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The WLRA Employee Benefit Plan and Trust is an exci<ng program designed specifically for your industry! Discover for yourself how a comprehensive employee benefit plan can…

v  Help you aFract and retain employees v  Offer you the flexibility you need, at a price you can

afford v  Increase employee morale and loyalty to your company

Must have at least two employees par<cipa<ng. Other minimum par<cipa<on requirements may apply. Ask for details.

You can customize your plan by selec<ng from the following op<ons:

ü  Six major medical plans ü  Three dental plans ü  Two vision plans ü  Two limited benefit medical plans ü  Group Life Insurance

MANY of these programs require NO employer contribu<on unless you opt to co-‐fund with the employee – they are voluntary and may be 100%

employee paid.

Benefits may be offered to: FULL-‐TIME; PART-‐TIME; SEASONAL;

TEMPORARY; H2B; SALARIED; or HOURLY… or almost any combina<on of the above.

Marketed to Members by:

For more informa<on, please contact: Ken Konicek, Account Execu9ve

PO Box 829 ● Pinedale, WY 82941 ● Toll-‐Free 1-‐800-‐438-‐2121 ● Phone: (307) 367-‐2154 ● Fax (307) 367-‐2632

Rev. November 22, 2013

Be Our Guest Check Out the Benefits

Wyoming Lodging & Restaurant Association

Benefit Plan & Trust Benefit Plan & Trust Rev. November 22, 2013

The WLRA Benefit Plan and Trust

provides group Medical, Dental and Vision

programs for eligible members of the

WLRA which are uniquely designed for this

industry.

Plan Descrip9on A Summary of the WLRA Welfare Benefit Plan

Ø  A Welfare Benefit Plan which has been established under Internal Revenue Service code as well as

Department of Labor regula<ons. Ø  Plan contribu<ons are held in a Trust that is directed by a Board of Trustees, chosen from the

member par<cipants of the Plan. Ø  The Wyoming Lodging & Restaurant Associa<on Benefit Plan & Trust, the Plan Sponsor, and its Board

of Directors assigns a Plan Administrator, retains Legal Counsel, Accoun<ng & Audi<ng Services and other Administra<ve Services as needed for the management of the Plan, all working for the benefit of the par<cipants.

Ø  Claims are paid by the contracted Claims Administrator (TPA) as directed by applicable State and Federal laws, the Trust Document, the Plan Declara<on, and the Summary Plan Descrip<on(s) of the benefit programs offered and administered by the Associa<on. Full copies of these documents are available upon request.

Ø  The Trust contracts with insurance and/or reinsurance companies in order to ensure the overall financial stability of the Trust and the benefits offered. These contracts may change from <me to <me and are voted upon and approved by the Trust Board or its designee.

Ø  The benefits offered by the Plan are reviewed annually to determine their viability for the members and par<cipants. The WLRA Benefit Associa<on, with available contracted counsel and advice may alter these benefits, remove a plan of benefits completely and/or add new plans for considera<on, without the consent of par<cipa<ng employers or par<cipa<ng employees.

Ø  The Trust is par<cipant-‐owned along with any surplus or deficits incurred. Par<cipant employers are encouraged to review the applicable documents (Trust Document and Plan Declara<on) to ascertain applicable benefits and liability of becoming a par<cipant prior to applying for coverage.

Benefit Plan & Trust


Program Objec9ves ü  More stability in insurance premiums, now and in the future ü  Broader accessibility to health insurance and coverage op<ons within the

community ü  Crea<on of a community-‐wide wellness mindset and culture ü  Educa<on about access to a broader range of choices to promote beFer

healthcare decision making

Defined Contribu9on Healthcare IN A DEFINED CONTRIBUTION STYLE PLAN EMPLOYERS CHOOSE the amount of money to contribute toward a benefit plan… From the menu of benefit programs and associated pricing, the EMPLOYER decides how much of a premium to contribute per employee and/or employee with dependents. The amount of the actual rate increase is not based on the individual employer’s loss ra<o, but is based on the overall loss ra<o to the Trust and each benefit plan. EMPLOYEES CHOOSE the plan that best fits their need… From the same menu of benefit programs and associated pricing, the EMPLOYEE decides which benefit plan best meets his or her need. The employee’s applicable out-‐of-‐pocket premium cost is determined based on how much the employer contributes. If the employee chooses a plan which is more costly than the employer’s contribu<on, the difference is paid by the employee through payroll deduc<on. If the plan chosen by the employee is less costly than the employer’s contribu<on, the difference is contributed to a Health Reimbursement Arrangement (HRA) or Health Savings Account (HSA), depending on the benefit plan chosen. The employee may choose a new/different benefit program every year during the open enrollment period.

