2018 Contractor Benefit Guide
2018 Contractor Benefit Guide
2018 Contractor Benefit Guide
Need Assistance?
Contact the Benefits Service Center at 1-866-886-9798 to speak with a Benefits Advisor.
We may refer in this guide to “ACA”, which stands for the Affordable Care Act. We also refer to your “Individual Mandate”
obligation. By this, we mean your obligation under the ACA to have Minimum Essential Coverage (which can simply mean an
employer group medical plan) or to pay a penalty on your tax return for not carrying such coverage.
If you decline coverage under the medical plans offered by Allegis Group, and you do not have other coverage that meets this
requirement through another source, or you are not eligible for an exemption, you may be subject to the Individual Mandate
tax. For additional information regarding the exemptions to the Individual Mandate and general information regarding the
Affordable Care Act, please visit www.healthcare.gov.
PAGE 22 EMPLOYEE ASSISTANCE PROGRAM (EAP) & WORK/LIFE BENEFIT | HEALTH ADVOCATE
• Confidential counseling for emotional, legal, financial, and other personal issues
• Company paid, automatically enrolled at hire
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You may elect or change these benefits during the annual Open Enrollment period or anytime during the year with a qualifying status change.
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You may elect or change these benefits anytime during the year with medical underwriting requirements.
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You may elect or change these benefits anytime during the year once you meet eligibility, without restriction.
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You may elect to open an HSA through Allegis during the annual Open Enrollment period or anytime during the year with a qualifying status change provided you elect
the High Deductible Comprehensive Medical plan offered by Allegis. You may change your contribution level to your HSA at any time during the year.
DISABLED CHILDREN
Coverage may be available to your disabled child who is over age 26, provided the child is financially dependent on you, is unmarried
and was enrolled in the plan prior to attaining age 26. If you have an over age disabled dependent child, documentation of the disability
may be required to continue coverage under the Plan.
Enrolling an individual that is not eligible for Allegis’s plans is a fraudulent act and could result in disciplinary action up to and
including termination.
Example 1: Example 2:
Hired: March 7, 2018 Hired: May 1, 2018
Benefit Coverage Begins: April 1, 2018 Benefit Coverage Begins: May 1, 2018
Must Enroll By: Midnight, April 30, 2018 Must Enroll By: Midnight, May 31, 2018
Please keep in mind, you pay for benefits through weekly payroll deductions and if you miss deductions, payment will automatically be
made up with double deductions. Please see the “Paying for Your Benefits” section of the guide for more detailed information.
How to Enroll
Enroll Online at www.AllegisMarketplace.com, an online benefits service that puts benefits information and enrollment at your
fingertips 24 hours a day, seven days a week. www.AllegisMarketplace.com lets you look at your personal benefits record, including
current coverage, dependents, and costs. You can also find details about all the available plans, so you can choose benefits that will work
best for you and your family. In addition:
• You DO NOT have to fill out a paper enrollment form.
• www.AllegisMarketplace.com is private, secure, and accessible from any computer, anywhere, anytime.
• You can enroll online and print a confirmation.
• You can print a Temporary Benefit Confirmation to present to your providers in the event you have not received your ID cards.
• You can access www.AllegisMarketplace.com after the enrollment period whenever you have questions about your benefits.
If you do not have web access, please contact your local office for a paper application. You may fax your enrollment form and all other
forms to the Benefits Service Center at 410-785-1637. If you have questions, you may contact the Benefits Service Center at 1-866-886-
9798 and speak with a Benefits Advisor.
Logging on to www.AllegisMarketplace.com
www.AllegisMarketplace.com is private, secure, and accessible from any computer, anytime, anywhere.
Beneficiaries
Many people overlook and underestimate the importance of designating a beneficiary. In many cases, people don’t designate a
beneficiary at all, and in other cases, the information is outdated. Taking the time to designate or update your beneficiaries today can
eliminate many challenges for your family in the event of your death.
