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EMPLOYEE
BENEFITS
GUIDE
PLAN YEAR:
JULY 1, 2017 - JUNE 30, 2018
5738 Foremost Drive, S.E. | Grand Rapids, MI 49546
Providing Specialized Insurance Services Since 1935
616.956.0040 | www.BuitenBenefits.com
2
Employees Eligibility for Coverage Dependent Eligibility for Coverage
Employees working 30 or more hours per week are
eligible for the benefits outlined in this guide.
Benefits terminate on your last active day of full
time assignment with QCI Healthcare.
All employees’ legal spouse’s and dependent children
are eligible for the medical, voluntary dental, and
voluntary vision benefits.
For details regarding when a dependent child’s eligibility
ends due to age, marriage, or school status please see
the Contributions & Eligibility Information (pg. 18).
When to Enroll Open Enrollment Elections Effective Date
Currently active ELIGIBLE employees are able to
enroll or make changes during the annual Open
Enrollment period from Monday, April 17, 2017
through Friday, May 12, 2017 without a qualifying
life event.
Benefits you elect during Open Enrollment will be
effective July 1, 2017 through June 30, 2018.
How to Make Changes Special Election Rights
All eligible employees MUST complete and return
the Benefit Election Form in order for coverage to
begin AND/OR continue.
Benefit Election Forms are the last two pages of
this guide and are to be returned to Ken Jewett by
May 12, 2017.
Unless you have a qualifying change in your family or
employment status you cannot make changes to your
benefits until the next Open Enrollment period. All
change requests must be received within 30 days of the
qualifying event or the change may not be made until
the next Open Enrollment period. Please ask HR if you
believe you are eligible for a Qualified Change in Status.
2017 Benefits Information QCI Healthcare works hard to offer exceptional options for employee
benefits at a reasonable cost. This guide should provide most of the
information you need about our benefits, however, if you have
questions not answered here, please contact Ken Jewett by phone at
(616) 365-9290 or e-mail at kenjewett@QCIHealthcare.com.
New for
2017!
Medical insurance
rates changing!
Voluntary Delta Dental
rates changing!
Voluntary VSP Vision
rates increased
effective 5/1/2017!
Table of Contents
Healthcare Reform Information 3
Medical & Prescription Drug Plan 4
Medical Enrollment Instructions 5
Voluntary Dental 6
Voluntary Vision 7
Voluntary Short Term Disability 8
Voluntary Long Term Disability 9
Group Life & AD&D 10
Important Employee Disclosures 11-16
Medicare Part D Disclosure 12
Instructions for Ancillary Enrollment 17
Contribution & Eligibility Information 18
Carrier Contact Information 19
Benefit Election Form 20-22
All eligible employees
MUST complete and return
the Benefit Election Forms
to Ken Jewett by end of
business on Friday, May
12, 2017.
The Benefit Election Form
is located on the last
three pages of this guide.
3
Health Care Reform The Affordable Care Act was enacted in 2010 to expand access for
millions of Americans to qualify for affordable health insurance, to control healthcare
costs, and to improve the healthcare delivery system in our country. As a reminder, part
of the Affordable Care Act is the Individual Mandate, which requires you and your
dependents to have health insurance or potentially risk the following tax penalties.
*The penalty is the greater of the dollar amount or percentage of income.
Tax Year Adult Child Family
OR
Maximum Penalty
2.5% of Household
Income1
2015 $325 $162.50 $2,975
2016 $695 $347.50 $2,085
2017
(forecast) $785 $392.50 $2,285
1 Maximum: Total yearly premium for the national average price of a Bronze plan sold through the Marketplace. (2014:
$9,800, 2015: $12,500, 2016: $13,000, 2017: $13,500 est.)
Annual Penalties:
Other plans that meet requirements for the Individual Mandate include, but are not limited to:
□ An individual health insurance policy obtained through a public health insurance marketplace/exchange or
elsewhere
□ A government plan such as a Medicare, Medicaid, Children’s Health Insurance Program (CHIP), TRICARE, or
veterans coverage.
□ Student health coverage
□ Medicare Advantage plan
□ Coverage for non-US citizens, provided by another country
Using the percentage method, only the part of your household income that’s above the yearly tax
filing threshold ($10,300 for individuals, $20,600 for couples filing jointly in 2015, the most
recent year available) is counted.
Using the per-person method, you pay only for people in your household who don’t have insurance
coverage.
Affordable Care Act (ACA) Requirement
Under the ACA, everyone in the United States (subject to limited exceptions) is required to have health insurance that
provides “minimum essential coverage” to satisfy the Individual Mandate. The Blue Cross Blue Shield & Blue Care Network
medical plans provide minimum essential coverage and therefore, you can use them to satisfy the Individual Mandate.
During this Open Enrollment, QCI Healthcare is offering a medical plan that is “affordable” under the Affordable Care Act
(ACA). As necessary to make the coverage affordable, an employer contribution towards individual coverage on the Plan has
been incorporated into the premiums.
If you decline coverage under the Medical Plans and you do not have other coverage that meets this requirement through
another source or you are not eligible for an exemption, you may be subject to tax penalties for a failure to meet the
Individual Mandate.
For additional information regarding the exemptions to the Individual Mandate and general information regarding the
Affordable Care Act, please visit www.healthcare.gov.
4
2017—2018 BCN HMO
Platinum 20% Must name PCP
BCN HMO Gold
$1,000 Must name PCP
Simply Blue PPO
Gold $500 (only in-network
benefits shown)
Simply Blue HSA
PPO Silver $2,700 (only in-network
benefits shown)
Deductible
Individual/Two or
More
$0 $1,000/$2,000 $500/$1,000 $2,700/$5,400
Coinsurance 20% 20% 20% 20%
Embedded
Coinsurance
Maximum
$1,000/$2,000 $2,500/$5,000 $3,000/$6,000 None
Out-of-Pocket
Maximum $6,600/$13,200 $6,600/$13,200 $6,600/$13,200 $5,000/$10,000
Office Visit/Specialist/
Urgent Care/ER
Copays
$25/$35/$35/
$150
$20/$40/$50/
$150
$20/$40/$60/
$250
Covered at 80% After
Deductible is Met
Prescription Drugs $4/$15/$40/
$80/20%/20%
$4/$15/$40/
$80/20%/20%
$15/
$50/50%/20%/
25%
After Deductible is
Met: $15/
$50/50%/20%/
25%
2017—2018 PRE-TAX Medical Cost Summary Single Double Family
BCN HMO Platinum 20% - Monthly Cost $300.65 $1,001.54 $1,301.94
Employee WEEKLY Payroll Deductions $69.38 $231.12 $300.45
BCN HMO Gold $1,000 - Monthly Cost $228.20 $827.68 $1,084.61
Employee WEEKLY Payroll Deductions $52.66 $191.00 $250.29
Simply Blue PPO Gold $500 - Monthly Cost $275.38 $940.91 $1,226.14
Employee WEEKLY Payroll Deductions $63.55 $217.13 $282.96
Simply Blue HSA PPO Silver $2,700 - Monthly Cost $181.04 $714.49 $943.12
Employee WEEKLY Payroll Deductions $41.78 $164.88 $217.64
Coverage for Employees is a private exchange that allows small Michigan employers the ability to offer a wide
selection of quality Blue Cross Blue Shield of Michigan and Blue Care Network group health plans.
