Maintenance Manager Assistance Program
Resume:
Employee Information – Please PRINT:
SSN: - -
Last Name: First Name:
Birth Date:
Hire Date:
Address (street):
Apt/Suite #:
City:
State:
ZIP:
Phone: -
Email:
Gender:
Marital Status:
Job Class: Crew Maintenance Manager
2024 Enrollment / Change Form
All employees (FT or PT) are eligible to enroll in the following coverage: Reimbursement Assistance Program (RAP), Dental, Vision, Basic Term Life, Supplemental Life, Short and Long Term Disability.
Covered Dependents: List all members to be added or voluntarily deleted (mark A for add or D for delete for each benefit).
Dental
Vision
Supp. Dep. Life
RAP
Name (and address if not residing with employee)
Date of Birth
Gender
Relationship
Social Security Number
Disabled
Medicare- eligible
A
D
A
D
A
D
A
D
Y
N
Y
N
A
D
A
D
A
D
A
D
Y
N
Y
N
A
D
A
D
A
D
A
D
Y
N
Y
N
Reason for Enrollment:
Newly Eligible (Coverage is effective the first of the month following a two month waiting period.)
Annual Open Enrollment Period (Coverage is effective January 1st)
Life Event: Date of Event _ _ / _ _ / _ _ _ _ (must choose event type below)
Birth of Child/Adoption (attach proof of birth/adoption)
Marriage (attach marriage license)
Loss of other Health Coverage (attach proof of loss/certificate of coverage)
2024 Bi-Weekly Benefit Costs
Dental:
We offer two different dental plans, comprehensive and preventive.
See next page for bi-weekly costs.
Vision:
Single: $2.54
Employee + Spouse/ Domestic Partner: $5.08
Employee + Child(ren): $5.08
Family: $7.35
RAP High Option:
Single: $30.46
Employee + Spouse/ Domestic Partner: $57.88
Employee + Child(ren): $50.56
Family: $77.06
RAP Low Option:
Single: $23.02
Employee + Spouse/ Domestic Partner: $43.74
Employee + Child(ren): $38.22
Family: $58.24
Are you eligible for Medicare? Yes
No
Short Team and Long Term Disability
Cost is based on current wage - See additional rate information on back.
Supplemental Employee Term Life/AD&D
Supplemental Spouse/Dependent Term Life
Supplemental Dependent Child(ren) Term Life
Cost is based on current wage - See additional rate information on back.
New hires can enroll following a 1 month waiting period. Coverage is effective the first of the month following the waiting period. Existing employees can enroll in any of the benefits by completing this form during Annual Open Enrollment. Employees experiencing a life event or loss of coverage can enroll within 31 days of the event.
Dental, Vision and RAP Coverage Elections:
Comprehensive Dental :
Single ($16.77 bi-weekly)
Employee + Spouse/ Domestic Partner ($35.18 bi-weekly)
Employee + Child(ren) ($38.56 bi-weekly)
Family ($75.42 bi-weekly)
DECLINE COVERAGE
Preventive Dental:
Single ($12.44 bi-weekly)
Employee + Spouse/ Domestic Partner ($26.11 bi-weekly)
Employee + Child(ren) ($28.60 bi-weekly)
Family ($55.94 bi-weekly)
DECLINE COVERAGE
Vision:
Single
Employee + Spouse/ Domestic Partner
Employee + Child(ren)
Family
DECLINE COVERAGE
Reimbursement Assistance Program (RAP):
High Option Low Option
Low Option
DECLINE COVERAGE
Reimbursement Assistance Program (RAP) coverage type:
Single Employee + Spouse/Domestic Partner Employee+Child(ren) Family
Employee + Child(ren) Family
Life and Disability Coverage Elections
Supplemental Employee Term Life/AD&D:
1x annual earnings 2x 3x 4x 5x
6x 7x 8x 9x 10x Decline
Supplemental Spouse/Dependent Term Life:
(Supplemental Employee Term Life required)
10,000 15,000 25,000 50,000
75,000 100,000 Decline
Supplemental Dependent Child(ren) Term Life:
(Supplemental Employee Term Life required)
Enroll
Decline
STD500:
Enroll
Decline
STD1000:
Enroll
Decline
Long-Term Disability:
Enroll
Decline
Beneficiary Information
The person(s) you name below will receive any Basic Term Life and Supplemental Term Life benefits that are payable at your death. If you name more than one beneficiary, they will share equally in any death benefit unless you specifically designate otherwise. Any previous beneficiary designation is automatically revoked.
Name (First, Last)
Beneficiary Address
Relationship
Allocation
Percent
Primary
Contingent
%
Primary
Contingent
%
Primary
Contingent
%
Employee Signature
Signature: Date:
Return completed enrollment form to your manager and ask them to scan it to Shawn Senn in Human Resources. You may also email your enrollment form to:
*****.****@*******************.***.
You can visit www.McDRMHCBenefits.com at any time during the year to get more details about your benefits and enrollment. The site is mobile-friendly and no password is needed! You may also contact Shawn Senn at 608-***-****.