One benefit plan

DOES NOT fit all employee’s healthcare needs!

DEFINED CONTRIBUTION HEALTHCARE For years, employers have provided benefits for employees and planned for those benefits to meet the needs of those employees and their families. The challenge for employers is that healthcare has become much more specialized and variable while benefit programs have adhered to a more “one-‐size-‐fits-‐all” model. Due to the evolving benefit needs of employees and their families, benefit choices must be available for employees to choose from to fit their individual needs.

ENROLLMENT REQUIREMENTS/CONTINGENCIES v  The employer must be a member of the Wyoming Lodging and Restaurant

Associa<on prior to applying. v  Each employer must have a minimum of 70% of eligible employees

par<cipa<ng for groups of 5 or more, and 100% par<cipa<on for groups of 4 or less. Minimum group size is 2 employees (husband/wife teams are treated as 1 employee.)

v  Completed Employee Enrollment/Waiver Applica<ons are required from each employee in order to qualify. The en<re employer group will either be accepted or denied coverage.

v  The TRUST renewal date is July 1st of each calendar year. Regardless of when enrollment is completed, any changes to the TRUST rates and/or benefits will take place on July 1st. Open enrollment (the ability to add employees who waived coverage or dependents which had been previously waived) is during the month of June each year for each par<cipa<ng employer.

v  Premium contribu<ons are made by the employer directly into the Trust Account and are used as described in the Trust Document, Summary Plan Descrip<on and Plan Declara<on. The Trust is governed by a Board of Trustees, elected as described in the Trust Document.


Group Medical Plans

All Loca/ons Plan 1 Plan 2 Plan 3 Plan 5 Plan 6 Value Plan

Calendar Year Deduc9ble

Single Family

$250 $500

$500 $1,000

$1,000 $2,000

$2,500 $5,000

HSA Qualified $2,500 $5,000

HSA Qualified $6,000 $12,000

In-‐Network Benefit Co-‐Insurance % Out-‐of-‐Pocket Maximum (incl. ded.)

Single Family

100%

$250 $500

70%

$1,700 $3,400

70%

$2,200 $4,400

70%

$4,300 $8,600

100%

$2,500 $5,000

100%

$6,000 $12,000

Out-‐of-‐Network Benefit Co-‐Insurance % Out-‐of-‐Pocket Maximum (incl. ded.)

Single Family

80%

$2,650 $5,300

50%

$2,500 $5,000

50%

$3,000 $6,000

50%

$5,500 $11,000

90%

$3,000 $6,000

90%

$7,000 $14,000

Doctor Office Visit (In-‐Network)

Primary Care Physician Specialist

Subject to ded. & co-‐insurance

$30 co-‐pay $65 co-‐pay



Subject to ded. &

co-‐insurance


Prescrip9on Drug Card Generic Preferred Brand Name Non-‐Preferred Brand

Name Specialty Mail Order Program Specialty Mail Order Out-‐of-‐Pocket Limit

$7.50 Co-‐Pay – 32 day supply $25 Co-‐Pay – 32 day supply $75 Co-‐Pay – 32 day supply

$75 Co-‐Pay + 10% to a max co-‐Pay of $250/fill $15/$50/$150 – 92 day supply

$150 + 10% to a max Co-‐Pay of $500/fill Co-‐Pays do not accumulate toward ded. or out-‐of-‐pocket

maximum



Accident Benefit Covered at 100% to $500 per person/per accident, then subject to deduc<ble & co-‐insurance



