minimum essential coverage for newly eligible...

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REM I N I M U M E S S E N T I A L C O V E R A G E

FOR NEWLY ELIGIBLE EMPLOYEES

After you have reviewed this guide, log in to Workday to make your benefit elections

Important to Note: You are receiving this guide because you

qualify for the MEC Plan based on the hours you worked

1 of 9 ©2016 The Reinalt-Thomas Corporation

Last updated: 12/06/2016

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Dear Employee,

Discount Tire/America’s Tire/Discount Tire Direct (the Company) cares for and cultivates our people by providing options to help you stay healthy. Your wellness is important to us.

Please carefully review the three Minimum Essential Coverage (MEC) plan options to determine which plan might be right for you.

WHAT IS MINIMUM ESSENTIAL COVERAGE? Minimum Essential Coverage, or MEC for short, is coverage that satisfies the Individual Mandate under the Affordable Care Act (ACA). An individual is required to have coverage under this law or they may pay a penalty tax. This MEC Plan you are being offered will satisfy this requirement.

Each year, your eligibility for the MEC plan is reevaluated based on hours you worked. When you log in to Workday, you will see an Inbox notification to start your enrollment process.

Please note: You must enroll in one of the MEC Medical plans in order to elect the optional Dental/Vision Insurance, Life Insurance, and/or Disability Insurance.

Refer to the enclosed Workday MEC Enrollment Quick Reference Guide (QRG) for instructions.

M E C E N R O L L M E N T



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M E C E L I G I B I L I T YE L I G I B I L I T YWho is Eligible to Enroll for Minimum Essential Coverage (MEC) Benefits?

Employees:Part-time employees are eligible for the Company’s benefit plans based on the number of hours worked over the past 12 months.

Dependents:Eligible dependents include your legal spouse and children up to age 26. The definition of “child” includes any of the following:

� Your child / stepchild

� A child placed with you for adoption

� Your legally adopted child

� A child for whom you have legal guardianship

� Your child for whom health coverage is required through a Qualified Medical Child Support Order (QMCSO)

Information About Making Mid-year Changes:Please enroll your covered dependents in Medical and Dental/Vision if needed. This is the only time during the year you may do so, unless a qualifying life event occurs in your family or employment status.

Once a qualifying life event occurs, you have 31 days from the date of the event (or 60 days in the event of Children’s Health Insurance Program) to log in to Workday to submit the changes to your benefits elections and upload your supporting documents (i.e. birth certificate, marriage certificate, Social Security card, etc.). Changes will be effective on the date of the qualifying event.

If you do not submit your changes within 31 days, you may not be eligible to change your benefit elections until the next open enrollment. The table below outlines Qualifying Life Events and the documentation needed to make changes to your elected benefits.

Qualifying Life Event Documentation Required

A change in marital status:

�Marriage � Divorce � Death of Spouse

�Marriage Certificate and Social Security card � Divorce Decree � Death Certificate

A change in the number of your dependents:

� Birth or adoption � Death of a dependent � Dependent(s) obtain their own coverage

� Birth Certificate/Adoption Agreement and Social Security card � Death Certificate � Proof of other coverage and effective date

Termination or commencement of employment by employee, spouse, or dependent

Documentation from the employer confirming prior coverage and effective date

Any significant change in your family’s health care plan coverage through your spouse’s health care plan

Documentation from spouse’s employer confirming change in coverage and effective date of change

A dependent child exceeds the maximum age for coverage Benefits for dependents over age 26 are automatically terminated the last day of the month of their 26th birthday



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Value Standard Premier

Preventive Services* 63 procedures are covered at 100% when using an

in-network provider

63 procedures are covered at 100% when using an

in-network provider

63 procedures are covered at 100% when using an

in-network provider

Additional Preventive Care (in addition to the 63 procedures cov-ered at 100%, you may be eligible for additional preventive care coverage based on your election)