BCN HMO plans have NO out-of-network coverage except in emergencies. Simply Blue PPO options offer in and
out-of-network benefits.
*Employees residing outside of Michigan MUST select a PPO option.*
New!
The rates above INCLUDE the QCI Healthcare’s contribution to your total monthly premium AND include
Pediatric Dental & Pediatric Vision for dependents enrolled in the medical that are under age 19 .
Please visit www.bcbsm.com to find in-network providers and view the prescription drug formulary.
MEDICAL INSURANCE
This is intended as an easy-to-read summary. For further plan details, please refer to Summary of Benefits located
www.qcistaffing.com/forms
5
COVERAGE FOR EMPLOYEES-MEDICAL
INSTRUCTIONS FOR ONLINE ENROLLMENT
1. You will receive an introductory e-mail from CoverageForEmployees that will let you know your open enrollment period has begun, and ask that you create a secure password. It will include the link to your custom website, and instructions on how to make your MEDICAL benefit selection. *PLEASE CHECK YOUR E-MAIL’S JUNK FOLDER IF YOU DO NOT RECEIVE THE E-MAIL ON APRIL 17.*
2. Click on the link to access your enrollment website and review details regarding the plans and
contribution available to you, how long you have to shop (your open enrollment period), and when
your coverage will become effective. There is no limit to how many times you may log in and out of
the website, as long as your selection is made by the close of the open enrollment period.
3. You will receive e-mails throughout the open enrollment period reminding you to make your
selection.
4. If you or one of your dependents are currently seeking treatment from a particular doctor or
specialist, and you would like to continue that relationship, we highly encourage you to consult the
Provider Directory (a link is available on the website) to ensure that your provider will accept the plan
you are selecting. We also suggest you consult the Drug List (a link is available on the website) to
determine whether any medications you or one of your dependents are currently taking are covered
under your new plan.
5. You can complete the entire MEDICAL enrollment process on your CoverageForEmployees website.
6. The Benefit Election Form found at the end of this guide MUST still be completed to enroll/change/
waive other benefits offered.
If you do NOT have access to a computer with internet, please see Ken Jewett regarding
your options/instructions for enrollment/changing/waiving coverage.
6
Delta Dental PPO (Point-of-Service)
Network Delta Dental PPO Delta Dental Premier/Non-Participating
Annual Maximum
(per person/per calendar year)
$2,000
Includes Diagnostic & Preventive, Basic Services, and Major Services
Diagnostic & Preventive Services 100%
Radiographs—X-Rays 100%
Emergency Palliative Treatment 80%
Periodontal Maintenance 80%
Minor Restorative Services 80%
Relines and Repairs 80%
Simple Extractions 80%
Oral Surgery Services 50%2
Periodontics/Endodontics 50%2
Major Restorative Services 50%2
Prosthodontics 50%2
Implants 50%2
Coverage Type Rates per MONTH WEEKLY Payroll Deduction
Employee Only $39.15 $9.03
Employee + Spouse $78.32 $18.07
Employee + Child(ren) $89.61 $20.68
Family $141.59 $32.67
This is intended as an easy-to-read summary. For further plan details, please refer to Summary of Benefits located
www.qcistaffing.com/forms
2017—2018 Voluntary Dental PRE-TAX Contribution Cost Summary
Below is a brief summary of the voluntary dental benefits offered by QCI Healthcare. *Dental coverage for
dependents under age 19 is included in the medical plans & rates provided by QCI Healthcare.*
The dental policy offered by QCI Healthcare is 100% EMPLOYEE paid. You will pay for
100% of the cost for yourself and any eligible dependents on a pre-tax basis .
VOLUNTARY DENTAL INSURANCE
2 Major services will not be covered until after a person is enrolled in the dental plan for 12 consecutive months.
New!
7
Below is a brief summary of the voluntary vision benefits offered by QCI Healthcare.
*Vision coverage for children under age 19 is included in the medical plan and
rates provided by QCI Healthcare*.
The vision policy offered by QCI Healthcare is 100% EMPLOYEE paid. You will pay for
100% of the cost for yourself and any eligible dependents on a pre-tax basis.
Type of Service from a VSP Doctor Amount You Pay
Exam
WellVision
Contacts
$10
Up to $60
Prescription glasses $25
Contacts No copay applies
Your coverage from a VSP Doctor Frequency
Exam covered in full Every 12 months
Prescription glasses
Lenses covered in full
Frame Every 12 months
Contact Lenses Instead of Glasses Every 12 months
Extra Discounts & Savings on Glasses &
Sunglasses
Average 30% savings on lens options like progressives
and scratch-resistant and anti-reflective coatings.
20% off additional glasses and sunglasses, including
lens options
Contacts
Laser vision correction
Coverage Type Rates per MONTH WEEKLY Payroll Deduction
Employee Only $14.88 $3.43
Employee + Spouse $22.71 $5.24
Employee + Child(ren) $22.71 $5.24
Family $40.72 $9.40
VOLUNTARY VISION INSURANCE
This is intended as an easy-to-read summary. For further plan details, please refer to Summary of Benefits located
www.qcistaffing.com/forms
2017—2018 Voluntary Vision PRE-TAX Contribution Cost Summary New!
8
Why Short Term
Disability?
Receiving an income
while you’re disabled can
make an enormous
financial difference.
Short Term Disability Benefits
Coverage for accidents and sicknesses for up to 26 weeks.
Weekly benefit is 60% of your weekly salary up to a maximum
benefit of $750 per week.
Benefits begin on the 1st day for injury, 8th day for sickness, and
8th day for hospital confinement.
