Medical Plan B

ELIGIBILITY

If you are an active, full time employee working at least 30 hours per week and are classified as benefits eligible.

You must enroll online (see pages 6-7 in the Yellow Book for instructions) by November 15, 2024. You are effective for benefits on the first day of the month following two (2) full calendar months of employment. If you enroll, you may cover eligible dependents by proving dependent eligibility. Dependent Eligibility forms on the Enrollment site https://jmsmith.bcenroll.net > Posted Forms. If you enroll your spouse a Working Spouse Affidavit will be sent to you for completion.

Eligibility continues as long as you are a regular full time employee scheduled to work at least 30 hours per week.

PLAN A & PLAN B COVERAGE DIFFERENCES

Plan A offers the highest out-of-pocket expense protection, with lower deductibles and out-of-pocket maximums. Plan A may be right for you if you know you are going to receive medical treatment apart from occasional illness.
This plan pays 80% of charges with participating providers after you reach your deductible, with a maximum out of pocket amount. The majority of medical benefits are covered this way under the plan.

Plan B (copay) offers co-payments for physicians (up to a maximum). All other benefits are subject to the deductible and coinsurance. Plan B has a higher deductible and out-of-pocket costs. Plan B may be right for you if you do not expect major health care problems and would like the 100% copay option.

VISION COVERAGE

J M Smith Corporation includes routine vision exams as a preventive service under the medical plan. Benefits for routine vision exams are paid at 100%.

Lasik or Laser Eye surgery is covered under the J M Smith Corporation’s medical plan. It is subject to your plan deductible then 50% up to $1,000 per year when utilizing participating providers only. A $2,000 lifetime maximum applies.

PREFERRED PROVIDERS

Preferred providers are selected by the Preferred Provider Network (PPO) in your area. Simply log on to www.southcarolinablues.com with your Login ID and Password, and you’ll have access to a list of providers in your area, or by clicking on the link to your PPO.

CHECKING ON THE STATUS OF A CLAIM

You may check on the status of any claim with J M Smith Corporation by going to their website by clicking the link below. Be sure to have your Login ID and Password handy for quick access.

CONTINUING COVERAGE AFTER I STOP WORKING

You may continue coverage for you and your legal dependents at your own expense. Certain conditions apply. You will be provided with the proper forms, information, and costs upon leaving your employment with J M Smith Corporation.

SPECIAL NOTICES

HIPAA
Health Insurance Portability and Accountability Act (HIPAA) of 1996 Notice

Special Enrollment Information

This information is being provided to you pursuant to the Health Insurance Portability and Accountability Act (HIPAA) of 1996. It contains some special information regarding your rights to enroll for coverage under the medical plan in the future. This information is very important if you are currently declining coverage under the medical plan for yourself or for any of your dependents. We are required to provide you with this notice in order to comply with HIPAA.

If You are Declining Coverage Now

If you have decided to decline coverage for yourself or for any of your dependents (including your spouse), you may be able to enroll yourself and/or your dependents in this plan later, under some circumstances, without waiting for an open enrollment period.

Special Enrollment Allowed

You can enroll yourself and your dependents in this plan without waiting for an open enrollment period if:

1. You decline coverage under this plan because you have other health care coverage, then you lose the other coverage because you are no longer eligible or because the employer failed to pay the required premium. In such cases, you must enroll in this plan within 30 days after losing the other coverage.
2. You decline coverage under this plan and then a new dependent is added to your family due to marriage, birth, adoption, or placement or adoption. In such cases, you must enroll in this plan (or add your new dependent) within 31 days after the marriage, birth, adoption, or placement for adoption.

Any request must be consistent with the change in family status. For example, the birth or adoption of a child would permit enrollment in or change to family coverage.

Other Late Entrants

If you decide not to enroll in this plan now and then want to enroll later, you must qualify for special enrollment as described above. If you do not qualify for special enrollment, you will have to wait until an open enrollment period.
For more information, please contact your human resources administrator.

WHCRA

Women’s Health and Cancer Rights Act (WHCRA) Notice
Re: Health Plan Coverage for Reconstructive Breast Surgery under The Women’s Health and Cancer Rights Act of 1998
Since 1998, Congress has required that all health plans cover reconstructive surgery following a mastectomy. When a covered individual receives benefits for a mastectomy and decides to have breast reconstruction based on consultation between the attending physician and the patient, the health plan must cover:

• reconstruction of the breast on which the mastectomy was performed;
• surgery and reconstruction of the other breast to produce symmetrical appearance; and
• prostheses and physical complications of all stages of mastectomy, including lymphedema.

Our plan complies with the Federal mandate. This coverage will be subject to all other Plan provisions.