EMEGC/APSI 2019 Benefits Guide

2019 BENEFITS AT A GLANCE

CONTENTS & CONTACT INFORMATION

Refer to this list when you need to contact one of your benefit vendors. For general information contact Human Resources.

BROKER Provider Name Broker Contact

M.E. Wilson Company

Amanda Sands

Provider Phone Number Provider Email Address

813-229-8021 Ext. 139 asands@mewilson.com

MEDICAL

page 3

Provider Name

FloridaBlue

Provider Phone Number Provider Web Address

800-322-2808

www.bcbsfl.com

DENTAL

page 6

Provider Name

Guardian

Provider Phone Number Provider Web Address

800-541-7846

www.guardiananytime.com

VISION

page 7

Provider Name

Guardian

Provider Phone Number Provider Web Address

800-541-7846

www.guardiananytime.com

BASIC AND VOLUNTARY LIFE

__________________ page 8

Provider Name

Mutual of Omaha

Provider Phone Number Provider Web Address

877-999-2330

www.mutualofomaha.com

SHORT-TERM AND LONG-TERM DISABILITY

__________________ page 9

Provider Name

Mutual of Omaha

Provider Phone Number Provider Web Address

877-999-2330

www.mutualofomaha.com

SUPPLEMENTAL BENEFITS

page 11

DISCLOSURE NOTICES

page 14

BENEFIT INFORMATION

Benefit

Who pays the cost?

EMEGC/APSI pays the majority of the employee portion of the medical plan. You may enroll your eligible dependents for an additional cost.

Medical Insurance

YOUR BENEFITS PLAN

EMEGC/APSI offers a variety of benefits allowing you the opportunity to customize a benefits package that meets your personal needs. In the following pages, you’ll learn more about the benefits offered. You’ll also see how choosing the right combination of benefits can help protect you and your family’s health and finances – and your family’s future.

You may elect dental coverage for yourself and your eligible dependents on a voluntary basis and you will be responsible for the cost.

Dental Insurance

You may elect vision coverage for yourself and your eligible dependents on a voluntary basis and you will be responsible for the cost.

Vision Insurance

Voluntary Life Insurance

The employee pays the entire cost.

Short and Long Term Disability

The employee pays the entire cost.

EMEGC/APSI pays the entire cost for employee coverage.

Basic Life

ELIGIBILITY

All Regular full-time employees are eligible to join the EMEGC/APSI Benefits Plan on the 1st of the month following 60-Days. “Regular Full-Time Employees” must be regularly scheduled and working at least 30 hours per week.

You may also enroll your dependents in the Benefits Plan when you enroll.

Eligible dependents include:

Your legal spouse

• Your married or unmarried natural children, step-children living with you, legally adopted children and any other children for whom you have legal guardianship, who are:

WHEN CAN YOU ENROLL?

► Under 26 years of age;

► A dependent who is older than 26 years of age, but less than 30 years of age may be eligible for medical benefits. To be eligible, a Dependent must: • Be unmarried and not have dependents of his or her own; AND

You can sign up for Benefits at any of the following times:

• After completing your initial eligibility period; • During the annual open enrollment period; • Within 30 days of a qualified family-status change. If you do not enroll at one of the above times, you may enroll during the next annual open enrollment period.

Be a resident of Florida or a student; AND

• Not have coverage of their own, or covered under any other plan, including Medicare

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BENEFIT INFORMATION

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CHOOSING YOUR BENEFITS

You must actively choose any benefit that you pay for, or share in the cost with EMEGC/APSI. Your part of the cost is automatically taken out of your paycheck. There are two ways that the money can be taken out:

WHY DO I PAY FOR BENEFITS WITH BEFORE-TAX MONEY?

There is a definite advantage to paying for some benefits with before-tax money: Taking the money out before your taxes are calculated lowers the amount of your pay that is taxable. Therefore, you pay less in taxes.

• BEFORE YOUR TAXES ARE CALCULATED – medical, dental, and vision

• AFTER YOUR TAXES ARE CALCULATED – voluntary life and accidental death & dismemberment, supplemental benefits

MAKING CHANGES

Generally, you can only change your benefit choices during the annual benefits enrollment period. However, you may be able to change your benefit choices during the plan year if you have a change in status including:

If you fail to notify Human Resources within 30 days of a family status change, you will be required to wait until the next annual enrollment period to make benefit changes unless you have another family status change.

