Table of Content
- Header
-
Welcome
- OPEN ENROLLMENT REMINDER!
-
Eligibility & Enrollment
- Eligibility
- Enrollment
-
Medical & Rx
- Medical/Rx Plans Overview
- Rx Information
- Providers & Networks
- Virtual Visits
- Carrier Resources & Education
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Accounts
- Health Savings Account (HSA)
- Flexible Spending Accounts (FSA)
- Dependent Care Reimbursement Account (DCRA)
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Dental
- Dental Plans Overview
- Providers & Networks
- Carrier Resources & Education
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Vision
- Network & Resources
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Financial Protection
- Life/AD&D
- Disability
- Voluntary Benefits
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Personal Support & Assistance
- Employee Assistance Plan (EAP)
- Travel Assistance
- 401k
- Additional Educational Videos
- Have Questions?
- Footer
OPEN ENROLLMENT REMINDER!
Open Enrollment is from October 15, 2023 through October 25, 2023. This is the time of year where you can elect new plans with Sample, Inc. You may switch between plans and make changes without being required to have a qualifying life event. Please also keep in mind the following when making your elections for 2024:
- If you are currently covered by the Voluntary Life/AD&D, you may increase your benefit by $10,000 with no evidence of insurability!
- Evidence of Insurability is not required if you are electing the Critical Illness Insurance for the first time during open enrollment, however preexisting condition limitations apply.
- THIS IS AN ACTIVE ENROLLMENT! You must make an active election for all benefits. Current elections will not carry forward.
Eligibility
Medical/Rx Plans Overview
Below is a high-level overview of your plan options and in-network benefit information:
You can view more details of these plans by accessing the benefit summaries provided below.
Providers & Networks
The three medical plans function differently when it comes to networks and access. The PPO and POS plans provide out-of-network coverage for a variety of services, whereas the HMO only provides out-of-network coverage in the event of a true emergency. If you do seek care out of network, you will experience higher cost sharing in addition to possible balance billing. View the comparison below for additional details on the differences between the PPO, POS, and HMO plans when it comes to networks and access.
Instructions and tips for locating participating providers below --
- PPO PROVIDERS Enter your zip code and select "Yes this is Correct" - then in the upper right corner select your plan "PPO Plans"
- POS MI PROVIDERS Use this button if you are a MI Resident electing a POS Plan or a non-MI resident traveling to MI. Enter your zip code and select "Yes this is Correct" - then in the upper right corner select your plan "Blue Care Network HMO & POS Plans"
- POS NON-MI PROVIDERS Use this button if you live outside of MI or are a MI resident traveling outside of MI. Enter your zip code and select "Yes this is Correct" - then rather than entering your card information, select "Browse a list of plans" and select "BlueCard Traditional"
- HMO PROVIDERS Available to MI residents only. Enter your zip code and select "Yes this is Correct" - then in the upper right corner select your plan "Blue Care Network HMO & POS Plans"
Virtual Visits
844.606.1608 | www.bcbsmonlinevisits.com
SAMPLEINC provides those employees who are covered by one of the BCBSM/BCN medical plans access to virtual visits with BCBSM Online Visits. BCBSM Online Visits provide members the opportunity to receive medical and mental health care from the comfort of your own home.
HOW MUCH DOES IT COST?
Medical Visits:
- Standard, Non-HSA Plans: Equal to your office visit copay
- HSA Plan: $59 charge applied to deductible; coinsurance applies after satisfaction of deductible.
Mental Health: For both non-HSA and HSA plans, the costs of these services are Subject to your plans normal cost sharing for mental health services, often, deductible & coinsurance. The charges applicable for the type of services, which will apply towards your deductible, are as follows:
- Therapy Visits: $85 (Masters Level) or $99 (Doctorates Level) – Once your deductible is satisfied, coinsurance will apply if applicable
- Psychiatry Visits: $199 for initial visit and $95 for follow up visits –Once your deductible is satisfied, coinsurance will apply if applicable
Prescriptions: If prescribed during a virtual visit, applicable Rx cost sharing will apply based on which medical plan you are enrolled in.
To get access to these convenient services, visit www.bcbsmonlinevisits.com - OR - you may call 844.606.1608.
Health Savings Account (HSA)
The Health Savings Account (HSA) allows you to set aside pre-tax dollars to pay for eligible medical, dental, and vision expenses. The POS Medical Plan is qualified for an HSA. By contributing to an HSA you reduce your taxable income, so you pay less in taxes — which saves you money.
HSA IRS Maximums are as follows and are on a calendar year basis. The maximums indicated below are a combined maximum for participant and any employer provided funds to the HSA. If you elect the HSA plan mid-year, maximums are prorated based on your effective date in the HSA plan.
$3,850 for a single contract | $7,750 for a two person or family
$1,000 "Catch Up" contribution for those age 55+
If you have an HSA with another bank or custodian, you can transfer your funds to the SAMPLEINC HSA's with Health Equity by completing this form.
Visit the Health Equity HSA page for more information by clicking HERE!
Flexible Spending Accounts (FSA)
Plan Details are as follows:
- You can contribute up to $3,050 annually.