How To Enroll:
You must elect and complete the Dearborn National enrollment form
at the time of hire or Open Enrollment. Coverage begins on your date
of hire/full-time assignment with QCI Healthcare.
This highlight flyer is intended to provide an overview of the benefits available from your employer and is not a complete description of plan provisions.
Receipt of this flyer does not certify eligibility for benefits under this plan. For further plan details, please request the Dearborn National Short Term Disa-
bility Certificate from your employer.
The short-term disability policy offered by QCI Healthcare is 100% EMPLOYEE paid.
Dependents are not eligible for disability insurance.
QCI Healthcare is continuing with their same short-term disability coverage through Dearborn National
with no change in rates or benefits.
VOLUNTARY SHORT- TERM DISABILITY INSURANCE
POST-TAX MONTHLY Premium Cost
If your annual salary is at least: You may select a
weekly benefit of: Under 40
Age 40 - 49
Age 50 - 59
Age 60 & Over
$8,665.00 $100.00 $8.20 $7.20 $9.20 $12.90
$13,000.00 $150.00 $12.30 $10.80 $13.80 $19.35
$17,330.00 $200.00 $16.40 $14.40 $18.40 $25.80
$21,665.00 $250.00 $20.50 $18.00 $23.00 $32.25
$26,000.00 $300.00 $24.60 $21.60 $27.60 $38.70
$30,330.00 $350.00 $28.70 $25.20 $32.20 $45.15
$34,665.00 $400.00 $32.80 $28.80 $36.80 $51.60
$39,000.00 $450.00 $36.90 $32.40 $41.40 $58.05
$43,330.00 $500.00 $41.00 $36.00 $46.00 $64.50
$47,665.00 $550.00 $45.10 $39.60 $50.60 $70.95
$52,000.00 $600.00 $49.20 $43.20 $55.20 $77.40
$56,330.00 $650.00 $53.30 $46.80 $59.80 $83.85
$60,665.00 $700.00 $57.40 $50.40 $64.40 $90.30
$65,000.00 $750.00 $61.50 $54.00 $69.00 $96.75
9
Disability can
happen to anyone.
Accidents happen. Make
sure you and your loved
ones avoid future financial
hardships due to an
accident.
Long Term Disability Benefits
Benefit is 60% of monthly earning up to a maximum benefit of $5,000 per
month.
Benefits may begin after the elimination period of 180 consecutive days of
absences due to a covered accident or sickness.
Employees must meet the definition of disability as defined in the policy to
be eligible for the long-term disability benefits.
Benefits are not payable for pre-existing conditions as defined in the policy.
How to enroll
You must elect and complete the Dearborn National enrollment form at the
time of hire. Coverage begins once the eligibility requirements are met and you
have satisfied any waiting period applicable to your policy.
QCI Healthcare is continuing with their same long-term disability coverage through Dearborn National
with no change in rates or benefits.
The long-term disability policy offered by QCI Healthcare is 100% EMPLOYEE paid.
Dependents are not eligible for disability insurance.
VOLUNTARY LONG-TERM DISABILITY INSURANCE
POST-TAX MONTHLY Premium Cost If your annual
salary is at least: You may select a
weekly benefit of: Under 30
Age 30-39
Age 40 - 44
Age 45 - 49
Age 50 - 54
Age 55 - 59 Age 60 & Over
$8,665.00 $100.00 $2.38 $3.75 $5.70 $8.15 $10.82 $11.90 $12.63
$13,000.00 $150.00 $3.57 $5.63 $8.55 $12.23 $16.23 $17.86 $18.94
$17,330.00 $200.00 $4.76 $7.50 $11.40 $16.31 $21.65 $23.81 $25.25
$21,665.00 $250.00 $5.95 $9.38 $14.25 $20.38 $27.06 $29.76 $31.57
$26,000.00 $300.00 $7.17 $11.26 $17.10 $24.46 $32.47 $35.71 $37.88
$30,330.00 $350.00 $8.33 $13.13 $19.95 $28.54 $37.88 $41.67 $44.19
$34,665.00 $400.00 $9.52 $15.01 $22.80 $32.61 $43.29 $47.62 $50.51
$39,000.00 $450.00 $10.71 $16.88 $25.65 $36.69 $48.70 $53.57 $56.82
$43,330.00 $500.00 $11.90 $18.76 $28.50 $40.76 $54.11 $59.52 $63.13
$47,665.00 $550.00 $13.10 $20.63 $31.35 $44.84 $59.52 $65.48 $69.44
$52,000.00 $600.00 $14.29 $22.51 $34.20 $48.92 $64.94 $71.43 $75.76
$56,330.00 $650.00 $15.48 $24.39 $37.05 $52.99 $70.35 $77.38 $82.07
$60,665.00 $700.00 $16.67 $26.26 $39.90 $57.07 $75.76 $83.33 $88.38
$65,000.00 $750.00 $17.86 $28.14 $42.75 $61.15 $81.17 $89.29 $94.70
$69,330.00 $800.00 $19.05 $30.01 $45.60 $65.22 $86.58 $95.24 $101.01
$73,665.00 $850.00 $20.24 $31.89 $48.45 $69.30 $91.99 $101.19 $107.32
$78,000.00 $900.00 $21.43 $33.77 $51.30 $73.38 $97.40 $107.14 $113.64
$82,330.00 $950.00 $22.62 $65.64 $54.15 $77.45 $102.81 $113.10 $119.95
$86,665.00 $1,000.00 $23.81 $37.52 $57.00 $81.53 $108.23 $119.05 $126.26
$91,000.00 $1,050.00 $25.00 $39.39 $59.85 $85.61 $113.64 $125.00 $132.58
$95,330.00 $1,100.00 $26.19 $41.27 $62.70 $89.68 $119.05 $130.95 $138.89
$99,665.00 $1,150.00 $27.38 $43.15 $65.55 $93.76 $124.46 $136.90 $145.20 This highlight flyer is intended to provide an overview of the benefits available from your employer and is not a complete description of plan provisions.
Receipt of this flyer does not certify eligibility for benefits under this plan. For further plan details, please request the Dearborn National Long Term Disa-
bility Certificate from your employer.
10
Employees working more than 30 hours per week are eligible for employer sponsored group
life and accidental death and dismemberment insurance.
35% at age 65
An additional 25% of the original amount at age 70
An additional 15% of the original amount at age 75
Benefits terminate at retirement
Benefits will Reduce:
What is AD&D Insurance?
Accidental Death & Dismemberment (AD&D) insurance provides specified benefits
for a covered accidental bodily injury that directly causes dismemberment (e.g. the
loss of a hand, foot, or eye). In the event that a death occurs from a covered
accident, both the life and the AD&D benefit would be payable.
