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Benefits Guide - Minimalist Template - Flipbook

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BENEFITS GUIDE An overview of the wide array of benefits provided XYZ COMPANY , to help you enjoy increased well - being and financial security PREPARED BY XYZ COMPANY FOR ABC COMPANY

2 TABLE OF CONTENTS I ▪ Introduction 3 ▪ Overview of Benefits Programs 6 ▪ Medical Benefits 8 ▪ Dental Benefits 12 ▪ Vision Benefits 14 ▪ Life Insurance 16 ▪ Short - term Disability Insurance 18 ▪ Health Savings Account (HSA) 19 ▪ Flexible Spending Account (FSA) 20 ▪ Value of Pre - Tax Benefits 21 ▪ Telemedicine 22 ▪ Legal Notices 23 ▪ Contact Page 33 ▪ Notes Page 34 BENEFITS GUIDE TABLE OF CONTENTS

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WE’VE GOT YOU COVERED XYZ COMPANY i s p r o u d t o o f f e r a c o m p r e h e n s i v e b e n e f i t s p a c k a g e f o r y o u a n d y o u r f a m i l y . T h i s p r o g r a m i s d e s i g n e d t o t a k e g r e a t c a r e o f y o u w h e n y o u n e e d i t . M a k e s u r e t o e x p l o r e y o u r o p t i o n s t o h e l p y o u m a k e t h e s e l e c t i o n s t h a t b e s t m e e t y o u r n e e d s .

I N T R O & O V E R V I E W I

5 5 INTRODUCTION I UPDATE ON HEALTH CARE REFORM BENEFITS GUIDE INTRODUCTION For the 2022 plan year, XYZ COMPANY has worked hard to offer a competitive total rewards package that includes valuable and competitive benefits plans. These programs reflect our commitment to keeping our staff healthy and secure. We understand that your situation is unique, and XYZ COMPANY is offering an overall benefits package that can be shaped and molded by you to fit your needs. As an employee of XYZ COMPANY enjoying your work and making valuable contributions to business are equally vital. The health, satisfaction and security of you and your family are important, not only to your well - being, but ultimately, in terms of achieving the goals of our organization. This benefits booklet is a summary description of your XYZ COMPANY benefit plans . If there is a discrepancy between these summaries and the written legal plan documents, the plan documents shall prevail . This booklet and plan summaries do not constitute a contract of employment . We hope this benefits booklet, along with our additional communication and decision - making tools, will help you make the best health care choices for you and your family.

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6 6 OVERVIEW I CHANGES AND QUALIFYING EVENTS WHEN COVERAGE BEGINS AND ENDS Your coverage under the benefits plans will end if you no longer meet the eligibility requirements, your contributions are discontinued or the Group Insurance Policy is terminated. QUALIFYING EVENTS • Eligible employees may enroll or make changes to their benefits elections during the annual open enrollment period . As with most benefits, once you elect an option you are bound to that choice for the entire plan year unless you experience a “Qualifying Event” . These may include, but are not limited to : • Changes in employment status • Changes in legal marital status • Changes in number of dependents • Taking an unpaid leave of absence • Dependent satisfies or ceases to satisfy eligibility requirement • Family Medical Leave Act (FMLA) leave . • A COBRA - qualifying event • Entitlement to Medicare or Medicaid • A change in the place of residence of the employee, resulting in the current carrier not being available BENEFITS GUIDE O V E RV I E W O F B E N E F I T S

Coverage Carrier Medical Empire BlueCross BlueShield of New York 7 7 OVERVIEW I BENEFITS AT - A - GLANCE ELIGIBILITY XYZ COMPANY provides an array of benefits that can help you enjoy increased well - being, deal with an unexpected illness or accident, build and protect your financial security, balance your personal and professional life and meet everyday needs. These benefits are affordable, comprehensive and competitive. The table below summarizes the benefits available to eligible staff and their dependents. These benefits are described in greater detail in this booklet. BENEFITS GUIDE O V E RV I E W O F B E N E F I T S

