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2017 NH Guide Employbridge PDF
2017 NH Guide Employbridge PDF
ASSOCIATE BENEFITS
NOW IS YOUR CHANCE TO ENROLL...
We value the contributions of our associates. In appreciation of your dedicated service we are pleased to offer a variety of affordable
benefit plans provided by The American Worker. Please carefully review this enrollment guide so you understand the benefits being
offered and can make the right choices for you and your family.
ENROLLMENT PERIOD
You can enroll during the new hire onboarding process or within 30 day of receiving your first paycheck.
To enroll after receiving your first paycheck use one of the options below.
ENROLL NOW
Online: www.TheAmericanWorker.com
Available anytime
Phone: (877) 220-1862
Monday - Friday, 8 AM - 8 PM ET
Mobile Device: Text Staff2017 to 24587
Available anytime
ENROLLING ONLINE...
Click Enroll - Start Here at the top of the page
Under New User? select the Employee ID button
Enter your information in the fields below
- Employee ID #: Your Social Security Number
- Date of Birth: Your Date of Birth
- Group #: 98418
Note: New Users must create an account before enrolling
PLAN 1
PLAN 2
OUTPATIENT DIAGNOSTIC
ADVANCED STUDIES
SUBSTANCE ABUSE
MENTAL ILLNESS
SKILLED NURSING
AWP VALUE RX
Included
Included
Included
Included
Included
Included
$15.92
$26.56
$26.72
$37.44
$22.43
$41.50
$38.75
$57.94
PHYSICIANS OFFICE
PREVENTIVE CARE
EMERGENCY ROOM SICKNESS
ACCIDENTAL INJURY CARE
SURGICAL
Daily Inpatient
Daily Inpatient Maximum
Daily Outpatient
Daily Outpatient Minor
Daily Outpatient Benefit Maximum
ANESTHESIA
HOSPITAL INDEMNITY
HOSPITAL ADMISSION (Lump Sum)
Weekly Rates**
Associate
Associate + Spouse
Associate + Child(ren)
Family
**Rates include a $0.25 weekly administrative fee
*The Med Basic Fixed Indemnity Plans (a) are not a substitute for minimum essential health coverage under the Affordable Care Act (ACA), (b) do not
qualify as minimum essential coverage under ACA, and (c) do not satisfy the ACAs individual mandate.
*The Med Basic Fixed Indemnity Plans are not available to New Hampshire or Vermont residents.
Tier 1: Select generic and brand name drugs available for $10 or less
Tier 2: Select generic and brand name drugs available for $20 or less
Tier 3: Select generic and brand name drugs available for $50 or less
Tier 4: Generic and brand name drugs for which a discounted price has been negotiated
Network providers submit claims for you to simplify the claim process
You can visit a First Health or out-of-network provider for service and the Med Basic Plans will pay the same benefit amount.
Teladoc is not available to AR & ID residents. 2Health Advisor does not replace health
insurance, provide medical care or recommend treatment. 3Savings may vary based
on geographic location, provider selected and procedure performed. The lab network
portion of this benefit is not available in MA, MD, ND, NE, NJ, NY, RI or SD.
Chiropractic
Hearing
Durable Medical
Equipment
IN-NETWORK
OUT-OF-NETWORK
No Coverage
Weekly Rates
Associate
Associate + Spouse
Associate + Child(ren)
Family
$6.84
$10.69
$11.46
$14.20
COVERED SERVICES
The Med Advantage plan covers the following services; however, the U.S. Preventive Services Task Force periodically updates the list
of covered services. For a current list, visit www.healthcare.gov/preventive-care-benefits. Plan limitations and exclusions apply.