Your marriage

Your divorce or legal separation

• Birth or adoption of an eligible child

• Death of your spouse or covered child

• Change in your spouse’s work status that affects his or her benefits

WHEN COVERAGE ENDS

• Change in your work status that affects your benefits

Medical, dental and vision coverages will stop on the last day of the month in which employment with the company ends.

• Change in residence or work site that affects your eligibility for coverage

• Change in your child’s eligibility for benefits

• Receiving Qualified Medical Child Support Order (QMCSO)

KEY BENEFIT TERMS

Copayment – A flat fee that you pay for medical services, regardless of the actual amount charged by your doctor or another provider. This generally applies to physicians’ office visits and prescription drugs. Deductible – The amount you pay toward medical and dental expenses each year before the plan begins paying benefits. Out of Pocket Maximum – The maximum amount you will pay in deductibles, coinsurance and copayments during the year.

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MEDICAL INSURANCE

EMEGC/APSI offers four medical plans through FloridaBlue. To find participating providers go to www.bcbsfl.com and click on “Find a Doctor”, then follow the prompts to complete the search. The chart below provides a brief overview of the medical plans. This chart is intended only to highlight the benefits available and should not be relied upon to fully determine your coverage.

If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.

BlueOptions (HSA) 05192/05193

BlueCare 70*

BlueCare 49

BlueCare 48

IN-NETWORK: Plan Year or Calendar Year Basis

Calendar Year

Calendar Year

Calendar Year

Calendar Year

Deductible (Individual / Family)

$5,500 / $11,000

$3,000 / $9,000

$2,500/$5,000

$2,000 / $6,000

Coinsurance

70% / 30%

80% / 20%

80% / 20%

100% / 0%

Maximum Out-of-Pocket (Individual/Family)

$7,350 / $14,700

$6,350 / $12,700

$5,800 / $11,600

$5,500 / $11,000

Deductible, Coinsurance & Copayments

Deductible, Coinsurance & Copayments

Deductible, Coinsurance & Copayments

Deductible, Coinsurance & Copayments

Maximum Out-of-Pocket Includes

Lifetime Maximum

Unlimited

Unlimited

Unlimited

Unlimited

PREVENTIVE CARE:

Wellness Immunizations Mammography/Colonoscopy COPAYMENTS: Referral Required

Covered 100%

Covered 100%

Covered 100%

Covered 100%

No (PCP Required)

No (PCP Required)

No

No (PCP Required)

Office Visits Consultations for Illness/Injury

$50 Copayment

$40 Copayment

Deductible & Coinsurance

$35 Copayment

Specialist Visits

$75 Copayment

$100 Copayment

Deductible & Coinsurance

$65 Copayment

$500 Per Admission + Deductible & Coinsurance

$100 Per Admission + Deductible & Coinsurance

Inpatient Hospital

Deductible & Coinsurance

Deductible & Coinsurance

Outpatient Surgery Emergency Room Urgent Care

Deductible & Coinsurance

Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance

$500 Copayment $80 Copay

$400 Copayment $100 Copay

$300 Copayment $70 Copay

Deductible & Coinsurance

OUTPATIENT DIAGNOSTIC SERVICES: Independent/Freestanding Lab Complex Diagnostic (MRI, CT, PET, Etc.) – Freestanding Facility

100%

100%

Deductible & Coinsurance

100%

Deductible & Coinsurance

$400 Copay

Deductible & Coinsurance

$300 Copay

PRESCRIPTIONS:

After Annual Deductible:

Tier 1: $10 copay Tier 2: Deductible & Coinsurance Tier 3: Deductible & Coinsurance

Tier 1: $10 copay Tier 2: $60 Copay Tier 3: $100 Copay

Tier 1: $10 copay Tier 2: $50 copay Tier 3: $80 copay

Tier 1: $10 copay Tier 2: $50 copay Tier 3: $80 copay

Retail (30 day supply)

OUT-OF-NETWORK 2 Deductible

Unavailable

Unavailable

$5,000 / $10,000

Unavailable

(Individual / Family)

Maximum Out-of-Pocket (Individual/Family)

Unavailable

Unavailable

$11,600 / $23,200

Unavailable

*Does not meet Medicare Part D Creditable Coverage standards.