M E D I C A L I

Plan Features MMI EPO 1000 2022 MMI EPO 2500 202 1 MMI EPO 500 202 2 IN NETWORK Calendar Year Deductibles (Indiv / Family) Preventive Care Primary Care Visit Specialist Visit Diagnostic Exam X - Rays Complex Images Outpatient Procedure Inpatient Visit Emergency Room Urgent Care Pharmacy / RX (30 Day Supply) Pharmacy / RX (90 Day Supply) Calendar Year Out - of - Pocket Max (Indiv / Family) OUT OF NETWORK Calendar Year Deductibles (Indiv / Family) Preventive Care Primary Care Visit Specialist Visit Diagnostic Exam X - Rays Complex Images Outpatient Procedure Inpatient Visit Emergency Room Urgent Care Pharmacy / RX (30 Day Supply) Pharmacy / RX (90 Day Supply) Calendar Year Out - of - Pocket Max (Indiv / Family) MONTHLY PRICING Employee $0.00 $0.00 $0.00 Employee + Spouse $0.00 $0.00 $0.00 Employee + Child(ren) $0.00 $0.00 $0.00 Employee + Family $0.00 $0.00 $0.00 9 9 MEDICAL PLAN I S U M M A R Y O F C O V E R A G E BENEFITS GUIDE MEDICAL PLAN

10 10 MEDICAL PLAN I OUT - OF POCKET MAXIMUM ANNUAL DEDUCTIBLE COPAYS AND COINSURANCE PLAN TYPES KEY TERMS TO REMEMBER BENEFITS GUIDE MEDICAL PLAN

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11 11 MEDICAL PLAN I • Routine Physical Exam • Well Baby and Child Care • Well Woman Visits • Immunizations • Routine Bone Density Test • Routine Breast Exam • Routine Gynecological Exam • Screening for Gestational Diabetes • Obesity Screening and Counseling • Routine Digital Rectal Exam • Routine Colonoscopy The US Preventive Services Task Force maintains a regular list of recommended services that all Affordable Care Act (i.e. Health Care Reform) compliant insurance plans should cover at 100% for in - network providers. Below is a list of common services that are included in the plans offered this year: Understanding the full value of covered benefits allows you to take responsibility for maintaining good health and incorporating healthy habits into your lifestyle. Some examples include getting regular physical examinations, mammograms and immunizations. Through the plans offered by XYZ COMPANY , all covered individuals and family members are eligible to receive routine wellness services like these, at no cost; all copays, coinsurance, and deductibles are waived. WHICH PREVENTIVE CARE SERVICES ARE COVERED? • Routine Colorectal Cancer Screening • Routine Prostate Test • Routine Lab Procedures • Routine Mammograms • Routine Pap Smear • Smoking Cessation Programs • Health Education/Counseling Services • Health Counseling for STDs and HIV • Testing for HPV and HIV • Screening and Counseling for Domestic Violence “AN OUNCE OF PREVENTION IS WORTH A POUND OF CURE” BENEFITS GUIDE MEDICAL PLAN

D E N TA L I

Plan Features IN NETWORK Annual Deductible (Individual / Family) Preventive Care Basic Procedures (Extractions, fillings, etc.) Major Procedures (Crowns, dentures, etc.) Child Orthodontia Calendar Year Maximum Benefit OUT OF NETWORK Annual Deductible (Individual / Family) Preventive Care Basic Procedures (Extractions, fillings, etc.) Major Procedures (Crowns, dentures, etc.) Child Orthodontia Calendar Year Maximum Benefit 13 13 DENTAL PLAN I S U M M A R Y O F C O V E R A G E BENEFITS GUIDE DENTAL PLANS

