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​Sample SPD Documents

 

Below are two separate sample templates. The “Sample Wrap Document (to meet Plan Document and SPD requirements)” can be used along with the Certificate of Coverage, Member Payment Summary, and Provider & Facility Directory to satisfy both the Plan Document and SPD ERISA requirements in situations where SelectHealth is the only plan/carrier offered to the employees.

The second document called “Sample Wrap Document (to meet SPD requirements)”, can be used in situations where employers need to create an SPD for the SelectHealth benefits offered under their plan.  This is commonly needed when employers offer more benefits than those offered by just SelectHealth (e.g. dental, health, life, or PBM offered through another carrier).  This template, along with the SelectHealth Certificate of Coverage, Member Payment Summary, and Provider & Facility Directory will only assist in satisfying the SPD portion (and not the Plan Document portion) of the ERISA requirements.  The employer must compile the plan information for all other benefits and carriers to satisfy the Plan Document requirement.

Please note that these are samples only and will need to be customized by you to meet your ERISA obligations.    When customized with your employer-specific information, and approved by your legal counsel, the resulting document could be used in conjunction with the Certificate of Coverage, Member Payment Summary, and Provider & Facility Directory supplied by SelectHealth to create the applicable Plan Document or Summary Plan Description.  SelectHealth does not customize this form for you or file any documents that may be required from you by ERISA, and it makes no representations about the legal adequacy of these documents in your specific circumstances. Please consult your own legal counsel.


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ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame a SelectHealth Advantage: 1-855-442-9900 (TTY: 711) / SelectHealth: 1-800-538-5038.


Cerrar

注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電SelectHealth Advantage: 1-855-442-9900 (TTY: 711) / SelectHealth: 1-800-538-5038. 。


退出

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số SelectHealth Advantage: 1-855-442-9900 (TTY: 711) / SelectHealth: 1-800-538-5038.


Thoát

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. SelectHealth Advantage: 1-855-442-9900 (TTY: 711) / SelectHealth: 1-800-538-5038. 번으로 전화해 주십시오.


종료

ध्यान दिनुहोस्: तपार्इंले नेपाली बोल्नुहुन्छ भने तपार्इंको निम्ति भाषा सहायता सेवाहरू निःशुल्क रूपमा उपलब्ध छ । SelectHealth Advantage: 1-855-442-9900 (TTY: 711)/ SelectHealth: 1-800-538-5038 मा फोन गर्नुहोस्।


बाहिरनिस्कनुहोस्

FAKATOKANGA’I: Kapau ‘oku ke lea fakatonga, ko e kau fakatonu lea te nau tokoni atu ta’etotongi, pea te ke lava ‘o ma’u ia. Telefoni ki he SelectHealth Advantage: 1-855-442-9900 (TTY: 711) / SelectHealth: 1-800-538-5038.


Hū‘anga ki tu‘a

ОБАВЕШТЕЊЕ: Ако говорите српски језик, услуге језичке помоћи доступне су вам бесплатно. Позовите Select Health Advantage: 1-855-442-9900 (TTY- Телефон за особе са отежаним говором или оштећеним слухом: 711)/Select Health: 1-800-538-5038.


IZLAZ

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa SelectHealth Advantage: 1-855-442-9900 (TTY: 711) / SelectHealth: 1-800-538-5038.


Isara

ملحوظة: إذا كنت تتحدث العربية، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل بشركة SelectHealth Advantage: 1-855-442-9900 (رقم هاتف الصم والبكم: 711) / SelectHealth: 1-800-538-5038.


خروج

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: SelectHealth Advantage: 1-855-442-9900 (TTY: 711) / SelectHealth: 1-800-538-5038.


Beenden

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги переводчика. Позвоните SelectHealth Advantage: 1-855-442-9900 (телетайп: 711) / SelectHealth: 1-800-538-5038.


выйти

សម្គាល់៖ បើសិនជាអ្នកនិយាយ ភាសាខ្មែរ សេវាជំនួយផ្នែកភាសា ដោយមិនគិតថ្លៃ គឺអាចមានសំរាប់ អ្នក។ សូមទូរស័ព្ទមក SelectHealth Advantage: 1-855-442-9900 (TTY: 711) / SelectHealth: 1-800-538-5038 ។


ចាកចេញ

注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。SelectHealth Advantage: 1-855-442-9900 (TTY: 711) / SelectHealth: 1-800-538-5038. まで、お電話にてご連絡ください。


終了

ATTENTION : si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Contactez SelectHealth Advantage au 1-855-442-9900 (TTY: 711) / SelectHealth: 1-800-538-5038.


fermer