Health Insurance Enrollment Form
Health Insurance Products Compliant with the Affordable Care Act
Complete the Enrollment Form to Elect Coverages
• You MUST Complete the Enrollment Form as part of the New Hire Process
• You MUST Elect or Decline Medical Coverage on the Enrollment Form
• You MUST Sign the Bottom of the Form, even if you Decline Coverage
• Return the Enrollment Form to your Manager
• Keep the Plan Information Packet for Your Records
The Affordable Care Act Individual Mandate requires that you obtain qualified health insurance or
pay a tax penalty. The penalty will be applied to your year-end federal modified adjusted gross
income for each month you don’t have health insurance.
Enroll Today and Avoid the Tax Penalty!
ENROLLMENT FORM
EMPLOYEE INFORMATION
DEPENDENT INFORMATION
Social Security Number: __ __ __ - __ __ - __ __ __ __
REQUIRED DEPENDENT INFORMATION
Date of Birth: __ __ / __ __ / __ __ __ __ Sex: M F
Name:
Name:
Social Security Number: __ __ __ - __ __ - __ __ __ __
Street Address:
Date of Birth: __ __ / __ __ / __ __ __ __
State: __ __ Zip:
City:
Home Phone: __ __ __ - __ __ __ - __ __ __ __
BENEFIT SELECTION
Weekly Rates
I DECLINE Medical Coverage completely
Relationship (circle one):
SPOUSE
CHILD
DOMESTIC PARTNER
Name:
Social Security Number: __ __ __ - __ __ - __ __ __ __
Date of Birth: __ __ / __ __ / __ __ __ __
If ACCEPTING Benefits, please choose one:
MEC PLAN
$13.85
Employee + Dependents
$18.46
Sex: M F
Relationship (circle one):
SPOUSE
Employee Only
Sex: M F
CHILD
DOMESTIC PARTNER
Name:
Social Security Number: __ __ __ - __ __ - __ __ __ __
MEC PLUS PLAN (includes 2 Doctor Office Visits)
Employee Only
$19.04
Employee + Dependents
$23.08
Date of Birth: __ __ / __ __ / __ __ __ __
Sex: M F
Relationship (circle one):
SPOUSE
CHILD
DOMESTIC PARTNER
Name:
Social Security Number: __ __ __ - __ __ - __ __ __ __
Date of Birth: __ __ / __ __ / __ __ __ __
Sex: M F
Relationship (circle one):
SPOUSE
CHILD
DOMESTIC PARTNER
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of insurance fraud and will be prosecuted.
I have read the benefit packet and understand its limitations. I understand that open enrollment is only available for a
limited time and I understand that making no benefit selection is a declination of coverage.
Employee Signature
Date
Step 1:
You MUST complete the Employee Information
Section as part of your new hire process.
Plan Information Packet
Please keep for your records.
Step 2: You MUST Accept or Decline Coverage.
Member Services:
BMGI Customer Service: 855-257-0145
Once enrolled, members can call this number for questions regarding plan coverage, ID Card,
claim status, policy booklets.
Customer Service Call Center hours are M-F 8:30am to 5:00pm Central Standard Time.
Payroll Manager:
To make changes or cancel coverage contact your Payroll Manager.
Step 3:
You MUST Sign and Date here
even if you decline coverage.
Staffing Benefit Group PROGRAM OVERVIEW
and FREQUENTLY ASKED QUESTIONS
How do I enroll?
Enrolling in the Staffing Benefit Group plan is easy. You
can enroll by completing an enrollment application and
returning it to your manager.
When can I enroll in the plan?
As a full-time and/or part-time employee, you are able to
enroll in the program within 30 days of your hire date, 1st
paycheck date, or your employer’s annual 30 day open enrollment period. If you do not enroll during one of
these time periods, you will have to wait until the next
annual open enrollment, unless you have a qualifying life
event. You have 30 days from the date of the qualifying
life event to enroll. You must submit proof of the event
along with your enrollment form.
In addition, you may request a special enrollment (for
yourself, your spouse, and/or eligible dependents) within
60 days (1) of termination of coverage under Medicaid or
a State Children’s Health Insurance Program (SCHIP), or (2) upon becoming eligible for SCHIP premium assistance
under this medical benefit.
May I cover my dependents?
Yes. Eligible dependents include your spouse and your
children up to age 26. On Enrollment Form, elect
“Employee + Dependent” coverage to be sure your eligible dependents are covered from Day 1.
Do I have to go to an in-network provider?
It is not required that you go to an in-network provider.
However, if you choose a provider who participates in
the Multiplan Network, your benefit will be paid at 100%.
