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.

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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.

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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

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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.

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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!

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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!

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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

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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.