Emergency Room Co-‐pay $150 Co-‐Pay waived if admiFed Subject to ded. &

co-‐insurance Subject to ded. & co-‐insurance

Maternity Subject to deduc<ble & co-‐insurance Op<onal: Addi<onal $7,500 deduc<ble for groups under 15 lives



Preventa9ve Care 100%, Deduc<ble Waived, In-‐Network

Subject to Deduc<ble & Coinsurance, Out-‐of-‐Network

In addi<on, the following services will be covered as Preven<ve Care: evidence-‐based items or services that have in effect a ra<ng of "A" or "B" in the current recommenda<ons of the United States Preven<ve Services Task Force; and immuniza<ons that are recommended from the Advisory CommiFee on Immuniza<on

Prac<ces of the Centers for Disease Control and Preven<on with respect to the Member or Dependent involved; and preven<ve care and screenings for infants, children, and adolescents, according to guidelines supported by the Health Resources and Services Administra<on; and in addi<on to the benefits or services listed above, addi<onal preventa<ve care and screening for women

according to the guidelines supported by the Health Resources and Services Administra<on.

Annual Maximum $2,000,000/covered par<cipant


Limited Health Benefit Plans

Benefits Plan 7 Plan 8

Overall Per Person Calendar Year Max $55,000 $25,000

Calendar Year Deduc9ble $0 $0

Wellness Benefit – Max Benefit of $150 Per Person Per Calendar Year $50 per Visit $50 per Visit

Physician Office Visits General Office Visits – 6 Visits Per Person Calendar Year Max Emergency Room – Sickness – Included in Office Visit Max

$75 $60

$50 $35

Emergency Room – Accident For treatment in an emergency room if performed within 72 hours of the accident

$500 (per occurrence)

$200 (per occurrence)

Lab & X-‐Ray Outpa9ent Outpa<ent X-‐Ray and Lab -‐ $450 Calendar Year Max Benefit $150/Test $50/Test

Surgery and Anesthesia – Scheduled Benefit Indemnity Inpa<ent – Calendar Year Max Per Person Outpa<ent – Calendar Year Max Per Person Anesthesiology

$2,500 $1,500

25% of surgery benefit

$1,000 $500

25% of surgery benefit

Daily Hospital Confinement Indemnity Calendar Year Maximum is 30 days per person $1,000 Per Day

1st Day $500, $250 Per Day Thereawer

Intensive Care Confinement Paid in addi<on to Daily Hospital Confinement Benefits Calendar Year Maximum is 30 days Per Person

$500 Per Day $250 Per Day

Outpa9ent Prescrip9on Drug Benefit Member pays 100% of discounted price for drugs

100% Co-‐Pay Discount Card

100% Co-‐Pay Discount Card

Life Insurance -‐ Employee Only $15,000 $15,000

Limited Benefits Plan LIMITED BENEFITS PLANS are designed specifically for: **Entry level **Part-‐<me workers **Seasonal workers These benefits are not intended to be comprehensive medical benefit plans, not to replace a major medical plan, but to provide employers with ability to provide benefits for those who may not have any benefits available. Plan are administered along with the major medical programs and dental programs of the Trust.


The Affordable Care Act prohibits health plans from applying arbitrary dollar limits for coverage for key benefits. This year, if a plan applies a dollar limit on the coverage it provides for key benefits in a year, that limit must be at least $750,000. Your health insurance coverage, offered by Wyoming Lodging and Restaurant Associa<on, does not meet the minimum standards required by the Affordable Care Act described above. Instead, it puts an annual limit of: $55,000 on Plan 7 and $25,000 on Plan 8 for all covered benefits. In order to apply the lower limits described above, your health plan requested a waiver of the requirement that coverage for key benefits be at least $750,000 this year. That waiver was granted by the U.S. Department of Health and Human Services based on your health plan’s representa<on that providing $750,000 in coverage for key benefits this year would result in a significant increase in your premiums or a significant decrease in your access to benefits. This waiver is valid for one year. If the lower limits are a concern, there may be other op<ons for health care coverage available to you and your family members. For more informa<on, go to: www.HealthCare.gov. If you have any ques<ons or concerns about this no<ce, contact Wyoming Lodging and Restaurant Associa<on at 307-‐634-‐8816.

