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Keyselect 6 plan options mec.pdf

Custom Proposal Prepared For: KeySolution Client Presented By: Proposal Date: 07/31/2013 Proposed Effective Date: 01/01/2014 Insurance Benefits Underwritten By: Fidelity Security Life Insurance Company Home Office: Kansas City, MO 64111 Premium rates are subject to change in accordance with policy provisions.
A certificate will not be issued until a policy is issued in accordance with an application submitted to the underwriting company.
This proposal is valid only for 90 days from the date of the proposal. This proposal is an invitation to contract and not an offer.
This proposal sets forth coverage highlights only. Certain limitations and exclusions apply. Please review the Policy for complete details.
Intr oducing KeySelectTM Why consider KeySelectTM Limited Benefit Group Healthcare? Because millionsof working Americans – nearly 20% of working adults1 – are either ineligible for,or unable to afford, health insurance through their workplace.
Workers who have access to quality medical care are in better overall health,both mentally and physically, than those who do not. They have less anxiety overhealth-related concerns – for themselves and for their families – which results ina more positive attitude and increased productivity.
Insured workers are more likely to seek treatment for medical problems, ratherthan waiting until a minor medical concern has become a major medical crisis.
And prompt medical attention means faster recovery times and decreasedabsenteeism.
Providing affordable, employee-paid health insurance is a powerful tool forrecruiting and retaining top-quality employees. Healthcare coverage, or lackthereof, is often a determining factor in any employment decision. Here is a briefsummary of the benefits: Benefits for the Employee No health questions - for newly eligible applicants² No deductibles or co-insurance - easy to use and understand No pre-existing limitations or exclusions³- may be waived for groups of 25 or moreenrolled No provider requirement - choose any doctor or from a discounted network No benefit coordination - pays fixed indemnity benefits Benefits for the Employer No contribution requirement - cost effective employee benefit No census requirement - easy to quote No complex participation requirements4 - does not vary by size of group No COBRA issues - full administration provided to satisfy continuation laws No required meetings - enrollment via call center, web, or group meetings 116 Million U.S. Adults are Underinsured, online at www.cmwf.org/publications.
2No health questions when enrolling within 30 days of initial eligibility.
3Pre-existing limitations and exclusions will apply if the group has less than 25 enrolled lives. Pleaseverify requirements with your insurance representative.
4At least five enrolled lives are required in most states. The number of enrolled lives may be higher in somestates. Please verify requirements with your insurance representative.
KeySolution Client Plan Name: Plan 1 KeySelectTM is one of the most flexible, innovative and affordable plans on themarket today. The following is a Group Limited Benefit Healthcare Plan for youremployees.
Required Insurance Benefits Daily In-Hospital Indemnity Benefit - Option One Surgery and Anesthesia Indemnity Benefit Outpatient Physician Office Visit Indemnity Benefit - Option One Outpatient Testing/Diagnostic X-ray and Laboratory Indemnity Benefit - Option One, Maximum Option $100 Outpatient Prescription Drug Benefit - - Option One Employee Group Term Life with AD&D Benefit Mental & Nervous Benefit Substance Abuse Benefit Required Non-Insurance Benefits Key Care Guide & Wellness Services - Includes Discount Vision Optional Insurance Benefits In-Hospital Intensive Care Unit Indemnity Benefit Hospital Admission Indemnity Benefit Hospital Emergency Room Indemnity Benefit for Accident/Injury Wellness Indemnity Benefit Ambulance Indemnity Benefit Daily Skilled Nursing Indemnity Benefit Group Dental Plan Group Vision Plan Optional Non-Insurance Benefits Total Cost of Benefits * Rates include a monthly $1.55 COBRA administration fee.
Supplemental Term Life Options *Applies to children over 6 months.
KeySolution Client Plan Name: Plan 2 KeySelectTM is one of the most flexible, innovative and affordable plans on themarket today. The following is a Group Limited Benefit Healthcare Plan for youremployees.
Required Insurance Benefits Daily In-Hospital Indemnity Benefit - Option One Surgery and Anesthesia Indemnity Benefit Outpatient Physician Office Visit Indemnity Benefit - Option One Outpatient Testing/Diagnostic X-ray and Laboratory Indemnity Benefit - Option One, Maximum Option $100 Outpatient Prescription Drug Benefit - - Option One Employee Group Term Life with AD&D Benefit Mental & Nervous Benefit Substance Abuse Benefit Required Non-Insurance Benefits Key Care Guide & Wellness Services - Includes Discount Vision Optional Insurance Benefits In-Hospital Intensive Care Unit Indemnity Benefit Hospital Admission Indemnity Benefit Hospital Emergency Room Indemnity Benefit for Accident/Injury Wellness Indemnity Benefit Ambulance Indemnity Benefit Daily Skilled Nursing Indemnity Benefit Group Dental Plan Group Vision Plan Optional Non-Insurance Benefits Total Cost of Benefits * Rates include a monthly $1.55 COBRA administration fee.
Supplemental Term Life Options *Applies to children over 6 months.
KeySolution Client Plan Name: Plan 3 KeySelectTM is one of the most flexible, innovative and affordable plans on themarket today. The following is a Group Limited Benefit Healthcare Plan for youremployees.
Required Insurance Benefits Daily In-Hospital Indemnity Benefit - Option One Surgery and Anesthesia Indemnity Benefit Outpatient Physician Office Visit Indemnity Benefit - Option One Outpatient Testing/Diagnostic X-ray and Laboratory Indemnity Benefit - Option One, Maximum Option $100 Outpatient Prescription Drug Benefit - - Option One Employee Group Term Life with AD&D Benefit Mental & Nervous Benefit Substance Abuse Benefit Required Non-Insurance Benefits Key Care Guide & Wellness Services - Includes Discount Vision Optional Insurance Benefits In-Hospital Intensive Care Unit Indemnity Benefit Hospital Admission Indemnity Benefit Hospital Emergency Room Indemnity Benefit for Accident/Injury Wellness Indemnity Benefit Ambulance Indemnity Benefit Daily Skilled Nursing Indemnity Benefit Group Dental Plan Group Vision Plan Optional Non-Insurance Benefits Total Cost of Benefits * Rates include a monthly $1.55 COBRA administration fee.
