemnity Medical Plan pays a flat amount for a covered event caused by an accident or illness. If the covered event costs more, you pay the difference. But if the covered event costs less, you keep the difference. Inpatient Benefits Outpatient Benefits 1 Physician Office Visit $100 per day Standard Care $300 per day Diagnostic (Lab) $75 per day Intensive Care Unit Maximum 4 $400 per day Diagnostic (X-Ray) $200 per day Inpatient Surgery $2,000 per day Ambulance Services $300 per day Anesthesiology $400 per day Physical, Speech, or Occupational Therapy $50 per day Skilled Nursing 5 $100 per day Emergency Room Benefit - Sickness $200 per day First Hospital Admission (1 per year) $250 Emergency Room Benefit - Accident $500 per day Annual Inpatient Maximum 6 No Limit Outpatient Surgery $500 per day Accidental Loss of Life, Limb & Sight Anesthesiology $200 per day Employee $20,000 Annual Outpatient Maximum $2,000 Spouse $20,000 Prescription Drugs (via reimbursement) 2,3 Dependent (6 months to 26 years) $5,000 Annual Maximum $600 Dependent (15 days to 6 months) $2,500 Generic Coinsurance 70% Wellness Care Brand Coinsurance 50% Wellness Care (one per year) $100 1 all outpatient benefits are subject to the outpatient maximum 2 not subject to outpatient maximum 3 To file a claim for reimbursement, save your receipt and remit to Planned Administrators, Inc. 4 pays in addition to standard care benefit 5 for stays in a skilled nursing facility after a hospital stay 6 Subject to internal limits of plan DENTAL BENEFIT Coverage A Coverage B Coverage C Waiting Period/Coinsurance None / 80% 3 Months / 60% 12 Months / 50% VISION BENEFIT 1 In-Network Eye Examination (including dilation) Exam Options (Standard or Premium Contact Lens Fit) Frames 3 Standard Plastic Lenses (single, bifocal, trifocal) 2 Lens Options Contact Lenses (Conventional) 2 Disposable Contact Lenses 2 Medically Necessary Contact Lenses 2 2 1 Annual Maximum Benefit $750 Deductible $50 Exams, Cleanings, Intraoral Films and Bitewings Fillings, Oral Surgery, and Repairs for Crowns, Bridges and Dentures Periodontics, Crowns, Bridges, Endodontics and Dentures Out-of-Network You Pay Plan Pays You Pay Plan Pays $10 Copay Up to $55 or 10% off Retail Price 80%, after $110 allowance $25 Copay $15-$45 or 20% discount $0 Copay, 85% of remaining $0 Copay $0 Copay 100% $0 $110, plus 20% of remaining 100% 100% or 20% off retail $110, plus 15% of remaining $110, plus balance 100% 100% 100% 100% 100% 100% 100% 100% $0 $35 $0 $55 $25-$55 $0 $88 $88 $200 For complete plan details, please visit www.essentialstaffcare.com/vision 2 Once every 12 months 3 Once every 24 months TERM LIFE BENEFIT Employee Amount $10,000 (reduces to $7,500 at 65; $5,000 at 70) Spouse Amount $5,000 (terminates at age 70) SHORT-TERM DISABILITY BENEFIT Benefit Amount Waiting Period/Maximum Benefit Period WEEKLY LIMITED BENEFITS PREMIUM Employee Only Employee + 1 Employee + Family Child Amount (6 mos to 26 yrs old) Infant Amount (15 days to 6 mos) $5,000 $1,000 60% of Salary up to $150 per week 7 days, up to 26 weeks Medical $19.98 $40.54 $54.14 Dental $5.40 $10.80 $17.82 Vision $2.42 $4.92 $6.56 Term Life $0.60 $0.90 $1.80 STD $4.20 - This is an Essential StaffCARE Enrollment Form. Essential StaffCARE Mail / Fax to: PLAN 1 - CHANGE FORM Planned Administrators, Inc. PO Box 6702 Columbia, SC 29260 251200-STM Telephone (866) 798-0803 Fax (803) 264-0772 Underwritten by BCS Insurance Company Oakbrook Terrace, IL Fill out this form ONLY if you are making changes in your coverage or terminating coverage. A. REASON FOR THE CHANGE Address Change Name Change Add Dependent(s) Coverage Change Terminate Coverage B. REQUIRED EMPLOYEE INFORMATION MUST BE FILLED OUT Address/Name Change Name Social Security # Home Phone Address City State Employer Sex Zip Hire Date / M F Apt. # Date of Birth / / / Add/Change Dependent Information Name