Dental & Vision Benefit Plans

DENTAL Plan 1 Plan 2 Plan 3

Calendar Year Deduc9ble Single Family

$100 $300

$50 $150

$50 $150

Preven9ve & Diagnos9c Services 80%; ded waived 100%; ded waived 100%, ded waived

Basic Services Ded, then 50% Ded, then 80% Ded, then 80%

Major Services (Subject to a 6 month wai<ng period) Ded, then 50% Ded, then 50% Ded, then 50%

Orthodon9c Services For children to age 19 (Subject to a 6 month wai<ng period)

Not Covered Not Covered $50 ded ($150/family), then 50%

Orthodon9c Life9me Maximum N/A N/A $1,000

Annual Maximum Benefit $750 $1,000 $1,000

Sec/on 125 – Sec<on 125 of the Internal Revenue Code allows for the premiums paid by employees for employer provided group benefits to be withheld from employee pay on a pre-‐tax basis. The WLRA Benefit Plan qualifies as an employer sponsored group benefit plan that could be offered under an employer’s Sec9on 125 plan. However, before an employer can offer pre-‐tax premium payments for his or her employees, the employer must adopt a separate “Sec9on 125 Plan” and allow employees the right to choose whether they wish to par9cipate. The claims administrator for the WLRA Benefit Plan has sample documents and/or administra<on op<ons an employer may need, in order to adopt a pre-‐tax Sec<on in consulta<on with the employer’s tax counsel.


VISION Plan B Plan C

Eye Exam $10 co-‐pay Every 12 months

$10 co-‐pay Every 12 months

Prescrip9on Glasses $25 co-‐pay $25 co-‐pay

Lenses Every 12 months Every 12 months

Frames Every 24 months; $130 allowance plus 20% off amount over allowance

Every 12 months; $130 allowance plus 20% off amount over allowance

Contact Lenses (in lieu of prescrip<on glasses)

Every 12 months $130 allowance

Every 12 months $130 allowance

Coverage with Non-‐VSP Providers

Eye Exam – up to $45 Single Vision Lenses – up to $30 Lined Bifocal Lenses – up to $50 Lined Trifocal Lenses – up to $65

Frames – up to $70 Contacts – up to $105

Benefits available…but NOT limited to: Acupuncture for anesthesia purposes

Allergy tests and allergy injec<ons Ambulatory/Outpa<ent Surgery Facility Care

Anesthesia charges Assistant surgeon charges

(if required due to surgical aspects) Birthing Center

Blood and blood related products Cardiac Rehabilita<on

Chemotherapy for treatment of a malignancy Chiroprac<c Manipula<on or adjustment of the spinal column

Colonoscopy (Diagnos<c) Diabetes Educa<on Equipment and supplies for persons with

diabetes Durable Medical Equipment

(purchase of rental up to the purchase price) Elec<ve Steriliza<on

Emergency Room Hospital inpa<ent or outpa<ent services

Laboratory Services Mastectomy due to diagnosed breast cancer

Mental Health and Substance Use (to plan limits)

Nursing Services Occupa<onal Therapy Orthopedic braces Oxygen & the equipment for its administra<on Pathological Services Physical Therapy Prescrip<on drugs requiring a prescrip<on under federal law Professional ambulance service if medically necessary (includes air ambulance) Prosthe<c/Ortho<cs Radia<on Therapy Respiratory/Inhala<on Therapy Services of Physicians a)  Hospital visits b)  Doctor’s office calls c)  Doctor’s office surgery Speech Therapy (only to restore speech abili<es lost due to illness or injury) Surgery charges Vision Care following covered medical procedure to the eye Wig -‐ up to 1 per life<me due to administra<on of cancer treatment X-‐ray Services

This is a par<al lis<ng of the benefits provided under the medical plan and is NOT intended to provide complete details of benefits and limita<ons. Please refer to the Summary Plan Descrip<on (SPD) for details of benefits, limita<ons and the applicability of these benefits to each situa<on.