Supplemental Term Life Options *Applies to children over 6 months.
KeySolution Client Plan Name: Plan 4 KeySelectTM is one of the most flexible, innovative and affordable plans on themarket today. The following is a Group Limited Benefit Healthcare Plan for youremployees.
Required Insurance Benefits Daily In-Hospital Indemnity Benefit - Option One Surgery and Anesthesia Indemnity Benefit Outpatient Physician Office Visit Indemnity Benefit - Option One Outpatient Testing/Diagnostic X-ray and Laboratory Indemnity Benefit - Option One, Maximum Option $100 Outpatient Prescription Drug Benefit - - Option Two Employee Group Term Life with AD&D Benefit Mental & Nervous Benefit Substance Abuse Benefit Required Non-Insurance Benefits Key Care Guide & Wellness Services - Includes Discount Vision Optional Insurance Benefits In-Hospital Intensive Care Unit Indemnity Benefit Hospital Admission Indemnity Benefit Hospital Emergency Room Indemnity Benefit for Accident/Injury Wellness Indemnity Benefit Ambulance Indemnity Benefit Daily Skilled Nursing Indemnity Benefit Group Dental Plan Group Vision Plan Optional Non-Insurance Benefits Total Cost of Benefits * Rates include a monthly $1.55 COBRA administration fee.
Supplemental Term Life Options *Applies to children over 6 months.
KeySolution Client Plan Name: Plan 5 KeySelectTM is one of the most flexible, innovative and affordable plans on themarket today. The following is a Group Limited Benefit Healthcare Plan for youremployees.
Required Insurance Benefits Daily In-Hospital Indemnity Benefit - Option One Surgery and Anesthesia Indemnity Benefit Outpatient Physician Office Visit Indemnity Benefit - Option One Outpatient Testing/Diagnostic X-ray and Laboratory Indemnity Benefit - Option One, Maximum Option $100 Outpatient Prescription Drug Benefit - - Option Two Employee Group Term Life with AD&D Benefit Mental & Nervous Benefit Substance Abuse Benefit Required Non-Insurance Benefits Key Care Guide & Wellness Services - Includes Discount Vision Optional Insurance Benefits In-Hospital Intensive Care Unit Indemnity Benefit Hospital Admission Indemnity Benefit Hospital Emergency Room Indemnity Benefit for Accident/Injury Wellness Indemnity Benefit Ambulance Indemnity Benefit Daily Skilled Nursing Indemnity Benefit Group Dental Plan Group Vision Plan Optional Non-Insurance Benefits Total Cost of Benefits * Rates include a monthly $1.55 COBRA administration fee.
Supplemental Term Life Options *Applies to children over 6 months.
KeySolution Client Plan Name: Plan 6 KeySelectTM is one of the most flexible, innovative and affordable plans on themarket today. The following is a Group Limited Benefit Healthcare Plan for youremployees.
Required Insurance Benefits Daily In-Hospital Indemnity Benefit - Option One Surgery and Anesthesia Indemnity Benefit Outpatient Physician Office Visit Indemnity Benefit - Option One Outpatient Testing/Diagnostic X-ray and Laboratory Indemnity Benefit - Option One, Maximum Option $100 Outpatient Prescription Drug Benefit - - Option Two Employee Group Term Life with AD&D Benefit Mental & Nervous Benefit Substance Abuse Benefit Required Non-Insurance Benefits Key Care Guide & Wellness Services - Includes Discount Vision Optional Insurance Benefits In-Hospital Intensive Care Unit Indemnity Benefit Hospital Admission Indemnity Benefit Hospital Emergency Room Indemnity Benefit for Accident/Injury Wellness Indemnity Benefit Ambulance Indemnity Benefit Daily Skilled Nursing Indemnity Benefit Group Dental Plan Group Vision Plan Optional Non-Insurance Benefits Total Cost of Benefits * Rates include a monthly $1.55 COBRA administration fee.
Supplemental Term Life Options *Applies to children over 6 months.
Plan Benefit Descr iptions The following is a summary of KeySelectTM Limited Benefit Group Healthcare.
This is a brief description and does not replace or modify the comprehensivedescription of all benefits, limitations and exclusions contained in thepolicy/certificate and riders that are subject to the laws of the state insurancedepartment having jurisdiction. Benefits, limitations, exclusions and rates mayvary by state: not available in all states.
Regardless of the combination of Limited Medical benefits selected, themaximum payable per person per calendar year is $100,000 (this maximum isnot applicable to dental, vision, Rx or life benefits). The employer elects whichbenefits to make available to their employees for all required and optionalbenefits.
Daily-Hospital Indemnity Benefit The Daily-Hospital Indemnity Benefit is a required benefit. It is available inincrements of $100, from $100 to $1,000 (or up to $1,500 for groups with 500+eligible lives). The individual must be confined in a hospital receiving treatmentor surgery for an accident or illness. This benefit requires a 24-hour hospitalstay; however, benefits are payable from the first day of confinement.
One of the following Maximum Benefit Options must be selected: Full Benefit--The indemnity benefit pays a daily amount as selected abovefor hospital confinements with no specific calendar year or perconfinement limits.
Full Benefit--The indemnity benefit pays a daily amount as selected abovefor hospital confinements at 30 consecutive days per confinement with a365-day lifetime maximum per person.
Three Graded Benefit--The indemnity benefit pays a graded daily benefit for hospital confinement based on length of stay with no specific calendaryear or per confinement limits: a. 100% of selected benefit for days 0-5 b. 50% of selected benefit for days 6-10 c. 25% of selected benefit for days 11-365 Not all surgical schedules are created equal! KeySelectTM benefits compare favorably against the competition! Surgery and Anesthesia Indemnity Benefit The Surgery and Anesthesia Indemnity Benefit is included in all KeySelectTMplans. It is available in increments of $500, from $500 to $5,000 maximum perperson per calendar year.
