2015 Health Insurance
Information
For 30 years, United Personnel has been pleased to offer health insurance coverage to our employees. In 2015, our coverage options are changing as part of United’s commitment to fully abide by the requirements of the Affordable Care Act (ACA). As part of this compliance, we are happy to inform you of your potential eligibility to participate in a new group insurance plan we’ll be offering starting March 1st of this year.
Under the ACA, employees working at least 30 hours per week, or 130 hours per month, are required to be offered compliant employer group medical coverage on the 90th day of
employment. United Personnel has decided to enhance this offering and make it available on the first of the month following 60 days of employment.
You are receiving this packet so that you have the information you need to make insurance decisions when you become eligible. In 2015, United will offer 4 health insurance plans through Health New England.
The most affordable coverage is Plan 1 (HMO Wise Plus HDHP), which meets the ACA’s affordability and minimum essential care and value requirements. For this plan, United Personnel will ensure 68% of the single premium ($ 2,866 annually). The total employee
contribution for this single coverage on Plan 1 is $1334 annually.In addition, this plan comes
with a $2000 deductible which must be paid out of pocket by the employee before insurance
coverage begins. This means that you, as the covered employee, pay for all medical
treatment/care/prescriptions, with the exception of preventive care visits with $0 copay, on your own until you reach a $2000 deductible. At that point, the insurance will help to pay for medical expense as outlined in the chart in this packet.
If you chose to upgrade to one of the other 3 plans offered, Essential HMO 500, 1500 or 2000, please refer to the chart in packet for plan description and cost. United’s contribution to these premium rates remains $2,866 annually.
If you achieve eligibility status and chose not to participate in this partially employer-paid plan, the ACA still requires all individuals over the federal poverty guidelines to purchase a policy referred to as “Minimum Essential Coverage.” If you chose not to participate in any of these health plans and do not own a compliant policy through another source, you may owe up to 2% of your income when filing your 2015 individual income tax return under ACA rules.
Weekly Contribution $25.65 $106.41 $94.30 $175.06
**Once any individual on a family plan has paid $2,600 towards the family deductible, the plan will begin to pay benefits for that individual.
(The most you pay for cost sharing on Essential Health Benefits during a Plan Year before your Plan begins to pay 100% of the allowed amount.)
$5,000 per Individual / $10,000 per Family
Radiological Services: $0 Copay After Deductible
(Ultrasound, X-Ray, Non-Routine Mammogram)
Diagnostic Imaging: $75 Copay After Deductible (3 copays per year)
(CT Scan, MRI, MRA, PET Scan, Nuclear Cardiac Imaging)
Inpatient Hospital Admission: $500 Copay After Deductible
Outpatient Surgery: $250 Copay After Deductible
Prescription Drugs Subject to Plan Year Deductible
Retail (30-Day Supply): $15/$30/$50 After Deductible
Mail Order (90-Day Supply): $30/$60/$150 After Deductible
Out-of-Pocket Maximum per Plan Year
Laboratory Services: $0 Copay After Deductible
Employee & Child(ren) Family
Benefit Summary
$0 Preventive Services Copay Plan Year Deductible
$2,000 per Individual / $4,000 per Family**
PCP Office Visit: $25 Copay After Deductible
Specialist Office Visit: $25 Copay After Deductible
Chiropractic Services: $20 Copay After Deductible
(12 visits per member per calendar year)
Emergency Room: $100 Copay After Deductible
Employee & Spouse
UNITED PERSONNEL SERVICES
Medical Insurance Programs Underwritten by Health New England Effective March 1, 2015
Plan 1: HMO Wise Plus HDHP
Weekly Weekly Weekly
Contribution Contribution Contribution
$66.16 $47.30 $41.49
$187.43 $149.71 $138.54
$169.23 $134.35 $124.02
$290.50 $236.76 $220.84
Plan Year before your Plan begins to pay 100% of the allowed amount.) Plan Year before your Plan begins to pay 100% of the allowed amount.) Plan Year before your Plan begins to pay 100% of the allowed amount.) $5,000 per Individual / $10,000 per Family $5,000 per Individual / $10,000 per Family $5,000 per Individual / $10,000 per Family
