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
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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.
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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.