The Surgery Benefit will pay for both inpatient and outpatient surgical proceduresaccording to the amount shown in the Surgical Schedule or comparable amountsfor surgeries not listed subject to the maximum benefit plan selected. If multipleprocedures are performed at the same time through the same or separateincisions, the amount payable is based on the primary procedure.
The Anesthesia Benefit pays 20% of the Surgery Benefit paid.
Outpatient Physician Office Visit Indemnity Benefit The Outpatient Physician Office Visit Indemnity Benefit is included in allKeySelectTM plans. It is available in increments of $10, from $30 to $100. It ispayable for treatment for injury or sickness in a physician's office.
One of the following Maximum Benefit Options must be selected: The indemnity benefit is payable per visit up to 6 visits per person percalendar year.
The indemnity benefit is payable per visit up to $500 per person percalendar year.
Outpatient Diagnostic X-ray and Laboratory Indemnity Benefit The Outpatient Diagnostic X-ray and Laboratory Indemnity Benefit is included inall KeySelectTM plans. The benefit is payable for medically necessary outpatientx-rays, lab exams, tests and procedures ordered by an attending physician.
One of the following Benefit Options must be selected: A calendar year maximum and a benefit amount maximum must beselected. The per person per calendar year maximum is available inincrements of $100, from $100 to $500. The indemnity benefit is payableper testing day per covered person. The benefit amount is available inincrements of $10, from $30 to $100; $125 or $150.
The indemnity benefit is payable per testing day, per covered person upto a maximum of 3 testing days per covered person per calendar year.
The benefit amount is available in increments of $25, from $75 to $150.
Outpatient Prescription Drug Benefit The Prescription Drug Benefit is included in all KeySelectTM plans. A physicianfor the treatment of a covered injury or accident must prescribe covered drugs.
One of the following Benefit Options must be selected: $15 Co-pay for Generic Formulary Drugs a) Up to 40% Discount for non-formulary and Brand name drugs b) $15 Co-pay for oral formulary contraceptives c) Benefit maximum - $750 per calendar year per covered person $10 Co-pay for Generic Formulary Drugs a) Up to 40% Discount for non-formulary and Brand name drugs b) $15 Co-pay for oral formulary contraceptives c) Benefit maximum - $1,000 per calendar year per covered person Three $10 Co-pay for Generic Formulary Drugs a) Up to 40% Discount for non-formulary drugs b) $15 Co-pay for oral formulary contraceptives c) $50 Co-pay for Brand Formulary Drugs d) Benefit maximum - $1,000 per calendar year per covered person $10 Co-pay for Generic Formulary Drugs/ $20 Co-Pay for Mail Order Generic Formulary a) $50 Co-Pay for Brand Formulary Drugs b) $100 Co-Pay Mail Order Brand Formulary Drugs c) Benefit maximums: Generic Formulary - Unlimited Brand Formulary - $2,000 per calendar year per covered person Please note that the Discount for non-formulary and Brand name drugs is a non-insurance benefit.
Employee Group Term Life with AD&D Benefits Employee Group Term Life with AD&D is included in all KeySelectTM plans. Atleast $5,000 of employee coverage is required. Additional amounts may bepurchased under the Optional Supplemental Benefit.
If the covered employee leaves the group, he or she can convert their groupterm coverage to an individual life insurance policy, without disability or othersupplementary benefits, subject to satisfying certain requirements. The terms ofconversion are given in the life insurance rider attached to the insurance policy.
Mental & Nervous Benefit Benefits are paid the same as for any other sickness.
Substance Abuse Benefit Benefits are paid the same as for any other sickness.
Key Care Guide and Wellness Services Benefit Key Care Guide and Wellness Services are included in all KeySelectTM plans. Itprovides discounts on vision services, nurse hotline, counseling services, andhearing aids. It is not insurance.
The Nurse Hotline (IntelliCare) allows telephone access to experiencedregistered nurses 24 hours a day, 7 days a week, 365 days a year. They are animmediate source of health information about general health concerns,medication and usage, etc. Spanish speaking nurses are on staff.
The Counseling Services (APS) allows employees to speak with a counselor24 hours a day, 7 days a week, 365 day a year regarding any personal problemsthey may be facing. In addition, if the employee is referred to one of the 27,000counseling providers nationwide, he/she will receive discounts of 25% to 30% offthe normal billing charges from those providers.
Key Care Guide provides the Health Tools and Self Care Resources. Thisproduct provides individuals with "personal wellness programs" designed aroundeach member's particular health characteristics. Ultimately the program helpsachieve the individual's personal health goals while helping the employerorganization reduce healthcare costs, improve morale, reduce absenteeism andincrease productivity.
A Personal Health Assessment (PHA) is completed on-line and will lead eachindividual through a series of questions that help determine his or her individualhealth risks.
A Healthy Living Educational Program is provided as a follow-up to thecompleted Health Assessment. The program includes self-care guides featuringhealth tips and tracking/reporting mechanisms that can be tied to companysponsored incentive and reward programs.
All health education lessons in The PHD Network™ are written and developedby experts at Duke University Medical Center.
Optional Benefits In-Hospital Intensive Care Unit Indemnity Benefit The In-Hospital Intensive Care Unit Indemnity Benefit is an optional benefit. It isavailable in increments of $100, from $100 to $1,000 ($1,500 for groups with500+ eligible employees).
The indemnity benefit is payable for each day of Intensive Care confinement upto the maximum number of days selected per covered person per calendar year.
A calendar year maximum of 10 days or 30 days can be selected. A 24-hourhospital stay is required.
The amount selected can be up to 100% of the Daily In-Hospital IndemnityBenefit. The In-Hospital Intensive Care Benefit is payable in addition to, but maynot exceed, the Daily In-Hospital Indemnity Benefit.
Hospital Admission Indemnity Benefit The Hospital Admission Indemnity Benefit for Bodily Sickness and Injury is anoptional benefit. The indemnity benefit is available in increments of $200, from$200 to $3,000. It is payable one time per calendar year per covered personand is paid in addition to any other benefit provided. It is payable from the firstday of confinement. A 24-hour stay is required.