Social Security # Date of Birth Gender / / M F Relationship M F M F C. INDEMNITY PLAN CHANGES - Select the change you wish to make for each benefit Weekly Rates You MUST enroll in the Fixed Indemnity Medical Insurance Plan before adding any additional benefits in Section C. Your coverage level for the additional benefits in Section C will be identical to your fixed indemnity medical plan selection. FIXED INDEMNITY MEDICAL 1 1 DENTAL VISION TERM LIFE SHORT-TERM DISABILITY 2 $4.20 Employee Only $19.98 $5.40 $2.42 $0.60 Employee + 1 $40.54 $10.80 $4.92 $0.90 Employee + Family $54.14 $17.82 $6.56 $1.80 Terminate Plan Enroll Enroll Enroll Enroll No Change Cancel Cancel Cancel Cancel No Change No Change No Change No Change This coverage is not available to residents of NH, HI, or PR. STD is not available to persons who work in CA, HI, NJ, NY, or RI. 2 Add/Change Life/Accidental Loss of Life, Limb and Sight Beneficiary Primary Relationship Secondary Relationship D. REQUIRED SIGNATURE I hereby authorize my employer to deduct the required premium contributions from my payroll earnings. If cancelling coverage, I understand that I have been offered an opportunity to become covered under the Essential StaffCARE plan, and I have chosen NOT to take advantage of this offer. I understand that deductions may continue under my old elections until this form is received and processed by PAI. Deductions will not be refunded. DATE __ __ /__ __ /__ __ __ __ Form: ESC S P1 v.18.2 SIGNATURE LIMITED BENEFIT EXCLUSIONS AND LIMITATIONS These are the standard limitations and exclusions. As they may vary by state, please see your summary plan description (SPD) for a more detailed listing. FIXED INDEMNITY MEDICAL AND ACCIDENTAL LOSS OF LIFE, LIMB OR SIGHT BENEFIT No benefits will be paid for loss caused by or resulting from: • Intentionally self-inflicted injuries, suicide or any attempt while sane or insane • Declared or undeclared war • Serving on full-time active duty in the armed forces • The covered person’s commission of a felony • Work-related injury or sickness, whether or not benefits are payable under workers’ compensation or similar law or • With regard to the accidental loss of life, limb or sight benefit - sickness, disease, bodily or mental infirmity or medical or surgical treatment thereof, or bacterial or viral infection regardless of how contracted. This does not include bacterial infection that is the natural and foreseeable result of an accidental external bodily injury or accidental food poisoning. No benefits will be paid for: • Eye examinations for glasses, any kind of eye glasses, or vision prescriptions • Hearing examinations or hearing aids • Dental care or treatment other than care of sound, natural teeth and gums required on account of injury to the covered person resulting from an accident that happens while such person is covered under the policy, and rendered within 6 months of the accident • Services rendered in connection with cosmetic surgery, except cosmetic surgery that the covered person needs for breast reconstruction following a mastectomy or as a result of an accident that happens while such person is covered under the policy. Cosmetic surgery for an accidental injury must be performed within 90 days of the accident causing the injury and while such person’s coverage is in force • Services provided by a member of the covered person’s immediate family. The fixed indemnity medical plan is not available to residents of Hawaii, New Hampshire or Puerto Rico. PRESCRIPTION DRUGS No benefits will be paid for over-the-counter products or medications or for drugs and medications dispensed while you are in a hospital. DENTAL The plan will pay only for procedures specified on the Schedule of Covered Procedures in the group policy. Many procedures covered under the plan have waiting periods and limitations on how often the