Get Started: McDonald’s Licensees Online Enrollment Instructions
Go to McDRMHCBenefits.com — the site is your one-stop for all benefits information! When you’re ready to enroll for 2024 benefits, simply click “Plan Participants” then click the link to the Participant Enrollment Site, where you will need to log in. Need help logging in? Call the Participant Support Line at 866-***-****.
This year, the Plan will use a newly enhanced enrollment website, so everyone must create a new account to register.
1.Under “New Users,” click “Get Started.”
2.You will be prompted to enter the last 4 of your SSN, Last Name, Date of Birth, Country, Zip Code, and complete a reCAPTCHA security check.
3.You will then select the email on file or phone number on file to receive your verification code and set up Multi-Factor Authentication.
4.You will then select your username and create your password.
If you do not have an email on file, you will be prompted to enter the last 4 of your SSN, Last Name, Date of Birth, Country, Zip Code, and complete a reCAPTCHA security check. You will then enter your email and be sent a verification code. You will then select your username and create your password.
If your email address on file is incorrect, you will be prompted to enter the last 4 of your SSN, Last Name, Date of Birth, Country, Zip Code, and complete a reCAPTCHA security check. When prompted to send a code to the email or phone number on file, click “I don’t have access to these anymore. Help me!” link. You will then be prompted to answer 3 to 4 security questions to verify your identity. You will then enter your email, and be sent a verification code. You will then select your username and create your password.
Enroll For 2024 Benefits
After logging into the site, you will have the opportunity to review all your benefits information for the 2024 plan year. If you’re enrolling a new dependent, you’ll need to provide verification that the dependent is eligible (Your Federal 1040 or State income tax return) to Mercer. If you don’t submit documentation, medical coverage for newly-added spouses or dependents will be terminated.
After reviewing your available 2024 options, log in and click “Go” to enroll. You will be guided through several screens where you will elect the benefits you wish to be enrolled in for the 2024 plan year.
IMPORTANT: Your elections will not be recorded and saved until you complete all the screen prompts and reach the Confirmation page. Don’t forget to write down your confirmation number and keep it for your records.
You can return and make additional changes to your elections at any time before December 14, 2023. Each time you make a change, you will receive a new confirmation number. Remember to write down your confirmation number each time. Only the last confirmation in the Annual Enrollment period will be processed.
Don’t Forget! After You’ve Enrolled…
You can access and print a copy of your 2024 confirmation statement online. You will also receive a confirmation statement in the mail at home. When you receive your statement, check it carefully to make sure everything looks accurate. If there are any issues, contact your employer or the Participant Support Line at 866-***-**** right away.
If you are enrolling a spouse or dependent in medical coverage, don’t forget to submit acceptable supporting documentation to finalize your enrollment request.
Reimbursement Assistance Program (RAP) You have two options for the RAP: A High Option (offering higher reimbursement amounts but costing more per paycheck) and a Low Option (offering lower reimbursement amounts for a lower paycheck cost). For Questions or Claim Forms, contact the RAP Support Center at 844-***-****
Reimbursement Assistance Program
The fixed dollar amount the RAP pays toward your medical bill
Type of Care
High Option
Low Option
Outpatient Medical Benefit
Outpatient Medical Benefit Maximum (all outpatient benefits are subject to outpatient maximum)
$1,500
$1,000
Physician Office Visit and Diagnostic (Lab) (per day)
$100
Diagnostic (X-ray) (per day)
$250
Ambulance Services (per day)
$350
Emergency Room Benefit - Sickness (per day)
$125
Emergency Room Benefit - Accident (per day)
$500
Surgery (per day)
$600
Anesthesiology (per day)
$120
Inpatient Hospital Benefit: requires 24-hour minimum stay
Surgery (per day)
$1,500
$1,000
Anesthesiology (per day)
$300
$200
Standard Care (per day, up to a 30-day calendar maximum per year)
$600
$350
Intensive Care (per day, up to a 15-day calendar maximum per year, and paid in addition to standard care benefit)
$600
$350
Skilled Nursing (per day, up to a 60-day calendar maximum per year, and payable for stays in a nursing facility after a hospital stay)
$100
Wellness Care
Wellness Care (1 per year)
$100
Prescription Drugs: unlike with medical care, you pay a flat copay for each prescription under the RAP
Annual Maximum (maximum benefit the RAP will pay over a calendar year)
$600
Generic Copay (the most you pay out-of-pocket for each generic prescription)
You pay up to $10
Brand Copay (the most you pay out-of-pocket for each name-brand prescription)
You pay up to $50
Life and Accident Insurance
Supplemental Term Life Insurance Benefits. Supplemental Life is provided by Securian Fnancial (lifebenefits.com). If you are newly eligible to the plan, you can add up to 10 times your annual salary (up to $500,000 of coverage) without providing evidence of insurability. Existing employees who chose to elect supplemental term life insurance must provide evidence of insurability (proof of your good health) whenever you increase your supplemental term life benefit by more than one level during Annual Enrollment. Election of one times salary or increase by one times salary is guaranteed without evidence of insurability during Annual Enrollment.