Hospital Emergency Room Indemnity Benefit The Hospital Emergency Room Indemnity Benefit is an optional benefit. It isavailable in increments of $100, from $300 to $1,000. The amount selected ispaid per visit per accident or injury. Emergency treatment for accident or injurymust be performed within 72 hours.
If coverage for sickness is elected, the indemnity benefit amount payable foreach emergency room visit is equal to the Outpatient Physician Office VisitBenefit Amount and will count against the Outpatient Physician Office VisitBenefit Calendar Year Maximum.
The sickness benefit cannot be selected as a "stand alone" benefit. Theaccident/injury benefit must be selected in order to select the sickness benefit.
Wellness Indemnity Benefit The Wellness Indemnity Benefit is optional, unless required by a specific state.
This benefit assists with expenses associated with routine physical exams,routine pap smears, and related laboratory charges, mammograms, well childcare including immunizations and prostate cancer screening services.
One of the following Benefit Options must be selected: An indemnity benefit in increments of $10, from $30 to $100; $125 or$150, is payable per visit. The maximum paid is $150 per covered personper calendar year.
An indemnity benefit of $100, $125 or $150, is payable per visit. Themaximum paid is $300 per covered person per calendar year.
Ambulance Indemnity Benefit The Ambulance Indemnity Benefit is optional and available in increments of $25,from $50 to $150. The amount selected is payable up to a maximum of threeoccurrences per covered person per calendar year, with a lifetime maximum offive times the benefit amount.
Benefits are payable for professional transportation furnished by a licensedambulance service to the nearest facility for treatment of an injury or sickness.
Air transportation to the nearest facility is payable only for medically necessarytreatment.
Daily Skilled Nursing Indemnity Benefit The Daily Skilled Nursing Benefit is optional. The available benefit amounts are60%, 80% or 100% of the Daily In-Hospital amount. It is limited to 60 days perconfinement in a qualified skilled nursing facility. The covered individual must beunder age 65 and the confinement must follow a hospital stay of at least threeconsecutive days. Three consecutive days are not required if the individual isreadmitted to a skilled nursing facility within 14 days.
Supplemental Group Term Life with AD&D Benefits Supplemental Group Term Life with AD&D is an optional benefit. The employermay select up to two benefit amounts to make available to the employees.
Employee coverage is available in increments of $2,500, from $2,500 to $20,000of benefit in excess of the required $5,000 benefit.
Employees who elect to include Supplemental Group Term Life with AD&DBenefits may choose to include Term Life only coverage for their Dependentspouse and/or Dependent child(ren). Those Dependents must also be enrolledin the limited medical plan to be eligible for Term Life Benefits. A spouse may becovered at 50% of the employee amount, in all amounts above the $5,000required employee coverage. Child coverage is 25% of the employee benefitamount in all amounts above the $5,000 required coverage; coverage is limitedto 2.5% of the benefit amount for children ages 14 days to 6 months.
Group Dental Benefits Group Dental coverage is optional. If elected by the employer, dental coveragewill automatically be included for all participants. The following chart summarizesthe benefit percentages payable. However, the benefit allowance may varybased on the usual and customary rates in the geographic area where expensesare incurred.
Participants may go to the Dentist of their choice. A 12-month waiting periodapplies to major dental services. The calendar year deductible does not applyto preventive and diagnostic services. Per person, per calendar year maximumsare available in increments of $100, from $300 to $700; $750, $800, $900 or$1,000.
Individual/Family Calendar Year $25/$75 or $50/$150 Deductible Benefit Selections Preventive & Diagnostic Dental Plan pays 80% subject to benefitguidelines Services (Exams, x-rays, cleanings, etc.) Basic Dental Services (Fillings, spacers, Plan pays 80% subject to benefit extractions, anesthesia, palliative, etc.) Major Dental Ser vices (Root canal, Plan pays 50% subject to benefit periodontal surgery, crowns, bridges, dentures, inlays, onlays, etc.) (For new enrollees, a 12-month waiting period applies.) Group Vision Benefits Group Vision coverage is an optional benefit. The fully-insured vision planutilizes the Avesis network of providers for in-network benefits. Avesis has anational network of over 18,000 vision care providers. Insureds may choosefrom: x A national network of independent optometrists and opthalmologists x Nationally recognized retail vision centers x Any out-of-network provider of their choice The network providers are listed on the Avesis website accessible through Once every 12 months Reimbursed up to $35 Discount of up to 20% off retail for lenses, frames and contact lenses.
Once every 12 months Reimbursed up to $35 Materials Co-pay -- Select One -- $10 or $25 Once every 12 months Covered in full after co-pay Reimbursed up to $35 Covered in full after co-pay Reimbursed up to $40 Covered in full after co-pay Reimbursed up to $50 Covered in full after co-pay Reimbursed up to $80 20% off U&C minus Reimbursed up to $40 Frames (Select One) Once every 12 months $35 wholesale allowance Reimbursed up to $45 Once every 24 months $35 wholesale allowance Reimbursed up to $45 Once every 12 months Medically Necessary Reimbursed up to $250 Reimbursed up to $110 PPO NetworkThe PPO Network is an optional non-insured enhancement to the KeySelectLimited Benefit Healthcare Plan and is not affiliated with FSL.
utilized, covered individuals will receive a discount off of billed charges whenseeing an in-network medical physician or receiving services at an in-networkmedical facility. Employees can choose to visit any provider, but will only receivediscounts from in-network providers. To see a listing of network providers, visitthe The MultiPlan national network is used nationwide. This network has over 4,300acute care facilities, 550,000 physician locations, and 103,000 ancillary careproviders.
The Encore Network is used for residents of Indiana. It has 142 general acutecare hospitals, 25,000 physician locations and over 1,500 ancillary facilities. It isIndiana's largest PPO.
Plan Participant Eligibility Group EligibilityEach employer must be an employer group. This means any firm, corporation,partnership or sole proprietor that is actively engaged in business, is not formedprimarily for the purposes of buying health insurance, and in which a bona fideemployer-employee relationship exists. The employer is required to be officed inor have a clearly defined division in an available state.