Coinsurance

Unavailable

Unavailable

60 / 40%

Unavailable

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MEDICAL CONTRIBUTION SCHEDULE

Tobacco Employee Pays (Weekly)

Non-Tobacco Employee Pays (Weekly)

BlueCare 70

Employee Only

$ 31.06 $138.11 $ 96.22 $195.51

$ 45.06 $152.11 $110.22 $209.51

Employee + Spouse Employee + Child(ren)

Family

Non-Tobacco Employee Pays (Weekly)

Tobacco Employee Pays (Weekly)

BlueCare 49

Employee Only

$ 52.56 $189.29 $135.79 $262.61

$ 66.56 $203.29 $149.79 $276.61

Employee + Spouse Employee + Child(ren)

Family

Non-Tobacco Employee Pays (Weekly)

Tobacco Employee Pays (Weekly)

BlueOptions (HSA) 05192/05193

Employee Only

$ 49.50 $178.37 $127.49 $248.10

$ 63.50 $192.37 $141.49 $262.10

Employee + Spouse Employee + Child(ren)

Family

Non-Tobacco Employee Pays (Weekly)

Tobacco Employee Pays (Weekly)

BlueCare 48

Employee Only

$ 59.21 $205.11 $148.02 $283.35

$ 73.21 $219.11 $162.02 $297.35

Employee + Spouse Employee + Child(ren)

Family

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HEALTH SAVINGS ACCOUNT (HSA)

Those employees enrolled in the BlueOptions 05192/05193 HDHP Plan are eligible to contribute towards the Health Savings Account (HSA).

What is a Health Savings Account (HSA)? It is an interest bearing account created to help you pay medical expenses. The funds in your HSA can be used to help pay your deductible, coinsurance and any qualified medical expenses not covered by your health plan (including dental and vision expenses). All of the money you contribute is tax-deductible when used to pay for qualified medical expenses. An HSA is your account. It goes with you if you change jobs or when you retire.

2019 IRS Annual Maximum HSA Contribution Limits (maximums include employer contributions)

Employee Only

$3,500

Family

$7,000

Catch-up Amount for employees 55 years or older

Additional $1,000 annually

Health Savings Account – Eligible Expenses (partial list) • Acupuncture • Alcohol and drug dependency treatment • Ambulance • Artificial limbs • Breast reconstruction surgery (mastectomy-related) • Dental expenses (exams, cleanings, X-rays, root canals bridges, etc.) • Diagnostic fees • Doctor fees (including Chiropractic services) • Drugs - prescription and over the counter (when ordered by physician) • Eyeglasses and exams, contact lenses & solutions, laser surgery • Fertility enhancements • Hearing aids and batteries • Hospital and Laboratory fees • Long-term care (medical expenses and premiums) • Nursing home • Physical and speech therapies • Psychiatric care • Smoking-cessation programs and products • Vasectomy • Weight-loss program (to treat a specific disease diagnosed by a physician)

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DENTAL INSURANCE

EMEGC/APSI offers dental coverage through Guardian. The Dental PPO Plan allows you to use in-network or out-of-network benefits. If out-of-network dentists are used, you will be responsible to pay the difference between Guardian’s allowed amount and what the dentist may charge, also known as “balance billing”. The chart below provides a brief overview of the plan.

Low Dental PPO Plan

High Dental PPO Plan

Out-of Network 1

Out-of Network 1

In-Network

In-Network

Calendar Year Deductible Individual

$50

$50

$50

$50

$150

$150

$150

$150

Family

Annual Maximum

$1,500

$1,500

Diagnostic & Preventive Exams

Cleanings Fluoride X-Rays Sealants Regular Restorative Services Fillings

Covered in full

Covered in full

Covered in full

Covered in full

Covered 90% after deductible

Covered 80% after deductible

Covered 80% after deductible

Covered in full

Extractions - Single Tooth

Major Services Crowns

Bridges Dentures Endodontics (Root Canal) Periodontics (Gum Disease)

Covered 60% after deductible

Covered 50% after deductible

Covered 60% after deductible

Covered 50% after deductible

50% $1,000 lifetime maximum per person

50% $1,000 lifetime maximum per person

50% $1,000 lifetime maximum per person

50% $1,000 lifetime maximum per person

Orthodontia

90% of Usual & Customary Charges

90% of Usual & Customary Charges

Basis of Payment

Contracted Rate

Contracted Rate

1 Subject to balance billing. Please refer to your plan document for specific details.

Low Dental Plan

High Dental Plan

Employee Contributions (Weekly)

Employee Only

$ 5.58 $12.08 $15.67 $22.16

$ 6.58 $14.28 $18.17 $25.88

Employee + Spouse Employee + Child(ren)

Family

6

VISION INSURANCE

EMEGC/APSI offers vision coverage through Guardian. The Vision PPO Plan allows you to use in-network or out-of-network benefits. If out-of-network vision providers are used, you will be responsible for pay the difference between Guardian’s allowed amount and what the provider may charge, also known as “balance billing”.