Benefits Exclusion: Abor<on

Acupuncture Charges for acupuncture or acupressure therapy

Adop<on or surrogate expenses Behavioral Counseling expenses

Biofeedback Therapy Blood handling and storage charges

Cosme<c surgery Chela<on Therapy

(except for heavy metal poisoning) Contracep<ves Devices

Correc<ve footwear Cosme<c services

Court ordered treatment Custodial care

Dental & Dental Implants Developmental delays

Discount Preferred Provider discount amounts or “cash discounts”

Educa<onal or voca<onal tes<ng Excess charges

Exercise Experimental or inves<ga<onal

Eyelid or Eyebrow Surgery Failure to keep appointments

Felonious Acts Charges resul<ng from or caused during the commission of a felony

Food Foot Care

Foreign medical care or Government provided services

Hair loss Hearing aids & exams Hypno<sm Liposuc<on Mailing expenses Marital counseling Massage therapy No obliga<on to pay No physician recommenda<on Non-‐prescrip<on items Not appropriate or not medically necessary Obesity Occupa<onal Personal comfort of convenience items Providing medical informa<on Rela<ve giving services Riot Sales tax Self-‐Inflicted, if not related to a medical condi<on Services before or awer coverage Sex changes Smoking cessa<on Surgical steriliza<on reversal Third Party liability Travel or accommoda<ons Unwanted hair Vision Care Visual training or orthop<cs War or Acts of War Worker’s Compensa<on

This is a par<al lis<ng of limita<ons and exclusions. A complete lis<ng, as well as suppor<ng details, is provided in the Summary Plan Descrip<on (SPD) supplied to each par<cipant.


BridgeHealth Surgery Benefit & Teladoc

BRIDGEHEALTH SURGERY BENEFITTM There are hospitals and physicians who through training and quality control measures perform their services to the very best levels. Many of these providers also contract with benefit plans for very aggressive pricing. When care is sought at these facili<es, for certain diagnosed condi<ons the Plan will alter the structure of how benefits are paid and include a travel allowance for the par<cipant and companion.


Teladoc physicians diagnose rou<ne, non-‐emergency medical problems via telephone, recommend treatment and prescribe medica<on when appropriate. You can access this service from anywhere. Simply log in to your Teladoc account or make a phone call to the 800 number. Teladoc consul<ng physicians treat illnesses that arise quickly and tend to run a brief course typically 5-‐10 days. Consul<ng physicians address acute episodes, and minor illnesses as approved chronic condi<ons such as hypertension, epilepsy or diabetes. and Teladoc can be used to treat problems such as: Teladoc Benefits Teladoc addresses key challenges facing healthcare today…below are just a few ways you can benefit from Teladoc Significant Cost Savings

Ø  No need to take <me off to see a doctor Ø  Access to care for rural residents and those who travel Ø  Consult with physicians who diagnose medical problems and prescribe

medica<on when appropriate Ø  Access to a physician within three hours or the consulta<on is free Ø  Physician consults at a frac<on of the cost of a physician office, urgent care or ER

visit Ø  Access to personal, portable and free electronic health record using HIPAA

compliant secure services Ø  Teladoc fees are FSA & HSA eligible expenses

When to Use Teladoc Call Teladoc whenever you need non-‐emergency medical assistance and cannot reach a primary care physician (Teladoc physicians do not replace the primary care physicians)

Ø  Your primary care physician’s office is closed Ø  Are on vaca<on or a business trip Ø  Need a recurring prescrip<on filled and don’t have <me to go to the doctor’s

office (short term refills only) Ø  Need medical aFen<on that might be resolved without seeing a primary care

physician or visi<ng the ER Ø  Have medical ques<ons, medical issues or concerns and would like to discuss

these with a physician Ø  Need a second opinion

Note: Teladoc consul<ng physicians do not prescribe DEA controlled medica<ons Teladoc does not replace the exis<ng primary care physician rela<onship Members must be at least 10 years of age to use the service (effec<ve 11/1/2008) Teladoc is not an insurance product or prescrip<on fulfillment warehouse