The following industries and/or groups are not eligible for the KeySelect product:Commercial Fishing, Mining, Oil and Gas Extraction, Logging and WoodProducts' Processing, Taxicabs, Junk and Scrap Dealers, Car Washes, SportsTeams, Members of Credit Unions, Multiple Employer Welfare Arrangements(MEWA's), Independent Contractors or Self-Employed Workers (issued1099's),Taft Hartley or Unions, Affinity Groups, Associations, Professional EmployerOrganizations (PEO's), Leasing Companies, Farming, Explosives, Bombs &Pyrotechnics, Abestos Products, and Fire Arms & Ammunition. The followingindustries require underwriting approval: Temporary Staffing Agencies, Casinos,Franchises, and Religious Organizations.
Eligibility GuidelinesBased on the coverage options selected by the employer, full-time, part-time andseasonal employees are eligible to apply for coverage. Employees are noteligible if covered under the employer's major medical plan or any other limitedmedical insurance plan made available through the employer. There is nomaximum age limit for an employee and the minimum age for participation is 18.
An employee is usually required to work an average of 15 hours per week andmust be listed on the employer's regular payroll. Employees must be actively atwork on the coverage effective date and must otherwise meet the employer'sguidelines for participation. Employees electing to drop coverage mid-year arenot eligible to re-enroll until the open enrollment period, unless a qualifying eventoccurs.
Spouses under age 65 and dependent children under 19 (or 25 for full-timestudents) may also be included in the plan. They must be added during the firstopen enrollment, or within 31 days of becoming eligible for coverage. Coveragefor children is allowed under one parent or guardian. The spouse may not becovered as both an employee and dependent.
Spouses are recognized under each state's legally married and common lawrequirements. Domestic partners are not eligible as dependents unless requiredby state law and are covered under the group's major medical plan. States varyin term of requirements, length of relationship, etc. Specific forms are requiredby state for common law and domestic partner enrollment.
www.keybenefitresources.com for more information.
Children must be dependent on the parent for maintenance.
children will automatically be cancelled within 31 days of the standardtermination date unless proof of incapacity is otherwise presented.
At least five enrolled lives are required in most states. The number of enrolledlives may be higher in some states. Pre-existing limitations and exclusions willapply if the group has less than 25 enrolled lives. Groups with less than 25eligible employees must submit a copy of their most recent State QuarterlyWage or Unemployment Withholding Report with the group application in orderto verify each employee's current status (full-time, part-time, terminated, etc.).
Please verify requirements by visiting www.keybenefitresources.com.
Eligibility Waiting PeriodEmployers may choose a required service period from a minimum of 30 days toa maximum of 90 days before new employees are eligible to enroll. Waitingperiods of less than 30 days require prior approval.
Open Enrollment PeriodDetermined by the Employer. Open enrollment periods may range from twoweeks to 60 days and will end on the effective date or anniversary date of thepolicy.
Enrollments will be conducted using our in-house call center. It can besupported by EZ Enrollment™ as well, an advanced electronic enrollmentsystem accessed by the group through a secured, password protected website.
This process can be utilized for both the annual enrollment as well ongoing newhire enrollments.
Coverage Effective DateA full month's deductions must be received by "Key Benefit Administrators, Inc.
(KBA), the plan administrator," in order for coverage to be effective on the first ofthe next month (i.e. bi-weekly or semi-monthly will have two deductions, weeklywill have four deductions).
The employer's effective date shall be stated according to these assumptions on the Employer Application.
For example, Carol Smith enrolls on November 29. Her semi-monthly deductionstarts on January 15th. The employer has established February 1 as the group'seffective date. Her coverage is effective on February 1, and benefit claimsincurred as of that date and thereafter are eligible.
Guaranteed Issue and Accept/Reject UnderwritingCoverage is guaranteed issue for all eligible employees and their dependents,subject to group eligibility, who enroll during the first open enrollment periodavailable to those who satisfy their employer's waiting period requirements.
A late entrant is defined as an employee and his/her dependents who seekentrance into the plan more than 31 days after initially becoming eligible forcoverage or after the open enrollment period ends. Late entrants must completean accept/reject enrollment form and are subject to simplified underwriting.
An insurance card will be issued once the enrollment has been approved. Anadditional card may be requested for a spouse or dependent(s).
Benefit PaymentsBenefits can be paid direct to the employee or assigned to a physician orhospital. If assigned, most providers will file a claim to receive payment. If thebilled amount exceeds the plan specific benefit amount, the provider will bill theemployee for the difference. Some providers will require that the entire bill bepaid up-front. In such cases, the employee can obtain a claim form from the KBRwebsite and should submit it along with an itemized billing statement to KBA forreimbursement. Claim forms and itemized billing statements can be sent by mailor by fax.
Premium PaymentAcceptable premium modes are weekly, bi-weekly, semi-monthly, monthly, 9-monthly, and 10-monthly. The first premium is due on or before the effectivedate of coverage. Premiums thereafter are due the first of each month.
COBRACoverage is not portable but is COBRA eligible. COBRA administration isprovided by KBA as part of the KeySelect plan.
Policy and Certificate FormsEach employer will receive a policy and administrative kit and each employeewill receive a certificate packet including valuable ‘how to' information to assistthem with understanding their benefits.
Administrative Contact and Carrier Information Key Benefit Administrators (KBA)KBA is one of the largest, privately held third party administrators (TPA)organizations in the country. KBA is licensed as a TPA, where required. KBAservices a large variety of group benefit plans and provides various functions likepolicy issue, billing and collection, customer service, claims, COBRAcontinuation, HRA, HSA, FSA, and Section 125 administration. It serves overhalf a million members, and processes over two million transactions per year.
The company has offices in Indianapolis, Indiana and Ft. Mill, South Carolina.
