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Interim Healthcare TransAmerica MEC & TransChoice Plans (Constant Contact)

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Interim Healthcare
TransAmerica MEC & TransChoice Plans
Effective May 1, 2021
MEC Plan
TransChoice 1
MEC and
TransChoice
BENEFITS
Monthly Premium
Monthly Premium
Monthly Premium
EMPLOYEE
$72.83 $41.73 $114.56
EMPLOYEE + SPOUSE
$106.90 $82.52 $189.42
EMPLOYEE + CHILD(REN)
$157.67 $61.96 $219.63
FAMILY
$191.75 $95.69 $287.44
MEC & TransChoice
MEC TransChoice Plan 1
In-Network In-Network
$0/$0
$0/$0
100%
100%
$0/$0
$0/$0
Multiplan Network
Multiplan Limited Network
Covers 100% of the government's 73
listed Preventive and Wellness Benefits
Covers 100% of the government's 73 listed
Preventive and Wellness Benefits
Unlimited Calls
Unlimited Calls
Unlimited Access
Unlimited Access
Fully Insured Indemnity Benefits
Daily In-Hospital Indemnity
Benefit
N/A
$100 daily benefit, up to 31 days per
confinement
Inpatient Surgery Daily Indemnity
Benefit
N/A
N/A
$500 per day, 1 day maximum per benefit
period
Outpatient Surgery Daily
Indemnity Benefit
$250 per day, 1 day maximum per benefit
period
Minor Outpatient Surgical
Indemnity Benefit
N/A
$50 per day, 1 day maximum per benefit
period
Anesthesia: 20% of surgical
amount
N/A
Included
Outpatient Physician Office Visit
Daily Indemnity Benefit
N/A
$50 per day, 6 day maximum per benefit
period
Outpatient Diagnostic Lab Benefit
N/A
$10 per day with a 3 day maximum per
benefit period
Outpatient Select Diagnostic
Benefit
N/A
$50 per day with a 2 day maximum per
benefit period
Outpatient Advanced Studies
Benefit
N/A
$200 per day up to 2 days maximum per
benefit period
Daily Prescription Drug Benefit
N/A
N/A
Initial Hospital Admission Daily
Indemnity Benefit
N/A
N/A
N/A
N/A
Emergency Room Visit Daily
Indemnity Benefit *covers illness
Ambulance Service Daily
Indemnity Benefit
N/A
N/A
N/A
$200 per day, up to 5 days per year
Off-the-job Accident Indemnity
Benefit
Inpatient Mental & Nervous
Indemnity Benefit
N/A
N/A
Inpatient Drug & Alcohol
Indemnity Benefit
N/A
N/A
Critical Illness Benefit
N/A
N/A
Employee Group Term Life
N/A
$5,000 per Employee
Karis Patient Advocacy
N/A
Included
Continuation
N/A
Included
Covered Preventive Services for Adults (ages 18 and older)
Covered Preventive Services for Women, Including Pregnant Women
1.
Alcohol and Drug Use assessments
2.
Autism screening for children limited to two screenings
up to 24 months
3.
Behavioral assessments for children limited to 5 assessments
up to age 17
4.
Blood Pressure screening
5.
Cervical Dysplasia screening
6.
Congenital Hypothyroidism screening fornewborns
7.
Depression screening for adolescents age 12 andolder
8.
Developmental screening for children under age 3, and
surveillance throughout childhood
9.
Dyslipidemia screening for children
10.
Fluoride Chemo Prevention supplements for childrenwithout
fluoride in their water source when prescribed by a physician
11.
Gonorrhea preventive medication for the eyes of all newborns
12.
Hearing screening for all newborns
13.
Height, Weight and Body Mass Index measurementsfor
children
14.
Hematocrit or Hemoglobin screening for children
15.
Hemoglobinopathies or sickle cell screening fornewborns
16.
HIV screening for adolescents
17.
Immunization vaccines for children from birth to age 18; doses,
recommended ages, and recommended populations vary: Diphtheria,
Tetanus, Pertussis, Hepatitis A & B, Human Papillomavirus, Inactivated
Poliovirus, Influenza (Flu Shot), Measles, Mumps, Rubella,
Meningococcal, Pneumococcal, Rotavirus, Varicella, Haemophilus
influenzae type b
18.
Iron supplements for children up to 12 months when prescribed
by a physician
19.
Lead screening for children
20.
Medical History for all children throughout development ages: 0
to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
21.
Obesity screening and counseling
22.
Oral Health risk assessment for young children up to age 10
23.
Phenylketonuria (PKU) screening innewborns
24.