plan will pay for them within a certain time frame. For more detailed information on covered procedures or limitations, please see your summary plan description. VISION No benefits will be paid for any materials, procedures or services provided under worker’s compensation or similar law; non-prescription lenses, frames to hold such lenses, or nonprescription contact lenses; any materials, procedures or services provided by an immediate family member or provided by you; charges for any materials, procedures, and services to the extent that benefits are payable under any other valid and collectible insurance policy or service contract whether or not a claim is made for such benefits. SHORT-TERM DISABILITY No benefits are payable under this coverage in the following instances: • Attempted suicide or intentionally self-inflicted injury • Voluntary taking of poison; voluntary inhalation of gas; voluntary taking of a drug or chemical. This does not apply to the extent administered by a licensed physician. The physician must not be you or your spouse, you or your spouse’s child, sibling or parent, or a person who resides in your home • Declared or undeclared war or act of war • Your commission of or attempt to commit a felony, or any loss sustained while incarcerated for the felony • Your participation in a riot • If you engage in an illegal occupation • Release of nuclear energy • Operating, riding in, or descending from any aircraft (including a hang glider). This does not apply while you are a passenger on a licensed, commercial, nonmilitary aircraft; or • Work-related injury or sickness. Short-Term Disability benefits are not available to persons who work in California, Hawaii, New Jersey, New York, or Rhode Island. TERM LIFE No Life Insurance benefits will be payable under the policy for death caused by suicide or self-destruction, or any attempt at it within 24 months after the person’s coverage under the policy became effective. Member Services: For frequently asked questions and network information for the the Fixed Indemnity Medical Plan, please go to www.essentialstaffcare.com/FAQVSI. PLEASE NOTE: To make changes or cancel coverage by telephone call (800) 269-7783. Your pin code for enrolling/making changes is 142 + _ _ _ _ (last four digits of your SSN). Your Company has chosen to take your payroll deductions on a Post-Tax basis. Essential StaffCARE Customer Service: 1-866-798-0803 • Once enrolled, members can call this number for questions regarding plan coverage, ID card, claim status, and policy booklets and to add, change, or cancel coverage. • Customer Service Call Center hours are M - F, 8:30 a.m. to 8 p.m. Eastern Standard Time. Bilingual representatives are available. • Members can also visit www.paisc.com and click on “Your Plan” and enter your group number. This is an Essential StaffCARE Enrollment Form. Formulario de registro del Beneficios Limitados Complete el formulario de registro para elegir o declinar la cobertura 1. Usted DEBE completar el Formulario de registro como parte de su proceso de nuevo empleado 2. Elija o decline todos los beneficios en el Formulario de registro 3. Usted DEBE Firmar y Fechar la parte inferior del formulario, aunque decline la cobertura 4. Entregue el Formulario de registro al gerente de su sucursal 5. Guarde para sus archivos la página Beneficios a simple vista Este plan no califica como cobertura esencial mínima tal como la define la ley llamada Affordable Care Act (ACA). Este plan es un suplemento del seguro de salud y no es un sustituto de una cobertura médica principal. Si usted no tiene una cobertura médica principal (u otra cobertura esencial mínima), quizá tenga que pagar más impuestos. TODA PERSONA QUE DELIBERADAMENTE PRESENTE UN RECLAMO FALSO O FRAUDULENTO PARA QUE LE PAGUEN UN BENEFICIO O UNA PÉRDIDA O QUE DELIBERADAMENTE PRESENTE INFORMACIÓN FALSA EN UNA SOLICITUD