2017 NH Guide Employbridge PDF

2017
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.
2017 COVERAGE CHOICES

MED ADVANTAGE - MINIMUM ESSENTIAL COVERAGE (MEC) PLAN
N
Covers all preventive services required by the Affordable Care Act (ACA)
Pays 100% for covered services at First Health network providers
Satisfies the ACAs Individual Mandate so you may not incur a tax penalty w
while
hile enrolled
enroll
en
llled
d
For 2017 the Individual Mandate penalty is 2.5% of household income,, or
$695 per adult and $347.50 per child, whichever is greater.
Visit www.healthcare.gov for more information.
Avoid the tax penalty with Associate Only coverage for less than $360 per year
yeear
MED BASIC - FIXED INDEMNITY PLANS
Coverage for basic healthcare services due to an illness or accident
Pay a specific amount per day for covered services with no deductibles or copays
opays
Covered services include doctor visits, labs, x-rays, hospital stays and more
Access to the First Health network and discounted prescription drugs
ADDITIONAL COVERAGE OPTIONS
Dental: Pays up to $500 per year with a $20 copay per visit
Vision: Coverage for eye exams and corrective eyewear
Short-term Disability: Pays $200 per week for up to 26 weeks
Life and AD&D Insurance: $20,000 of Life and AD&D coverage for associates
iaates
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
MED BASIC - FIXED INDEMNITY PLANS*

The American Worker Med Basic Plans provide first dollar coverage. The Plans offer coverage for basic healthcare services and
prescription drug discounts. The Med Basic Plans also pay in addition to other coverage you may have, which can help pay for
out-of-pocket expenses such as deductibles and coinsurance when receiving medical treatment.
The Med Basic Plans are underwritten by Nationwide Life Insurance Company. The Plans include the AWP Value Rx, First Health
Network and New Benefits Discount programs, which are provided by separate vendors.
PLAN 1
PLAN 2
Plan Pays $60 per Day,

6 Days per Person per Year

OUTPATIENT DIAGNOSTIC LAB
Plan Pays $50 per Testing Day,


OUTPATIENT DIAGNOSTIC X-RAY


OUTPATIENT DIAGNOSTIC
ADVANCED STUDIES




1 Day per Person per Year

Plan Pays $300 Maximum per Occurrence
Plan Pays $500 Maximum per Occurrence
Plan Pays $1,000

Plan Pays $500
Plan Pays $100
Plan Pays $1,500

Plan Pays $750
Plan Pays $150
Plan Pays 30% of Surgical Benefit
Plan Pays 30% of Surgical Benefit

500 Day Lifetime Maximum

500 Day Lifetime Maximum
Plan Pays $500 per Confinement
Plan Pays $500 per Confinement
INTENSIVE CARE UNIT


SUBSTANCE ABUSE


MENTAL ILLNESS


SKILLED NURSING

60 Days per Person per Stay

60 Days per Person per Stay
AWP VALUE RX
Included
Included
FIRST HEALTH NETWORK
Included
Included
NEW BENEFITS DISCOUNT PROGRAM
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.
MED BASIC PLANS - ADDITIONAL FEATURES

AWP Value Rx* - Provided by Phoenix Benefits Management
The AWP Value Rx program is designed to provide substantial savings on your prescription drug expenses. This Plan will help you
identify affordable generic and brand name drugs by therapeutic class.
Tier 1: Select generic and brand name drugs available for $10 or less
Tier 4: Generic and brand name drugs for which a discounted price has been negotiated
Over 56,000 participating pharmacies nationwide
No maximum annual benefit, deductibles or claim forms
To view drug prices or locate a pharmacy, visit www.AWPValueRx.com
*The AWP Value Rx benefit is a non-insurance discount prescription drug program
First Health Network

Members have access to the First Health Network, which provides savings on Physician and Hospital services.
By visiting a First Health provider you can reduce your out-of-pocket expenses.
Over 490,000 provider locations across the country
Network providers submit claims for you to simplify the claim process
To locate a provider online, visit www.FirstHealthLBP.com
You can visit a First Health or out-of-network provider for service and the Med Basic Plans will pay the same benefit amount.
New Benefits Health Services Discount Program*