Remember that you must meet your Individual Mandate under the Affordable Care Act (ACA) or pay an IRS tax. If you do not have coverage outside
of Allegis, we encourage you to enroll in the medical PPO plan offered by Allegis to ensure you meet your Individual Mandate and avoid the IRS tax.
Medical Coverage
Since everyone’s health care needs are different, we offer a variety of plans so you can customize your own coverage. By enrolling in
a BlueCross BlueShield Medical Plan, you can have medical and prescription coverage and access to BlueCross BlueShield’s national
network of providers. And, you will avoid the IRS penalty tax for not satisfying the Individual Mandate (i.e., not carrying “Minimum
Essential Coverage.”)
To learn more about how to personalize your medical coverage, call a Benefits Advisor at 1-866-886-9798—Monday– Friday, 8 am–6 pm
EST or visit www.AllegisMarketplace.com.
I need...
A budget friendly, basic medical plan with no up-front deductible and no copays that satisfies my
Individual Mandate responsibility under the ACA (No Hospitalization Coverage)
A comprehensive medical plan with no annual or lifetime limits that satisfies my Individual Mandate
responsibility under the ACA
A budget friendly, basic medical plan with no up-front deductible that satisfies my Individual Mandate
responsibility under the ACA AND additional cash reimbursement for hospitalization expenses
A comprehensive medical plan with no annual or lifetime limits that satisfies my Individual Mandate
responsibility under the ACA AND additional cash reimbursement for out-of-pocket expenses (like deductibles)
Options to provide me with cash reimbursements even though I have coverage elsewhere (through
an exchange, spouse’s plan, parental coverage, etc.)
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Coordination of Benefits
IRS regulations specify you (and your spouse/domestic partner, if you have family coverage and wish to contribute to an HSA) generally
cannot have any other health coverage if you are enrolled in the High Deductible Comprehensive Medical Plan. However, you can have
additional insurance that provides benefits for the following items.
• Liabilities incurred under workers’ compensation laws, tort liabilities, or liabilities related to ownership or use of property;
• A specific disease or illness;
• A fixed amount per day (or other period) of hospitalization.
You can also have coverage (whether provided through insurance or otherwise) for the following items.
• Accidents
• Disability
• Dental care
• Vision care
• Long-term care
Courtesy of the Department of Treasury Internal Revenue Service
*Negotiated Charges and Recognized Charges are the allowed amount that BlueCross BlueShield will pay for covered services regardless of a provider's actual charge.
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This summary is for descriptive purposes only. It is not an agreement or contract. Further information can be found in the applicable plan documents.
For more information, including how services are covered when you use out-of-network providers,
visit www.AllegisMarketplace.com or talk with a Benefits Advisor at 1-866-886-9798.
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Employee $40.98
Family $114.19
Employee $79.64
Family $215.03
To learn more about how to personalize your medical coverage, call a Benefits Advisor at 1-866-886-9798, Monday– Friday, 8 am–6 pm EST
or visit www.AllegisMarketplace.com.
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Preferred Brand Prescriptions $0 100% until deductible is met, then $35 copay
Non-Preferred Brand Prescriptions Not Covered 100% until deductible is met, then $60 copay
This summary is for descriptive purposes only. It is not an agreement or contract. Further information can be found in the applicable contract.
Please note, Specialty Prescriptions are not covered under the Basic Medical Plan.
For a full description of covered services and exclusions, please see the Evidence of Coverage document available online at
www. AllegisMarketplace.com.
Filling Prescriptions
Allegis Group has a partnership with CVS/Caremark and through that partnership is able to negotiate better rates on maintenance drugs
for our employees. This will require you to fill prescriptions for certain medications at a CVS pharmacy or by mail order, as explained below.
If you fill prescriptions of maintenance drugs at a pharmacy other than CVS (such as Rite Aid, Walgreens, etc.), our plan will not cover the cost,
meaning the prescription cost will not be at the discounted CVS price nor will the amount you pay count toward your deductible.
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What is an HSA?