Eligible employees are guaranteed $25,000 without health questionnaires for life and
accidental death and dismemberment insurance.
Open Enrollment or time of hire are the only times an employee can enroll in the group
life/AD&D insurance without Evidence of Insurability.
A delayed effective date will apply if the employee is not actively at work at time of
enrollment.
If you terminate your employment or become ineligible for this coverage, you have the
option to convert all or part of the amount of coverage in force to an individual life
policy on the date of termination without Evidence of Insurability. Conversion election
must be made within 31 days of your date of termination.
Who is Eligible?
The group life and accidental death and dismemberment (AD&D) policy is
paid for by QCI Healthcare. NO employee contributions are required to receive
the group life and AD&D insurance.
Benefits
LIFE/AD&D INSURANCE
This highlight flyer is intended to provide an overview of the benefits available from your employer and is not a complete description of plan provisions.
Receipt of this flyer does not certify eligibility for benefits under this plan. For further plan details, please request the Dearborn National Group Life/AD&D
Certificate from your employer.
11
Employers must provide disclosures to employees
regarding certain legal requirements; including the Health
Insurance Portability and Accountability Act (HIPAA) and
the Patient Protection and Affordable Care Act (PPACA).
This document provides you with certain required
disclosures related to our employee benefits plan (the
“Plan”). If you have any questions or need further
assistance please contact your Plan Administrator as
follows:
QCI Healthcare
Human Resources
2805 Coit Ave NE
Grand Rapids, MI 49505
This Document Is For Information Purposes Only
This communication is intended for illustrative and
information purposes only. The plan documents, summary
plan descriptions, insurance certificates, and policies
serve as the governing documents to determine plan
eligibility, benefits, and payments.
If you have Medicare or will become
eligible for Medicare in the next 12
months, federal law gives you more
choices about your prescription drug
coverage. See page 12 for details.
Limitations And Exclusions
Insurance and benefit plans always contain exclusions
and limitations. Please see benefit booklets and/or
contracts for complete details of coverage and eligibility.
Future Of The Plan
QCI Healthcare reserves the right to amend, modify, or
terminate its benefit plan at any time, including during
treatment.
Notice Regarding Special Enrollment Rights
If you do not timely or properly complete the enrollment
process, you and your eligible dependents generally will
not be covered under the Plan, upon your initial eligibility
date. Also, if you fail to specifically enroll your eligible
dependents on the enrollment form, your eligible
dependents will not be covered under the Plan upon the
dependent’s initial eligibility date. If enrollment does not
occur on an individual’s initial eligibility date, coverage
may not be applied for until the next annual open
enrollment period. However, if an employee or dependent
experiences a special enrollment rights circumstance,
coverage may begin immediately, before the next annual
open enrollment. This section explains the special
enrollment rights rules.
If an individual experiences a loss of health coverage, if an
employee has a new dependent, or an individual loses or
gains eligibility with respect to Medicaid or a State
Children’s Health Insurance Program (“CHIP”), an eligible
employee and/or a dependent may have special enrollment
rights to participate in coverage under the group health plan
immediately without being required to wait until the next annual
open enrollment period.
A loss of other coverage may occur when COBRA has been
exhausted, an individual becomes ineligible for coverage
(for example, due to a change in status), employer
contributions for the coverage have been terminated, the
other coverage is an HMO and the individual no longer lives
or works in the HMO service area, coverage is lost because
the other plan no longer offers any benefits to a class of
similarly-situated individuals (such as part-time employees),
or a benefit package option is terminated unless the
individual is provided a current right to enroll in alternative
coverage. A loss of other coverage for this purpose does not
include, however, termination due to the nonpayment of
required contributions, for cause due to the filing of a
fraudulent application or claim, or where the individual
voluntarily terminates other coverage.
The addition of a new dependent may occur due to
marriage, birth, adoption or placement for adoption.
If an individual’s Medicaid or CHIP coverage is terminated
as a result of a loss of eligibility or if the individual becomes
eligible for a premium assistance subsidy under Medicaid or
a CHIP, the individual has special enrollment rights.
Enrollment must generally be requested in a special enrollment
rights situation within 30 days after the loss of other coverage
or the addition of the new dependent, whichever is applicable.
However, in the case of loss or gain of Medicaid or CHIP
eligibility, a health plan must allow immediate enrollment if the
individual submits a request within 60 days after the loss or
gain of eligibility.
Notice Regarding Women's Health And Cancer Rights Act
The Women's Health and Cancer Rights Act requires group
health plans and insurers offering mastectomy coverage to also
provide coverage for:
Reconstruction of the breast on which the mastectomy was
performed;
Surgery and reconstruction of the other breast to produce a
symmetrical appearance; and
Prostheses and treatment of physical complications at all
stages of the mastectomy, including lymph edemas
These services are payable to a patient who is receiving benefits
in connection with a mastectomy and elects reconstruction. The
physician and patient determine the manner in which these
services are performed.
The plan may apply deductibles and copayments consistent with
other coverage within the plan. This notice serves as the official
annual notice and disclosure of the fact that employer’s health
plan has been amended to comply with this law.
IMPORTANT EMPLOYEE DISCLOSURES
12
Notice Regarding Newborns And Mothers Health Protection
Act
Group health plans and health insurance issuers offering
group health insurance may not, under federal law, restrict
benefits for any hospital length of stay in connection with
childbirth for the mother or newborn child for less than 48
hours following normal vaginal delivery, or less than 96 hours
following a cesarean section, or require that a provider obtain
authorization from the plan or insurance issuer to prescribe a
length of stay not in excess of the above periods.
Notice Regarding GINA
The Genetic Information Nondiscrimination Act of 2008
(GINA) states that group health plans and insurance issues
may not:
Adjust group premium or contribution amounts on the
basis of genetic information.
Request or require individuals to undergo a genetic test
Request, require or purchase genetic information prior to
or in connection with enrollment, or at any time for
underwriting purposes.
Notice Regarding Patient Protections
The following paragraphs outline certain protections under
the PPACA and only apply when the Plan requires the
designation of a Primary Care Physician.
One of the provisions in the PPACA is for plans and insurers
that require or allow for the designation of primary care
providers by participants to inform the participants of their
rights.
You will have the right to designate any primary care provider
who participates in the Plan's network and who is available to
accept you and/or your Eligible Dependents. For children, you
may designate a pediatrician as the primary care provider.