(The most you pay for cost sharing on Essential Health Benefits during a (The most you pay for cost sharing on Essential Health Benefits during a (The most you pay for cost sharing on Essential Health Benefits during a Mail Order (90-Day Supply): $30/$100/$225 Mail Order (90-Day Supply): $30/$100/$225 Mail Order (90-Day Supply): $30/$100/$225
Out-of-Pocket Maximum per Plan Year Out-of-Pocket Maximum per Plan Year Out-of-Pocket Maximum per Plan Year
Not Subject to Plan Year Deductible Not Subject to Plan Year Deductible Not Subject to Plan Year Deductible
Retail (30-Day Supply): $15/$50/$75 Retail (30-Day Supply): $15/$50/$75 Retail (30-Day Supply): $15/$50/$75
Prescription Drugs Prescription Drugs Prescription Drugs
Inpatient Hospital Admission: $0 After Deductible Inpatient Hospital Admission: $0 After Deductible Inpatient Hospital Admission: $0 After Deductible
Outpatient Surgery: $0 After Deductible Outpatient Surgery: $0 After Deductible Outpatient Surgery: $0 After Deductible
Diagnostic Imaging: $75 After Deductible (3 copays per year) Diagnostic Imaging: $100 After Deductible (3 copays per year) Diagnostic Imaging: $100 After Deductible (3 copays per year)
(CT Scan, MRI, MRA, PET Scan, Nuclear Cardiac Imaging) (CT Scan, MRI, MRA, PET Scan, Nuclear Cardiac Imaging) (CT Scan, MRI, MRA, PET Scan, Nuclear Cardiac Imaging) Radiological Services: $0 After Deductible Radiological Services: $0 After Deductible Radiological Services: $0 After Deductible
(Ultrasound, X-Ray, Non-Routine Mammogram) (Ultrasound, X-Ray, Non-Routine Mammogram) (Ultrasound, X-Ray, Non-Routine Mammogram)
Plan Year Deductible Plan Year Deductible Plan Year Deductible
$500 per Individual / $1,000 per Family $1,500 per Individual / $3,000 per Family $2,000 per Individual / $4,000 per Family
$150 Emergency Room Copay $150 Emergency Room Copay $150 Emergency Room Copay
Laboratory Services Covered in Full Laboratory Services Covered in Full Laboratory Services Covered in Full
$20 Chiropractic Copay $20 Chiropractic Copay $20 Chiropractic Copay
(12 visits per member per calendar year) (12 visits per member per calendar year) (12 visits per member per calendar year) $0 Preventive Services Copay $0 Preventive Services Copay $0 Preventive Services Copay $20 PCP Office Visit Copay ($20 Specialist Copay) $20 PCP Office Visit Copay ($20 Specialist Copay) $20 PCP Office Visit Copay ($20 Specialist Copay)
Family Family Family
Benefit Summary Benefit Summary Benefit Summary
Employee & Spouse Employee & Spouse Employee & Spouse
Employee & Child(ren) Employee & Child(ren) Employee & Child(ren)
Single Single Single
UNITED PERSONNEL SERVICES
Medical Insurance Programs Underwritten by Health New England Effective March 1, 2015
enrollment/add/termination
form
PLEASE PRINT AND COMPLETE ALL INFORMATIONREASON
CHANGE COVERAGE TYPE
ADD DEPENDENT LISTED ABOVE
TERMINATE DEPENDENT LISTED ABOVE
TRANSFER TO COBRA
NAME/ADDRESS CHANGE
LOSS OF INSURANCE (must attach documents)
MARRIAGE
OTHER
CHANGE TO CURRENT POLICY EFF. DATE TERMINATION OF POLICY END DATE
REASON
LEFT EMPLOYMENT NO LONGER ELIGIBLE
VOLUNTARY CANCELLATION DECEASED
MOVED FROM SERVICE AREA
TYPE OF PLAN: HMO Advantage Plus (POS) PPO TYPE OF COVERAGE: INDIVIDUAL FAMILY OTHER
DATE OF HIRE: __________________ HNE GROUP #: — EMPLOYER SIGNATURE: _________________________________________________________ DATE: __________________________
NEW ENROLLMENT EFF. DATE REASON
NEW HIRE PART-TIME TO FULL-TIME
ANNUAL OPEN ENROLLMENT OTHER
LOSS OF INSURANCE (must attach documents)
MOVED INTO SERVICE AREA
GROUP/COMPANY NAME EMPLOYEE NAME (FIRST, MIDDLE, LAST)
IS THIS YOUR DOCTOR NOW?
YES NO
-EACH MEMbER MUST SELECT A PRIMARY CARE PHYSICIAN. IF A PCP IS NOT CHOSEN, HNE MAY NOT bE AbLE TO PROCESS YOUR CLAIMS (DOES NOT APPLY TO PPO).
SS#
PCP FIRST & LAST NAME (does not apply to PPO)
-DOB MONTH DAY YEAR GENDER
MALE FEMALE
PCP PROVIDER ID# (Found in the provider directory)
DEPENDENT NAME(S) ETHNICITY RACE DATE OF BIRTH MO DAY YR -SEX M F M F M F M F
SOCIAL SECURITY NUMBER
Y N Y N Y N Y N PCP
LAST FIRST PROVIDER ID#
Spouse Other
Dependent
Dependent
Dependent
FIRST MIDDLE LAST (if not same as employee)
-IS TH-IS YOUR DOCTOR NOW?
ADDRESS APT. NO. STREET PO BOX
CITY STATE ZIP
TELEPHONE (HOME) TELEPHONE (WORK) EMAIL
MARITAL STATUS SINGLE MARRIED DIVORCED OTHER PRIMARY LANGUAGE SPOKEN
( ) ( )
OPTION
One Monarch Place • Suite 1500 • Springfield, MA 01144-1500
Phone 413-787-4000 • 800-842-4464 • Enrollment Fax 413-233-2635
hnewhizkidz.com • hne.com
4/15/08 07520LE FOR DEPENDENT(S) AGED 21-26, I ATTEST TO THE FOLLOWING: (DEPENDENT ELIGIBILITY RULES MAY VARY FOR SELF-FUNDED PLANS.)