V I S I O N I

Plan Features IN NETWORK Vision Exam Lenses Single Bifocal Trifocal Progressive Frames Elective Contact Lenses Medically Necessary Contact Lenses Frequency (Months) Exam Lenses Frames Contacts OUT OF NETWORK Vision Exam Lenses Single Bifocal Trifocal Progressive Frames Elective Contact Lenses Medically Necessary Contact Lenses 15 15 VISION PLAN I S U M M A R Y O F C O V E R A G E BENEFITS GUIDE VISION PLAN

L I F E I

Supplemental / Voluntary Term Life Insurance Plan Features Employee Benefit Amount Employees can choose different amounts of coverage between the minimum and maximum benefit amount. See plan documentation for more details. Minimum Benefit Amount Maximum Benefit Amount Spouse Benefit Dependent Benefit The following shows how much benefits are reduced at certain ages: Age Band Benefit Reduction Employer - paid Basic Life Insurance Plan Features Employee Benefit Amount Maximum Benefit Amount AD&D Benefit The following shows how much benefits are reduced at certain ages: Age Band Benefit Reduction 17 17 LIFE INSURANCE I S U M M A R Y O F C O V E R A G E BENEFITS GUIDE LIFE

D I S A B I L I T Y I

Plan Features Employee Benefit Amount Maximum Benefit Amount Elimination Period (Accident) Elimination Period (Sickness) Benefit Duration 19 19 DISABILITY – SHORT TERM I S U M M A R Y O F C O V E R A G E BENEFITS GUIDE DISABILITY PLAN S H O R T T E R M

20 20 HSA I Refer to your HSA documentation for more information. A health savings account (HSA) is a health care account and savings account in one . The main purpose of this account is to offset the cost of a qualifying high deductible health plan (HDHP) and provide savings for your out - of - pocket eligible health care expenses – those you and your tax dependents may have now, in the future, and during your retirement . This is a “portable” account . You own your HSA! It’s included in your employee benefits package, but after you set up your account, it’s yours to keep, even if you change jobs or retire . Once your HSA is established, money is contributed to your account by you, XYZ COMPANY or friends and family, and you can then use your HSA dollars tax - free to pay for eligible health care expenses . You save money on expenses you’re already paying for, like doctors’ office visits, prescription drugs, and much more . Best of all, you decide how and when to use your HSA dollars . WHY IS IT A GOOD IDEA TO HAV E AN HSA? HSAs benefit everyone who is eligible to have this account – single individuals, families, and soon - to - be retirees . You save money on taxes in three ways : HSA funds roll over from year to year and accumulate in your account . There is no “use - it - or - lose - it” rule with HSAs, and you decide how and when to use your HSA funds, which can be used for eligible expenses you have now, in the future, or during retirement . And when you have a certain balance in your HSA, investment opportunities are available . FOR 2022 XYZ COMPANY IS OFFERING A HEALTH SAVINGS ACCOUNT (HSA). THIS IS HOW AN HSA W ORKS: Tax - free withdrawals M oney used toward eligible health care expenses isn’t taxed – now or in the future Tax - free earnings Your interest and any investment earnings grow tax - free Tax - free deposits The money you contribute to your HSA isn’t taxed (up to the IRS annual limit) Setting aside pre - tax dollars into your HSA you pay fewer taxes and increase your take - home pay by your tax savings. You save money on eligible expenses that you are paying for out of your pocket. The amount you save depends on your tax bracket. For example, if you are in the 30 percent tax bracket, you can save $30 on every $100 spent on eligible health care expenses. BENEFITS GUIDE H E A LT H S AV I N G S A C C O U N T ( H S A )

