Women’s Health and Cancer Rights Act If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: • All stages of reconstruction of the breast on which the mastectomy was performed; • Surgery and reconstruction of the other breast to produce a symmetrical appearance; • Prostheses; and treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this Plan. For further details on WHCRA benefits, please refer to the Plan’s Summary Plan Description. Newborns’ and Mothers’ Health Protection Act Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after 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 issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). If you would like more information on maternity benefits, call your plan administrator. HIPAA Notice of Special Enrollment Rights If you decline enrollment in your employer’s health plan for you or your dependents (including your spouse) because of other health insurance or group health plan coverage, you or your dependents may be able to enroll in your employer’s health plan without waiting for the next open enrollment period if you: • Lose other health insurance or group health plan coverage. You must request enrollment within 30 days after the loss of other coverage. • Gain a new dependent as a result of marriage, birth, adoption, or placement for adoption. You must request health plan enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. • Lose Medicaid or Children’s Health Insurance Program (CHIP) coverage because you are no longer eligible. You must request medical plan enrollment within 60 days after the loss of such coverage. If you request a change due to a special enrollment event within the 30-day timeframe, coverage will be effective the date of birth, adoption or placement for adoption. For all other events, coverage will be effective the first of the month following your request for enrollment. In addition, you may enroll in your employer’s health plan if you become eligible for a state premium assistance program under Medicaid or CHIP. You must request enrollment within 60 days after you gain eligibility for medical plan coverage. If you request this change, coverage will be effective the first of the month following your request for enrollment. Specific restrictions may apply, depending on federal and state law.
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit 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 Medicaid 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 be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or 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 plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, 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 askebsa.dol.gov or call 1-866-444-EBSA (3272) .
program, you might qualify for an opportunity to earn the same reward by different means. Contact us at 931-525-5323 and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status. Notice Regarding Wellness Program HealthCheck360 is a voluntary wellness program available to all employees. The program is administered according to federal rules permitting employer- sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program you may be asked to complete a voluntary health risk assessment or “HRA” that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You may also be asked to complete a biometric screening, which would include a blood test for glucose, HDL, LDL, triglycerides and total cholesterol. You are not required to complete an HRA or to participate in any blood tests or other medical examinations. However, employees who choose to participate in the wellness program will receive an incentive of Red Thinkin’ Rewards for participation. Although you are not required to complete an HRA or participate in any biometric screenings, only employees who do so will receive the incentive.
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2024. Contact your State for more information on eligibility.
ALABAMA – Medicaid http://myalhipp.com 855-692-5447