Not Included $100 per day, 1 day per year $100 per day, 1 day per year

Office Sick Visits $10 co-pay per visit 5 visits per calendar year

$10 co-pay per visit 5 visits per calendar year

$10 co-pay per visit 5 visits per calendar year

Additional Doctor’s Office Benefit $60 per day 6 days per calendar year

$60 per day 6 days per calendar year


Daily In-Hospital Indemnity $200 per day 500 days lifetime max

$300 per day 500 days lifetime max

$600 per day 500 days lifetime max

Intensive Care $400 per day 30 days per calendar year max

$600 per day 30 days per calendar year max

$1,200 per day 30 days per calendar year max

Mental Illness $100 per day 30 days per calendar year max



Substance Abuse $100 per day 30 days per calendar year max



In-Patient Skilled Nursing $100 per day 60 days per in-patient stay max

$150 per day 60 days per in-patient stay

$300 per day 60 days per in-patient stay max

Surgical Indemnity Benefit • Daily Inpatient Surgical • Daily Outpatient Surgical • Daily Outpatient Minor Surgical • Outpatient Benefit Maximum • Anesthesia

Not Included

$500 per day, 1 day per year $250 $50

1 day per year 30% of Surgical Benefit

$1,000 per day, 1 day per year $500 $100

1 day per year 30% of Surgical Benefit

Outpatient Diagnostic X-Ray $50 per testing day 3 days per calendar year

$75 per testing day 3 days per calendar year


Outpatient Diagnostic Lab $50 per testing day 3 days per calendar year



Outpatient Diagnostic Advanced Studies

N/A$100 testing per day

3 days per calendar year$300 testing per day

3 days per calendar year

Emergency Room Sickness $75 per day 4 days per calendar year



Life + AD&D Insurance • Employee • Spouse (Life Only) • Child (Life Only) • Infant (Life Only)

$5,000 $2,500 $1,250 $200

$5,000 $2,500 $1,250 $200

$5,000 $2,500 $1,250 $200

Accident Expense Benefit $1,000 per occurrence $1,000 per occurrence $2,500 per occurrence

Critical Illness Benefit $5,000 Employee $2,500 Spouse

$1,250 Child

$5,000 Employee $2,500 Spouse

$1,250 Child

$5,000 Employee $2,500 Spouse

$1,250 Child

* This benefit not underwritten by Nationwide Life Insurance

M E C M E D I C A L C O V E R A G E O P T I O N S



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C O V E R E D P R E V E N T I V E S E R V I C E S

COVERED PREVENTIVE SERVICES FOR ADULTS1. Abdominal Aortic Aneurysm one-time screening for men of specified ages

who have ever smoked2. Alcohol Misuse screening and counseling3. Aspirin use for men and women of certain ages4. Blood Pressure screening for all adults5. Cholesterol screening for adults of certain ages or at higher risk6. Colorectal Cancer screening for adults over 507. Depression screening for adults8. Type 2 Diabetes screening for adults with high blood pressure9. Diet counseling for adults at higher risk for chronic disease

10. HIV screening for all adults at higher risk11. Immunization vaccines for adults--doses, recommended ages, and

recommended populations vary: Hepatitis A; Hepatitis B; Herpes Zoster; Human Papillomavirus; Influenza (Flu Shot); Measles, Mumps, Rubella; Meningococcal; Pneumococcal; Tetanus, Diphtheria, Pertussis; Varicella

12. Obesity screening and counseling for all adults13. Sexually Transmitted Infection (STI) prevention counseling for adults at

higher risk14. Tobacco Use screening and cessation interventions for tobacco users15. Syphilis screening for all adults at higher risk

COVERED PREVENTIVE SERVICES FOR CHILDREN1. Alcohol and Drug Use assessments for adolescents2. Autism screening for children at 18 and 24 months3. Behavioral assessments for children of all ages4. Blood Pressure screening5. Cervical Dysplasia screening for sexually active females6. Congenital Hypothyroidism screening for newborns7. Depression screening for adolescents8. Developmental screening for children under age 3, and surveillance

throughout childhood9. Dyslipidemia screening for children at higher risk of lipid disorders10. Fluoride Chemoprevention supplements for children without fluoride in

their water source11. Gonorrhea preventive medication for the eyes of all newborns12. Hearing screening for all newborns13. Height, Weight and Body Mass Index measurements14. Hematocrit or Hemoglobin screening for children