The Plan provides you and your eligible Dependents with an op<on to receive certain surgical procedures through the BridgeHealth Surgery Benefit when a trea<ng Physician recommends certain Covered Expenses and you or your eligible Dependent elects to receive treatment at certain medical providers par<cipa<ng in the BridgeHealth network (“BridgeHealth Providers”). Surgeries may include, but are not limited to: Joint procedures (knees, hips, shoulders and others) Heart surgeries (bypasses, valves, pacemakers and others) Spinal surgeries (fusions, discectomies and others) General surgeries: (prostate, thyroid, hysterectomy, and others) Addi<onal procedures are offered. Please call to learn more. Covered Expenses include all medical costs incurred under the BridgeHealth Surgery Benefit, with no Copay, Deduc<ble or Coinsurance applied, as well as transporta<on, lodging, meals and incidentals for the Covered Person and one (1) companion. (1) Transporta9on and lodging includes round trip transporta<on for the pa<ent and one (1) companion between the pa<ent’s home loca<on and the loca<on of the BridgeHealth Provider where treatment is to be performed; and hotel accommoda<ons near the BridgeHealth Provider. Hotel accommoda<ons are limited to one (1) room to be shared by the pa<ent and companion. All transporta<on and lodging must be reserved and scheduled through BridgeHealth Medical, Inc. (2) Meals and incidentals include a daily allowance calculated for the number of days the pa<ent and companion are at the des<na<on and is intended to cover incidental and “out-‐of-‐pocket” expenses incurred by the pa<ent in connec<on with his/her treatment. The meals and incidentals allowance shall be established and payable at ini<a<on of the travel associated with such treatment.

Teladoc (Plans 4, 5 & 6 Only) In an effort to provide par<cipants with the very best access to quality medical advice, the Teladoc program allows par<cipants to speak with a licensed physician in their State of Residence regarding certain diagnosis and health condi<on issues.

For addi<onal details regarding the benefits and limita<ons of these programs, please consult the Summary Plan Descrip<on.

Teladoc Services Teladoc for Plans 4-‐ 6 Teladoc is a network of state licensed, board cer<fied primary care physicians providing cross coverage consulta<ons 24 hours a day, 7 days a week, and 365 days a year.


•  Respiratory infec<ons •  Bronchi<s •  Gastroenteri<s

•  Urinary Tract infec<ons •  Pharyngi<s Sinusi<s •  Allergies RX Refill (short term only)


Submission Checklist To apply for coverage with the WLRA Benefit Plan and Trust, the following forms need to be submiFed: ü  Employer Applica9on: Completed in full and dated no more than 60 days prior to the requested effec<ve

date ü  Employee Applica9on: Completed in full. Any employee correc<ons must be ini<ated by the employee.

All medical ques<ons must be answered, details given, and, if requested, a ques<onnaire asking addi<onal details provided. Applica<ons must be dated no more than 60 days from the requested effec<ve date. Employee must complete waiver form for any eligible dependents who are not signing up for coverage.

ü  Unemployment Report: A copy of the employer’s most recent Quarterly Unemployment Report as filed for SUI, itemized by employee, must be included.

ALL FORMS MUST BE COMPLETED AND SIGNED FOR VERIFICATION.

Once the applica<on set is complete, it is forwarded to the Trust underwriter. The underwriter makes the decision whether the en<re group is accepted into the Trust or declined. If employer is approved, the following forms and informa<on is requested: ü  Acceptance Form: This form shows that the group has been accepted along with the names of the

employees who applied, the benefit plan chosen, the billed rates for that plan, and the group’s total premium per month. This form must be signed and returned by the employer within 1 week.

ü  First Month’s Premium: The first month’s premium must be submiFed (check made out to the Trust). Available bill payment op<ons are included (invoicing with either check payment, ACH payment or EFT payment).

ü  Adop9on Agreement: This contract outlines the obliga<ons of the Plan and the Employer, for the dura<on of the benefit plan. Two copies must be signed and returned. Both will be countersigned and one returned to the employer.


for$more$informaon,$please$contact:$ ken&konicek,&account ... · all,loca/ons plan1 plan2...

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