INDIANA – Medicaid Health Insurance Premium Payment Program All other Medicaid: https://www.in.gov/ medicaid http://www.in.gov/fssa/dfr Family and Social Services Administration: 800-403-0864 Member Services: 800-457-4584 IOWA – Medicaid and CHIP (Hawki) Medicaid: https://hhs.iowa. gov/programs/welcome-iowa- medicaid 800-338-8366 Hawki: https://hhs.iowa.gov/ programs/welcome-iowa- medicaid/iowa-health-link/ hawki 800-257-8563 HIPP: https://hhs.iowa.gov/ programs/welcome-iowa- medicaid/fee-service/hipp 888-346-9562 KANSAS – Medicaid https://www.kancare.ks.gov 800-792-4884 HIPP Phone: 800-967-4660 KENTUCKY – Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP): https://chfs.ky.gov/agencies/ dms/member/Pages/kihipp.aspx 855-459-6328 KIHIPP.PROGRAM@ky.gov KCHIP: https://kynect.ky.gov 877-524-4718 Medicaid: https://chfs.ky.gov/ agencies/dms LOUISIANA – Medicaid www.medicaid.la.gov or www. ldh.la.gov/lahipp 888-342-6207 (Medicaid hotline) or 855-618-5488 (LaHIPP) MAINE – Medicaid https://www. mymaineconnection.gov/ benefits/s/?language=en_US 800-442-6003 (TTY: Maine relay 711) Private Health Insurance Premium: https://www.maine. gov/dhhs/ofi/applications-forms 800-977-6740 (TTY: Maine relay 711)
MASSACHUSETTS – Medicaid and CHIP https://www.mass.gov/ masshealth/pa 800-862-4840 (TTY: 711) masspremassistance@accenture. com MINNESOTA – Medicaid https://mn.gov/dhs/health-care- coverage 800-657-3672 MISSOURI – Medicaid http://www.dss.mo.gov/mhd/ participants/pages/hipp.htm 573-751-2005 MONTANA – Medicaid http://dphhs.mt.gov MontanaHealthcare Programs/HIPP 800-694-3084 HHSHIPPProgram@mt.gov NEBRASKA – Medicaid http://www.ACCESSNebraska. ne.gov 855-632-7633
NORTH CAROLINA – Medicaid https://medicaid.ncdhhs.gov 919-855-4100 NORTH DAKOTA – Medicaid https://www.hhs.nd.gov/healthcare 844-854-4825 OKLAHOMA – Medicaid and CHIP http://www.insureoklahoma.org 888-365-3742 OREGON – Medicaid and CHIP http://healthcare.oregon.gov/ Pages/index.aspx 800-699-9075 PENNSYLVANIA – Medicaid and CHIP https://www.pa.gov/en/services/ dhs/apply-for-medicaid-health- insurance-premium-payment- program-hipp.html 800-692-7462 CHIP: https://www.pa.gov/en/ agencies/dhs/resources/chip. html 800-986-KIDS (5437) RHODE ISLAND – Medicaid and CHIP http://www.eohhs.ri.gov 855-697-4347 , or 401-462-0311 (Direct RIte Share Line) SOUTH CAROLINA – Medicaid https://www.scdhhs.gov 888-549-0820 SOUTH DAKOTA - Medicaid http://dss.sd.gov 888-828-0059 TEXAS – Medicaid https://www.hhs.texas.gov/ services/financial/health- insurance-premium-payment-
VERMONT– Medicaid https://dvha.vermont.gov/ members/medicaid/hipp- program 800-250-8427 VIRGINIA – Medicaid and CHIP https://coverva.dmas.virginia. gov/learn/premium-assistance/ famis-select https://coverva.dmas.virginia. gov/learn/premium-assistance/ health-insurance-premium- payment-hipp-programs 800-432-5924
ALASKA – Medicaid The AK Health Insurance Premium Payment Program: http://myakhipp.com 866-251-4861 CustomerService@MyAKHIPP. com Medicaid Eligibility: https:// health.alaska.gov/dpa/Pages/ default.aspx ARKANSAS – Medicaid http://myarhipp.com 855-MyARHIPP (855-692-7447) CALIFORNIA – Medicaid Health Insurance Premium Payment (HIPP) Program: http:// dhcs.ca.gov/hipp 916-445-8322
Averitt Express also offers discounted medical plan premiums for associates and spouses who are tobacco-free.
If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive, you may be entitled to a reasonable accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by contacting HealthCheck360 at support@healthcheck360.com or call 866-511-0360 . The information from your HRA and/or the results from your biometric screening will be used to provide you with information to help you understand your current health and potential risks and may also be used to offer you services through the wellness program, such as health coaching. You also are encouraged to share your results or concerns with your own doctor. Protections from Disclosure of Medical Information We are required by law to maintain the privacy and security of your personally identifiable health information. Although the wellness program and Averitt Express may use aggregate information it collects to design a program based on identified health risks in the workplace, HealthCheck360 will never disclose any of your personal information either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment. Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements. The only individual that may receive your personally identifiable health information is a health coach in order to provide you with services under the wellness program. In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making any employment decision. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you immediately. You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate. If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact Marsha Brock, Benefits Manager at benefits@averitt.com .