21 21 F SA I Refer to your F SA documentation for more information. XYZ COMPANY is offering a Flexible Spending Account (FSA) for 2022. This is how an FSA works: • You set aside money for your FSA from your paycheck before taxes are taken out. • Then use your pre - tax FSA funds throughout the plan year to pay for eligible health care or dependent care expenses. • You save money on expenses you’re already paying for. You may also be able to carry over up to $500 of unused funds to the following plan year. Refer to your FSA documentation for more details. • Medical expenses: co - pays, co - insurance, and deductibles • Dental expenses: exams, cleanings, X - rays, and braces • Vision expenses: exams, contact lenses and supplies, eyeglasses, and laser eye surgery • Professional services: physical therapy, chiropractor, and acupuncture • Prescription drugs and insulin • Over - the - counter health care items: bandages, pregnancy test kits, blood pressure monitors, etc. • Care for your child who is under age 13 • Before and after - school care • Baby sitting and nanny expenses • Day care, nursery school, and preschool • Summer day camp • Care for a relative who is physically or mentally incapable of self - care and lives in your home HEALTH FSA ELIGIBLE EXPENSES DEPENDENT CARE FSA ELIGIBLE EXPENSES BENEFITS GUIDE F L E X I B L E S P E N D I N G A C C O U N T ( F S A )

22 22 PRE - TAX BENEFITS I Section 125 Plan X YZ C O MPAN Y operates a Premium Only Section 125 Plan, which allows you to reduce your total taxable income by your portion of group insurance premiums. In effect, this is just like getting a raise - your withholding taxes are reduced, and your take - home pay increases! Example: Employee earning $30,000 annually, paying $200/month for benefits Without Pre - Tax Benefits With Pre - Tax Benefits Gross Pay $30,000 $30,000 Insurance Deductions/Payments $0 $2,400 Taxable Income $30,000 $27,600 Taxes at 25% $7,500 $6,900 After - Tax Income $22,500 $20,700 After - Tax Payment for Benefits $2,400 $0 Take - home Pay $20,100 $20,700 INCREASE IN TAKE - HOME PAY +$600 VA LU E OF PR E - TAX B EN EFITS BENEFITS GUIDE

23 23 TELEMEDICINE I X YZ CO MPANY employees have access to around the clock access to a doctor, no matter where they are, through CARRIERNAME PLANNAME . This Telemedicine benefit will connect you to a board - certified doctor by phone or video chat. Examples of illnesses you can have a consultation with are (but not limited to): • Sinus Infections • Pink Eye • Strep Throat • Ear Infections Consultation appointments with a doctor only cost you $COST out of pocket. You can access CARRIERNAME PLANNAME in several different ways: Contact Information: • Log on to the website http://www.example.com • Download the PLANNAME App from the App Store, Google Play, or Windows Store • Call (888) 888 - 8888 BENEFITS GUIDE TELEMEDICINE

L E G A L N O T I C E S I

25 LEGAL NOTICES I BENEFITS GUIDE LEGAL NOTICES Health Insurance Portability and Accountability Act of 1996 (HIPAA) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that addresses the privacy and secur ity of certain individually identifiable health information, called protected health information (or PHI). You have certain rights w ith respect to your PHI, including a right to see or get a copy of your health and claims records and other health information maintained by a health plan or carrier. For a copy of the Notice of Privacy Practices, describing how your PHI may be used and disclosed and how you ge t access to the information, contact Human Resources. Women’s Health and Cancer Rights Act Enrollment Notice If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Woman’s Health and Cance r Rights Act of 1998 (WHCRA). For individuals receiving mastectomy - related benefits, coverage will be provided in a manner determi ned in consultation with the attending physician and the patient, for: 1. All stages of reconstruction of the breast on which mastectomy was performed. 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses. 3. Treatment of physical complications of the mastectomy, including lymphedema. These will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits prov ide d under this benefits plan. Therefore, the following deductibles and coinsurance apply: [insert medical deductibles and coinsurance applicable to these benefits ]. If you would like more information on WHCRA benefits, call your plan administrator at 646 - 300 - 7016. Newborns’ and Mothers’ Health Protection Act Disclosure Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital leng th of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 9 6 h ours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, aft er consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance iss uer for prescribing a length of stay not in excess of 48 hours (or 96 hours). Patient Protection Notice Your carrier generally may require the designation of a primary care provider. You have the right to designate any primary c are provider who participates in your network and who is available to accept you or your family members. Until you make this des ign ation, your carrier may designate one for you. For information on how to select a primary care provider, and for a list of the parti cip ating primary care providers, contact the [plan administrator or carrier] at [insert contact information]. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from your c arr ier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in your network who specializes in obstetrics or gynecology. The health care professional, however, may be re quired to comply with certain procedures, including obtaining prior authorization for certain services, following a pre - approved treatm ent plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gyn eco logy, contact the [plan administrator or carrier] at [insert contact information].