Vision

Routine Eye Exams

$10 Copay

Lenses* Single

$25 Copay $25 Copay $25 Copay $25 Copay

Bifocal Trifocal Lenticular

Frames

$130 allowance, then 20% Discount

Contact Lenses

$130 allowance, then 15% Discount

Frequency Exam

Once every 12 months

Lenses or contact lenses

Once every 12 months

Frame

Once every 24 months

• Lenses, Frames & Contacts are limited to either one pair of contacts or frames/lenses per calendar year.

Employee Contributions (Weekly)

Vision

Employee Only

$1.44 $2.42 $2.47 $3.91

Employee + Spouse Employee + Child(ren)

Family

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BASIC LIFE AND AD&D & VOLUNTARY LIFE INSURANCE

BASIC LIFE INSURANCE EMEGC/APSI provides life insurance to all active full time employees at no cost to the employee. The chart below provides an overview of the plan.

Basic Life Insurance

Employee Benefit Amount

$10,000

35% at age 65 60% at age 70 75% at age 75

Age Reduction Schedule

Included Equal to basic life

Accidental Death & Dismemberment (AD&D)

VOLUNTARY LIFE INSURANCE

EMEGC/APSI provides all active employees working 30 or more hours per week the option to purchase life insurance coverage through a group plan, at the employee’s cost. The chart below provides an overview of the plan. Please note that anyone enrolling outside of their initial open enrollment period is considered a late entrant and will be subject to medical underwriting.

Voluntary Life Insurance

Employee Life

Increments of $10,000 up to $500,000

Employee Guarantee Issue

$150,000 for timely entrants

Spouse Life

Increments of $5,000 up to lesser of 50% of employee's amount or $250,000

Spouse Guarantee Issue

$20,000 for timely entrants

Dependent Life

Increments of $2,000 up to lesser of 50% of employee’s amount or $10,000

Accidental Death & Dismemberment (AD&D)

Included Equal to voluntary life amount

VOLUNTARY LIFE - Weekly Life Rates per $10,000 of benefit (cost of AD&D included) *Spouse premium is based on employee age.

Age

Employee

Spouse*

Child

<30

$0.28

$0.28

$0.44

30-34

$0.30

$0.30

35-39

$0.39

$0.39

40-44

$0.60

$0.60

45-49

$0.95

$0.95

50-54

$1.39

$1.39

55-59

$2.03

$2.03

60-64

$3.30

$3.30

65-69

$5.91

$5.91

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SHORT TERM DISABILITY INSURANCE

SHORT TERM DISABILITY

EMEGC/APSI provides all active employees working 30 or more hours per week the option to purchase short term disability insurance coverage through a group plan, at the employee’s cost.

Short Term Disability

Benefit Percentage

60% of basic earnings

Maximum Weekly Benefit

$1,000 per week

Benefits commence on the 8th day for an accident Benefits commence on the 8th day for a sickness

Elimination Period

Duration of Benefit

12 weeks

Definition of Earnings

Salary

Voluntary STD Premium Calculation Worksheet

To calculate your approximate STD weekly premium, follow these steps:

STEP 1 Enter your basic weekly pay (divide your annual pay by 52) rounded to the nearest dollar. STEP 2 Multiply the amount in Step 1 by 60% and enter the result (rounded to the next higher dollar). This is your weekly benefit. Do not enter more than $1,000.

1. _________

2. _________

STEP 3 Divide the amount in Step 2 by 10 and enter that amount.

3. _________

STEP 4 The rate per $10 benefit.

4. __$.23___

STEP 5 Multiply the amount in Step 3 by the amount in Step 4 and then enter it here. This is your approximate monthly premium. STEP 6 Multiply the amount in Step 4 by 12 and then divide by 52 and then enter it here. This is your approximate weekly premium.

5. _________

6. _________

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LONG TERM DISABILITY INSURANCE

LONG TERM DISABILITY EMEGC/APSI provides all active employees working 30 or more hours per week the option to purchase Long term disability insurance coverage through a group plan, at the employee’s cost.