15. Hemoglobinopathies or sickle cell screening for newborns16. HIV screening for adolescents at higher risk17. Immunization vaccines for children from birth to age 18 —doses,

recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis; Haemophilus influenzae type b; Hepatitis A; Hepatitis B; Human Papillomavirus; Inactivated Poliovirus; Influenza (Flu Shot); Measles, Mumps, Rubella; Meningococcal; Pneumococcal; Rotavirus; Varicella

18. Iron supplements for children ages 6 to 12 months at risk for anemia19. Lead screening for children at risk of exposure20. Medical History for all children throughout development21. Obesity screening and counseling22. Oral Health risk assessment for young children up to 10 years23. Phenylketonuria (PKU) screening for this genetic disorder in newborns24. Sexually Transmitted Infection (STI) prevention counseling and screening

for adolescents at higher risk25. Tuberculin testing for children at higher risk of tuberculosis26. Vision screening for all children

The above list is subject to change per government agency

COVERED PREVENTIVE SERVICES FOR WOMEN, INCLUDING PREGNANT WOMEN1. Anemia screening on a routine basis for pregnant women2. Bacteriuria urinary tract or other infection screening for pregnant women3. BRCA counseling about genetic testing for women at higher risk4. Breast Cancer Mammography screenings every 1 to 2 years for women over 405. Breast Cancer Chemoprevention counseling for women at higher risk6. Breastfeeding comprehensive support and counseling from trained providers,

as well as access to breastfeeding supplies, for pregnant and nursing women7. Cervical Cancer screening for sexually active women8. Chlamydia Infection screening for younger women and other women at

higher risk9. Contraception: Food and Drug Administration-approved contraceptive

methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs

10. Domestic and interpersonal violence screening and counseling for all women11. Folic Acid supplements for women who may become pregnant

12. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes

13. Gonorrhea screening for all women at higher risk14. Hepatitis B screening for pregnant women at their first prenatal visit15. Human Immunodeficiency Virus (HIV) screening and counseling for sexually

active women16. Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three

years for women with normal cytology results who are 30 or older17. Osteoporosis screening for women over age 60 depending on risk factors18. Rh Incompatibility screening for all pregnant women and follow-up testing for

women at higher risk19. Tobacco Use screening and interventions for all women, and expanded

counseling for pregnant tobacco users20. Sexually Transmitted Infections (STI) counseling for sexually active women21. Syphilis screening for all pregnant women or other women at increased risk22. Well-woman visits to obtain recommended preventive services



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O T H E R B E N E F I T O P T I O N S

Dental

Annual Deductible $50 per covered person

Annual Maximum $500 per covered person

Co-Insurance

Type 1 - Preventive and Diagnostic (routine exam and cleanings, fluoride treatments, x-rays)

Type 2 - Basic Treatments (extractions, fillings,

endodontics, periodontics)

Type 3 - Major Treatment (crowns and dentures)

Plan pays 80% of Usual and Customary Rate (no waiting period)

Plan pays 80% of Usual and Customary Rate (3 month waiting period)

Plan pays 50% of Usual and Customary Rate (no waiting period)

Orthodontia Plan pays 50% of Usual and Customary Rate, Lifetime Maximum of $250

Vision

Co-Insurance Plan pays 80%

Benefit Maximum $150 calendar year max per covered person

Benefit Frequency1 exam every 12 months1 pair of glasses or contacts every 24 months

Life/AD&D Insurance

Life/AD&D Insurance $20,000 (employee only, age restrictions apply)

Short Term Disability

Short Term Disability (STD)Pays up to 66 2/3% of your pre-disability income up to $300 per week. You must satisfy a 14 day waiting period and then benefits will pay for up to 26 weeks should you become disabled due to a non-occupational injury or illness.