26 LEGAL NOTICES I BENEFITS GUIDE LEGAL NOTICES HIPAA Special Enrollment Notice If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or gr oup health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility fo r that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request en rol lment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other cov erage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or pla cem ent for adoption. If you or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or b eco me eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must req ues t enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistan ce subsidy. To request special enrollment or to obtain more information about the plan's special enrollment provisions, contact the plan adm inistrator at [insert contact information] .

27 LEGAL NOTICES I BENEFITS GUIDE LEGAL NOTICES Premium A ssistance Under Medicaid and t he Children’s Health Insurance Program (CH I P) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state ma y have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your chi ldren aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy ind ividual insurance coverage through the Health Insurance Marketplace . For more information, visit www.healthcare.gov . If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State M edi caid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might b e e ligible for either of these programs, contact your State Medicaid or CHIP office or dial 1 - 877 - KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer - sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer pl an, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment ” o pportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1 - 866 - 444 - EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. Th e following list of states is current as of July 31, 2020. Contact your State for more information on eligibility – ALABAMA – Medicaid COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) Website: http://myalhipp.com/ Phone: 1 - 855 - 692 - 5447 Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1 - 800 - 221 - 3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/child - health - plan - plus CHP+ Customer Service: 1 - 800 - 359 - 1991/ State Relay 711 Health Insurance Buy - In Program (HIBI): https://www.colorado.gov/pacific/hcpf/health - insurance - buy - program HIBI Customer Service: 1 - 855 - 692 - 6442 ALASKA – Medicaid FLORIDA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1 - 866 - 251 - 4861 Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp /index.html Phone: 1 - 877 - 357 - 3268 ARKANSAS – Medicaid GEORGIA – Medicaid Website: http://myarhipp.com/ Phone: 1 - 855 - MyARHIPP (855 - 692 - 7447) Website: https://medicaid.georgia.gov/health - insurance - premium - payment - program - hipp Phone: 678 - 564 - 1162 ext 2131 CALIFORNIA – Medicaid INDIANA – Medicaid Website: https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx Phone: 916 - 440 - 5676 Healthy Indiana Plan for low - income adults 19 - 64 Website: http://www.in.gov/fssa/hip/ Phone: 1 - 877 - 438 - 4479 All other Medicaid Website: https://www.in.gov/medicaid/ Phone 1 - 800 - 457 - 4584