Long Term Disability

Benefit % of Monthly Covered Payroll

60% of basic earnings

Monthly Maximum

$5,000 per month

Elimination Period

Benefits commence on the 91st day

Benefit Duration

Social Security Normal Retirement Age (SSNRA)

Definition of Earnings

Salary

VOLUNTARY LONG-TERM DISABILITY Rates per $100 of benefit

PREMIUM CALCULATION

AGE

Monthly Rates per $100 of benefit

< 25

$0.13

Monthly Pay

$__________

25-29

$0.13

30-34

$0.32

/ 100.00

35-39

$0.32

= $________

40–44

$0.65

Rate per $100.00 (See Chart)

x _________

45-49

$1.02

X 12______

50–54

$1.63

/ 52_______

55-59

$1.79

Weekly Premium $____________

60+

$1.57

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SUPPLEMENTAL BENEFITS

Critical Illness Benefit Summary

Benefit Amount

Employee may choose a lump sum of $1,000 benefit up to $10,000.

Cancer Type I, Heart Attack, Kidney Failure, Organ Transplant, Stroke, Cancer Type II (Non-Invasive), Coronary Artery Bypass Graft

Covered Conditions

Spouse Benefit

50% of employees lump sum benefit

Child Benefit

50% of employees lump sum benefit

AGE

Weekly Premiums - Employee $1,000 Benefit

Weekly Premiums Employee $5,000 Benefit

Weekly Premiums Employee $10,000 Benefit

< 20

$1.09

$1.68

$2.40

20-24

$1.19

$1.84

$2.65

25-29

$1.27

$2.02

$2.95

30-34

$1.36

$2.28

$3.43

35–39

$1.55

$2.79

$4.35

40-44

$1.81

$3.66

$5.98

45–49

$2.24

$5.11

$8.70

50-55

$2.82

$7.09

$12.44

55-59

$3.31

$8.47

$14.92

Accident Benefit Summary

Accident Coverage Type

Off Job

Employee: $25,000 Spouse: $12,500 Child: $5,000

Benefit Amount

Portability

Included

Emergency Room Visits, Burns, Dental, Stitches, Fractures, Surgeries, and so much more!

Example of Covered Benefits

Employee Contributions (Weekly)

Accident Weekly Premiums

Employee Only

$4.50

Employee & Spouse

$7.36

Employee & Child(ren)

$7.42

Employee & Family

$10.28

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SUPPLEMENTAL BENEFITS – cont.

Cancer Benefit Summary

Employee: $2,500 Spouse: $2,500 Child: $2,500

Benefit Amounts

Pre-Existing

12 Month look back period, 12 month exclusion

Portability

Included

Ambulance, Bone Marrow, Stem Cell, Experimental Treatment, Home Health Care, Hospice, Hospital Confinement, ICU, Medical Imaging, Physical Therapy, Speech Therapy, Radiation Treatment, Chemotherapy, Reconstructive Surgery, Second Surgical Opinion, Skin Cancer, Surgical Benefit, Transportation and so much more!

Features

Waiver of Premium

Included

Benefit Waiting Period

30 Days

Employee Contributions (Weekly)

Cancer Weekly Premiums

Employee Only

$5.97

Employee & Spouse

$13.29

Employee & Child(ren)

$7.08

Employee & Family

$14.39

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SUPPLEMENTAL BENEFITS – cont.

Hospital Benefit Summary

Benefit Amounts

Option 1

Option 2

$1,000 (Per admission to a max of 1 admission per year, per insured, max of 3 admissions) $100 (Per day to a max of 30 days, per insured) $100 (Per day to a max of 30 days, per insured)

$2,500 (Per admission to a max of 1 admission per year, per insured, max of 3 admissions) $500 (Per day to a max of 30 days, per insured) $500 (Per day to a max of 30 days, per insured)

First Day Hospital Confinement Benefits

Daily Hospital Confinement Benefits

Hospital Intensive Care Benefits

Additional Benefits

Maternity Hospitalization

Included

Included

Waiver of Pre-Ex Conditions

Included

Included

Employee Contributions (Weekly)

Hospital – Option 1

Hospital – Option 2

Employee Only

$ 3.04

$ 9.57

Employee & Spouse

$ 7.91

$23.33

Employee & Child(ren)

$ 5.31

$17.77

Employee & Family

$10.19

$31.53

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REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES

Required Annual Employee Disclosure Notices

THE NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT OF 1996

WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998 The Women’s Health and Cancer Rights Act of 1998 requires EMEGC/APSI to notify you, as a participant or beneficiary of the EMEGC/APSI Health and Welfare Plan, of your rights related to benefits provided through the plan in connection with a mastectomy. You, as a participant or beneficiary, have rights to coverage to be provided in a manner determined in consultation with your attending physician for: 1. 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; and