Not available to WA residents.
This package of health service and discount programs can help reduce
out-of-pocket expenses and provide savings on a variety of services that
promote healthy living.
Teladoc1: 24/7 access to a network of U.S. board-certified doctors

that will diagnose, treat and prescribe medication, when necessary,
over the phone for medical issues including cold or flu symptoms,
allergies, bronchitis, ear infections and more.
Medical Bill SaverTM: can help lower out-of-pocket costs on medical

or dental bills over $400 through provider negotiation.
Medical Health Advisor2: access to Personal Health Advocates

that can assist in resolving insurance claim and billing issues.
NurselineTM and Personal Counseling Services
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.
*Discount benefits administered by New Benefits, Ltd.
In addition, members will receive

discounts on the following services or
supplies at participating providers.
Lab and Imaging3

Vision
Diabetic Supplies
Vitamins
Chiropractic
Hearing
Durable Medical
Equipment
MED ADVANTAGE - MINIMUM ESSENTIAL COVERAGE*

The Affordable Care Act (ACA) requires all individuals have coverage that meets certain criteria, which is known as the Individual
Mandate. The Med Advantage Plan provides coverage that meets the ACAs requirements, so you and your covered dependents may
not have to pay the Individual Mandate penalty while enrolled in the Plan.
For 2017 the Individual Mandate penalty is 2.5% of household income, or $695 per adult and $347.50 per child, whichever is
greater. Visit www.healthcare.gov for more information.
The Med Advantage Plan provides 100% in-network coverage for all ACA required preventive care services. The Plan is not
comprehensive health insurance. It only covers preventive services and does not provide any coverage for illness or accidents.
COVERS ALL ACA REQUIRED

PREVENTIVE CARE SERVICES
IN-NETWORK
OUT-OF-NETWORK
Plan Pays 100%
No Coverage
The Summary of Benefits and Coverage (SBC) is available online at www.TheAmericanWorker.com.

If you are unable to access the SBC online or want a copy mailed to your home call (877) 220-1862.
Weekly Rates
Associate
Associate + Spouse
Family
$6.84
$10.69
$11.46
$14.20
FIRST HEALTH NETWORK

Members must use a First Health provider for services to be covered.
First Health has over 490,000 provider locations nationwide. To locate a provider visit www.FirstHealthLBP.com.
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
WOMEN INCLUDING PREGNANT WOMEN OR WOMEN WHO MAY BECOME PREGNANT
Anemia screening on a routine basis

Breast Cancer Genetic Test counseling (BRCA) for women at higher risk
Breast Cancer Mammography screenings every 1-2 years for women over 40
Breast Cancer Chemoprevention counseling for women at higher risk
Breastfeeding comprehensive support & counseling from trained providers, &
access to breastfeeding supplies for pregnant & nursing women
Cervical Cancer screening for sexually active women
Chlamydia Infection screening for younger women & other women at higher
risk
Contraception: Food & Drug Administration-approved contraceptive methods,
sterilization procedures, & patient education & counseling, as prescribed by
a health care provider for women with reproductive capacity (not including
abortifacient drugs)
Domestic & Interpersonal Violence screening & counseling for all women
Folic Acid supplements for women who may become pregnant
Gonorrhea screening for all women at higher risk
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
Alcohol & Drug use assessments for adolescents

Autism screening for children at 18 & 24 months
Behavioral assessments for children ages: 0-11 months, 1-4 years, 5-10 years,
11-14 years, 15-17 years
Blood Pressure screening for children 0-11 months, 1-4 years, 5-10 years, 11-14
years, 15-17 years
Cervical Dysplasia screening for sexually active females
Depression screening for adolescents
Developmental screening for children under age 3
Dyslipidemia screening for children at higher risk of lipid disorders ages: 1-4
years, 5-10 years, 11-14 years, 15-17 years
Fluoride Chemoprevention supplements for children without fluoride in their
water source
Gonorrhea preventive medication for the eyes of all newborns
Hearing screening for all newborns
Height, Weight & Body Mass Index measurements for children ages: 0-11
months, 1-4 years, 5-10 years, 11-14 years, 15-17 years
Hematocrit or Hemoglobin screening for all children
Hemoglobinopathies or Sickle Cell screening for newborns
Hepatitis B screening for adolescents at high risk
HIV screening for adolescents at higher risk