Dependent Supplemental Term Life Insurance can be added for eligible dependents. Dependent coverage amount cannot exceed your total life insurance coverage amount. You must be enrolled in employee Supplemental term life to be eligible to enroll in dependent supplemental term life.
Supplemental Term Life Insurance is guaranteed issue for all spouse/domestic partner coverage up to $25,000 if elected within 31 days of initial eligibility. Supplemental term life insurance is always guaranteed issue for all child coverage.
Type of Coverage
Amount of Coverage
Spouse/domestic partner (may not exceed 100% of your total basic and supplemental amount)
$10,000
$15,000
$25,000
$50,000
$75,000
$100,000
Child (each)
$10,000
Short-Term and Long-Term Disability Insurance
Disability coverage is available to help protect you against loss of income in the event of an extended illness or injury. Coverages are now issued by The Hartford (replacing Lincoln Financial Group) www.thehartford.com.
Short-Term Disability (STD): This coverage pays a benefit beginning on the 15th day of a sickness or injury.
There are two Short-Term Disability options:
STD 500: Pays 50% of your basic earnings, up to $500 per week
STD 1000: Pays 66-2/3% of your basic earnings, up to $1000 per week
Long-Term Disability (LTD): This coverage pays benefits after 180 days of consecutive disability. The monthly benefit is 60% of your of your basic monthly income. If you remain disabled, benefits generally continue until your normal retirement age as defined under the Social Security Act.
All disability claims are subject to approval by The Hartford. Employees who newly elect disability coverage are subject to the pre-existing condition limitation. A pre-existing condition is a condition resulting from an injury or sickness for which the employee is diagnosed or treated within three months prior to the employee’s effective date of coverage.
Dental Insurance
Participants have a choice between the Preventative Plan and the Comprehensive Plan. The Preventative Plan offers a lower premium cost, a higher deductible, and does not cover orthodontia. The Comprehensive Plan has a higher premium cost, a lower deductible, and does include orthodontia coverage. Participants in either plan can go to any licensed dentist, and benefits are the same whether you use a network or non-network provider. If you go to a non-network dentist, your benefit level is the same, but your out-of-pocket expenses may be higher.
Participants must actively elect coverage during 2024 Annual Enrollment to participate in the new Preventive Plan. Participants enrolled in dental coverage in 2023 who do not make an active dental plan election during Annual Enrollment will default to coverage under the new Comprehensive Plan.
Comprehensive Dental Plan Benefits
Service
Deductible
Plan Pays
Maximum Benefit
Preventive Care
None
100% of maximum allowed fees
$2000 annual maximum for covered services (excluding orthodontia)
Primary Care
$50 per person per calendar year (covers both Primary and Major services)
90% of maximum allowed fees
Major Care
50% of maximum allowed fees
Orthodontics
None
50% of maximum allowed fees
$2000 per person lifetime maximum
Preventive Dental Plan Benefits
Service
Deductible
Plan Pays
Maximum Benefit
Preventive Care
None
100% of maximum allowed fees
$1000 annual maximum for covered services
Primary Care
$100 per person per calendar year (covers both Primary and Major services)
80% of maximum allowed fees
Major Care
50% of maximum allowed fees
Orthodontics
Not covered
N/A
N/A
To locate a Delta Dental PPO or Delta Dental Premier provider, visit www.deltadentalil.com or call customer service at 1-800-***-****. Dentists in the Delta Dental PPO and Delta Dental Premier networks will have lower fees.
Vision Insurance
Benefits for the vision care plan are provided through EyeMed. EyeMed’s network includes private doctors as well as major chains including LensCrafters, Shopko Optical, most Pearle Vision locations, Target, and more.
Summary of Vision Plan Benefits
Services and Materials
In-Network
Out-of-Network
Maximum Benefits
Eye Exam for eyeglasses once per calendar year
Covered in Full
Up to $60
Standard uncoated plastic lenses once per calendar year:
Single vision
Bifocal Vision
Trifocal vision
Standard Progressive
Premium Progressive
Covered in full
Covered in full
Covered in full
$55 copayment
Contact EyeMed
Up to $30
Up to $50
Up to $65
Up to $50
Up to $50
Lens options
Contact EyeMed
$5 reimbursement
Frames once per calendar year
$175 maximum benefit
Up to $55
Standard contact lens fitting and follow-up
Member pays up to $40
Not covered
Contact lenses once per calendar year in lieu of spectacle lenses (materials only, conventional/disposable)
$175 maximum benefit
Up to $75
Contact lenses once per calendar year when medically necessary (materials only)
Paid in full
Up to $130
Additional pairs (unlimited) of eyeglasses/contact lenses
40% discount off complete pair eyeglass purchases
Not covered
For more information or to find a participating EyeMed provider, call 1-866-***-****, visit www.eyemed.com, or download the EyeMed app from the App Store or Google Play. Choose “Select” from the network options.
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