An HSA is a tax-advantaged savings account that allows you to put aside pre-tax income, invest your savings, and use your tax-free
savings for eligible medical expenses. Unlike other medical savings accounts, any money you do not use stays in your account.
An HSA helps you save for health care expenses over your lifetime. If you use the account to pay for eligible medical expenses, (a list can
be found at www.irs.gov/pub/irs-pdf/p502.pdf ), you will not have to pay federal income taxes on your savings. You may choose to
use the funds for ineligible expenses, but you will be taxed on the amount, and if you are under age 65, you will also be subject to an
additional 20% tax penalty. (Please note you may want to keep your receipts for IRS purposes).
In addition to being an excellent way to put money aside for current expenses, an HSA is a tax-free way to save for future expenses— such
as the need to cover retiree health premiums (excluding Medicare Supplement plans) or to pay for uncovered healthcare expenses at
some time in the future.
Your HSA is your personal account and is entirely portable. This means if you leave Allegis Group, you can take the account with you.
Allegis Group has partnered with Optum to manage your Health Savings Account. Once you set up your HSA, you will receive a
Welcome Package from Optum (which will include your Healthcare Payment card), quarterly Health Savings Account statements and
other information pertaining to your HSA.
You may contribute to your HSA through pre-tax payroll deductions or through post-tax contributions of your own (you will set this up
directly with Optum), up to the amount allowed by the IRS. If you choose to contribute through post-tax contributions, you will adjust
your gross income when filing your income tax return the following year.
It is important to note although some expenses are eligible for reimbursement from your HSA, they may not count toward your annual deductible or
annual out-of-pocket maximum (such as certain over-the-counter medications or long term care insurance premiums). For additional information about
eligible and ineligible expenses, please refer to IRS Publication 502 www.irs.gov/pub/irs-pdf/p502.pdf.
HSA Contributions
You determine how much you want to contribute to your HSA on an annual basis however you must contribute at least $260 per
year ($5 per pay).
You may contribute up to the following IRS maximums:
If you are age 55 or older, for the 2017 plan year and beyond you are also eligible to make an additional contribution of $1,000 to your HSA by
logging into your account at www.optumbank.com. From the main dashboard page, click on “make a deposit” and follow the prompts to make
a deposit from the bank account of your choosing. Call Optum customer service at 1-844-326-7967 if you have questions or need assistance.
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HSA Changes
You may change your HSA contributions at any time during the year by logging on to www.AllegisMarketplace.com. A voluntary HSA
contribution change will take effect on the following week’s paycheck.
Account Balance
Depending on your health care expenses in a given year, you may not need to use all of the funds in your HSA. In this event, the remaining
balance in your HSA will be available for your use in future years.
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The Hospital Cost Protection Plans pay a fixed daily cash benefit directly to you to help you offset the cost of medical services such as
hospitalization, major diagnostic testing, emergency room visits, and more, up to the shared and annual allowed maximums (see details
below). Coverage is “guaranteed issue”, which means you cannot be denied coverage, regardless of current or prior personal or family
health history.
While the plans work well together, the Hospital Cost Protection Plans do not coordinate benefits with the BlueCross BlueShield Medical
plans and are purchased separately.
Three coverage options are available: Advantage ($25,500/Covered Person/Year); Advantage Plus ($50,500/Covered Person/Year);
Advantage Premium ($101,500/Covered Person/Year).
Personalize Your Coverage…Consider the Basic Medical Plan + Hospital Cost Protection Plan…
The Basic Medical Plan features low premiums and no deductible while providing you with 100% coverage for unlimited sick and well
visits to doctors and coverage for generic and preferred brand name prescription drugs. However, the Basic Medical Plan does not
cover surgery, hospitalization, emergency room services, x-ray/diagnostic imaging or non-preferred brand name or specialty
prescription drugs. Combining the Basic Medical Plan with a Hospital Cost Protection Plan allows you to expand your coverage and
build a personalized program that suits your needs and is budget friendly. Any one of the Hospital Cost Protection Plans can supplement
the Basic Medical Plan or any other coverage you may have. You can also choose to further expand your coverage by choosing Critical
Illness Protection and/or Accident Protection Plan.