The Newborns’ and Mothers’ Health Protection Act of 1996 prohibits group and individual health insurance policies from restricting benefits for any hospital length of stay for the mother or newborn child in connection with childbirth; (1) following a normal vaginal delivery, to less than 48 hours, and (2) following a cesarean section, to less then 96 hours. Health insurance policies may not require that a provider obtain authorization from the health insurance plan or the issuer for prescribing any such length of stay. Regardless of these standards an attending health care provider may, in consultation with the mother, discharge the mother or newborn child prior to the expiration of such minimum length of stay. 1. Deny to the mother or newborn child eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely to avoid providing such length of stay coverage; 2. Provide monetary payments or rebates to mothers to encourage such mothers to accept less than the minimum coverage; 3. Provide monetary incentives to an attending medical provider to induce such provider to provide care inconsistent with such length of stay coverage; 5. Restrict benefits for any portion of a period within a hospital length of stay described in this notice. These benefits are subject to the plan’s regular deductible and co-pay. For further details, refer to your Summary Plan Description. Keep this notice for your records and call Human Resources for more information. Further, a health insurer or health maintenance organization may not: 4. Require a mother to give birth in a hospital; or

2. Prostheses and treatment of physical compilations of the mastectomy, including lymphedema.

These benefits are subject to the plan’s regular deductible and co-pay. For further details, refer to your Summary Plan Description. Keep this notice for your records and call Human Resources for more information.

MICHELLE’S LAW

The law allows for continued coverage for dependent children who are covered under your group health plan as a student if they lose their student status because of a medically necessary leave of absence from school. This law applies to medically necessary leaves of absence that begin on or after January 1, 2010 If your child is no longer a student, as defined in your Certificate of Coverage, because he or she is on a medically necessary leave of absence, your child may continue to be covered under the plan for up to one year from the beginning of the leave of absence. This continued coverage applies if your child was (1) covered under the plan and (2) enrolled as at student at a post-secondary educational institution (includes colleges, universities, some trade schools and certain other post-secondary institutions). Your employer will require a written certification from the child’s physician that states that the child is suffering from a serious illness or injury and that the leave of absence is medically necessary.

SECTION 111

Effective January 1, 2009 group health plans are required by Federal government to comply with Section 111 of the Medicare, Medicaid, and SCHIP Extensions of 2007’s new Medicare Secondary Payer regulations. The mandate is designed to assist in establishing financial liability of claims assignments. In other words, it will help establish who pays first. The mandate requires group health plans to collect additional information, more specifically Social Security numbers for all enrollees, including dependents 6 months of age or older. Please be prepared to provide this information on your benefits enrollment form when enrolling into benefits.

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Required Annual Employee Disclosure Notices continued REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES continued

HIPAA PRIVACY POLICY FOR FULLY-INSURED PLANS WITH NO ACCESS TO PHI

PATIENT PROTECTION: If the Group Health Plan generally requires the designation of a primary care provider who participates in the network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from the carrier 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 the network who specializes in obstetrics or gynecology. The health care professionals, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, or for information on how to select a primary care provider, and for a list of the participating primary care providers, contact the Plan Administrator or refer to the carrier website. It is your responsibility to ensure that the information provided on your application is accurate and complete. Any omissions or incorrect statements made by you on your application may invalidate your coverage. The carrier has the right to rescind coverage on the basis of fraud or misrepresentation. CHILDREN’S HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT (CHIPRA) OF 2009 Effective April 1, 2009, a special enrollment period provision is added to comply with the requirements of the Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009. If you or a dependent is covered under a Medicaid or CHIP plan and coverage is terminated as a result of the loss of eligibility for Medicaid or CHIP coverage, you may be able to enroll yourself and/or your dependent(s). However, you must enroll within 60 days after the date eligibility is lost. If you or a dependent becomes eligible for premium assistance under an applicable State Medicaid or CHIP plan to purchase coverage under the group health plan, you may be able to enroll yourself and/or your dependent(s). However, you must enroll within 60 days after you or your dependent is determined to be eligible for State premium assistance. Please note that premium assistance is not available in all states.