You also do not need prior authorization from the Plan or
from any other person (including your primary care provider)
in order to obtain access to obstetrical or gynecological care
from a health care professional in the Plan's network. The
health care professional, however, may be required to comply
with certain procedures, including obtaining prior
authorization for certain services, following a pre-approved
treatment plan or procedures for making referrals or notifying
primary care provider or Plan of treatment decisions.
If you do not make a provider designation, the Plan may
make one for you. For information on how to select or change
a primary care provider, and for a list of the participating
primary care providers, pediatricians, or obstetrics or
gynecology health care professionals, please contact the
insurer.
Other PPACA Protections
Other PPACA requirements include allowing eligible
dependent children to continue health coverage until age 26,
not retroactively rescinding coverage except as permitted by
law and issuing eligible individuals a summary of benefits
and coverage (SBC) describing the terms of the group health
plan. You will be provided with an SBC as required by law.
Medicare Notice
You must notify QCI Healthcare when you or your dependents
become Medicare eligible. QCI Healthcare is required to
contact the insurer to inform them of your Medicare status.
Federal law determines whether Medicare or the group
health plan is the primary payer. You must also notify
Medicare directly that you have group health insurance
coverage. Privacy laws prohibit Medicare from discussing
coverage with anyone other than the Medicare beneficiary or
their legal guardian. The toll free number to Medicare
Coordination of Benefits is 1-800-999-1118.
Important Information About Your Prescription Drug Coverage
And Medicare
Please note that the following notice only applies to
individuals who are eligible for Medicare.
Medicare eligible individuals may include employees,
spouses or dependent children who are Medicare eligible for
one of the following reasons.
Due to the attainment of age 65
Due to certain disabilities as determined by the Social
Security Administration
Due to End Stage Renal Disease (ESRD)
If you are covered by Medicare, please read this notice
carefully and keep it where you can find it. This notice has
information about your current prescription drug coverage
with QCI Healthcare and about your options under Medicare's
prescription drug coverage. This information can help you
decide whether or not you want to join a Medicare drug plan.
If you are considering joining, you should compare your
current coverage, including which drugs are covered at what
cost, with the coverage and costs of the plans offering
Medicare prescription drug coverage in your area.
Information about where you can get help to make decisions
about your prescription drug coverage is at the end of this
notice.
There are two important things you need to know about your
current coverage and Medicare's prescription drug coverage:
1. Medicare prescription drug coverage became available in
2006 to everyone eligible for Medicare. You can get this
coverage if you join a Medicare Prescription Drug Plan or
join a Medicare Advantage Plan (like an HMO or PPO)
that offers prescription drug coverage. All Medicare drug
plans provide at least a standard level of coverage set by
Medicare. Some plans may also offer more coverage for
a higher monthly premium.
2. QCI Healthcare has determined that the prescription
drug coverage offered by their Blue Cross Blue Shield
PPO AND Blue Care Network HMO plans is, on average
for all plan participants, expected to pay out as much as
standard Medicare prescription drug coverage pays and
is therefore considered Creditable Coverage. If your
existing coverage is Creditable Coverage, you can keep
this coverage and not pay a higher premium (a penalty) if
you later decide to join a Medicare drug plan.
IMPORTANT EMPLOYEE DISCLOSURES
13
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become
eligible for Medicare and each year from October 15th
through December 7th. This may mean that you may have
to wait to join a Medicare Prescription Drug Plan and that
you may pay a higher premium (a penalty) if you join later.
You may pay that higher premium (a penalty) as long as
you have Medicare prescription drug coverage. In addition,
if you lose creditable prescription drug coverage, through
no fault of your own, you will be eligible for a sixty (60) day
Special Enrollment Period because you lost creditable
coverage to join a Part D plan. In addition, if you lose or
decide to leave employer-sponsored coverage; you will be
eligible to join a Part D plan at that time using an
Employer Group Special Enrollment Period. You should
compare your current prescription drug coverage,
including which drugs are covered at what cost, with the
coverage and costs of the plans offering Medicare
prescription drug coverage in your area.
When Will You Pay A Higher Premium (Penalty) To Join A
Medicare Drug Plan?
You should also know that if you drop or lose your current
coverage and don't join a Medicare drug plan within 63
continuous days after your current coverage ends, you
may pay a higher premium (a penalty) to join a Medicare
drug plan later. If you go 63 continuous days or longer
without creditable prescription drug coverage, your
monthly premium may go up by at least 1% of the
Medicare base beneficiary premium per month for every
month that you did not have that coverage. For example, if
you go 19 months without creditable coverage, your
premium may consistently be at least 19% higher than the
Medicare base beneficiary premium. You may have to pay
this higher premium (a penalty) as long as you have
Medicare prescription drug coverage. In addition, you may
have to wait until the following October to join.
For More Information About This Notice or Your Current
Prescription Drug Coverage...
Contact your HR Representative. You'll get this notice each
year. You will also get it before the next period you can join
a Medicare drug plan, and if this coverage through your
company changes. You also may request a copy of this
notice at any time.
For More Information About Your Options Under Medicare
Prescription Drug Coverage...
More detailed information about Medicare plans that offer
prescription drug coverage is in the "Medicare & You"
handbook.
You'll get a copy of the handbook in the mail every year from
Medicare. You may also be contacted directly by Medicare
drug plans. For more information about Medicare
prescription drug coverage:
Visit www.medicare.gov
Call your State Health Insurance Assistance Program
(see the inside back cover of your copy of the "Medicare
& You" handbook for their telephone number) for
personalized help
Call 1-800-MEDICARE (1-800-633-4227). TTY users
should call 1-877-486-2048.
If you have limited income and resources, extra help paying
for Medicare prescription drug coverage is available. For
information, visit Social Security at www.socialsecurity.gov ,
or call 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you
decide to join one of the Medicare drug plans, you may be
required to provide a copy of this notice when you join to
show whether or not you have maintained creditable
coverage and, therefore, whether or not you are required to
pay a higher premium (penalty).
HIPAA Privacy And Security
Employer and any health insurance issuer in connection
with employer’s group health plan are committed to
complying with the privacy and security requirements of
HIPAA as modified by the HIPAA/HITECH Omnibus Final
Rule. Participants will receive a notice of privacy practices in
connection with the Plan. You will also receive a new copy in
the event the notice is modified. If you would like to receive
another copy of the notice of privacy practices, you may do
so at any time, by contacting the plan administrator.
Duplicate copies are provided free of charge.