DE SEGURO SERÁ CULPABLE DE FRAUDE CONTRA LA ASEGURADORA Y SERÁ ENJUICIADA. Los planes médico de compensación fija, de recetas médicas, dental y de la vista y el seguro de pérdida de la vida, de un miembro o de la vista por accidente, de Essential StaffCARE tienen el aval de BCS Insurance Company, Oakbrook Terrace, Illinois, bajo las pólizas número 25.1204, 26.1214, 26.212 y 26.213. Los planes de seguro de vida y por discapacidad a corto plazo tienen el aval de 4 Ever Life Insurance Company, Oakbrook Terrace, Illinois bajo la póliza número 62.200. Si tiene preguntas o necesita ayuda, llame al departamento de Servicio al cliente de Essential StaffCARE al 1-866-798-0803. STM ESC S P1 v18.2 251200-STM VSI LOCATION ____________ SÓLO USO DE OFICINA Rehire Date __ __ /__ __ /__ __ __ __ FORMULARIO DE REGISTRO ESC S P1 v18.2 A. INFORMACIÓN REQUERIDA DEL EMPLEADO LETRA DE IMPRENTA, TINTA NEGRA o AZUL (Contestar todo) Nombre # de Seguro Social Teléfono Sexo Dirección H M Apt. # Ciudad Estado Código Zip B. ¿USTED O ALGUNO DE SUS DEPENDIENTES TIENE MEDICARE? Fecha de nacimiento / Número de reclamo al seguro de salud de Medicare (HICN) Sí No. Si contestó “Sí”: Fecha efectiva de Medicare Nombre de la(s) persona(s) cubierta(s): 1. 3. 2. C. SELECCIÓN DEL PLAN DE BENEFICIOS LIMITADOS / Pagos semanales deducidos del cheque DEBE registrarse en el Plan de seguro médico de compensación fija (Fixed Indemnity Medical Insurance) antes de agregar más beneficios en la Sección C. El nivel de cobertura de sus beneficios adicionales de la Sección C será idéntico a su selección del plan médico de compensación fija. Este plan tiene el aval de BCS Insurance Company. PLAN MÉDICO DE COMPENSACIÓN FIJA 1 PLAN DENTAL PLAN DE LA VISTA SEGURO DE VIDA DISCAPACIDAD A CORTO PLAZO 2 $4.20 Solo empleado $19.98 $5.40 $2.42 $0.60 Empleado + 1 $40.54 $10.80 $4.92 $0.90 Empleado + Familia $54.14 $17.82 $6.56 $1.80 NO a TODOS los beneficios 1 Sí No Sí No Sí No Sí No Cobertura no disponible a residentes de NH, HI o PR. 2 Beneficios de discapacidad a corto plazo no disponibles a trabajadores de CA, HI, NJ, NY o RI. Escriba la información del beneficiario de su seguro de vida y del seguro por pérdida de la vida, de un miembro o de la vista por accidente. El seguro por pérdida de la vida, de un miembro o de la vista por accidente es parte del beneficio del plan médico de compensación fija. Nombre Relación D. INFORMACIÓN REQUERIDA SOBRE LOS DEPENDIENTES Nombre Nombre Nombre Nombre F. FIRMA REQUERIDA # de Seguro Social Nacimiento / / Sexo H M Relación Esposa/o Hijo/a Compañero doméstico # de Seguro Social Nacimiento / / Sexo H M Relación Esposa/o Hijo/a Compañero doméstico # de Seguro Social Nacimiento / / Sexo H M Relación Esposa/o Hijo/a Compañero doméstico # de Seguro Social Nacimiento / / Sexo H M Relación Esposa/o Hijo/a Compañero doméstico DEBE FIRMAR Y PONER LA FECHA AUNQUE DECLINE LA COBERTURA He leído el resumen de beneficios y comprendo sus limitaciones. Entiendo que el registro está disponible sólo por un tiempo limitado y entiendo que el no hacer una selección de la cobertura de beneficios significa rechazarla. FECHA __ __ /__ __ /__ __ __ __ FIRMA Este es un Formulario de registro de Essential StaffCARE. Número de póliza RESUMEN DE LOS BENEFICIOS LIMITADOS 251200-STM BENEFICIOS MÉDICO DE COMPENSACIÓN FIJA El Plan médico de compensación fija paga una cantidad fija para un evento cubierto causado por accidentes y enfermedades. Si el evento cubierto cuesta más, usted pagará la diferencia. Si el evento cubierto cuesta menos, usted se queda con la diferencia. Beneficios para servicios internos Beneficios para servicios externos 1 Consultas del doctor $100 diarios Atención estándar $300 diarios 4 Diagnóstico (laboratorio) $75 diarios Máximo en la unidad de cuidados intensivos $400 diarios Diagnóstico (rayos X) $200 diarios Cirugía internado $2,000 diarios Servicios