I. No access to protected health information (PHI) except for summary health information for limited purpose and enrollment / dis-enrollment information. Neither the group health plan nor the plan sponsor (or any member of the plan sponsor’s workforce) shall create or receive protected health information (PHI) as defined in 45 C.F.R. § 160.103 except for (1) summary health information for purpose of (a) obtaining premium bids or (b) modifying, amending, or terminating the group health plan, and (2) enrollment and dis- enrollment information. The insurer for the group health plan will provide the group health plan’s notice of privacy practices and will satisfy the other requirements under HIPAA related to the group health plan’s PHI. The notice of privacy practices will notify participants of the potential disclosure of summary health information and enrollment / dis-enrollment information to the group health plan and the plan sponsor. The group health plan is a fully-insured group health plan sponsored by the “Plan Sponsor”. The group health plan and the plan sponsor intend to comply with the requirements of 45 C.F.R. § 164.530 (k) so that the group health plan is not subject to most of HIPAA’s privacy requirements. II. Insurer for group health plan will provide privacy notice The group health plan shall not intimidate, threaten, coerce, discriminate against, or take other retaliatory action against individuals for exercising their rights , filing a complaint, participating in an investigation, or opposing any improper practice under HIPAAA. The group health plan shall not require an individual to waive his or her privacy rights under HIPAA as a condition of treatment, payment, enrollment or eligibility. If such an action should occur by one of the plan sponsor’s employees, the action shall not be attributed to the group health plan. IV. No Waiver III. No intimidating or retaliatory acts

PATIENT PROTECTION: If the Group Health Plan generally requires the designation of a primary care provider who participates in the network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider.

15

Required Annual Employee Disclosure Notices - Continued REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES continued

If you decide to join a Medicare drug plan and drop your current FloridaBlue coverage, be aware that you and your dependents will be able to get this coverage back.

MEDICARE PART D

This notice applies to employees and covered dependents who are eligible for Medicare Part D. Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with FloridaBlue and about your options under Medicare’s prescription drug Plan. If you are considering joining, you should compare your current coverage including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare through Medicare prescription drug plans and Medicare Advantage Plan (like an HMO or PPO) that offer prescription drug coverage. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. FloridaBlue has determined that the prescription drug coverage offered by the BlueCare 70 plan is, on average for all plan participants, NOT expected to pay out as much as standard Medicare prescription drug coverage pays. Therefore, your coverage is considered Non-Creditable Coverage. This is important because, most likely, you will get more help with your drug costs if you join a Medicare drug plan, than if you only have prescription drug coverage from the BlueCare 70 plan. This also is important because it may mean that you may pay a higher (a penalty) if you do not join a Medicare drug plan when you first become eligible. 3. You can keep your current coverage from BlueCare 70. However, because your coverage is non-creditable, you have decisions to make about Medicare prescription drug coverage that may affect how much you pay for that coverage, depending on if and when you join a drug plan. When you make your decision, you should compare your current coverage, including what drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. Read this notice carefully – it explains your options. You should also know that if you drop or lose your coverage with FloridaBlue and don’t enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more (a penalty) to enroll in Medicare prescription drug coverage later. _______________________________________________________ You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 th to December 7 th . However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What happens to your current coverage if you decide to join a Medicare Drug Plan? If you decide to join a Medicare drug plan, your current FloridaBlue coverage will not be affected. You can keep this coverage if you elect part D and this plan will coordinate with Part D coverage. When can you join a Medicare Drug Plan?

When will you pay a higher premium (penalty) to join a Medicare drug Plan?

You should also know that if you drop or lose your current coverage with FloridaBlue and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For more information about this notice or your current prescription drug coverage… Contact our office for further information (see contact information below). NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through FloridaBlue changes. You also may request a copy of this notice at any time. For more information about your options under Medicare prescription drug coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: • Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number) for personalized help, • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486- 2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1- 800-772-1213 (TTY 1-800-325-0778). • Visit www.medicare.gov

Remember: Keep this notice. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage, you may be required to provide a copy of this notice when you join to show that you are not required to pay a higher premium amount.

Date:

3/1/2019

Name of Entity/Sender: Contact--Position/Office:

EMEGC/APSI

Crystal Jurado 3615 E. Lake Ave Tampa, FL 33610

Phone Number:

813-241-9000

16

HEALTHCARE REFORM AND YOU

The Patient Protection and Affordable Care Act & The Health Care and Education Affordability Reconciliation Act of 2010, together, create the most comprehensive health insurance reform ever under taken in recent history by our Country. Many of the new law’s required changes have already been incorporated into company health plans across the country since the effective date in September of 2010. However, there will be many more changes taking place in the months to come, as more guidance is issued by the government to employers, insurance carriers and individuals. One of the key requirements of the new law beginning in 2014, is the mandate that all U.S. citizens & legal residents either carry health insurance or pay an income tax penalty. While the tax penalty is not too severe in the first year, it becomes progressively more costly each year thereafter. In 2014, the greater of $95 or 1% of taxable income; In 2015, the greater of $325 or 2% of taxable income; In 2016, the greater of $695 or 2.5% of taxable income; and After 2016, the penalty is indexed for inflation. However, there are two ways to avoid the tax penalty: You can buy coverage for you and your family through your place of employment, if your employer offers such coverage. That coverage must meet certain standards set by the law in order for you and the employer to escape respective tax penalties. The coverage must meet certain minimum coverage standards (Generally pays at least 60% of your covered medical expenses) and must be considered “affordable” (Employer cannot charge you a premium for single or employee only coverage greater than 9.5% of your W-2 earnings for the year). The 9.5% would apply to annual salaries of up to about $45,000. Or, you can provide coverage for you and your family through a Federally run Insurance Exchange that is supposed to be up and running by 1/1/2014. Essentially, an Exchange is an interactive site where an individual can go to research, evaluate and buy health plans. The State of Florida chose not to set up a state run exchange, so the Federal government will take over that responsibility. Penalties for failing to buy coverage Tax penalties for failing to buy coverage are phased in according to the following schedule:

If you obtain coverage through an Exchange:

The Exchange will eventually sell insurance policies at certain levels of coverage: • Bronze level – a medical plan designed to pay 60% of covered medical benefits; • Silver level – a medical plan designed to pay 70% of covered medical benefits; • Gold level – a medical plan designed to pay 80% of covered medical benefits; • Platinum level – a medical plan designed to pay 90% of covered medical benefits; • Catastrophic – available to young adults up to age 30 or those exempt from the individual mandate (additional requirements may apply) If you satisfy certain low income thresholds and do not have medical coverage through an employer, or have employer-provided coverage that is considered “unaffordable” or pays benefits that are below the “Bronze” plan discussed above, there are tax credits available to help you pay the premiums for coverage purchased through the Exchange. The credits also help pay for expenses like deductibles and co pays. More information on these credits will be provided to you later. If you and your family are below 133% of the Federal Poverty Level in 2014, you may qualify for Medicaid. Other changes to take effect in 2014 are: The health plan may no longer exclude coverage of a pre-existing condition; The health plan may not impose more than a 90-day waiting period for coverage; Your plan may no longer place an annual limit on key benefits in the plan; Your health plan must allow dependent children up to age 26 to enroll in coverage, regardless of the availability of employer- sponsored coverage where they work. You may only obtain coverage through an Exchange if you are not participating in your employer’s plan.

17

COBRA NOTICE

COBRA

Consolidated Omnibus Budget Reconciliation Act (COBRA) provides terminated employees and their covered dependents the opportunity for a temporary extension of health coverage at group rates (plus 2% service fee) in certain instances where coverage under the plan would otherwise end. You and your covered dependents have the right to choose continuation coverage if group health coverage is lost under the health plan for any of the following reasons: (1) death of the employee; (2) a termination of the employee’s employment (for reasons other than gross misconduct) or a reduction in the employee’s hours of employment; (3) divorce or legal separation from employee; (4) employee becomes entitled to Medicare; or (5) the dependent child ceases to be a “dependent child” by definition under the plan. Under the law, you or the covered dependent has the responsibility to inform us, as the employer, within 30 days of a qualifying event such as divorce, legal separation, or a child losing dependent status under the plan. We, as the employer, have the responsibility to notify you and your covered dependents of the right to continue coverage should coverage end due to death, employment termination, reduction in hours of employment, or Medicare entitlement.

WELLNESS NOTICE

NOTICE REGARDING WELLNESS PROGRAM

EMEGC/APSI 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.

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 EMEGC/APSI may use aggregate information it collects to design a program based on identified health risks in the workplace, EMEGC/APSI 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. 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.

18

New Health Insurance Marketplace Coverage Options and Your Health Coverage

Form Approved OMB No. 1210-0149 (expires 5-31-2020)

PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment-based health coverage offered by your employer. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. 1 Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis.

How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact:

Amanda Sands 813-349-2259

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.

PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.

3. Employer Name

4. Employer Identification Number (EIN)

E.M. Enterprises General Contractors

51-0462433

5. Employer Address

6. Employer Phone Number

3615 E. Lake Avenue

813-241-9000

7. City

8. State

9. Zip Code

Tampa

FL

33610

10. Who can we contact about employee health coverage at this job?

Amanda Sands – M.E. Wilson Company

11. Phone Number (if different from above)

12. E-mail address

813-229-8021

asands@mewilson.com

1 An employer-sponsored health plan meets the "minimum valuestandard" if the plan's share of the total allowed benefit costscovered by the plan is no less than 60 percent of such costs

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