ADULTS
Abdominal Aortic Aneurysm one-time screening for men of specified ages who
have ever smoked
Alcohol misuse screening & counseling
Aspirin use to prevent cardiovascular disease for men & women of certain ages
Blood Pressure screening
Cholesterol screening for adults of certain ages or at higher risk
Colorectal Cancer screening for adults over 50
Depression screening
Diabetes (Type 2) screening for adults with high blood pressure
Diet counseling for adults at higher risk for chronic disease
Hepatitis B screening for people at high risk
Hepatitis C screening for adults at increased risk, & one-time for everyone born
1945-1965
HIV screening for everyone ages 15-65, & other ages at increased risk
Immunization vaccines for adults (doses, recommended ages, & recommended
populations vary): Diphtheria, Hepatitis A, Hepatitis B, Herpes Zoster, Human
Papillomavirus (HPV), Influenza (Flu Shot), Measles, Meningococcal, Mumps,
Pertussis, Pneumococcal, Rubella, Tetanus, Varicella (Chickenpox)
Lung Cancer screening for adults 55-80 at high risk for lung cancer because they
are heavy smokers or have quit in the past 15 years
Obesity screening & counseling
Sexually Transmitted Infection (STI) prevention counseling for adults at higher
risk
Syphilis screening for all adults at higher risk
Tobacco Use screening for all adults & cessation interventions for tobacco users
Gestational Diabetes screening for women 24-28 weeks pregnant & those at high
risk of developing gestational diabetes
Hepatitis B screening for pregnant women at their first prenatal visit
HIV screening & counseling for sexually active women
Human Papillomavirus (HPV) DNA test every 3 years for women with normal
cytology results who are 30 or older
Osteoporosis screening for women over age 60 depending on risk factors
Rh Incompatibility screening for all pregnant women & follow-up testing for
women at higher risk
Sexually Transmitted Infection counseling for sexually active women
Syphilis screening for all pregnant women, women who may become pregnant &
women at increased risk
Tobacco Use screening & interventions
Expanded tobacco intervention & counseling for pregnant tobacco users
Urinary Tract or other infection screening
Well-woman visits to get recommended services for women under 65
*Massachusetts residents: This Plan does not meet the individual health coverage requirements & does not satisfy the individual mandate in your state.
CHILDREN
DEDUCTIBLE
COVERED SERVICES
WAITING PERIOD
COINSURANCE
None
Covered at 100%
(U&C Charges)
BASIC TREATMENT
Restorative Amalgams and Composites
Endodontics, Periodontics, Extractions, etc.
3 Months
Covered at 60%
(U&C Charges)
MAJOR TREATMENT
Onlays, Crowns, Prosthodontics, etc.
12 Months
Covered at 50%
(U&C Charges)
Weekly Rates
Associate
Associate + Spouse
Associate + Child(ren)
Family
$4.75
$11.88
$8.55
$12.83
TO FIND A PROVIDER
Call (800) 659-2223 and select option 2
Visit www.Ameritas.com and click on FIND
A PROVIDER. Then select DENTAL and
click on NETWORK PROVIDER.
COVERED SERVICES
OUT-OF-NETWORK
Covered in Full
Up to $45
Covered in Full
Covered in Full
Up to $30 / Up to $50
Up to $65 / Up to $100
CONTACTS
Fit and Follow Up Exams
Elective
Medically Necessary
15% Discount
Up to $120
Covered in Full
No Benefit
Up to $105
Up to $210
Up to $1202
Up to $70
FRAMES
FREQUENCY
Exam / Lens / Frame
Weekly Rates
Associate
Associate + Spouse
Associate + Child(ren)
Family
$2.07
$4.10
$3.82
$5.84
TO FIND A PROVIDER
Call (800) 877-7195
Visit www.Ameritas.com and click on FIND
A PROVIDER. Then select VISION: VSP
and click on LOOK UP VSP PROVIDERS.
26 Weeks
7 Days (Accidents and Sickness)
Weekly Rates
Associate
$3.87
LIFE INSURANCE
Spouse
Child (6 months - 26 years)
Infant (10 days - 6 months)
Weekly Rates
Associate
Associate + Spouse
Associate + Child(ren)
Family
$0.60
$0.90
$0.90
$1.80
ENROLLMENT INSTRUCTIONS
You can enroll during the new hire onboarding process or within 30 day of receiving your first paycheck. To enroll after receiving
your first paycheck use one of the options below. If you have benefit questions, call the enrollment center for assistance.
1
2
3
Enroll Online:
Visit www.TheAmericanWorker.com and at the top of
the page click on the Enroll - Start Here link.
Under New User? select Employee ID and enter
your information in the fields below.
- Employee ID #: Your Social Security Number
- Date of Birth: Your Date of Birth
- Group #: 98418
www.TheAmericanWorker.com
Available anytime
Enroll By Phone:
(877) 220-1862
Monday - Friday: 8 AM to 8 PM ET
EFFECTIVE DATE: Your coverage begins the Monday after premium is deducted from your paycheck.
PLEASE HAVE THE FOLLOWING AVAILABLE WHEN ENROLLING
Associate Information: Full Name, Social Security Number, Date of Birth, Home Address, Phone Number, Email Address
Dependent Information: Full Name, Social Security Number, Date of Birth
Plan Choices: Med Basic* (Plan 1 or Plan 2), Med Advantage, Dental, Vision, Short-Term Disability*, Life and AD&D Insurance*
*Coverage is not available to New Hampshire or Vermont residents.