de ambulancia $300 diarios Anestesiología $400 diarios Terapia física, del habla y ocupacional $50 diarios Enfermeras especializadas 5 $100 diarios Beneficio de sala de emergencia - Por enfermedad $200 diarios Primera admisión al hospital (1 por año) $250 6 Beneficio de sala de emergencia - Por accidente $500 diarios Máximo anual para servicios internos No hay limite Cirugía en servicios externos $500 diarios Pérdida de la vida, de un miembro o de la vista por accidente $20,000 Anestesiología $200 diarios Empleado Máximo anual para servicios externos $2,000 Esposa/o $20,000 Dependientes (de 6 meses a 26 años) $5,000 Recetas médicas (por reembolso) 2,3 Máximo anual $600 Dependiente (de 15 días a 6 meses) $2,500 Coseguro por medicinas genéricas 70% Atención para el bienestar Coseguro por medicinas de marca 50% Atención para el bienestar (una vez al año) $100 1 los beneficios para servicios externos están sujetos al máximo por servicios externos 2 no está sujetos al máximo por servicios externos 3 Para presentar un reclamo para el reembolso, guarde el recibo y envíelo a Planned Administrators, Inc. 4 se paga además del beneficio para atención estándar 5 por centros especializados tras la hospitalización 6 Con sujeción a los límites internos del plan BENEFICIOS DENTALES Cobertura A Cobertura B Cobertura C Período de espera/Coseguro Nada/ 80% 3 meses/ 60% 12 meses/ 50% BENEFICIO DE LA VISTA 1 Examen de la vista para anteojos 2 (incluyendo dilatación) Opciones del Examen (ajuste de lentes de contacto estándar o premium) Armazones 3 Prueba de lentes de contacto estándar (visión regular, bifocales , o trifocales) 2 Opciones de Lentes Lentes de contacto (Convencional) 2 Lentes Desechables 2 Lentes de contacto médicamente necesarios 2 1 Beneficio anual máximo $750 Deducible $50 Exámenes, limpiezas, radiografías intrabucales y mordidas Empastes, cirugía oral y reparaciones de coronas, puentes y dentaduras postizas Periodoncia, coronas, puentes, endodoncia y dentaduras postizas En Red Fuera de la Red Tu pagas El plan paga Tu pagas El plan paga $10 Copago Hasta $55 o 10% del precio de venta 80%, después $110 descuento $25 Copago $15-$45 o 20% descuento $0 Copago, 85% de los restantes $0 Copago $0 Copago 100% $0 $110, más el 20% de permanecer 100% 100% o 20% descuento $110, más el 15% de permanecer $110, más el saldo 100% 100% 100% 100% 100% 100% 100% 100% $0 $35 $0 $55 $25-$55 $0 $88 $88 $200 Para información sobre el beneficio de la vista, que incluye servicios premium, visite www.essentialstaffcare.com/vision 2 Cada 12 veces 3 Cada 12 meses BENEFICIO DE SEGURO DE VIDA Para el empleado $10,000 (baja a $7,500 a los 65 años y a $5,000 a los 70 años) Para la esposa/o $5,000 (termina a los 70 años) BENEFICIO DE DISCAPACIDAD A CORTO PLAZO Cantidad del beneficio Período de espera/ Período máximo de los beneficios PRIMA SEMANAL PARA LOS BENEFICIOS LIMITADOS Solo empleado Empleado + 1 Empleado + Familia Para los hijos (de 6 meses a 26 años) Para bebés (de 15 días a 6 meses) $5,000 $1,000 60% del salario hasta $150 por semana 7 días hasta 26 semanas Plan médico $19.98 Plan dental $5.40 Vista $2.42 Seguro de vida $0.60 STD $4.20 $40.54 $10.80 $4.92 $0.90 - $54.14 $17.82 $6.56 $1.80 - Este es un Formulario de registro de Essential StaffCARE. Essential StaffCARE Enviar por correo/fax a: PLAN 1 - FORMULARIO DE CAMBIOS Planned Administrators, Inc. PO Box 6702 Columbia, SC 29260 Teléfono (866) 798-0803 Fax (803) 264-0772 251200-STM Con el aval de BCS Insurance Company Oakbrook Terrace, IL Llene este formulario SÓLO si va a hacer cambios a la cobertura o a cancelarla. A. RAZÓN DEL CAMBIO Cambio de dirección Cambio de nombre Agregar dependiente(s) Cambio de cobertura B. INFORMACIÓN REQUERIDA DEL EMPLEADO CONTESTAR TODO Nombre # de Seguro Social Teléfono Dirección Ciudad Estado Cancelar la cobertura Cambio de dirección/nombre Empleador H M Sexo Código