Hypothyroidism screening for newborns
Immunization vaccines for children from birth to age 18 (doses, recommended
ages, & recommended populations vary): Diphtheria, Tetanus, Pertussis,
Haemophilus Influenzae Type B, Hepatitis A, Hepatitis B, Human
Papillomavirus (PVU), Inactivated Poliovirus, Influenza (Flu Shot), Measles,
Meningococcal, Pneumococcal, Rotavirus, Varicella (Chickenpox)
Iron supplements for children ages 6-12 months at risk for anemia
Lead screening for children at risk of exposure
Medical History for all children throughout development ages: 0-11 months, 1-4
years, 5-10 years, 11-14 years, 15-17 years
Obesity screening & counseling
Oral Health risk assessment for young children ages: 0-11 months, 1-4 years,
5-10 years
Phenylketonuria (PKU) screening for newborns
Sexually Transmitted Infection (STI) prevention counseling & screening for
adolescents at higher risk
Tuberculin testing for children at higher risk of tuberculosis ages: 0-11 months,
1-4 years, 5-10 years, 11-14 years, 15-17 years
Vision screening for all children
DENTAL (Provided by Ameritas Life Insurance Corporation)

Keep a bright, healthy smile while supporting your overall well-being with affordable dental coverage. You can use any provider
for service, but have access to a dental network to lower out-of-pocket costs.
CALENDAR YEAR MAXIMUM
Plan Pays up to $500 per Covered Member
DEDUCTIBLE
$20 per Visit
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)
PREVENTIVE AND DIAGNOSTIC

Routine Exams, Cleanings, X-rays, etc.
Weekly Rates
Associate
Associate + Spouse
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.
VISION (Provided by Ameritas Life Insurance Corporation)

A regular eye exam wont just help you see better, it can also detect the first signs of serious health conditions. With this Plan youll
get coverage for exams as well as corrective eyewear. Get the most benefit from the Plan by visiting a VSP Choice provider.
DEDUCTIBLES
$10 Exam, $25 Eye Glass Lenses or Frames1
COVERED SERVICES
VSP CHOICE NETWORK
OUT-OF-NETWORK
ANNUAL EYE EXAM
Covered in Full
Up to $45
LENSES (per pair)

Single Vision / Bifocal
Trifocal / Lenticular
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
Based on Date of Service

12 Months / 12 Months / 24 Months
Weekly Rates
Associate
Associate + Spouse
Family
$2.07
$4.10
$3.82
$5.84
Deductible applies to a complete pair of glasses

or frames, whichever is selected.
2
The Costco allowance will be the wholesale
equivalent.
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.
SHORT-TERM DISABILITY* (Provided by Nationwide Life Insurance Company)

Your family and daily life can depend on consistent income. If you get sick or injured and cant work, this benefit will pay you cash.
Enroll in this benefit to protect your income when you are unable to work.
WEEKLY MAXIMUM
Plan Pays $200 Lump Sum
MAXIMUM BENEFIT PERIOD

WAITING PERIOD
26 Weeks
7 Days (Accidents and Sickness)
Coverage includes disability due to pregnancy and childbirth
Weekly Rates
Associate
$3.87
Note: CA, NJ, NY & RI residents may be entitled

to additional disability benefits through your state.
LIFE AND AD&D INSURANCE* (Underwritten by Nationwide Life Insurance Company)

Life insurance can help your loved ones during a trying time. This benefit provides cash that can assist your family in the event of
your death. Enroll in this benefit to protect the future of the ones that depend on you the most.
LIFE AND AD&D INSURANCE
Associate
Plan Pays $20,000
LIFE INSURANCE
Spouse
Child (6 months - 26 years)
Infant (10 days - 6 months)
Plan Pays $2,500

Plan Pays $1,250
Plan Pays $200
Weekly Rates
Associate
Associate + Spouse
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
Enroll By Mobile Device:
Click Continue to enroll in coverage.