DEPENDENT NAME(S)
X
I WILL CLAIM HIM/HER AS A DEPENDENT FOR IRS TAX PURPOSES IN THE CURRENT CALENDAR YEAR.
YES NO
YES NO
IF NO, THE LAST YEAR I CLAIMED HIM/HER AS A DEPENDENT FOR IRS TAX PURPOSES WAS IN CALENDAR YEAR:
HE/SHE IS A FULL-TIME STUDENT?
YES NO
YES NO
bELOW SECTION TO bE COMPLETED bY EMPLOYER
I UNDERSTAND THAT BY ACCEPTING COVERAGE UNDER THIS PLAN, HNE AND ANY HEALTH CARE PROVIDER MAY RECEIVE, USE AND DISCLOSE MY MEDICAL INFORMATION FOR TREATMENT, PAYMENT, HEALTH CARE OPERATIONS, AND ANY AND ALL OTHER USES ALLOWED BY LAW. I HAVE READ AND UNDERSTAND THE TERMS OF ENROLLMENT ON THE BACK OF THIS FORM. I CERTIFY THAT ALL INFORMATION ON THIS FORM IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
EMPLOYEE SIGNATURE DATE
IF YOU’VE EVER BEEN AN HNE MEMBER, PLEASE LIST FORMER NAME (if applicable)
AND FORMER IDENTIFICATION NUMBER ___________________________________________________________________________ WILL YOU OR ANY MEMBER OF YOUR FAMILY BE COVERED THROUGH ANOTHER HEALTH INSURANCE? YES NO SUBSCRIBER’S NAME _______________________________________ DATE OF BIRTH _____________________________________ POLICY #NAME OF INSURANCE CO. __________________________ EFFECTIVE DATE ____________________________________ NAMES OF COVERED INDIVIDUALS ________________________________________________________________________________ IS EMPLOYEE RETIRED? YES (provide copy of Medicare card) NO
ARE YOU OR ANY OF YOUR DEPENDENTS COVERED BY MEDICARE? YES NO IF YES, PART A PART B BOTH a cOpy Of yOur meDicare carD(S) muSt be attacheD
ETHNICITY (Use codes from back of form.) RACE (Use codes from back of form)
1st 2nd Other
(Use codes from back of form)
-RACE & ETHNICITY
Why are these questions being asked?
The Commonwealth of MA has established statewide goals for improving health care quality and reducing racial and ethnic disparities in health care. HNE wants to do our part to remove any barriers to fair and unbiased treatment for all of our members. By collecting information about your race and ethnic background, we may be able to identify possible issues that affect the care or treatment you receive. HNE will then be able to work with our provider community to address any issues. We appreciate your assistance in this effort.
this information is designed for the purpose of data collection and will not be used for determining eligibility, rating or claim payment.
Code Description
2182-4 Cuban
2184-0 Dominican
2148-5 Mexican, Mexican American, Chicano 2180-8 Puerto Rican
2161-8 Salvadoran
2155-0 Central American (not otherwise specified)
2165-9 South American (not otherwise specified)
2060-2 African 2058-6 African American AMERCN American 2028-9 Asian 2029-7 Asian Indian BRAZIL Brazilian 2033-9 Cambodian
CVERDN Cape Verdean CARIBI Caribbean Island
Code Description 2034-7 Chinese 2169-1 Columbian 2108-9 European 2036-2 Filipino 2157-6 Guatemalan 2071-9 Haitian 2158-4 Honduran 2039-6 Japanese 2040-4 Korean 2041-2 Laotian 2118-8 Middle Eastern PORTUG Portuguese RUSSIA Russian
EASTEU Eastern European 2047-9 Vietnamese OTHER Other Ethnicity UNKNOWN Unknown/not specified
IMPORTANT: PLEASE READ THESE TERMS OF ENROLLMENT
As an employee I understand that:
1. By submitting this form or accepting coverage under the plan, I agree, on behalf of myself and all enrolled dependents, to abide by the terms of the Health New England (HNE) Agreement, which includes this form as well as the applicable Explanation of Coverage or Summary Plan Description.
2. Membership will become effective upon acceptance by the Plan and that benefits under the Plan will be explained in a separate
document (Explanation of Coverage or Summary Plan Description).
3. I may only enroll dependents subject to the guidelines outlined in my HNE Agreement.
4. Whenever I seek treatment or services, I must identify myself as a HNE member by presenting my HNE Identification Card.
5. I must select a Primary Care Physician for myself and my dependents (does not apply to PPO).
6. If appropriate, I authorize my employer to deduct from my wages the rate required for the coverage selected.
As an employer I understand that:
1. By submitting this form, I certify that the information provided on this form is accurate.
RACE Please choose from the following:
Fill in the code where indicated on the front of this form.
Code Description
R1 American Indian/Alaska Native
R2 Asian
R3 Black/African American
R4 Native Hawaiian or other Pacific Islander
R5 White
R9 Other Race
UNKNOWN Unknown/not specified
ETHNIC GROUP Please choose from the following: (you may choose more than one.)
