Healthcare Benefits Enrollment Application Template - with no RX

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Congratulations! You are now eligible to enroll in group healthcare insurance products only offered through your employer.

Please click the link below to view the benefits you are eligible to enroll in, and either accept or decline each of them.

This is a required step in order to complete the new hire and rehire process.

Fixed Indemnity Medical Plan 

Covers the most common medical expenses at an easy-to-afford price. 

Without copays, deductibles, or waiting periods, Fixed Indemnity Medical Plan pays a flat amount for each covered claim such as: Doctor’s Office Visits, Emergency Room, Lab & X-Rays, Urgent Care, Outpatient Surgery, Inpatient Care and Ambulance Service. 

This is our most popular plan option as it offers highly usable benefits. 

The fixed indemnity plan is not a major medical plan designed to meet certain minimum essential coverage requirements.  It is a supplemental insurance plan that provides a limited, fixed dollar per day or occurrence amount for certain basic, health care costs. 

Dental

• No Waiting Period
• Cleanings and Exams
• X-Rays
• Filling and Crowns
• Oral Surgery
• Periodontal and Endodontics

Vision

• Exams
• Frames
• Lenses
• Contact Lenses
• Network Discounts

Term Life

• Term Life Benefits for Employees
• Term Life Benefits for Spouse and Dependent Children

Short-Term Disability

• 26 Weeks of Coverage
• No Waiting Period for Injury
• 7 Day Waiting Period for Sickness

Accident

• Emergency Care
• Ambulance
• Rehabilitative Therapy
• Durable Medical Equipment
• X-Rays

Critical Illness

• Heart Attack and Stroke
• Cancer
• Major Organ Transplant
• Kidney Failure

Hearing

• Hearing Examination, one per 12 consecutive month period
• Hearing Aid, one per ear, per 24 consecutive month period
• No waiting period

Minimum Essential Coverage (MEC) 

Preventive Wellness Plan 

The Minimum Essential Coverage (MEC) plan meets the Affordable Care Act's definition of minimum coverage.

This plan DOES NOT cover medical services. It provides coverage for preventive services such as immunization and routine health screening. It does not cover conditions caused by accident or illness.
Associates are able to select a different coverage level than the selected Fixed Indemnity and ancillary coverage level.

Enrolling in the Optional MEC Wellness/Preventive Benefit may DISQUALIFY you from receiving a subsidy from the health insurance exchange. This benefit is offered and provided by your employer. Note: The Patient Protection and Affordable Care Act (PPACA) individual mandate no longer imposes a penalty at the federal level; however, please check with your state for any state specific individual mandate requirements or penalties.

Availability of Summary Health Information for Minimum Essential Coverage Plan 

Choosing a health coverage option is an important decision. To help you make an informed choice, your plan makes available a Summary of Benefits and Coverage (SBC), which summarizes important information about any health coverage option in a standard format, to help you compare across options.

  1. Your SBC is available for viewing upon request and Free of Charge at your employers local office.
  2. The SBC is also be available upon request and Free of Charge by contacting PAI Customer Service at 1-866-798-0803.
  3. A sample electronic version of your SBC can be accessed at: https://www.paisc.com/productsservices/specialty-administration/aca-plans.

For more information, please refer to our FAQs.

 

Minimum Essential Coverage (MEC) Plus Covered Benefits (ACA Compliant Plan)

The MEC Plus Plan benefits include the following per day benefits and preventative services:

  • Doctor’s Office Visits
  • Prescription Drugs
  • Wellness
  • Outpatient Diagnostic Labs and X-Rays
  • Ambulance
  • Emergency Room for Injuries and Sickness
  • Inpatient and Outpatient Surgery
  • Anesthesia for Inpatient and Outpatient Surgery
  • First Day Admission and Daily Hospital Confinement
  • Skilled Nursing Facility Confinement
  • 100% for in-network and 40% for out of-network preventive services for Adults, Women and Children. For more information about the covered preventive service, please visit  https://www.healthcare.gov/coverage/preventive-care-benefits/

Enrolling in the MEC Plus Plan may DISQUALIFY you from receiving a subsidy from the health insurance exchange. Note: The Patient Protection and Affordable Care Act (PPACA) individual mandate no longer imposes a penalty at the federal level; however, please check with your state for any state specific individual mandate requirements or penalties.

Availability of Summary Health Information for Minimum Essential Coverage Plan 

Choosing a health coverage option is an important decision. To help you make an informed choice, your plan makes available a Summary of Benefits and Coverage (SBC), which summarizes important information about any health coverage option in a standard format, to help you compare across options.

  1. Your SBC is available for viewing upon request and Free of Charge at your employer’s local office.
  2. The SBC is also be available upon request and Free of Charge by contacting PAI Customer Service at 1-866-798-0803.
  3. A sample electronic version of your SBC can be accessed at: https://www.paisc.com/productsservices/specialty-administration/aca-plans.

For more information, please refer to our FAQs.