Zip Fecha de contratación / / Apt. # Fecha de nacimiento / / Agregar/cambiar información de dependientes Nombre # de Seguro Social Nacimiento / / Sexo H M Relación H M H M C. CAMBIOS AL PLAN DE COMPENSACIÓN FIJA - Elija el cambio que quiere en cada beneficio Pagos semanales DEBE registrarse en el Plan de seguro médico de compensación fija (Fixed Indemnity Medical) antes de agregar más beneficios en la Sección C. El nivel de cobertura de sus beneficios adicionales de la Sección C será idéntico a su selección del plan médico de compensación fija. PLAN MÉDICO DE COMPENSACIÓN FIJA 1 1 PLAN DENTAL PLAN DE LA VISTA SEGURO DE VIDA DISCAPACIDAD A CORTO PLAZO 2 $2.42 $0.60 $4.20 Solo empleado $19.98 $5.40 Empleado + 1 $40.54 $10.80 $4.92 $0.90 Empleado + Familia $54.14 $17.82 $6.56 $1.80 Cancelar el plan Registrarse Registrarse Registrarse Registrarse Sin cambio Cancelar Cancelar Cancelar Cancelar Sin cambio Sin cambio Sin cambio Sin cambio Cobertura no disponible a residentes de NH, HI o PR. Beneficios de discapacidad a corto plazo no disponibles a trabajadores de CA, HI, NJ, NY o RI. 2 Agregar/cambiar al beneficiario del seguro de vida y del seguro por pérdida de la vida, de un miembro o de la vista por accidente Primario Relación Secundario Relación D. REQUIRED SIGNATURE Por medio del presente autorizo a mi empleador a deducir los aportes de las primas requeridas de mis ingresos por nómina. Si estoy cancelando mi cobertura, entiendo que se me ha ofrecido la oportunidad de obtener cobertura bajo el plan Essential StaffCARE, y yo he elegido NO aprovechar esta oferta. Entiendo que las deducciones pueden continuar bajo mis antiguas selecciones hasta cuando este formulario sea recibido y procesado por PAI. Las deducciones no serán devueltas. FECHA __ __ /__ __ /__ __ __ __ Formulario: ESC S P1 v.18.2 FIRMA EXCLUSIONES Y LIMITACIONES DE LOS BENEFICIOS LIMITADOS Estas son las limitaciones y exclusiones estándar. Como podrían variar de un estado a otro, para ver una lista detallada de ellos, consulte el Resumen de descripción del plan (SPD). BENEFICIO DE COMPENSACIÓN FIJA PARA LA PÉRDIDA DE LA VIDA, DE UN MIEMBRO O DE LA VISTA POR ACCIDENTE O POR CUESTIONES MÉDICAS No se pagarán beneficios por pérdidas causadas por o resultantes de: • Lesiones hechas a sí mismo intencionalmente, suicidio o intento de suicidio, ya sea cuerdo o demente • Guerra declarada o sin declarar • Servir en las Fuerzas Armadas a tiempo completo • Un delito grave perpetrado por una persona cubierta por el Plan • Enfermedades o lesiones relacionadas al trabajo, ya sea que los beneficios se paguen o no bajo la Ley de compensación de empleados u otra similar; o • En relación con el beneficio de la pérdida de la vida, de un miembro o de la vista por accidente, no se pagarán beneficios por enfermedades físicas o mentales, ni por tratamientos médicos o quirúrgicos para dicha enfermedad, ni para infecciones bacterianas o virales sin importar cómo se contrajeron. Esto no incluye infecciones bacteriales que sean consecuencia natural y previsible de una lesión física accidental o la ingestión accidental de alimentos tóxicos. No se pagarán beneficios por: • Exámenes de la vista para prescribir lentes, cualquier tipo de anteojos y sus prescripciones • Exámenes del oído y dispositivos para oír • Tratamiento o atención dental que no sea la atención de las encías y los dientes naturales y sanos requerida para las lesiones que resulten de un accidente mientras la persona está cubierta por la póliza y se haga en los 6 meses siguientes al accidente • Los servicios relacionados con cirugía cosmética, excepto la que necesite la persona cubierta para la reconstrucción de los senos después de una mastectomía o como resultado de un accidente que ocurra mientras está cubierta bajo esta póliza. Las cirugías cosméticas para lesiones accidentales se deben realizar dentro de los 90 días