This is only a summary. document at www.bdaeap
Bensinger, DuPont & Associates Employee Assistance Program: Kelly Services Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: Beginning on 1/1/2014 Coverage for: Employee + spouse and dependents |
| Plan Type: Employee Assistance Program (EAP)
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 or by calling 1-800-272-2727
Important Questions
What is the overall deductible? Are there other deductibles for specific services? Is there an out?of? pocket limit on my expenses? What is not included in the out?of?pocket limit? Is there an overall annual limit on what the plan pays?
Does this plan use a network of providers?
Do I need a referral to see a specialist?
Answers
$0
No.
N/A. This plan has no out-of pocket expenses.
N/A. This plan has no out-of pocket expenses.
No, but there are limits to the numbers of sessions provided by issue. Yes. A referral to an EAP network provider is available by calling the EAP at 800-2722727.
N/A. The EAP does not cover specialists.
Why this Matters: There is no deductible for services covered under your Employee Assistance Program ("EAP").
There are no deductibles to meet for services covered under your EAP.
Not applicable because there are no out-of-pocket expenses for services covered under your EAP.
Not applicable because there are no out-of-pocket expenses for services covered under your EAP
There is not a dollar amount limit but the number of covered sessions is limited to up-to-3 sessions per issue.
Up-to-3 sessions with an EAP network provider are covered. Your EAP does not cover out-of-network providers.
Not applicable because your EAP does not cover specialists. Referrals for specialized or long-term services are made through your health insurance benefits, if applicable, or to a community resource.
Are there services this plan doesn't cover?
Yes.
Some of the services that your EAP doesn't cover are listed on pages 2-4.
Questions: Call 1-800-272-2727 or visit us at . If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at ebsa/healthreform or iio. or call 1-866-444-EBSA (3272) to request a copy.
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Bensinger, DuPont & Associates Employee Assistance Program: Kelly Services Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: Beginning on 1/1/2014 Coverage for: Employee + spouse and dependents |
| Plan Type: Employee Assistance Program (EAP)
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 plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven't 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 in-network providers by charging you lower deductibles, copayments and coinsurance amounts.
Common Medical Event
Services You May Need
If you visit a health care provider's office or clinic
If you have a test
If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at .
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) Generic drugs Preferred brand drugs Non-preferred brand drugs
Specialty drugs
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 Not covered
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 Not covered
Limitations & Exceptions
--------None---------------None---------------None---------------None---------------None---------------None---------------None---------------None---------------None---------------None--------
Questions: Call 1-800-272-2727 or visit us at . If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at ebsa/healthreform or iio. or call 1-866-444-EBSA (3272) to request a copy.
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Bensinger, DuPont & Associates Employee Assistance Program: Kelly Services Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: Beginning on 1/1/2014 Coverage for: Employee + spouse and dependents |
| Plan Type: Employee Assistance Program (EAP)
Common Medical Event
If you have outpatient surgery
If you need immediate medical attention
If you have a hospital stay
Services You May Need
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
Your Cost If You Use an In-network
Provider Not covered Not covered
Not covered Not covered Not covered
Not covered Not covered
No Charge
If you have mental health, behavioral health, or substance abuse needs
Mental/Behavioral health inpatient services Substance use disorder outpatient services
Not Covered Not Covered
Substance use disorder inpatient services
Not Covered
Prenatal and postnatal care If you are pregnant Delivery and all inpatient services
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 Not covered Not Covered
Not Covered
Not Covered
Not Covered
Not Covered Not Covered
Limitations & Exceptions
--------None---------------None---------------None---------------None---------------None---------------None---------------None--------
Limited to up-to-3 sessions per issue. Referrals are made through your health insurance benefit, if applicable, or to a community resource. Referrals are made through your health insurance benefit, if applicable, or to a community resource. Referrals are made through your health insurance benefit, if applicable, or to a community resource. --------None---------------None--------
Questions: Call 1-800-272-2727 or visit us at . If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at ebsa/healthreform or iio. or call 1-866-444-EBSA (3272) to request a copy.
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Bensinger, DuPont & Associates Employee Assistance Program: Kelly Services Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: Beginning on 1/1/2014 Coverage for: Employee + spouse and dependents |
| Plan Type: Employee Assistance Program (EAP)
Common Medical Event
Services You May Need
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
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
Limitations & Exceptions
--------None---------------None---------------None---------------None---------------None---------------None---------------None---------------None---------------None--------
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)
Acupuncture Bariatric surgery Chiropractic care Cosmetic surgery Dental care (Adult)
Hearing Aids Infertility treatment Inpatient care Long-term care Non-emergency are when traveling outside the U.S.
Physicians/psychiatrists Private-duty nursing Psychological testing Routine eye care (Adult) Routine foot care Weight loss programs
Questions: Call 1-800-272-2727 or visit us at . If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at ebsa/healthreform or iio. or call 1-866-444-EBSA (3272) to request a copy.
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Bensinger, DuPont & Associates Employee Assistance Program: Kelly Services Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: Beginning on 1/1/2014 Coverage for: Employee + spouse and dependents |
| Plan Type: Employee Assistance Program (EAP)
Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)
Legal consultation
Financial consultation
Child and elder care referrals
Your Rights to Continue Coverage:
EAP services will remain available to any employee or dependent for 30 days post-employment.
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 EAP at 800-272-2727.
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 not provide minimum essential coverage [because the EAP is not covered under the Affordable Care Act].
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 [because the EAP is not covered under the Affordable Care Act].
Language Access Services:
[Spanish (Espa?ol): Para obtener asistencia en Espa?ol, llame al 1-800-272-2727. [Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-272-2727. [Chinese (): 1-800-272-2727. [Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-272-2727.
??????????????????????To see examples of how this plan might cover costs for a sample medical situation, see the next page.??????????????????????
Questions: Call 1-800-272-2727 or visit us at . If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at ebsa/healthreform or iio. or call 1-866-444-EBSA (3272) to request a copy.
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