R AT E S

Benefit EmployeeEmployee + Spouse

Employee + Child(ren)

Family

MED

ICA

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OIC

ES

Value Plan $12.41 $26.04 $22.54 $31.13

Standard Plan $17.92 $37.77 $31.59 $43.13

Premier Plan $24.84 $55.11 $43.71 $61.08

OPT

ION

AL

BEN

EFIT

S Dental/Vision $5.75 $14.38 $10.35 $14.92

Life/AD&D $1.98 N/A N/A N/A

Short Term Disability (STD) $3.33 N/A N/A N/A

You must enroll in one of the medical plans in order to elect Dental/Vision Insurance, Life Insurance, and/or Disability Insurance.

Premiums will be paid through payroll deductions every week. See the table below for the weekly deduction amounts.



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F R E Q U E N T LY A S K E D Q U E S T I O N S

WHAT DOESN’T THE MEC PLAN COVER? The MEC plans offered provide limited benefit coverage and may not be right for everyone. These plans differ from comprehensive major medical insurance, and are not intended to replace major medical insurance.

CAN I USE ANY DOCTOR? No, with the MEC Plan you are required to see a First Health Network Provider. The MEC Plan will only cover claims when a First Health Network Provider is used. You can call Member Services at 1-855-495-1190 for assistance in finding Network Providers or log on to www.yourmedbenefits.com.

WHAT WILL HAPPEN IF I DON’T SIGN UP? If you don’t have qualifying medical coverage, you may be subject to Individual Mandate tax penalties when you file your taxes. The penalty is a flat dollar amount or percentage of your annual income, whichever is greater. The flat dollar and percentage fees are established by the IRS and rise with inflation. Visit www.healthcare.gov to view penalty amounts for the current year.

IS THIS SIMILAR TO COVERAGE AVAILABLE ON THE HEALTHCARE.GOV EXCHANGE? Research what medical plan options are available to you. You may be eligible for subsidies through the Marketplace website at www.healthcare.gov. For further assistance with your choices for medical plans through the Marketplace, you may contact Mylo, a free service provided to you by the Company at 844-893-9889.

HOW DO I SUBMIT A MEDICAL CLAIM? There are two ways to file a claim for benefits under this plan:

Option 1: Present your ID card to the provider at the time of service. If the provider will file the claim with the insurance company on your behalf, then you do not have to pay for the services in advance. The insurance carrier will pay that benefit to the provider. You would be responsible for paying the provider any billed amount that the insurance company does not pay them.

Option 2: Pay the full billed amount to the provider and submit a claim for reimbursement to the insurance carrier. When filing a claim for reimbursement, you need to provide the certificate or member number from your insurance booklet and the original bill for service which includes the patient name, date of service, diagnosis code and itemized charges, along with a reimbursement form. The benefit will be payable to you.

ONLINE RESOURCES FOR EMPLOYEES AND FAMILIESHave you visited www.discounttirefamily.com yet? The Discount Tire Family website can be accessed from work or at home; for more information on Minimum Essential Coverage, simply type “MEC” in the search box. Browse the site to stay informed and up-to-date on:

Employee Benefits and Assistance

Financial Resources

Health and Wellness

Discount Tire In the News

Healthy Recipes

And more!



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A D D I T I O N A L P R O G R A M S

FIRST HEALTH NETWORK The First Health Network provides access to one of the nation’s largest and most respected networks. By going to a First Health Provider you can reduce your out-of-pocket expenses and stretch your benefit dollars.

� Access to more than 490,000 provider locations across all 50 states and the District of Columbia

� First Health logo on medical ID card for fast and easy recognition by the provider

� Re-priced claims will be assigned directly to the provider to simplify the claims process

To find a provider online, visit www.yourmedbenefits.com. Members retain the ability to choose any doctor they wish and have those claims assigned under the illness and accident plans. All illness and accident benefits will pay as specified in the benefit provisions of the policy regardless of the provider chosen.

The MEC Preventive Plan requires First Health Network use.

DISCOUNT HEALTH SAVINGS PROGRAM Your membership provides significant savings on the following services:

� Vision

� Hearing

� Chiropractic

� Vitamins & Diabetic Supplies

In addition, members also receive access to the following:

� Teladoc

� Health Advocate Services (Medical Bill Saver™, Medical Health Advisor, Nurseline™)

� Telephonic Counseling Services

TELADOC Teladoc provides 24/7 access to a national network of U.S. board-certified doctors who can resolve many of your medical issues via telephone at no additional charge to you. Teladoc doctors can diagnose, treat and prescribe medication, when necessary, for medical issues including cold and flu symptoms, allergies, bronchitis, sinus problems, urinary tract infection, respiratory infection, pink eye, ear infection and more! More information on how to access services will be sent in your welcome kit.