IMPORTANT EMPLOYEE DISCLOSURES
14
ERISA RIGHTS
As a participant in the Plan, you are entitled to certain rights
and protections under the Employee Retirement Income
Security Act of 1974, as amended (ERISA). ERISA provides that
all plan participants shall be entitled to the following:
Receive Information About Your Plan and Benefits
You can examine, without charge, at the Plan Administrator’s
office and at other specified locations, such as worksites all
documents governing the Plan, including insurance contracts
and a copy of the latest annual report (Form 5500 Series) filed
by the Plan with the U.S. Department of Labor and available at
the Public Disclosure Room of the Employee Benefit Security
Administration.
You can obtain, upon written request to the Plan Administrator,
copies of documents governing the operation of the Plan,
including insurance contracts and copies of the latest annual
report (Form 5500 Series) and an updated summary plan
description. The administrator may make a reasonable charge
for the copies.
Continue Group Health Plan Coverage
You can continue health care coverage for yourself, spouse, or
dependents if there is a loss of coverage under the Plan as a
result of a qualifying event. Your or your dependents may have
to pay for such coverage. Review your summary plan
description and the documents governing the Plan on the rules
governing your COBRA continuation coverage rights.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for participants, ERISA imposes
duties upon the people who are responsible for the operation of
the employee benefit plan. The people who operate your Plan,
called “fiduciaries” of the Plan, have a duty to do so in the
interest of you and other Plan participants and beneficiaries.
No one, including your Employer, or any other person, may fire
you or otherwise discriminate against you in any way to prevent
you from obtaining a benefit or exercising your rights under
ERISA.
Enforce Your Rights
If your claim for a welfare benefit is denied or ignored, in whole
or in part, you have a right to know why this was done, to obtain
copies of documents relating to the decision without charge,
and to appeal any denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above
rights. For instance, if you request a copy of Plan documents or
the latest annual report from the Plan and do not receive them
within 30 days, you may file suit in a Federal court. In such a
case, the court may require the Plan Administrator to provide
the materials and pay you up to $110 a day ($147 a day for
penalties assessed after August 1 2016, as adjusted for
inflation) until you receive the materials, unless the materials
were not sent because of reasons beyond the control of the
Plan Administrator.
If you have a claim for benefits which is denied or ignored,
in whole or in part, you may file suit in state or Federal
court. In addition, if you disagree with the Plan’s decision
or lack thereof concerning the qualified status of a
domestic relations order or a medical child support order,
you may file suit in Federal court. If it should happen that
Plan fiduciaries misuse the Plan’s money, or if you are
discriminated against for asserting your rights, you may
seek assistance from the Employee Benefits Security
Administration, U.S. Department of Labor, listed in your
telephone directory or the Division of Technical Assistance
and Inquiries, Employee Benefits Security Administration,
U.S. Department of Labor, 200 Constitution Avenue N.W.,
Washington, D.C. 20210. You may also obtain certain
publications about your rights and responsibilities under
ERISA by calling the publications hotline of the Employee
Benefits Security Administration.
PLAN ADMINISTRATOR CONTACT INFORMATION
For more information about any of the notices contained
herein, or any of your rights under the Plan, please contact
the Plan Administrator at:
QCI Healthcare
2805 Coit Ave NE
Grand Rapids, MI 49505
NOTICE OF ELIGIBILITY FOR HEALTH CARE RELATED TO
MILITARY LEAVE
If you take a military leave, federal law under the Uniformed
Services Employment and Reemployment Rights Act
(USERRA) provides the following rights:
If you leave your job to perform military service, you
have the right to elect to continue your existing
employer-based health plan coverage for you and your
dependents for up to 24 months while in the military.
If you don’t elect to continue employer-based health
plan coverage during your military services, you have
the right to be reinstated in your employer’s health plan
when you are reemployed, generally without any waiting
period or exclusions (e.g., pre-existing condition
exclusions) except for service-connected illnesses or
injuries.
The Plan Administrator can provide you with additional
information about how to elect continuation coverage under
USERRA.
IMPORTANT EMPLOYEE DISCLOSURES
15
ALABAMA – Medicaid
Website: http://www.myalhipp.com
Phone: 1-855-692-5447
ALASKA – Medicaid
The AK Health Insurance Premium Payment Program
Website: http://myakhipp.com
Phone: 1-866-251-4861
Email: customerservice@myakhipp.com
Medicaid Eligibility:
https://dhss.alaska.gov/dpa/pages/mediciad/default.aspx
ARKANSAS – Medicaid
Website: http://myarhipp.com
Phone: 1-855-MyARHIPP (855-692-7447)
COLORADO – Medicaid
Medicaid Website: http://www.colorado.gov/hcpf
Medicaid Customer Contact Center: 1-800-221-3943
FLORIDA – Medicaid
Website: https://www.flmedicaidtplrecovery.com/hipp
Phone: 1-877-357-3268
GEORGIA – Medicaid
Website: http://dch.georgia.gov/medicaid
Click on Health Insurance Premium Payment (HIPP)
Phone: 1-404-656-4507
INDIANA – Medicaid
Healthy Indiana Plan for low-income adults 19-64
Website: http://www.hip.in.gov
Phone: 1-877-438-4479
All other Medicaid
Website: http://www.indianamedicaid.com
Phone: 1-800-403-0864
IOWA – Medicaid
Website: www.dhs.state.ia.us/hipp/
Phone: 1-888-346-9562
KANSAS – Medicaid
Website: http://www.kdheks.gov/hcf/
Phone: 1-785-296-3512
KENTUCKY – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-635-2570
LOUISIANA – Medicaid
Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331
Phone: 1-888-695-2447
MAINE – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html
Phone: 1-800-442-6003
TTY Main relay 711
MASSACHUSETTS – Medicaid and CHIP
Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120
MINNESOTA – Medicaid
Website: http://mn.gov/dhs/ma
Phone: 1-800-657-3739
MISSOURI – Medicaid
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: 573-751-2005
MONTANA – Medicaid
Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
Phone: 1-800-694-3084
NEBRASKA -
Website: http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages?
accessnebraska_Index.aspx
Phone: 1-855-632-7633
NEVADA – Medicaid
Medicaid Website: http://dwss.nv.gov/
Medicaid Phone: 1-800-992-0900
NEW HAMPSHIRE – Medicaid
Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
NEW JERSEY – Medicaid and CHIP
Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of
states is current as of July 31, 2016. Contact your State for more information on eligibility -
Premium Assistance Under Medicaid And The Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state
may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs.