Office Visits $0
Preventive Care
$0
(Adult Physical Exams, Routine GYN visit, Well-Child Care exams/immunizations)
Lab Work, X-ray/Imaging (e.g., MRI) X-ray & Diagnostic Imaging not covered. Outpatient lab work covered at 100%
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Surgery (inpatient) Per day, per Per day, per Per day, per
$10,000
Surgery (outpatient) schedule “C”* schedule “C”* schedule “D”*
Outpatient Surgical Facility $350 /day $350 $500/day $500 $500/day $1,000
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ACCIDENT PROTECTION
Accident Protection, offered by Symetra, pays for medical services related to an accidental injury not incurred at
work (up to 3 per calendar year per covered person). The plan covers any type of accident and pays your actual billed
expenses up to the maximum plan benefit of $10,000 per year. Accident Protection can be purchased separately, or
it can be purchased in combination with either the Basic Medical Plan or High Deductible Comprehensive Medical
Plan option, providing a lump sum cash benefit to help with out-of-pocket costs and unforeseen expenses.
Note: Due to state regulations, the Accident Protection Plan is not available to employees who live in Idaho and New Hampshire.
For more information on the plans, rates, and how to select what’s best for you, visit the Allegis Marketplace at www.AllegisMarketplace.com,
review the Benefits Guide, or contact a Benefits Advisor at 1-866-886-9798.
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Simply call 1-866-799-2728 (toll-free) or visit online at www.HealthAdvocate.com/members to access EAP or Work/Life services.
Your Death
Your spouse or domestic partner, and your dependent children, remain eligible for the EAP and Work/Life program for 36 months from
your death if you die while working for Allegis at least 20 hours a week.
Notices
All notices required under this section must be made in writing to:
Allegis Group, Inc. Benefits Service Center, 1 Kelly Way, Sparks, MD 21152. Tel: 1-866-886-9798 | Fax: 410-785-1637.
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Annual (calendar year) Deductible (for Type B and C Expenses Combined) $50 per person $50 per person
Annual (calendar year) Plan Limit Maximum Benefit $1,000 per person $1,000 per person
Type A Expenses - Preventive Oral Exams once every six months Cleaning,
Plan pays 100%* no deductible Plan pays 100%** no deductible
polishing once every six months
Type B Expenses - X-rays, fillings, minor oral surgery Plan pays 80%* after deductible Plan pays 80%** after deductible
Type C Expenses - Crowns, dentures, bridgework, complex oral surgery Plan pays 50%* after deductible Plan pays 50%** after deductible
This summary is for descriptive purposes only. It is not an agreement or contract. Further information can be found in the applicable contract.
Additional Type A, B & C information can be found in the MetLife Dental Plan Certificate of Insurance. *Plan Benefits subject to the Maximum Allowed Charge for the types of dental services
shown in section C of the Plan Certificate of Insurance. The Maximum Allowed Charge is the lower of: a. the amount charged by the Participating Provider for the service or supply; and b. the
maximum amount that the Participating Provider agreed with us to charge for that service or supply. This maximum amount is specified or based on the amounts specified in the Preferred Dentist
Program Table of Maximum Allowed Charges. ** Plan Benefits subject to Reasonable and Customary (R&C) limits for the types of dental services shown in section C of the Plan Certificate of
Insurance. The Reasonable and Customary Charge is the lowest of: a. the usual charge by the Dentist or other provider of the services or supplies for the same or similar services or supplies; or b.
the usual charge of most other Dentists or other providers in the same geographic area for the same or similar services or supplies; or c. the actual charge for the services or supplies.
MYBENEFITS BY METLIFE
MyBenefits is a secure, online portal that enables you to manage your MetLife dental benefits quickly and easily from your own desktop.
At the MyBenefits website, what you need is in one place—so you can manage your dental benefits in less time than ever before.