Non-Network benefits are paid at 40%.
When does coverage begin?
Benefit Coverage begins the first day of the month
following the date of your first payroll deduction.
Benefit Coverage ends the last day of the month
following termination. Your eligibility must fall within
the Service date for benefits to be paid.
Initial coverage begins following a payroll deduction and
continues as long as you have a deduction on your
paycheck. Please review your check stub for deductions.
If you miss a payroll deduction, to avoid a break in
service you should consult your employer. After four (4)
consecutive weeks without payroll deductions, coverage
will be terminated and COBRA information will be sent
to you at that time.
When should I expect an ID card?
ID cards will be mailed as soon as your enrollment
form is received and processed. You should receive
your ID card within 10 business days of your effective
date.
If I complete an enrollment form, but do not get
placed on assignment right away, will I have to
complete a new form?
After six months if there has not been a deduction
from your paycheck, please fill out a new enrollment
form. Missing information will delay the process.
Can I make changes or cancel coverage?
You may cancel or reduce coverage at any time unless
your premiums are deducted pre-tax. You will only
have 30 days from your hire date or first paycheck
date to enroll, add additional benefits or add
dependents. After this time frame, you will only be
allowed to enroll, add benefits or add dependents
during your annual open enrollment period or within
30 days of a qualifying life event.
How can I make changes?
To make changes or cancel coverage, contact your
payroll manager.
It may take up to two or three weeks for the changes
or cancellation to be reflected on your paycheck.
Coverage will continue as long as you have a
paycheck deduction.
What is a qualifying life event?
A qualifying life event is defined as a change in your
status due to one of the following:
• Marriage or divorce
• Birth or adoption of a child(ren)
• Termination
• Death of an immediate family member
• Medicare entitlement
• Employer bankruptcy
• Loss of dependent status
• Loss of prior coverage
Claims Address:
1520 Kensington Rd. Ste 200
Oak Brook, IL 60523
Customer Service: 855-257-0145
PPO Provider Network:
Multiplan/PHCS
unless otherwise indicated
Coverage begins the first day of the month following 30 days from date of hire.
Coverage ends the last day of the month following termination.
Minimum weekly hours for full time: 30 hours per week.
Self-Funded Minimum Essential Coverage Plan / Preventive Services
MEC Plan (Minimum Essential Coverage):
(for a detailed listing see the Summary Plan Description)
Network
Non-Network
16 Covered Preventive Services for Adults
100%
60%
22 Covered Preventive Services for Women
100%
60%
26 Covered Preventive Services for Children
100%
60%
Network
Non-Network
Generic - $10 co-pay
Brand – 25% co-pay
No Benefit
No co-pay for first 2calls,
$50 per call thereafter
No Benefit
Prescription Drugs and Telemedicine:
Covered Prescription Drugs - Catamaran
Telemedicine – Stat Doctors
The MEC PLUS Plan covers routine preventive services and limited physician visits.
MEC PLUS PLAN:
(above services plus 2 Doctor Office Visits)
Doctor Office Visits
Visit/Exam Includes Lab Work & X-rays
Network
Non-Network
100%; Limit 2 visits per year
Limited to Preventative Diagnosis Only
No Benefit
MEC Plan Covered Preventive Services
16 Covered Preventive Services for Adults
1
2
3
4
5
6
7
8
9
10
11
Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
Alcohol Misuse screening and counseling
Aspirin use for men and women of certain age
Blood Pressure screening for all adults
Cholesterol screening for adults of certain ages or at higher risk
Colorectal Cancer screening for adults over 50
Depression screening for adults
Type 2 Diabetes screening for adults with high blood pressure
Diet counseling for adults at higher risk for chronic disease
HIV screening for all adults at higher risk
Immunization vaccines for adults—doses, recommended ages, and recommended populations vary:
· Hepatitis A
· Hepatitis B
· Herpes Zoster
· Human Papillomavirus
· Influenza (Flu Shot)
12
13
14
15
16
· Measles, Mumps, Rubella
· Meningococcal
· Pneumococcal
· Tetanus, Diphtheria, Pertussis
· Varicella
Learn more about immunizations and see the latest vaccine schedules.
Obesity screening and counseling for all adults
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 and cessation interventions for tobacco users
22 Covered Preventive Services for Women, Including Pregnant Women
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
The eight new prevention-related health services marked with an asterisk (*) must be covered with no costsharing in plan years starting on or after August 1, 2012.