If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but
you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit
www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State
Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might
be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or
www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the
premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your
employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a
“special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium
assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at
www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
IMPORTANT EMPLOYEE DISCLOSURES
16
NEW YORK – Medicaid
Website: http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-541-2831
NORTH CAROLINA – Medicaid
Website: http://www.ncdhhs.gov/dma
Phone: 919-855-4100
NORTH DAKOTA – Medicaid
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 1-844-854-4825
OKLAHOMA – Medicaid and CHIP
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
OREGON – Medicaid
Website: http://healthcare.oregon.gov/Pages/index.aspx
http://www.oregonhealthcare.gov/index-es.html
Phone: 1-800-699-9075
PENNSYLVANIA – Medicaid
Website: http://www.dhs.pa.gov/hipp
Phone: 1-800-692-7462
RHODE ISLAND – Medicaid
Website: www.eohhs.ri.gov
Phone: 401-462-5300
SOUTH CAROLINA - Medicaid
Website: http://www.scdhhs.gov
Phone: 1-888-549-0820
SOUTH DAKOTA - Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
TEXAS – Medicaid
Website: https://www.gethipptexas.com/
Phone: 1-800-440-0493
UTAH – Medicaid and CHIP
Medicaid: http://health.utah.gov/medicaid
CHIP: http://health.utah.gov/chip
Phone: 1-877-543-7669
VERMONT– Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
VIRGINIA – Medicaid and CHIP
Medicaid Website: http://www.coverva.org/
programs_premium_assistance.cfm
Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm
CHIP Phone: 1-855-242-8282
WASHINGTON – Medicaid
Website: http://www.hca.wa.gov/free_or_low_cost_health_care/program-
administration/premium-payment-program
Phone: 1-800-562-3022 ext. 15473
WEST VIRGINIA – Medicaid
Website: www.dhhr.wv.gov/bms/Medicaid%20Expansion/pages/default.aspx
Phone: 1-877-598-5820, HMS Third Party Liability
WISCONSIN – Medicaid
Website: http://www.dhs.wisconsin.gov/publications/p1.p10095.pdf
Phone: 1-800-362-3002
WYOMING – Medicaid
Website: http://wyequalitycare.acs-inc.com/
Phone: 307-777-7531
To see if any other states have added a premium assistance program since July 31, 2016, or for more information on special enrollment
rights, contact either:
U.S. Department of Labor U.S. Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/ebsa www.cms.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565
IMPORTANT EMPLOYEE DISCLOSURES
17
INSTRUCTIONS FOR EMPLOYEES
All forms can be requested from Ken Jewett OR
Found online at www.qcistaffing.com/forms
Instructions for Voluntary Dental, Voluntary Vision, Voluntary Short & Long
Term Disability during Open Enrollment
Coverage Offered Employee Action Forms Required
Enroll for the first time
Add spouse/dependents to policy
Remove self/spouse/ dependents
from policy
Benefit Election Form
Voluntary Delta Dental
Continue with same election (waived
or enrolled) with NO changes Benefit Election Form
Voluntary VSP Vision Enroll for the first time
Add spouse/dependents to policy
Remove self/spouse/dependents from
policy
Benefit Election Form
Continue with same election (waived
or enrolled) with NO changes Benefit Election Form
Voluntary Dearborn
National Short &/or
Long Term Disability &
Life Insurance Enroll for the first time
Dearborn National Enrollment
Form
Evidence of Insurability (EOI)
Form
Benefit Election Form
Make changes to current election/
salary
Remove self from policy
Change life insurance beneficiary
Dearborn National Change Form
Benefit Election Form
18
Coverage Dependent Age Eligibility Ends
Pediatric Dental & Pediatric Vision
included with Medical Coverage End of calendar year in which they turn age 19
Medical End of the calendar year in which they turn age 26
Voluntary Dental End of the month in which they turn age 26
Voluntary Vision 11:59PM the day before they turn age 23
ELIGIBILITY & CONTRIBUTIONS
INFORMATION
Coverage Effective Date & Payroll Deduction
Medical Pro-rated PER DAY if not enrolled on the first of
the month
Voluntary Dental
If enrolled the 1st - 14th of the month, charged for
entire month of coverage
If enrolled the 15th through end of the month, no
charge for that month
Voluntary Vision First of the month following date of hire ONLY
Voluntary Short & Long Term
Disability
If enrolled the 1st - 14th of the month, charged for
entire month of coverage
If enrolled the 15th through end of the month, no
charge for that month
Benefit Summaries and carrier forms can be found at www.QCIStaffing.com/Forms
19
Company Phone number/website Reasons to contact
General
Information QCI Healthcare
Ken Jewett
KenJewett@QCIHealthcare.com
Www.qcistaffing.com/forms
616.365.9290
Questions regarding
enrollment, eligibility, or
costs.
Medical/
Pharmacy
Blue Cross Blue
Shield of Michigan
Blue Care Network
www.bcbsm.com
800.292.3501
888.265.4703
Find participating
physicians
Change your primary
care physician
Inquiries about
eligibility
Confirm benefits
Questions about a bill
or EOB (explanation of
benefits)
Obtain claim forms
File a claim
Problems with
eligibility
Problems with
resolving claims
through your carrier
Problems with
obtaining benefit
information through
your carrier
Dental Delta Dental
www.deltadentalmi.com
800.524.0149
Vision Vision Service Plan
(VSP)
www.vsp.com
800.877.7195
Short and
Long Term
Disability and
Group Life/
AD&D
Dearborn National
www.dearbornnational.com
Short Term: 877.348.0487
Long Term: 877.348.0487
Group Life: 800.348.4512
Insurance
Agency
Buiten &
Associates, LLC
MaKenzi Bezemek
Makenzi.bezemek@buiteninsurance.
com
616.284.3028
Kevin Cumings
Kevin.cumings@buiteninsurance.
com
616.956.0040
The information in this Employee Benefits Guide is presented for illustrative purposes and is based on information provided
by the employer. The text contained in this Guide was taken from various summary plan descriptions and benefit
information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In
case of discrepancy between the Guide and the actual plan documents the actual plan documents will prevail. All
information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any
questions about your Guide, contact Human Resources.
Refer to this list for contact information for QCI Healthcare’s benefit vendors/carriers. For general
information, please contact Human Resources. Please contact the carrier directly for issues/
questions pertaining to specific procedures and/or claims .