With MyBenefits, you can:
• View, manage and gain a better understanding of your dental benefits
• Review recent claims
• Elect to receive automatic e-mail alerts when there are updates to your dental claims
• Access information on oral health news
• Locate an in-network dentist
You also have access to:
• A home page with access to personalized information which highlights the benefits available to you, and gives you quick links to
other valuable tools
• Special message boxes with timely benefits information
• A My Account section that gives you a quick snapshot of your benefit options and activities
You can access MyBenefits directly from www.AllegisMarketplace.com by selecting the MyBenefits by MetLife link located on the left
side of your home page or go to www.metlife.com/mybenefits.
*When you sign in to MyBenefits, you should enter “Allegis Group” in the box where it says “Enter Your Company Name”.
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Employee $6.54
Family $16.94
For more information on the Dental Plan, including how to find a participating dentist, visit www.AllegisMarketplace.com for a direct
link to MetLife or go to www.metlife.com/dental. You can also call MetLife at 1-800-942-0854 or contact the Benefits Service Center
at 1-866-886-9798 to speak with a Benefits Advisor.
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Employee $1.69
Family* $4.37
*Please see the eligibility section of this guide for further details regarding eligibility.
For more information on the Vision Plan, contact the Benefits Service Center at 1-866-886-9798 to speak with a Benefits Advisor.
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Purchasing an individual health plan is not considered a qualifying change and does not allow you to cancel your coverage with Allegis Group.
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This is a brief overview of some potential qualifying events. Eligible qualifying events are dictated by Internal Revenue Code Section 125.
Also note that you may be able to add coverage mid-year for yourself and/or your dependents (including your spouse or domestic
partner) if you decline enrollment for yourself or your dependents because of other health insurance or group health plan coverage, and
if you or your dependents subsequently lose eligibility for that other coverage (or if the employer stops contributing towards your or your
dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage
ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of
marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must
request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. To request special enrollment or
obtain more information, contact the Benefit Service Center at 1-866-886-9798 or via e-mail at askbenefits@allegisgroup.com.
You have 30 days from the date of the status change to change your benefits. However, if you or your dependent become eligible for
a state premium subsidy for Medicaid or through a state children’s health insurance program with respect to coverage under this plan,
you have 60 days from the date of such eligibility determination to enroll in the plan. If you or your dependent decline to participate in
the plan because you have Medicaid coverage or coverage under a state children’s health insurance program and you later lose that
coverage you have 60 days from the date of such loss of coverage to enroll in the plan.
You may make your change on www.AllegisMarketplace.com or submit a change form. In either case, you need to submit hard copy
proof of the change, such as a birth or marriage certificate. You can only make changes consistent with the status change. For example,
if you add a child, you may add dependent life insurance and change your medical plan coverage level (i.e. employee plus one or family),
but you may not change or cancel your medical plan.
Additionally, you may be able to drop your medical coverage during the year if your position changes and you are no longer expected to
work at least 20 hours a week, or you become eligible for an open enrollment or special enrollment on a government health insurance
exchange. You will be required to certify that you will intend to enroll in other medical coverage. Please contact a Benefits Advisor at
1-866-886-9798 for more information.
HSA CHANGES
You may change your HSA contributions at any time during the year by logging on to www.AllegisMarketplace.com. A voluntary HSA
contribution change will take effect on the following week’s paycheck.
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Example 1: Example 2:
Employment Ends: June 8, 2018 Employment Ends: August 1, 2018
Benefit Coverage Ends: Midnight, Saturday, June 9, 2018 Benefit Coverage Ends: Midnight, Saturday, August 4, 2018
Disability, Life and AD&D coverage end on your last day of work. Your benefit coverage also ends when you are no longer eligible, when
you stop paying premiums, or when the group plan ends, whichever comes first. Coverage for dependents ends when they are no
longer eligible, when dependent coverage is no longer offered, or when your coverage ends. Please see the Eligibility section of this
guide for the definition of an eligible dependent.