For further information on KBA, contact: Key Benefit Administrators Key Benefit Administrators 534 Rivercrossing Drive Fort Mill, SC 29716-1989 Fort Mill, SC 29715-7900 Policyholder Customer Service/Claims 1-866-387-3402Group Billing Fidelity Security Life Insurance Company (FSL)FSL is the insurance company underwriting the KeySelectTM plan. It is theprovider of the health indemnity, term life, prescription drug, vision and dentalinsurance benefits. FSL is located in Kansas City, Missouri, and has been ratedA- (Excellent) based on an analysis of financial position and operatingperformance by A.M. Best Company, an independent analyst of the insuranceindustry. All administrative and claims questions should be submitted to KBA.
KeySelectTM Limitations and Exclusion Limited Benefit Group Healthcare Insurance This product includes a 12/6/12 Pre-Existing Condition Limitation for groups withless than 25 participants. Pre-Existing condition means any injury or sickness forwhich medical treatment or advice was rendered or recommended by a licensedphysician within 12 months prior to the effective date of coverage. An injury orsickness will no longer be considered pre-existing after the earlier of thefollowing occurrences: 1) the expiration of 6 consecutive months commencing onand ending after the effective date of coverage during which period there hasbeen no medical treatment or advice rendered or recommended for such injuryor sickness; or 2) the expiration of 12 consecutive months from the effective dateof coverage.
Coordination of Benefits does not apply to this product. Benefits are not limitedby amounts paid under other insurance plans.
KeySelectTM does not provide any benefits for the following charges, services orsupplies: Suicide or any attempt of suicide, while sane or insane (while sane in Colorado or Missouri); any intentionally self-inflicted Injury or Sickness orany attempt there at (while sane in Colorado or Missouri); Participation in a riot, insurrection, rebellion, civil commotion, civil disobedience or unlawful assembly. For purposes of this exclusion,"participation" means to take an active part in common with others; "riot"means any use or threat to use force or violence or disturbance by three ormore persons without authority of law. This does not include a loss, whichoccurs while acting in a lawful manner within the scope of authority; Committing, attempting to commit or taking part in a felony, battery, assault or engaging in an illegal occupation; Participation in a contest of speed in power driven vehicles, parachuting, parasailing, bungee jumping, scuba diving, stunt driving, rock climbing,flying ultra-light aircraft, skydiving or hang gliding, or any hazardous sportsactivity for exhibition purposes; Flying as a pilot, crewmember or passenger in any aircraft, except as a fare-paying passenger in any regularly-scheduled commercial aircraft flyingbetween established airports on a regularly-scheduled route; Any Accident occurring while the Insured Person is intoxicated (where the blood alcohol content meets the legal presumption of intoxication under thelaw of the state where the Accident took place); Declared or undeclared war or acts thereof; Accidental bodily Injury occurring while serving on full-time active duty in any Armed Forces of any country or international authority (any premiumpaid will be returned by the Company pro-rata for any period of active duty); Accident or Sickness arising out of or in the course of any occupation for compensation, wage or profit or Benefits which the Insured Person isentitled to under any Workers' Compensation Law, Occupational DiseaseLaw or similar law, whether or not application for such Benefits have beenmade; Unless specifically provided for in the Policy, charges for the treatment of: a. Mental or Nervous Disorder; c. The voluntary taking of any poison or inhalation of gas, or voluntary taking of any drug, sedative or narcotic, unless prescribed by aPhysician and taken according to the prescribed dosage; d. Substance abuse; Charges for the treatment of: b. Social, occupational or religious maladjustment; c. Compulsive gambling; d. Chronic marital or family problems when not related to the primary focus of treatment, which must be a diagnosable mental disorder; Unless specifically provided for in the Policy, rest care or rehabilitative care and treatment; Cosmetic surgery or care or treatment solely for cosmetic purposes or complications from such surgery, care or treatment. This includes but is notlimited to: reconstructive surgery and prosthetic devices, unless due to anAccident and performed within one year from the Accident or to repair acongenital or abnormal defect of a newborn child, while covered under thePolicy; Unless specifically provided for in the Policy, immunization shots and routine examinations such as: health exams, periodic check-ups, pre-marital exams and routine physicals, unless they are necessary for thediagnosis and treatment of a Sickness; Routine newborn care such as Hospital and Physician services during Hospital Confinement immediately following birth. Payment for routinePhysician's services will be limited to one routine Inpatient examination ofthe well newborn child performed by a Physician other than the Physicianwho delivered the baby or administered anesthesia during delivery; Voluntary abortion, except with respect to the Eligible Employee or covered Dependent spouse: a) where such person's life would beendangered if the fetus were carried to term; or b) where medicalcomplications have arisen from an abortion; The reversal of tubal ligation and vasectomies; Charges for treatment of male or female infertility; artificial insemination, in vitro or in vivo fertilization, including any related testing, medications orPhysician's services; Dependent child maternity; Unless specifically provided for in the Policy, treatment of obesity, weight reduction or dietetic control, except morbid obesity or disease etiology; Unless specifically provided for in the Policy, charges for Outpatient food, food supplements or vitamins; Unless specifically provided for in the Policy, charges for services in the nature of educational or vocational testing or training; Charges related to smoking cessation; Pre-Existing Conditions, except as described in the Schedule of Benefits.