CONTACT INFORMATION
2017 - 2018 OPEN ENROLLMENT BENEFIT ELECTION FORM ALL Forms must be returned to QCI Healthcare by MAY 12, 2017
Employee Information (All portions MUST be completed to process your elections)
Name Hours Worked per Week
SSN Job Title
Date of Birth Salary & Pay Frequency
E-mail Hire Date
Address Effective Date of Coverage
Election Options (All costs represent pre-tax WEEKLY deductions)
Open Enrollment is the period during which an employee can enroll, add/remove dependents, change, or terminate certain benefit elections for the upcoming
year. Please complete ALL portions of this form. A Dearborn National form must accompany the Benefit Election Form for ANY new enrollments/changes you
wish to make to your disability and/or life insurance coverage during Open Enrollment. Carrier forms can be found at www.qcistaffing.com/forms.
Medical Plans (if you are located outside of Michigan, you must choose one of the PPO options)
Option 1: BCN HMO Platinum 20% Option 2: BCN HMO Gold $1,000 Option 3: Simply Blue PPO Gold $500
Option 4: Simply Blue PPO Health Savings Account
(HSA) Silver $2,700
Employee Only - $69.38 Employee Only - $52.66 Employee Only - $63.55 Employee Only - $41.78
Employee + One - $231.12 Employee + One - $191.00 Employee + One - $217.13 Employee + One - $164.88
Employee + Family - $300.45 Employee + Family - $250.29 Employee + Family - $282.96 Employee + Family - $217.64
I do NOT want to participate in the Medical plan*
COMPLETE OTHER SIDE OF THIS PAGE TO FINISH YOUR BENEFIT ELECTIONS
-Dependent Information - ONLY complete if you wish to make CHANGES (if you need more space, please attach a blank piece of paper to this form)
Name (Last, First, M.I.) Social Security # Sex Birthdate
(mm/dd/yyyy)
Medical
(Add/Delete)
Voluntary Dental
(Add/Delete)
Voluntary Vision
(Add/Delete) Relationship
*The medical plans offered by QCI Healthcare meet the Affordable Care Act (ACA) definition of affordable and “minimum essential coverage”. Meaning the medical plans offered by QCI
Healthcare satisfy the ACA’s Individual Mandate making you INELIGIBLE for a subsidy on the Health Insurance Marketplace. Should you decide to decline the medical coverage and do not have
medical coverage through another source, you may be subject to a tax penalty.
Must name Primary Care Doctor Must name Primary Care Doctor
Dearborn National Basic Life/AD&D
Company Paid - $25,000 Benefit Change Beneficiary - complete Dearborn National Beneficiary Change Form
Voluntary Dearborn National Long Term Disability (100% EMPLOYEE Paid) Voluntary Dearborn National Short Term Disability (100% EMPLOYEE Paid)
Elect - coverage varies based on age and income (please refer to the Employee
Benefits Guide for more information)
Elect - coverage varies based on age and income (please refer to the Employee
Benefits Guide for more information)
Change Current Salary - complete Dearborn National Change form Change Current Salary - complete Dearborn National Change form
Decline Decline
If you refuse coverage for yourself, you automatically refuse that coverage for any dependents. If you are declining enrollment for any of the benefits offered you may in the
future be able to enroll yourself and your dependents in the plan, during annual enrollment or within 30 days after a qualifying life event. If you decide to waive the short term
and/or long term disability coverage when you are first eligible, you may be subject to medical underwriting and pre-existing limitation exclusions.
I hereby acknowledge and certify the above benefit elections; I understand that if I decide to waive my benefits I will be subject to any late entrant penalties that do apply if I
decide to enroll at a later date. I also understand that since these deductions are performed on a pre-tax basis that all elections must remain the same until open enrollment
unless I experience a qualifying life event.
I acknowledge that anyone who is covered under the medical policy and has other health benefits, I will disclose that information to the medical carrier.
I acknowledge that I have received the following documents from my employer, in a timely manner and that I understand my rights and coverages.
I also understand that these documents are available to me electronically as well as by request from HR.
Compliance Notice’s
Marketplace/Exchange Notice of Coverage Options Newborn’s Rights Act Notice Medical Summary of Benefits & Coverage (SBC) HIPAA Privacy Policy
Benefit Coverage Plan Summaries & Contracts CMS Creditable Coverage Notice Grandfathered Health Status GINA Notice
Women’s Health & Cancer Rights Act Notice CHIP Notice Section 125 Pre-tax Notice SPD/Wrap document
Employee Signature: Date:
By signing below, I acknowledge that the information on this enrollment form are true and that I have received and read all documents as noted above.
Important Notice
Signature Authorizing Payroll Deduction of Above Benefits
Pediatric Dental AND Vision coverage is included in medical coverage & rates for dependents under age 19.
Voluntary Delta Dental Plan (100% EMPLOYEE Paid)
Employee Only - $9.03 Employee + Child(ren) - $20.68
Employee + Spouse - $18.07 Employee + Family - $32.67
I do NOT want to participate in the Voluntary Dental plan
Voluntary VSP Vision Plan (100% EMPLOYEE Paid)
Employee Only - $3.43 Employee + Child(ren) - $5.24
Employee + Spouse - $5.24 Employee + Family - $9.40
I do NOT want to participate in the Voluntary Vision plan
Primary Care Physician Election Form must accompany Benefit Election Form
(Used for employees electing a Blue Care Network HMO plan ONLY)
Employee Information (All portions MUST be completed to process your elections)
Name Hours Worked per Week
SSN Job Title
Date of Birth Salary & Pay Frequency
E-mail Hire Date
Address Effective Date of Coverage
Primary Care Physician (PCP) Election - Required for members electing a BCN HMO plan. If PCP is not named, one will be auto-assigned by BCN.
Member Information
Name (Last, First) Physician Name (Last, First) Physician’s NPI # Physician Address If changing PCPs,
list reason
Seen in the last
12
Months?
Subscriber
Spouse
Dep. 1
Dep. 2
Dep. 3
Dep. 4
You can choose a different primary care physician for each member of your family, or one to care for your entire family. If you elect to have one doctor for your entire family,
you must select a family or general practice physician. You cannot choose a specialist as a primary care physician. You can go to www.bcbsm.com/find-a-doctor to view the
most current information on BCN-affiliated primary care physicians. It is advised to check with the doctor's office to confirm participating with Blue Care Network HMO plans.
Employee Signature: Date:
I understand that if I wish to change my primary care physician at any time during the plan year that all changes become effective two business days after BCN receives the
form - unless you request a later effective date. If you change your primary care physician while you are being treated by a specialist, your new primary care physician must
reauthorize the treatment you are receiving. Your treatment may not be covered until that occurs. I have read and understand the conditions of this form.
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