COBRA information will be mailed to you when your COBRA eligible coverage ends. This information will come in the mail to you from
Kelly & Associates Insurance Group in Sparks, Maryland. You may want to verify that your address is correct in the Benefits System to
prevent any delays in receiving your information.
COBRA eligible plans include: BlueCross BlueShield Medical plans, Dental, Vision, and EAP.
Please note, Hospital Cost Protection Plans, Critical Illness Protection, and Accident Protection are not COBRA eligible plans. You
may elect to continue these plans after your Allegis Group coverage ends. Please contact Symetra for instructions.
Life Insurance, AD&D Insurance and Disability Insurance are also not COBRA eligible plans. However, you may elect to
continue Life Insurance and AD&D Insurance for yourself and your dependents under the Portability and Conversion
terms of the plan. You have 30 days to send your completed application to the Allegis Group Benefits Department.
Please refer to the plan certificate, which can be located on www.AllegisMarketplace.com for more details.
REINSTATEMENTS
If you are rehired within 30 days from the date your employment ended, you have the option to have your medical/prescription, dental,
and vision coverage reinstated without a lapse in coverage. In order to do so, you must contact the Benefits Service Center. You will
be reinstated with the same coverage and contributions you had prior to your employment ending. Please keep in mind, you will be
responsible for any missed weekly premiums—payment will automatically be made up with double deductions.
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HIGH DEDUCTIBLE
COVERAGE LEVEL BASIC PLAN COMPREHENSIVE DENTAL PLAN VISION PLAN
MEDICAL PLAN
Employee Only $181.12 $352.01 $28.93 $7.48
Please note, the Hospital Cost Protection Plans, Critical Illness Protection and Accident Protection are not COBRA eligible.
You may elect to continue these plans after your Allegis Group coverage ends. Please contact Symetra for instructions.
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Family $.210
*The costs shown above are per $10,000 of coverage.
Example: For an individual who chooses family AD&D coverage of $50,000, the weekly cost is $1.05 [$.210 (weekly rate for family coverage) times 5].
• To care for the employee’s child during the first 12 months following birth, adoption or foster care.
• To care for the employee’s spouse/domestic partner, child, child of domestic partner, or parent with a serious health condition.
• For incapacity due to the employee’s pregnancy or child birth.
• For the employee’s own serious health condition.
• Furthermore, qualified individuals may be eligible to take up to 26 weeks of unpaid Family and Medical Leave within a rolling 12
months period for the following reasons:
• To care for the employee’s spouse/domestic partner, child, child of domestic partner, parent or next of kin who is a service member
recovering from serious illness or injury sustained in the line of active duty.
• Due to a qualifying exigency arising because the employee’s spouse/domestic partner, child or parent is on active duty or has been
notified of an impending call to order to active duty in support of a contingency operation.
In addition to FMLA leave, employees may also be eligible for leave under a similar state law. For more information about the availability
of state leave, please contact the Benefits Service Center at 1-866-886-9798 or via email at Leave_Disability@allegisgroup.com.
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diagnosed within the six months before joining the STD plan, Example – For an individual age 36 with $480 in weekly pay, the weekly benefit is $288
and the weekly cost to the employee is $3.51.
including pregnancy. • The weekly STD benefit of $288 is based on 60% of the $480 weekly pay.
• Weekly premiums are calculated for every $10 of weekly benefit amount (i.e.
The cost of coverage is based on your age and weekly benefit $288/$10 = $28.80).
• Using the age of the employee (36) and the chart above, the premium multiplier
amount, as shown in the following chart. When completing your in this example is $.122.
new hire enrollment on www.AllegisMarketplace.com, you will • When the $.122 is multiplied by $28.80, the employee arrives at his/her weekly
premium of $3.51.
be able to automatically calculate your weekly STD premium.