6
IMPORTANT INFORMATION
PRETAX PREMIUM DEDUCTIONS (SECTION 125)
Premium for your coverage is deducted from your paycheck on a pretax basis. By enrolling you agree to the following:
I hereby elect to participate in The American Worker Plan for benefits made available under the Internal Revenue Code Section
79, 105, 106, 125, and these sections as amended. I understand that the Plan will automatically convert to pretax status any eligible
payroll deductions which are provided through the Plan. I understand that by participating in this Plan my Social Security benefits
may be reduced since these premiums will be deducted before my salary is taxed. This election will remain in effect for the entire
Plan Year. My election CANNOT be changed during the Plan Year in accordance with the Internal Revenue Service Guidelines
unless a qualifying event occurs. Qualifying events include: marriage, divorce, legal separation, death of spouse, birth or legal
adoption of a child, death of a child, or spousal change of employment affecting insurance coverage.
DISCLOSURES
MED BASIC FIXED INDEMNITY PLANS
These Plans are not intended or recommended to replace any comprehensive program of insurance in which you currently or intend
to participate. These Plans are not designed to replace or provide major medical coverage. This enrollment guide is for summary
purposes only. The insurance benefits of the Med Basic Fixed Indemnity Plans are offered by Nationwide Life Insurance Company. A
detailed Certificate of Coverage is available upon enrollment. Plan exclusions and limitations apply.
The Med Basic Fixed Indemnity Plans (a) are not a substitute for minimum essential health coverage under the Affordable Care
Act (ACA), (b) do not qualify as minimum essential coverage under ACA, and (c) do not satisfy the ACAs individual mandate.
STATE RESTRICTIONS
Massachusetts residents are eligible for the Med Basic Fixed Indemnity and Med Advantage Minimum Essential Coverage (MEC),
but neither of these Plans meet the individual health coverage requirements and will not satisfy the individual mandate that you have
health insurance in your state.
New Hampshire and Vermont residents are not eligible for the Med Basic Fixed Indemnity, Short-term Disability and Life and
AD&D benefits.
Hawaii residents are not eligible for any of the benefits provided by The American Worker.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.fbg.com or by calling 1-855-495-1190.
Important Questions
Answers
$0
See the chart starting on page 2 for your costs for services this plan covers.
No
You dont have to meet deductibles for specific services, but see the chart starting on page
2 for other costs for services this plan covers.
Is there an outof
pocket limit on my
expenses?
No
There is no limit on how much you could pay during a coverage period for your share of the cost
of covered service.
Is there an overall
annual limit on what
the plan pays?
No
The chart describes any limits on what the plan will pay for specific covered services, such as
office visits.
Yes
Does this plan use a
network of providers?
If you use an in-network doctor or other health care provider, this plan will pay some or all of the
costs of covered services. Be aware, your in-network doctor or hospital may use an out-ofnetwork provider for some services. Plans use the term in-network, preferred, or participating for
providers in their network. See the chart starting on page 2 for how this plan pays different kinds
of providers.
Do I need a referral to
see a specialist?
No
You can see the specialist you choose without permission from this plan.
NOTE: Only preventive services performed by specialists are covered by this plan.
Yes
Some of the services this plan doesnt cover are listed on page 4. See your policy or plan
document for additional information about excluded services.
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Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plans allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if
you havent met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical Event
If you visit a health
care providers office
or clinic
If you have a test
Your Cost If
You Use an
In-network
Provider
Not Covered
Not Covered
Not Covered
No Charge
Not Covered
Not Covered
Your Cost If
You Use an
Out-of-network
Provider
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
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If you have
outpatient surgery
If you need
immediate medical
attention
If you have a
hospital stay
If you have mental
health, behavioral
health, or substance
abuse needs
If you are pregnant
Your Cost If
You Use an
In-network
Provider
Generic drugs
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Specialty drugs
Facility fee (e.g., ambulatory surgery center)
Physician/surgeon fees
Emergency room services
Emergency medical transportation
Urgent care
Facility fee (e.g., hospital room)
Physician/surgeon fee
Mental/Behavioral health outpatient services
Mental/Behavioral health inpatient services
Substance use disorder outpatient services
Substance use disorder inpatient services
Prenatal and postnatal care
Delivery and all inpatient services
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
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Your Cost If
You Use an
In-network
Provider
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
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Acupuncture
Bariatric surgery
Chiropractic care
Cosmetic surgery
Habilitation services
Hearing aids
Hospice Care
Infertility Treatment
Long-term Care
Private-duty Nursing
Rehabilitation services
Surgery
Urgent Care
Other Covered Services (This isnt a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
Please visit the Healthcare.gov for a complete and current list of Preventative Care Benefits that are required and covered under this plan.
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This is
not a cost
estimator.
Dont use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information about
these examples.
Having a baby
(normal delivery)
(routine maintenance of
a well-controlled condition)
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$0
$0
$0
$7,500
$7,500
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$0
$0
$0
$5,300
$5,300
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