- At the end of the 2024 plan year, if you have not used all of your FSA funds, a maximum of $610 will carry over into next year's FSA plan (should you elect an FSA for the 2025 plan year).
- You have 90 days after the end of the plan year to submit for expenses that occurred on or before 12/31/2023.
- If you are enrolled in an HSA plan, you will be eligible for the Limited Purpose FSA only which can be used for qualifying dental, vision, and post-deductible medical expenses.
- You have access to your full annualized election amount on day one.
- Unused funds will be forfeited.
Visit the Health Equity FSA page for more information by clicking HERE!
Dependent Care Reimbursement Account (DCRA)
Plan Details are as follows:
- You can contribute up to $5,000 annually or limited to $2,500 if you are married and file separate tax returns.
- The plan includes a Grace Period which allows you to incur and submit expenses using your 2024 funds until March 15, 2025.
- You have 90 days after the end of the plan year to submit for expenses that occurred on or before 12/31/2023.
- You only have access to the funds of which you have paid into the account.
- Any unused funds are forfeited.
Dental Plans Overview
You have the choice of two dental plans - The Core Plan includes a deductible (for basic and major services only), no ortho coverage, higher cost sharing for your basic and major services, and a lower annual maximum - OR - The Buy-Up Plan. The Buy-Up plan has no deductible, richer benefits for basic and major services, orthodontia coverage is included for dependents (through age 19), and a higher annual maximum
Below is a high-level overview of your plan options and benefit information:
What are Preventive Services? Routine oral exams and cleanings, x-rays,, sealants & fluoride treatments
What are Basic Services? Periodontics, endodontics (root canals), oral surgery, fillings, prosthetic maintenance
What are Major Services? Prosthodontics, crowns, dentures, implants & bridges
You can view more details of these plans by accessing the benefit summaries provided below.
Vision
Group #1234 | 866.939.3633 | www.eyemed.com
SAMPLEINC offers vision coverage through EyeMed to help pay for eye exams, prescription glasses and contact lenses. EyeMed also provides discounts for Hearing Care and Lasik.
If you are already enrolled in one of the SAMPLEINC's EyeMed vision plan today and have not already done so, please be sure to register through the EyeMed member portal where you can access important information pertaining to your vision plan with EyeMed including participating providers, coverage information, and explanation of benefits/claims. If you are not currently covered, you will be able to register in the EyeMed portal as of your effective date of coverage.
Below is a high-level overview of your plan and in-network benefits:
Life/AD&D
(800) 351-7500 | www.reliancestandard.com
A sudden accident or death can leave you or your loved ones in a vulnerable position. SAMPLEINC provides all eligible employees Basic Life and Accidental Death & Dismemberment (AD&D) coverage in the amount of 1 time's your annual salary up to $500,000 at no cost to you. Employees have the opportunity to enroll in additional Life and Accidental Death & Dismemberment insurance which will supplement lost income in the event of an accident or death. If you choose to enroll in employee coverage, this will be in addition to your employer provided Basic Life coverage.
- Evidence of Insurability (EOI) is required for increases in excess of 1 increment during open enrollment and for those electing voluntary life for the first time after initially waiving the coverage.
- Who's Your Beneficiary? Naming a beneficiary is a crucial part of electing life insurance. Also, don't forget to update your primary or secondary beneficiary if you experience a life event, such as a divorce or birth of a child.
- *Guarantee Issue only applies to new hires or newly eligible spouses (due to marriage) electing benefits for the first time; or, when increasing benefits during open enrollment. You are eligible to increase your benefits by 1 increment, not to exceed the guarantee issue amount, during the 2023 open enrollment period with no evidence of insurability.
Disability
(800) 351-7500 | www.reliancestandard.com
SAMPLEINC provides both Short & Long Term Disability benefits at no cost to you!
Everyday illnesses or injuries can interfere with your ability to work, more serious issues can impact your ability to work indefinitely. Even a few weeks away from work can make it difficult to manage household costs. Disability coverage provides financial protection for you by paying a portion of your income, so you can focus on getting better and worry less about keeping up with your bills.
Voluntary Benefits
SAMPLEINC provides a competitive benefits package for all employees as part of our total compensation package. We realize you make benefit choices based on what’s important to you and the needs of your changing lifestyle. Therefore, along with our core benefits, we offer these additional benefits which help to provide financial support to you. These benefits are paid for through payroll deduction on a post tax basis so that the benefits are tax free.
Accident, Critical Illness, & Hospital coverage is provided through Reliance Standard Life Insurance. Hopefully you are never in the position to use it, but if you were to experience an accident, illness, or hospitalization, it could end up costing you a lot of money. With these plans, you will be paid money for qualifying situations/services to cover our of pocket expenses or you may use the funds for whatever you like.
Identity Protection and Legal Services are provided through ID Shield/Legal Shield. These benefits are offered in an effort to protect and assist with the expenses and services needed in the event you are faced with compromises to your identity or legal matters.
See plan summaries below for additional details.
Employee Assistance Plan (EAP)
401k