28 LEGAL NOTICES I BENEFITS GUIDE LEGAL NOTICES IOWA – Medicaid and CHIP (Hawki) MONTANA – Medicaid Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1 - 800 - 338 - 8366 Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1 - 800 - 257 - 8563 Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1 - 800 - 694 - 3084 KANSAS – Medicaid NEBRASKA – Medicaid Website: http://www.kdheks.gov/hcf/default.htm Phone: 1 - 800 - 792 - 4884 Website: http://www.ACCESSNebraska.ne.gov Phone: (855) 632 - 7633 Lincoln: (402) 473 - 7000 Omaha: (402) 595 - 1178 KENTUCKY – Medicaid NEVADA – Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI - HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1 - 855 - 459 - 6328 Email: [email protected] KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1 - 877 - 524 - 4718 Kentucky Medicaid Website: https://chfs.ky.gov Medicaid Website: http://dhcfp.nv.gov/ Medicaid Phone: 1 - 800 - 992 - 0900 LOUISIANA – Medicaid NEW HAMPSHIRE – Medicaid Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1 - 888 - 342 - 6207 (Medicaid hotline) or 1 - 855 - 618 - 5488 (LaHIPP) Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603 - 271 - 5218 Toll free number for the HIPP program: 1 - 800 - 852 - 3345, ext 5218 MAINE – Medicaid NEW JERSEY – Medicaid and CHIP Website: http://www.maine.gov/dhhs/ofi/public - assistance/index.html Phone: 1 - 800 - 442 - 6003 TTY: Maine relay 711 Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications - forms Phone: - 800 - 977 - 6740. TTY: Maine relay 711 Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ Medicaid Phone: 609 - 631 - 2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1 - 800 - 701 - 0710 MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1 - 800 - 862 - 4840 Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1 - 800 - 541 - 2831 MINNESOTA – Medicaid NORTH CAROLINA – Medicaid Website: https://mn.gov/dhs/people - we - serve/children - and - families/health - care/health - care - programs/programs - and - services/other - insurance.jsp Phone: 1 - 800 - 657 - 3739 Website: https://medicaid.ncdhhs.gov/ Phone: 919 - 855 - 4100 MISSOURI – Medicaid NORTH DAKOTA – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573 - 751 - 2005 Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1 - 844 - 854 - 4825 OKLAHOMA – Medicaid and CHIP UTAH – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1 - 888 - 365 - 3742 Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1 - 877 - 543 - 7669 OREGON – Medicaid VERMONT – Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index - es.html Phone: 1 - 800 - 699 - 9075 Website: http://www.greenmountaincare.org/ Phone: 1 - 800 - 250 - 8427 PENNSYLVANIA – Medicaid VIRGINIA – Medicaid and CHIP Website: https://www.dhs.pa.gov/providers/Pages/Medical/HIPP - Program.aspx Phone: 1 - 800 - 692 - 7462 Website: http://www.coverva.org/hipp/ Medicaid Phone: 1 - 800 - 432 - 5924 CHIP Phone: 1 - 855 - 242 - 8282

29 LEGAL NOTICES I BENEFITS GUIDE LEGAL NOTICES RHODE ISLAND – Medicaid WASHINGTON – Medicaid Website: http://www.eohhs.ri.gov/ Phone: 1 - 855 - 697 - 4347, or 401 - 462 - 0311 (Direct RIte Share Line) Website: https://www.hca.wa.gov/ Phone: 1 - 800 - 562 - 3022 SOUTH CAROLINA – Medicaid WEST VIRGINIA – Medicaid Website: http://www.scdhhs.gov Phone: 1 - 888 - 549 - 0820 Website: http://mywvhipp.com/ Toll - free phone: 1 - 855 - MyWVHIPP (1 - 855 - 699 - 8447) SOUTH DAKOTA - Medicaid WISCONSIN – Medicaid and CHIP Website: http://dss.sd.gov Phone: 1 - 888 - 828 - 0059 Website: https://www.dhs.wisconsin.gov/badgercareplus/p - 10095.htm Phone: 1 - 800 - 362 - 3002 TEXAS – Medicaid WYOMING – Medicaid Website: http://gethipptexas.com/ Phone: 1 - 800 - 440 - 0493 Website: https://health.wyo.gov/healthcarefin/medicaid/programs - and - eligibility/ Phone: 1 - 800 - 251 - 1269

30 LEGAL NOTICES I BENEFITS GUIDE LEGAL NOTICES To see if any other states have added a premium assistance program since July 31, 2020, or for more information on special en rol lment rights, contact either: U.S. Departm e nt of Lab o r Employee B e nefits Security Administration www.dol.gov/agencies/ebsa 1 - 866 - 444 - EBSA ( 3 272) U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1 - 877 - 267 - 2323, Menu Option 4, Ext. 61565 Pape r wor k Reduction A ct Stateme n t According to the Paperwork Reduction Act of 1995 (Pub. L. 104 - 13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Fe der al agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently va lid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB con tro l number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply wi th a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately four minutes per respond ent . Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, inc luding suggestions for reducing this burden, to the U.S. Department of Labor, Office of Policy and Research, Attention: PRA Clearanc e O fficer, 200 Constitution Avenue, N.W., Room N - 5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210 - 0137. OMB Control Number 1210 - 0137 (expires 1/31/2023)