(This exclusion will not be included in any policies issued for which Pre-Existing Conditions have been waived.) Unless specifically provided for in the Policy, air, water or ground ambulance service; Unless specifically provided for in the Policy, charges for treatment or services for: Temporo-Mandibular Joint Dysfunction or TMJ pain syndrome,Orofacial, or Myofacial syndrome whether medical or dental in scope; With regard to any Outpatient benefit, visits made, examinations given, or x-rays or laboratory tests performed as an in-patient while Confined to aHospital; Unless specifically provided for in the Policy, prescription drugs; Unless specifically provided for in the Policy, routine eye examinations, refractions, eyeglasses or their fitting; Unless specifically provided for in the Policy, any procedure intended to enhance an Insured Person's quality of vision that is not essential to thetreatment of a Sickness or Injury; Unless specifically provided for in the Policy, hearing aids or their fitting; Unless specifically provided for in the Policy, dental examinations, dental care or oral surgery other than expenses resulting from accidental Injury; Experimental or investigational treatments or surgery; Unless specifically provided for in the Policy, diagnostic and surgical procedures, including but not limited to, diagnostic laboratory and pathologyprocedures, diagnostic radiology, nuclear medicine and ultra soundprocedures; Charges for stand-by surgeons, pediatricians, anesthesiologists, anesthetists or other doctor as defined by the plan, or stand-by supplies,equipment, rooms, or any other service, supply or treatment not actuallyused in the care or treatment of an Accident or Sickness; Charges made by, durable equipment recommended by, or drugs dispensed by; a physician, surgeon, nurse or other doctor who: a) normallylives with the Insured Person; b) is a member of the Insured Person'sfamily; c) is the Insured Person's plan sponsor; Charges for services provided outside the scope of the license of the institution or practitioner rendering service; Any charge for which there is no legal obligation to pay; no charge is made; or in the absence of coverage, no charge would be made; Charges incurred prior to the Insured Person's Effective Date of coverage or after termination of coverage; Charges for care or services furnished by any agency or program funded by federal, state or local government. This does not apply to Medicaid orwhere prohibited by law; Charges which are not Medically Necessary for treatment of an Accident Charges for services which are not related to and consistent with the treatment of any Accident or Sickness of the Insured Person; Charges for medical care, services or supplies which are not furnished or prescribed by a Physician; Charges for care, treatment, services or supplies that are not approved or accepted for the treatment of an Injury, Accident or Sickness by any of thefollowing: a. The American Medical Association;b. The U.S. Surgeon General;c. The U.S. Department of Public Health;d. The National Institutes of Health; Charges in excess of the plan maximums as shown in the Schedule of Any charge for a service or supply not specifically covered in the Schedule of Benefits; Unless specifically provided for in the Policy, charges for Intensive Care.
Some provisions, benefits, exclusions or limitations listed herein may vary bystate.
Policy No. LM-109 Policy Form No. M-6005 Term Life Exclusions and LimitationsSuicide Limitation: Death by suicide, while sane or insane (while sane inMissouri) is not covered for 24 months (in Colorado, one year) from the Insured'seffective date. In such event only the premiums paid will be refunded.
Benefits are not payable for any loss caused by or contributed to by: (1) sickness, bodily or mental health, or diagnostic medical or surgical treatment; (2) infection, except pyogenic infections resulting from an accidental Injury or resulting from the accidental ingestion of a contaminated substance; (3) attempted suicide or intentional self-inflicted injury or sickness while sane or insane (while sane in Missouri); (4) declared or undeclared war or acts thereof; (5) military service for any country or organization, including service with military forces as a civilian whose duties do not include combat; war or any act of war whether declared or undeclared. Upon notice to the insurance company of entering the armed forces, the company will return to the insured person, pro-rata any premium paid, less any benefits paid, for any period during which the insured person is in such service; (6) participation in a riot or insurrection. "Participation" means taking an active part in common with others. "Riot" means any use or threat to use force or violence by three or more persons without authority of law; (7) insured person's commission or attempted commission of a felony, assault or illegal action; (8) voluntary taking of any poison, drug, sedative or narcotic or inhalation of any kind of gas unless prescribed by a physician and taken according to the prescribed dosage; (9) legal intoxication where the blood alcohol content of the insured person exceeds the legal limit of the state in which the accident took place; (10) an on-the-job injury that is covered by Workers' Compensation; (11) participation in any non-occupational activity in which an insured person purposely exposes themselves to an increase in bodily Injury.
These activities include but are not limited to: (a) belaying and repelling rock climbing;(b) flying ultra-light aircraft;(c) hang-gliding, skydiving, scuba diving, para-sailing;(d) motorized vehicle stunt driving, racing, jumping, drag racing and demolition;(e) bungee jumping;(f) any hazardous activity for exhibition purposes; or(g) flying as a pilot, crew member, or passenger in any aircraft, except as a fare-paying passenger in any regularly scheduled commercial aircraft flying between established airports on a regularly scheduled route.
Some provisions, benefits, exclusions or limitations listed herein may vary bystate.
Policy No. LM-109 Policy Form M-6005/R-02818 Prescription Drug Exclusions and Limitations Benefits are not payable for the following items: All over-the-counter products and medications unless shown under the definition of Prescription Drug. This includes, but is not limited to, electrolytereplacement, infant formulas, miscellaneous nutritional supplements and allother over-the-counter products and medications.
Blood glucose meters; insulin injecting devices.
Depo-Provera; levonorgestrel; condoms, contraceptive sponges, and spermicides; sexual dysfunction drugs.
Biologicals (including allergy tests); blood products; growth hormones; hemophiliac factors; MS injectables; immunizations; all other injectables unlessshown under the definition of Prescription Drug.
Aerochamber, Aerochamber with Mask; Peak Flow Meter; all other medical supplies and durable medical equipment unless shown under the definition ofPrescription Drug.
Liquid nutritional supplements; pediatric Legend Drug vitamins; prenatal Legend Drug vitamins; prescribed versions of Vitamins A, D, K, B12, Folic Acidand Niacin - used in treatment versus as a dietary supplement; all other LegendDrug vitamins and nutritional supplements.
Anorexiants; Any cosmetic drugs including, but not limited to, Renova, skin pigmentation preps; Any drugs or products used for the treatment of baldness;Topical dental fluorides.
Refills in excess of that specified by the prescribing Physician; or refills dispensed after one year from the original date of the prescription.
All newly marketed pharmaceuticals or currently marketed pharmaceuticals with a new FDA approved indication for a period of oneyear from such FDA approval for its intended indication.
Any drug labeled "Caution - limited by Federal Law for Investigational Use" or experimental drugs.
Any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment.
Drugs needed due to conditions caused, directly or indirectly, by an Insured Person taking part in a riot or other civil disorder; or the InsuredPerson taking part in the commission of a felony.
Drugs needed due to conditions caused, directly or indirectly, by declared or undeclared war or an act of war; or drugs dispensed to an InsuredPerson while on active duty in any armed force.