WASHINGTON – Medicaid https://www.hca.wa.gov 800-562-3022
WEST VIRGINIA – Medicaid and CHIP https://dhhr.wv.gov/bms http://mywvhipp.com 304-558-1700 CHIP Toll-free phone: 855-MyWVHIPP (1-855-699- 8447) WISCONSIN – Medicaid and CHIP https://www.dhs.wisconsin.gov/ badgercareplus/p-10095.htm 800-362-3002
Fax: 916-440-5676 hipp@dhcs.ca.gov
COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) Health First Colorado: https:// www.healthfirstcolorado.com 800-221-3943 /State Relay 711 CHP+: https://hcpf.colorado.gov/ child-health-plan-plus 800-359-1991 /State Relay 711 HIBI: https://www.mycohibi.com 855-692-6442 FLORIDA – Medicaid https://www. flmedicaidtplrecovery.com/ flmedicaidtplrecovery.com/hipp/ index.html 877-357-3268 GEORGIA – Medicaid HIPP: https://medicaid.georgia. gov/health-insurance-premium-
Lincoln: 402-473-7000 Omaha: 402-595-1178
NEVADA – Medicaid http://dhcfp.nv.gov 800-992-0900
WYOMING – Medicaid https://health.wyo.gov/ healthcarefin/medicaid/ programs-and-eligibility 800-251-1269
NEW HAMPSHIRE – Medicaid https://www.dhhs.nh.gov/ programs-services/medicaid/ health-insurance-premium- program 603-271-5218 Toll free number for the HIPP program: 800-852-3345 , ext. 15218 DHHS.ThirdPartyLiabi@dhhs. nh.gov NEW JERSEY – Medicaid and CHIP Medicaid: http://www.state. nj.us/humanservices/ dmahs/clients/medicaid 800-356-1561 CHIP Premium Assistance: 609- 631-2392 CHIP: http://www.njfamilycare. org/index.html 800-701-0710 (TTY: 711) NEW YORK – Medicaid https://www.health.ny.gov/ health_care/medicaid 800-541-2831
To see if any other states have added a premium assistance program since July 31, 2023, or for more information on special enrollment rights, contact: U.S. Department of Labor Employee Benefits Security Administration dol.gov/agencies/ebsa 866-444-EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services cms.hhs.gov 877-267-2323 , Menu Option 4, Ext. 61565
Note: If your dependent becomes eligible for a special enrollment rights, you may add the dependent to your current coverage or change to another health plan.
Availability of Privacy Practices Notice We maintain the HIPAA Notice of Privacy Practices for Averitt Express, Inc. describing how health information about you may be used and disclosed. You may obtain a copy of the Notice of Privacy Practices by contacting the Averitt Express Benefits Department at 931-525-5323 . ACA Disclaimer This offer of coverage may disqualify you from receiving government subsidies for an Exchange plan even if you choose not to enroll. To be subsidy eligible you would have to establish that this offer is unaffordable for you, meaning that the required contribution for employee only coverage under our base plan exceeds 8.39% in 2025 of your modified adjusted household income. Notice of Availability of Alternative Standard for Wellness Plan Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a reward under this wellness
hipp-program 800-440-0493
UTAH – Medicaid and CHIP Utah’s Premium Partnership for Health Insurance (UPP) : https:// medicaid.utah.gov/upp
payment-program-hipp 678-564-1162 , Press 1
CHIPRA: https://medicaid. georgia.gov/programs/third- party-liability/childrens- health-insurance-program- reauthorization-act-2009-chipra 678-564-1162 , Press 2
upp@utah.gov 888-222-2542 Adult Expansion: https://
medicaid.utah.gov/expansion Utah Medicaid Buyout Program: https://medicaid.utah.gov/ buyout-program CHIP: https://chip.utah.gov
OMB Control Number 1210-0137 (expires 1/31/2026)
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