31 LEGAL NOTICES I BENEFITS GUIDE LEGAL NOTICES Genetic Information Nondiscrimination Act (GINA) Disclosures Genetic Information Nondiscrimination Act of 2008 The Genetic Information Nondiscrimination Act of 2008 (“GINA”) protects employees against discrimination based on their genetic information. Unless otherwise permitted, your Employer may not request or require any genetic information from you or your family members. The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical hist ory , the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

32 LEGAL NOTICES I BENEFITS GUIDE LEGAL NOTICES USERRA Notice Your Rights Under USERRA A. The Uniformed Services Employment and Reemployment Rights Act USERRA protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake military service or certain types of service in the National Disaster Medical System. USERRA also prohibits employers from discriminating against past and present members of the uniformed services, and applicants to the uniformed services. B. Reemployment Rights You have the right to be reemployed in your civilian job if you leave that job to perform service in the uniformed service and: • You ensure that your employer receives advance written or verbal notice of your service; • You have five years or less of cumulative service in the uniformed services while with that particular employer; • You return to work or apply for reemployment in a timely manner after conclusion of service; and • You have not been separated from service with a disqualifying discharge or under other than honorable conditions. If you are eligible to be reemployed, you must be restored to the job and benefits you would have attained if you had not been absent due to military service or, in some cases, a comparable job. C. Right to Be Free from Discrimination and Retaliation If you: • Are a past or present member of the uniformed service; • Have applied for membership in the uniformed service; or • Are obligated to serve in the uniformed service; then an employer may not deny you o Initial employment; o Reemployment; o Retention in employment; o Promotion; or o Any benefit of employment because of this status. In addition, an employer may not retaliate against anyone assisting in the enforcement of USERRA rights, including testifying or making a statement in connection with a proceeding under USERRA, even if that person has no service connection. D. Health Insurance Protection • If you leave your job to perform military service, you have the right to elect to continue your existing employer - based health plan coverage for you and your dependents for up to 24 months while in the military. • Even if you do not elect to continue coverage during your military service, you have the right to be reinstated in your employer's health plan when you are reemployed, generally without any waiting periods or exclusions (e.g., pre - existing condition exclusions) except for service - connected illnesses or injuries.

33 LEGAL NOTICES I BENEFITS GUIDE LEGAL NOTICES E. Enforcement • The U.S. Department of Labor, Veterans' Employment and Training Service (VETS) is authorized to investigate and resolve complaints of USERRA violations. For assistance in filing a complaint, or for any other information on USERRA, contact VETS at 1 - 866 - 4 - USA - DOL or visit its Web site at http://www.dol.gov/vets. An interactive online USERRA Advisor can be viewed at http://www.dol.gov/elaws/userra.htm . • If you file a complaint with VETS and VETS is unable to resolve it, you may request that your case be referred to the Department of Justice or the Office of Special Counsel, as applicable, for representation. • You may also bypass the VETS process and bring a civil action against an employer for violations of USERRA. The rights listed here may vary depending on the circumstances. The text of this notice was prepared by VETS, and may be viewed on the Internet at this address: http://www.dol.gov/vets/programs/userra/poster.htm . Federal law requires employers to notify employees of their rights under USERRA, and employers may meet this requirement by displaying the text of this notice where they customarily place notices for employees. U.S. Department of Labor, Veterans' Employment and Training Service, 1 - 866 - 487 - 2365.

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Carrier Name Website Email Phone Number Empire BlueCross BlueShield of New York http://www.empireblue.com/ [email protected] om (800) 300 - 8181 34 CONTACTS I CONTACTS I BENEFITS GUIDE

35 35 I NOTES BENEFITS GUIDE NOTES

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