Note: You must create an account before enrolling.
Text Staff2017 to 24587

Available anytime
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.
PAYING FOR YOUR BENEFITS

Your coverage will continue uninterrupted as long as premiums are deducted from your paycheck. If you receive a paycheck without
a premium deduction, your benefits will be suspended. Coverage will remain suspended until the Monday following the date you
receive your next paycheck with a premium deduction, unless you make a premium payment for the missed deduction. To avoid
having coverage suspended you must make a missed premium payment every time a deduction is not processed from your paycheck.
MISSED PREMIUM PAYMENTS

You have 30 days from the date of your paycheck without a deduction to make a missed premium payment. If you do not pay for the
missed premium deduction within 30 days, you will not be able to pay for that coverage period at a later date.
You can pay for missed premium deductions online, over the phone or by mail. Payment options include electronic check, credit
or debit card, check and money order. You can authorize an automatic payment be processed every time premium is not deducted
from your paycheck. If you setup automatic payments, you are responsible for contacting The American Worker to cancel the
automatic payment once your employment has been terminated. If you do not, your account will be charged for coverage and
you will not receive a refund.
If you missed a premium deduction and want to find out the balance due, make a payment or authorize automatic payments, visit
www.TheAmericanWorker.com or call (877) 220-1862.
NONPAYMENT COVERAGE TERMINATION

If you do not have payroll deductions or make missed premium payments for 6 consecutive weeks, your coverage will be terminated
for nonpayment. To avoid a nonpayment termination it is recommended that you make a missed premium payment every time a
deduction is not processed from your paycheck.
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.
MED ADVANTAGE MINIMUM ESSENTIAL COVERAGE (MEC)

This Plan is designed to provide Plan Participants with minimum essential coverage under the federal income tax rules. This Plan is
designed so that Plan Participants may enroll in this Plan and may not have to pay a federal individual income tax penalty. However, while you are enrolled in this Plan, you may not be eligible for a federal tax credit though a federal or state exchange (sometimes
referred to as the insurance marketplace). If you do not enroll in this Plan, you may be eligible for a federal tax credit that lowers your
monthly premium or a reduction in certain cost-sharing if you enroll in a health insurance plan through the federal or state exchange.
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.
NEW BENEFITS PROGRAMS (Discount benefits administered by New Benefits, Ltd.)

The Discount Health Savings Program is NOT insurance. The Plan is not insurance coverage and does not
meet the minimum creditable coverage requirements under the Affordable Care Act or Massachusetts M.G.L.
c. 111M and 956 CMR 5.00. It contains a 30 day cancellation period, provides discounts only at the offices
of contracted health care providers, and each member is obligated to pay the discounted medical charges in
full at the point of service. The range of discounts for medical or ancillary services provided under the Plan
will vary depending on the type of provider and medical or ancillary service received. Members shall receive
a reimbursement of all periodic membership fees if membership is canceled within the first 30 days after the
effective date. AR and TN residents: A refund of all fees will be issued if membership is canceled within the
first 30 days. Discount Medical Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box
671309, Dallas, TX 75367-1309, 800-800-7616. Website to obtain participating providers: MyMemberPortal.com.
Teladoc is not available to Arkansas and Idaho residents. 2016 Teladoc, Inc. All rights reserved.
Teladoc and the Teladoc logo are registered trademarks of Teladoc, Inc. and may not be used without
written permission. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a
prescription will be written. Teladoc operates subject to state regulation and may not be available in certain
states. Consults are not available outside of the U.S. Teladoc does not prescribe DEA controlled substances,
non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse.
Teladoc physicians reserve the right to deny care for potential misuse of services. Teladoc phone consultations
are available 24 hours, 7 days a week while video consultations are available during the hours of 7am to 9pm, 7
days a week.
EmployBridge Holding Company MEC Plan

Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/02/2017-12/31/2017

Coverage for: Individual & Family | Plan Type: PPO
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
Why this Matters:
What is the overall

deductible?
$0
See the chart starting on page 2 for your costs for services this plan covers.
Are there other

deductibles for specific
services?
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.
What is not included in

the outofpocket
limit?
This plan has no out-of-pocket

limit.
Not applicable because theres no out-of-pocket limit on your expenses.
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?
For a list of participating

providers, see
www.firsthealthlbp.com or call
1-800-226-5116.
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.
Are there services this

plan doesnt cover?
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.
Questions: Call 1-855-495-1190 or visit us at www.fbg.com.

If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthcarereform or call 1-855-495-1190 to request a copy.
1 of 8

Coverage Period: 01/02/2017-12/31/2017

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
Services You May Need

Primary care visit to treat an injury or illness
Specialist visit
Other practitioner office visit
Preventive care/screening/immunization
Diagnostic test (x-ray, blood work)
Imaging (CT/PET scans, MRIs)
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

Limitations & Exceptions

---None-----None-----None--Certain age restrictions may apply.
---None-----None---
2 of 8

Common
Medical Event
If you need drugs to

treat your illness or
condition
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
Coverage Period: 01/02/2017-12/31/2017

Your Cost If
You Use an
Out-of-network
Provider
Generic drugs
Not Covered
Not Covered
Preferred brand drugs
Not Covered
Not Covered
Non-preferred brand drugs
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


FDA approved contraceptive methods
as prescribed by a health care provider
for women with reproductive capacity
(not including abortifacient drugs).
---None-----None-----None-----None-----None-----None-----None-----None-----None-----None-----None-----None-----None-----None---
3 of 8

Common
Medical Event
If you need help

recovering or have
other special health
needs
If your child needs

dental or eye care

Home health care
Rehabilitation services
Habilitation services
Skilled nursing care
Durable medical equipment
Hospice service
Eye exam
Glasses
Dental check-up
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
Coverage Period: 01/02/2017-12/31/2017

Your Cost If
You Use an
Out-of-network
Provider
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered


---None-----None-----None-----None-----None-----None-----None-----None-----None---
4 of 8

Coverage Period: 01/02/2017-12/31/2017

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isnt a complete list. Check your policy or plan document for other excluded services.)
Acupuncture
Bariatric surgery
Care when traveling outside the U.S.
Chiropractic care
Cosmetic surgery
Dental care (Adult)
Diagnostic testing (e.g. X-ray imaging, Labs)
Durable Medical Equipment
Emergency Room services
Emergency medical transportation
Habilitation services
Hearing aids
Home Health Care
Hospice Care
Hospital Room & Board
Imaging (CT/PET scans, MRIs)
Infertility Treatment
Inpatient or Outpatient Care
Long-term Care
Natural / Cesarean Child birth
Non-preventive prenatal and postnatal care
Office visit to treat an injury or illness
Prescription Drugs (except preventive)
Private-duty Nursing
Rehabilitation services
Routine eye care (adult)
Routine foot care
Skilled Nursing Facility
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.

5 of 8

Coverage Period: 01/02/2017-12/31/2017

Your Rights to Continue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay
while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-855-495-1190. You may also contact your state insurance department, the
U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and
Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact the plan at 1-855-495-1190 or the Department of Labors Employee Benefits
Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does
provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?

The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage does not meet the minimum value standard for the benefits it provides.
Language Access Services:

Spanish/Espaol: Para obtener asistencia en Espaol, llame al the plan at 1-855-495-1190.
To see examples of how this plan might cover costs for a sample medical situation, see the next page.
6 of 8

Coverage Examples
About these Coverage

Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
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.
Coverage Period: 01/02/2017-12/31/2017

Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
Amount owed to providers: $7,540

Plan pays: $ 40
Patient pays: $ 7,500
Amount owed to providers: $5,400

Plan pays: $100
Patient pays: $ 5,300
Sample care costs:

Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Sample care costs:

Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$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

7 of 8

Coverage Examples
Coverage Period: 01/02/2017-12/31/2017

Questions and answers about the Coverage Examples:

What are some of the
assumptions behind the
Coverage Examples?
Costs dont include premiums.

Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and arent specific to a
particular geographic area or health plan.
The patients condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example

show?
Can I use Coverage Examples

to compare plans?
For each treatment situation, the Coverage

Example helps you see how deductibles,
copayments, and coinsurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isnt covered or payment is limited.
Yes. When you look at the Summary of
Does the Coverage Example

predict my own care needs?
No. Treatments shown are just examples.

The care you would receive for this
condition could be different based on your
doctors advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example

predict my future expenses?
No. Coverage Examples are not cost

estimators. You cant use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Benefits and Coverage for other plans,

youll find the same Coverage Examples.
When you compare plans, check the
Patient Pays box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should

consider when comparing
plans?
Yes. An important cost is the premium

you pay. Generally, the lower your
premium, the more youll pay in out-ofpocket costs, such as copayments,
deductibles, and coinsurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.

8 of 8

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2017

2017 COVERAGE CHOICES

MED BASIC - FIXED INDEMNITY PLANS*

Plan Pays $60 per Day,

Plan Pays $100 per Day,

OUTPATIENT DIAGNOSTIC LAB

Plan Pays $50 per Testing Day,

Plan Pays $75 per Testing Day,

OUTPATIENT DIAGNOSTIC X-RAY

Plan Pays $100 per Testing Day,

Plan Pays $200 per Testing Day,

Plan Pays $100 per Testing Day,

Plan Pays $300 per Testing Day,

Plan Pays $50 per Day,

Plan Pays $100 per Day,

Plan Pays $150 per Day,

Plan Pays $300 Maximum per Occurrence

Plan Pays $500 Maximum per Occurrence

Plan Pays $1,000

Plan Pays $1,500

Plan Pays 30% of Surgical Benefit

Plan Pays 30% of Surgical Benefit

Plan Pays $100 per Day,

Plan Pays $300 per Day,

Plan Pays $500 per Confinement

Plan Pays $500 per Confinement

INTENSIVE CARE UNIT

Plan Pays $200 per Day,

Plan Pays $600 per Day,

Plan Pays $50 per Day,

Plan Pays $150 per Day,

Plan Pays $50 per Day,

Plan Pays $150 per Day,

Plan Pays $50 per Day,

Plan Pays $150 per Day,

FIRST HEALTH NETWORK

NEW BENEFITS DISCOUNT PROGRAM

MED BASIC PLANS - ADDITIONAL FEATURES

Over 56,000 participating pharmacies nationwide

No maximum annual benefit, deductibles or claim forms

To view drug prices or locate a pharmacy, visit www.AWPValueRx.com

*The AWP Value Rx benefit is a non-insurance discount prescription drug program

First Health Network

Over 490,000 provider locations across the country

To locate a provider online, visit www.FirstHealthLBP.com

New Benefits Health Services Discount Program*

Teladoc1: 24/7 access to a network of U.S. board-certified doctors

Medical Bill SaverTM: can help lower out-of-pocket costs on medical

Medical Health Advisor2: access to Personal Health Advocates

NurselineTM and Personal Counseling Services

*Discount benefits administered by New Benefits, Ltd.

In addition, members will receive

Lab and Imaging3

MED ADVANTAGE - MINIMUM ESSENTIAL COVERAGE*

COVERS ALL ACA REQUIRED

Plan Pays 100%

The Summary of Benefits and Coverage (SBC) is available online at www.TheAmericanWorker.com.

FIRST HEALTH NETWORK

WOMEN INCLUDING PREGNANT WOMEN OR WOMEN WHO MAY BECOME PREGNANT

Anemia screening on a routine basis

Alcohol & Drug use assessments for adolescents

HIV screening for adolescents at higher risk

DENTAL (Provided by Ameritas Life Insurance Corporation)