Any expenses related to the administration of any drug.
Needles or syringes unless shown under the definition of Prescription Drugs or medicines taken while in or administered by a hospital or any other health care facility or office.
Drugs covered under Worker's Compensation, Medicare, Medicaid or other Governmental program.
Drugs, medicines or products, which are not Medically Necessary.
Brand Name Prescription Drugs (except for Option Three).
Diaphragms, erectile dysfunction Legend drugs, unless specifically listed in the definition of Prescription Drug; Infertility Legend drugs.
Epi-Pen, Epi-Pen Jr., Ana-Kit, Ana-Guard; Glucagon-auto injection; Smoking deterrents, Legend or over-the-counter.
Dispensing Limits and Authorized Refills: Retail: the lesser of a 30-day supply or specified unit doses.
Some provisions, benefits, exclusions or limitations listed herein may vary bystate.
Policy No. PD-281/PD-282 Policy Form No. M-9031/M-9022 Dental Exclusions and Limitations Notwithstanding any provision in the Policy to the contrary, the Policy does notprovide any benefits for the following charges, services or supplies: which, in the absence of insurance, the Insured would not be required to related to self-inflicted injuries (while sane in Colorado or Missouri); related to war or an act of war, whether or not declared; related to the Insured's commission of a felony or an assault on another related to a riot, nuclear accident, or a major disaster; caused by, related to, or as a condition of employment, including self- employment. This exclusion applies even if Workers' Compensation or anyOccupational Disease or similar law does not cover the charges; which are more than Reasonable and Customary Charges; which are incurred, or for which treatment began, before the Insured's effective date of coverage or after the Insured's termination of coverage; related to congenital or development malformations existing when the Insured's coverage became effective under the Policy; which are not Medically Necessary, appropriate or are primarily for cosmetic reasons; which are Experimental/Investigational; related to surgical implants or transplants of any type (including prosthetic devices attached to them); related to temporomandibular joint syndrome; related to periodontal splinting; related to facings on crowns, or pontics posterior to the 2nd bicuspid; for replacement of partial or full dentures, fixed bridge work, crowns, gold restorations and jackets more often than once in any 5-year period; related to relining of dentures more often than once in any 2-year period; related to lost, stolen, or missing dentures or bridges or for duplicates; related to fixed or removable bridgework involving replacement of a natural tooth or teeth, which was lost prior to the Insured's effective date ofcoverage under the Policy. Benefits may be payable for bridgework requiredfor loss of teeth while insured under the Policy, if such bridgework is not anabutment for non-covered bridgework; related to prescription drugs and analgesia pre-medication; related to charges for telephone consultations, failure to keep a scheduled appointment, to complete claim forms or attending physician statements,and any other services or supplies which are not part of the direct treatmentof the Insured; which are not made by a Dentist; related to dental education or training programs (this includes oral hygiene or plaque control programs); related to counseling on diet and nutrition; received from a provider who (i) is the Insured's spouse, child, brother, sister, parent or in-law, (ii) resides with the Insured, or (iii) is acting outsidethe scope of his/her license; caused by or related to an Insured's military service, including service in a military reserve unit; for services and supplies not included in a Covered Procedure; related to orthodontia; which are payable under any medical insurance; made by any government entity unless the Insured is required to pay; or by any public entity from which coverage could have been obtained byapplication or enrollment even if application or enrollment was not actuallymade; related to the use of materials, other than fluorides or sealants, to prevent for bite registrations; bacteriologic cultures in connection with a covered dental service; or therapeutic injections administered by a Dentist.
Some provisions, benefits, exclusions or limitations listed herein may vary bystate.
Policy No. DT-173 Policy Form No. M-9037 Vision Limitations and ExclusionsPlease note for examination only benefit, all vision materials are excluded.
Limitation: Vision Examination and Vision Materials - Fees charged by aProvider for services other than Vision Examination or covered Vision Materialsmust be paid in full by the Covered Person to the Provider. Such fees ormaterials are not covered under this Policy.
Benefit allowances provide no remaining balance for future use within the sameBenefit Period.
Exclusions: No benefits will be paid for services or materials connected with orcharges arising from: Orthoptic or vision training, subnormal vision aids, and any associated supplemental testing; Aniseikonic lenses; Medical and/or surgical treatment of the eye, eyes, or supporting Any corrective eye wear, required by an Employer as a condition of employment and safety eyewear, unless specifically covered under thePolicy; Services provided as a result of any Workers' Compensation law, or similar legislation, or required by any governmental agency or programwhether Federal, state, or subdivisions thereof; Plano (non-prescription) lenses; Two pair of glasses in lieu of bifocals; Services or materials provided by any other group benefit plan providing Certain frame brands in which the manufacturer imposes a no-discount Lost or broken lenses, frames, glasses, or contact lenses will not be replacedexcept in the next Benefit Period when Vision Materials would next becomeavailable.
Some provisions, benefits, exclusions or limitations listed herein may vary bystate.
Policy Form No. M-9059/M-9004 Exceptional Product Value KBA's years of working in the health and worksite insurance industry havecontributed to the value, affordability, and flexibility of KeySelectTM to bothemployers and employees.
World Class Service KBA's reputation as an efficient and reliable customer service and administrationorganization has made it a leader in the third party administration field. Let KBAprove to you what "World Class Service" really means.
Web-based Technological Advantages In a world with unlimited information available at the touch of a button, manyinsurance providers remain locked in complex, inefficient mainframe systems.
KBA started from the ground up with an easy to access, open architecture web-based system which offers incredible flexibility in plan designs, billing, claims andadministration.
Flexible Enrollment Options With the KeySelectTM enrollment system you can use EZ Enrollment – ourelectronic web enrollment system to enroll plan participants. A monthly in-housecall center is included with the plan for timely enrollment of new hires, utilizingspecially trained in-house customer service professionals. In addition, yourinsurance representative can provide a highly experienced onsite enrollment.
Simply complete and sign the KeySelectTM Employer Application and submit it toyour insurance representative. For more information, please contactTextBox

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