Anemia screening on a routine basis for pregnant women
Bacteriuria urinary tract or other infection screening for pregnant women
BRCA counseling about genetic testing for women at higher risk
Breast Cancer Mammography screenings every 1 to 2 years for women over 40
Breast Cancer Chemoprevention counseling for women at higher risk
Breastfeeding comprehensive support and counseling from trained providers, as well as access to
breastfeeding supplies, for pregnant and nursing women*
Cervical Cancer screening for sexually active women
Chlamydia Infection screening for younger women and other women at higher risk
Contraception Food and Drug Administration-approved contraceptive methods, sterilization procedures, and
patient education and counseling, not including abortifacient drugs*
Domestic and interpersonal violence screening and counseling for all women*
Folic Acid supplements for women who may become pregnant
Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing
gestational diabetes*
Gonorrhea screening for all women at higher risk
Hepatitis B screening for pregnant women at their first prenatal visit
Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women*
Human Papillomavirus (HPV) DNA Test high risk HPV DNA testing every three years for women with normal
cytology results who are 30 or older*
17
18
19
20
21
22
Osteoporosis screening for women over age 60 depending on risk factors
Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
Sexually Transmitted Infections (STI) counseling for sexually active women*
Syphilis screening for all pregnant women or other women at increased risk
Well-women visits to obtain recommended preventive services*
26 Covered Preventive Services for Children
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Alcohol and Drug Use assessments for adolescents
Autism screening for children 18 and 24 months
Behavioral assessments for children of all ages (children up to age 18)
Blood Pressure screening for children (children up to age 18)
Cervical Dysplasia screening for sexually active females
Congenital Hypothyroidism screening for newborns
Depression screening for adolescents
Developmental screening for children under age 3, and surveillance throughout childhood
Dyslipidemia screening for children at higher risk of lipid disorders (children age 1 to 18)
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 and Body Mass index measurements for children (children up to age 18)
Hematocrit or Hemoglobin screening for children
Hemoglobinopathies or sickle cell screening for newborns
HIV screening for adolescents at higher risk
Immunization vaccines for children from birth to age 18 – doses, recommended ages, and recommended
populations vary:
· Diptheria, Tetanus, Pertussis
· Haemophilus influenza type b
· Hepatitis A
· Hepatitis B
· Human Papillomavirus
· Inactivated Poliovirus
18
19
20
21
22
23
24
25
26
· Influenza (Flu Shot)
· Measles, Mumps, Rubella
· Meningococcal
· Pneumococcal
· Rotavirus
· Varicella
Learn more about immunizations and see the latest vaccine schedules
Iron supplements for children ages 6 to 12 months at risk for anemia
Lead screening for children at risk of exposure
Medical History for all children throughout development (children up to age 18)
Obesity screening and counseling
Oral Health risk assessment for young children (newborn to age 10)
Phenylketonuria (PKU) screening for this genetic disorder in newborns
Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk
Tuberculin testing for children at higher risk of tuberculosis (children up to age 18)
Vision screening for all children (children up to age 18)
NETWORK INFORMATION
Prescription Drug Network
If enrolled in the medical plan, you are automatically
covered by the prescription drug program through the
Catamaran Pharmacy Network. Catamaran has a national
network with over 67,000 participating pharmacies. To
find a local participating pharmacy, you can visit
www.catamaranrx.com. Prescription drug benefit
information can be found on the Benefits at a Glance
page.
Stretch Your Benefit Dollars
This benefit plan offers you and your family savings for
medical care through discounts negotiated with providers
and facilities in the Multiplan Network. Choosing an innetwork provider helps maximize benefits. When you use
an in-network provider, you will automatically receive the
network discount and the doctor’s office will file the claim for you. If you use a doctor who is not part of the
network, you will not receive the discount and you may
need to file the claim yourself.
How Do I Locate a Doctor?
Enrolled members are encouraged to visit providers in the
networks listed in order to maximize their benefit dollars.
To find a participating provider or verify your current
medical provider is in-network, please call or visit the
network websites referenced on this page.
Member ID Cards
An ID card and confirmation of coverage letter will be
mailed to your home address. If you do not receive these
documents within 10 business days of your effective date,
or have a change of address, please contact the Customer
Service line at 855-257-0145. Present your ID card to the
provider at the time of service. These ID cards are used
for identification purposes and providers use them to
verify eligibility status.
Medical
• Multiplan Network
1-888-342-7427
www.multiplan.com
Prescription
• Catamaran
1-877-459-8474
www.mycatamaranrx.com/CASHCARD
Do not contact the above Networks for questions
regarding your medical benefits. All medical benefit
questions should be directed to the Customer Service
line at 855-257-0145.