WELCOME TO OPEN ENROLLMENT

 

The open enrollment period for all FULL TIME EMPLOYEES to our health care plan is now available from 11/01/2018-11/31/2018. This is the opportunity to enroll if you are not currently enrolled or the opportunity to make needed changes to your information without a qualifying event. Full time employees define as employees working 30 or more hours per week. (or 130 hours a month). A full time employee will qualify for insurance after working for a consecutive 12 weeks with full time hours.

MINIMUM ESSENTIAL COVERAGE (MEC)

According to the Affordable Care Act (ACA), more commonly referred to as Obamacare, all individuals must have at least Minimum Essential Coverage (MEC) or are required to pay a penalty. As of January 1, 2017, the penalty for not have MEC coverage is $695.00. MEC covers 17 preventative services for adults, 22 additional services for women and 26 services for children.
 

THE FOLLOWING HEALTH INSURANCE PLANS ARE CURRENTLY AVAILABLE

 

MEC Basic: This plan covers ONLY preventative services as outlined in the Affordable Care Act (ACA). Please note, MEC does NOT cover any additional medical services. MEC includes telemedicine through 1800MD and prescription discounts are available through Rx Valet.

MEC Plus: Covers all preventative services outlined in MEC and provides additional medical services such as Primary Care, Specialist and Urgent Care visits; Labs, X-Rays and Generic Rx offered at various copays. Note: MEC Plus does not cover hospitalization, surgical procedures, emergency or out-of-network services. MEC Plus includes telemedicine through 1800MD.

 
ACKNOWLEDGEMENT OF RECEIPT

 
I,         , hereby acknowledge receipt of the 2018-2019 offer of health benefits. I have been provided with the Enrollment Guide and with the information pertaining to the benefit plan offering. I have been offered a plan for myself and my qualified dependents that provides Minimum Essential Coverage (MEC).
 
Please choose 1:

          I CHOOSE to DECLINE coverage at this time. I acknowledge that I and/or my dependent(S) may have to wait until the plan's next open enrollment period, or have a qualifying event, to request group coverage and that i may not qualify for a subidy on the PPACA Health Exchange. I also Acknowledge that i could be subject ot a penalty under the Individual Mandate.

                I CHOOSE to ACCEPT coverage at this time. I authorize my employer to make salary reductions on a pretax basis for my portion of the group insurance premiums. I understand that:
 
• I cannot change this election during the plan year unless I have a change in status as provided in the Internal Revenue Code and Regulations.
• My Social Security benefits may be reduced by this election.
• This election replaces any previous elections and will terminate on the earlier of (1) when I am no longer being paid compensation in an amount at least equal to my total salary reduction or (2) termination of the plan.
• My employer may reduce or cancel this election if necessary to comply with provisions of the Internal Revenue Code.
 
  
Print name: 

Social Security Number: 
 

  
 
PLEASE COMPLETE THE NEXT SECTION ONLY IF YOU CHOOSE TO ACCEPT COVERAGE
 
                                                                                                                                          





ENROLLMENT APPLICATION
 


EMPLOYEE INFORMATION

  Name:                    Social Security:   

Employer Name:                   Hire Date:            

DOB:        
       Sex: 

Address:                    Phone Number:    
 
City:      State:    Zip:                           Email:                 
 

DEPENDENT INFORMATION


    Name:                     

   Social Security                    

   DOB:       
      Sex: 
 
   Relationship:  

 Name:                    

Social Security                    

DOB:     
          Sex: 
 
Relationship:  

 Name:                    

Social Security                    

DOB:   
            Sex: 
 
Relationship:  

 Name:                    

Social Security                    

DOB:   
            Sex: 
 
Relationship:  

MEDICAL

MEC BASIC

 
 

MEC PLUS


Employee + Family

EMPLOYEE DECLARATION

I declare the information provided above is complete and accurate. I understand an agent or broker cannot guarantee coverage, revise rates, benefits or provisions without written approval from SBMA. Please review pricing and benefit summaries prior to finalizing your selections.