HEALTH ADVOCATE SERVICES Medical Bill Saver™ - The Health Advocate Medical Bill Saver™ benefit can lower out-of-pocket costs on medical bills not covered by insurance. Advocates will work with healthcare providers and attempt to lower the balance on any uncovered medical or dental bill over $400.

Medical Health Advisor - The services are organized around Personal Health Advocates, typically registered nurses, supported by a team of medical directors and administrative experts, who assist individuals in getting the most value from their healthcare benefits. One call to Medical Health Advisor and we’ll help members resolve insurance claims and billing issues. Health Advocate does not replace health insurance, provide medical care or recommend treatment.

DISCOUNT PRESCRIPTION PROGRAM The neighborhood pharmacy program assures members the lowest price on prescription drugs, saving 10% to 85% on most prescriptions. It’s simple to use. The member simply presents the membership card to the pharmacist with the prescription. The pharmacist calculates the discount and the member pays the discounted price. No other forms required. Pharmacy locations may be obtained by contacting customer service at 800-800-7616. Pharmacy Discounts are Not Insurance and are Not Intended as a Substitute for Insurance. The discount is only available at participating pharmacies.



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I M P O R T A N T N O T I C E S

The Nationwide program is not intended or recommended to replace any comprehensive program of insurance in which you currently participate, or intend to participate. This plan is not designed to replace or provide major medical or catastrophic coverage.

This brochure is for summary purposes only. The insurance benefits for the medical indemnity plan are offered by Nationwide Life Insurance Company. Additional information will be provided upon enrollment in the Program. Plan exclusions and limitations apply.

The Discount Health Savings Program and Discount Prescription Program are administered by New Benefits, Ltd.

DISCLOSURES The Discount Health Savings Program is Not Insurance The plan is not insurance coverage and does not meet the minimum creditable coverage requirements under the Affordable Care Act or Massachusetts M.G.L. c. 111M and 956 CMR 5.00. This plan provides discounts at certain healthcare providers for medical services. This plan does not make payments directly to the providers of medical services. The plan member is obligated to pay for all healthcare services but will receive a discount from those healthcare providers who have contracted with the discount plan organization. This discount card program contains a 30 day cancellation period. The range of discounts for medical or ancillary services provided under the plan will vary depending on the type of provider and medical or ancillary service received. Member shall receive a full refund of membership fees if membership is cancelled within the first 30 days after the effective date. AR and TN residents: A refund of all fees will be issued if membership is cancelled within the first 30 days. Discount Medical Plan Organization: New Benefits, Ltd., Attn.: Compliance Department, PO Box 671309 Dallas, TX 75367-1309, 800-800-7616. Website to obtain participating providers: MyMemberPortal.com.

Teladoc is not available to Idaho residents. © 2014 Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are registered trademarks of Teladoc, Inc. and may not be used without written permission. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services. Teladoc phone consultations are available 24 hours, 7 days a week while video consultations are available during the hours of 7 a.m. to 9 p.m., 7 days a week.

Minimum Essential Coverage (MEC) Preventive Information This Plan is designed to provide Plan Participants with minimum essential coverage under the federal income tax rules. This Plan is designed so that Plan Participants may enroll in this Plan and not have to pay a federal individual income tax penalty. However, while you are enrolled in this Plan, you will not be eligible for a federal tax credit though a federal or state exchange (sometimes referred to as the insurance marketplace). If you do not enroll in this Plan, you may be eligible for a federal tax credit that lowers your monthly premium or a reduction in certain cost-sharing if you enroll in a health insurance plan through the federal or state exchange.

NETWORK BENEFITS ONLY IMPORTANT: This Plan only pays benefits if you receive care through a Network Provider. No benefits are paid or provided if you receive care from an out of network provider.



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