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FILING CLAIMS
• Medical/Prescription/Dental/Vision Claims – If you see a • Life Insurance/Long Term Disability Claims – Follow the
participating provider, the provider will submit the claim to instructions on the appropriate claim form.
the insurance carrier. If you see a non-participating provider, • Short Term Disability Claims – Contact The Hartford at
you will pay the claim out-of-pocket and submit the claim to the number listed in the chart above or file a claim online at
the appropriate carrier using the appropriate claim form. www.TheHartford AtWork.com.
• Hospital Cost Protection Plans/Critical Illness Protection/
Accident Protection Claims – Mail a copy of your itemized All Claim Forms can be located in the Document Library
receipt for services (given to you by your provider to the under the Resource Center at www.AllegisMarketplace.com.
address on the claim form.
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_______ I understand that I have been given an offer of health care coverage, including medical coverage, by my
employer. I have received the summary of the benefit plans that explains the offer of this coverage and understand
that I am eligible to enroll in health care coverage following the applicable waiting period (which is the first
of the month coinciding with or following my hire date).
_______ I have received the notice titled “New Health Insurance Marketplace Coverage Options and Your Health Coverage.” I
understand that this notice indicates that my employer is offering me a medical plan that meets the requirements
of Minimum Value (as defined in the notice) and is intended to be affordable based on my wages.
_______ I understand that if my employer offers me the Minimum Value coverage noted above and that coverage
is affordable based on my wages that I am not eligible for a premium tax credit from any state or federal
healthcare marketplaces. If I receive a premium tax credit I am not eligible for, I will need to refund the
government for the credits. For more information on eligibility for premium tax credits, I can go to: http://www.
irs.gov/Affordable-Care-Act/Individuals-and-Families/Questions-and-Answers-on-the-Premium-Tax-Credit.
_______ I have received a Summary of Benefits and Coverage describing the medical benefits available to me. I understand
that this Summary of Benefits and Coverage indicates that my employer is offering me a medical plan that meets
the requirements of Minimum Value (as defined in the Summary of Benefits and Coverage).
_______ I acknowledge the Benefits Guide I received is only a summary of the benefits. Complete descriptions of the
plans are contained in the applicable plan documents. If there is any disagreement between the Benefits,
Guide, this acknowledgement and the wording of the applicable contract or plan document, the contract or
plan document will govern. Allegis Group, Inc. and its operating companies reserve the right to modify, amend,
suspend, or terminate any plan in whole or in part, at any time.
_______ I understand that I may access more information about the medical benefits available to me at any time by visiting
www.AllegisMarketplace.com or by calling 1-866-886-9798 to request a paper copy of relevant documents at
any time free of charge.
_______ I acknowledge if I choose to participate in the benefit for which I am eligible, I will need to visit
www.AllegisMarketplace.com or complete the required paper enrollment forms to enroll.
_______ I acknowledge that I have received the Notice of Automatic Contribution Arrangement and Qualified Default
Investment Alternative related to the Allegis Group 401(k) Plan. I acknowledge that if I would like more
information regarding the Allegis Group 401(k) Plan, I can visit www.AllegisMarketplace.com or go directly to
www.wellsfargo.com.
This acknowledgement does not constitute a guarantee of employment.
Please Note: If you enroll in benefits during the first month in which you are eligible to participate, your enrollment will be
retroactive to the first of the month and you will be double deducted from your paycheck for any missed weekly premiums.
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Kelly & Associates Insurance Group, Inc (KELLY) provides administrative services that include: billing, enrollment and call center
service for insurance benefits. The administration of benefits by KELLY does not guarantee coverage. Billing and collecting premi-
ums or sending payroll deduction files, does not constitute coverage being bound. Please refer to specific insurance carrier contract
for rules requiring evidence of insurability (EOI) or other underwriting requirements regarding final insurance carrier approval.
KELLY is not an insurer and is not responsible for paying insurance benefit claims relative to KELLY's involvement with billing
and collecting insurance premiums.
*This booklet summary is only intended as a brief summary of your benefits. Benefits are subject to the contractual terms,
limitations and exclusions as set forth in the master contracts.
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