siguientes al accidente que causó la lesión y mientras la cobertura de esta persona sigue vigente • Servicios proporcionados por un miembro de la familia inmediata de la persona cubierta. Este Plan médico de compensación fija no está disponible para los residentes de Hawaii, New Hampshire o Puerto Rico. RECETAS MÉDICAS No se pagarán beneficios por medicinas y productos que se venden sin receta ni por medicinas que le administren a usted mientras está hospitalizado. PLAN DENTAL El plan sólo pagará los procedimientos especificados en el Programa de procedimientos cubiertos de la póliza de grupo. Muchos de los procedimientos cubiertos bajo el plan tienen períodos de espera y limitaciones sobre la frecuencia en que los pagará el plan. Si desea más información sobre los procedimientos cubiertos o las limitaciones, vea el Resumen de descripción del plan. PLAN DE LA VISTA No se pagarán beneficios por materiales, procedimientos o servicios provistos bajo la Ley de compensación a los trabajadores u otra ley similar; anteojos sin receta, armazones para tales anteojos o lentes de contacto sin receta; materiales, procedimientos o servicios provistos por un familiar directo o por usted mismo; cobros por materiales, procedimientos o servicios en la medida que se puedan pagar bajo otro contrato de servicio o póliza de seguro válidos y cobrables, ya sea que se haga el reclamo por tales beneficios o no. DISCAPACIDAD A CORTO PLAZO En esta cobertura no se pagan beneficios en los casos siguientes: • Intento de suicidio o lesiones hechas a sí mismo intencionalmente • Ingerir veneno voluntariamente; inhalar gas voluntariamente; ingerir drogas o sustancias químicas voluntariamente. Esto no se aplica a las que administra un médico certificado. El médico no debe ser usted o su esposa/o, su hijo o el hijo de su esposa/o, un hermano o padre ni una persona que viva en su casa • Guerra declarada o sin declarar y las acciones relacionadas • Cometer o intentar cometer un delito grave, o por pérdidas que ocurren durante el encarcelamiento debido a un delito grave • Participar en un motín • Participar en una ocupación ilegal • Liberar energía nuclear • Operar, viajar en una nave aérea o descender de ella (incluyendo un planeador "hang glider"). Estas limitaciones no se aplican mientras usted es pasajero de una aeronave con licencia, comercial y no militar, o • Enfermedades y lesiones relacionadas con el trabajo. Los beneficios de discapacidad a corto plazo (STD) no están disponibles para personas que trabajan en California, Hawaii, New Jersey, New York o Rhode Island. SEGURO DE VIDA No se pagarán beneficios de seguro de vida por muertes causadas por suicidio o autodestrucción, o intento de éstos, en los 24 meses posteriores a la fecha en que entró en vigor la cobertura del asegurado por la póliza. Servicios para miembros: Para ver las preguntas frecuentes e información sobre la red del Plan médico de compensación fija (Fixed Indemnity Medical Plan, visite www.essentialstaffcare.com/FAQVSI. NOTA: Para hacer cambios o cancelar la cobertura llame al (800) 269-7783. Su código de pin para registrarse o hacer cambios es (últimos cuatro dígitos de su SSN). Su Compañía decidió tomar sus deducciones después de descontarle los impuestos. 142 +____ Servicio al cliente de Essential StaffCARE: 1-866-798-0803 • Después de registrarse, los miembros pueden llamar a este teléfono para preguntar sobre la cobertura de su plan, su tarjeta de identificación, el estatus de un reclamo y los folletos de las pólizas y para agregar, cambiar o cancelar la cobertura. • El Centro de llamadas de Servicio al cliente está abierto de lunes a viernes, de 8:30 a.m. a 8 p.m. tiempo del este. Hay representantes bilingües. • Además, los miembros pueden visitar www.paisc.com y hacer clic en “Your Plan” y escribir el número de su grupo. Este es un Formulario de registro de Essential StaffCARE.