Sexually Transmitted Infection (STI) prevention counseling and
screening for adolescents
25.
Tuberculin testing for children
26.
Vision screening for all children underthe age of 5
27.
Skin Cancer Behavioral Counseling – age 10-24 for exposure tosun
28.
Tobacco intervention and counseling forchildren
29.
Fluoride varnish for primary teeth through age 5.
MEC Benefit Summary
This list below summarizes some but not all services. Please reference the US Preventive Services Task Force website for the entire
list.
Covered Services for Children
1.
Anemia screening on a routine basis for pregnantwomen
2.
Bacteriuria urinary tract or other infection screening for
pregnant women
3.
BRCA counseling and genetic testing for women at higherrisk
4.
Breast Cancer Mammography screenings every year for
women age 40 and over
5.
Breast Cancer Chemo Prevention counseling forwomen
6.
Breastfeeding comprehensive support and counseling from
trained providers, as well as access to breastfeeding supplies, for
pregnant and nursingwomen.
7.
Cervical Cancer screening
8.
Chlamydia Infection screening
9.
Contraception: Food and Drug Administration-approved
contraceptive methods, sterilization procedures, and patient
education and counseling, not including abortifacient drugs
10.
Domestic and interpersonal violence screening and
counseling for allwomen
Revised 6-12-15
Enrollment Form
1. Enrollee Information
Group Name:
Plan Coverage Effective Date:
Last Name:
Date you became a Full time Employee:
First Name:
Date of Birth (DOB):
Sex: M F
SS #:
No. Hours Work/per week:
Home Phone #:
Work Phone #:
Street Address:
City:
State:
Zip:
Plan Selection (per your enrollment guide):
MEC Plan
MEC + Plan 1 MEC + Plan 2
Plan 1 ____ Plan 2 ____
Voluntary Life
Beneficiary of Life Insurance (If applicable):
Full Name:
Address:
City, State Zip:
Phone #:
Date of Birth:
Relationship:
2. Dependent Information
1
For disabled dependents; SUBMIT appropriate documentation as proof of disabled status with this enrollment form.
2
If a court decree requires you to cover your dependent under this plan, SUBMIT that portion of the court decree with this enrollment form.
I hereby apply for benefit plan participation for myself and/or my dependents listed above and agree to abide by the terms, provisions and limitations as outlined by the Plan
Sponsor in the issuance of the Summary Plan Description. I declare all statements contained in this entire form are true and correct and that no material information has been
withheld or omitted. I agree that no benefits will be effective until the date specified by Key Benefit Administrators. I agree a photographic copy of this authorization shall be as
valid as the original and that said authorization shall be valid for the maximum length of time permitted by law. I understand that I have the right to receive a copy of this
authorization upon request. I authorize my employer to deduct from earnings the contributions (if any) required toward the benefits.
I am waiving/declining plan coverage because I have other coverage
Individual coverage Medicare coverage Spousal coverage
Carrier Name
Carrier Phone Number
Policy #
Member ID
Employee (print name): ____________________________ Employee Signature: Date:_____________
I would like to be covered under this plan along with the following dependents:
Spouse
Domestic Partner
Last Name:
First:
SS#:
DOB:
Male Female
Last Name:
First:
SS#:
DOB:
Male Female
Child Disabled
1
Court Ordered
2
Last Name:
First:
SS#:
DOB:
Male Female
Child Disabled
1
Court Ordered
2
Last Name:
First:
SS#:
DOB:
Male Female
Child Disabled
1
Court Ordered
2
Last Name:
First:
SS#:
DOB:
Male Female
Child Disabled
1
Court Ordered
2
Last Name:
First:
SS#:
DOB:
Male Female
Child Disabled
1
Court Ordered
2
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Interim Healthcare TransAmerica MEC & TransChoice Plans (Constant Contact)

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Completed 10 April 2021

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