(Salaried) 2019 McKibbon Benefit Guide

Salaried

2019 Benefits at a Glance

PLAN YEAR:

January 15, 2014 – December 31, 2014

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Hospitality begins with us.

Support Each Other

Beyond building and managing hotels, we

Think Bigger

create experiences that reflect and define the

local culture. Our legacy is built on a

Make A Lasting Impression

foundation of integrity, anchored in how we

Do the Right Thing

value our guests, treat our associates and

partners, and give back to our communities.

Love Your Community

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CONTENTS &

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

HUMAN RESOURCES

Benefits@mckibbon.com 813-472-7390 Courtney Semler 813-682-6007 Kaitlyn Barkley

BROKER PARTNER - M.E. WILSON COMPANY

813-984-3602 Katie Reeves Miller 813-984-3614 Cindy Buttrill 813-349-2230 Jeff Lenderman McKibbon@mewilson.com

HOW TO ENROLL

page 1

MEDICAL

page 4

United Healthcare 877-844-4999 www.myuhc.com

HEALTH SAVINGS ACCOUNT (H.S.A.)

page 5

Optum Bank 800-243-5543 www.optumbank.com

WAYS TO SAVE & VIRTUAL VISITS

page 6

DENTAL

page 7

United Healthcare 877-816-3596 www.myuhc.com

VISION

page 8

United Healthcare 800-638-3120 www.myuhcvision.com

LIFE INSURANCE

page 9

United Healthcare 888-451-7986 - Claims 877-683-8601 - Portability www.myuhc.com

DISABILITY INSURANCE

page 10

United Healthcare 888-229-2070 www.myuhc.com

ACCIDENT INSURANCE

page 11

United Healthcare 888-229-2070 www.myuhc.com

EMPLOYEE ASSISTANCE PROGRAM & CARE24

page 12

United Healthcare 888-887-4114 www.livewellworkwell.com

ID CARD & TERMS TO KNOW

page 13

DISCLOSURE NOTICES

page 14

HOW TO ENROLL

STEP 1

Login (or register) into your Paylocity account by going to https://access.paylocity.com (Your Company ID will be 10944.)

For assistance with username/password resets please contact benefits@mckibbon.com

Once logged in, hover over the grey Web Pay icon and select Enterprise Web Benefits.

STEP 2

Click the button labeled “Start your enrollment”, located on the home page. The site will take you through 4 tabs to finalize your enrollment. Please review and print or email a copy of your confirmation statement for your records.

VERIFY PERSONAL INFORMATION

Please review the personal information listed for yourself and any enrolled family members to ensure accuracy. If any changes are needed, please make updates in Web Pay. Any changes made will be reflected in Web Benefits within 24 hours. (PLEASE NOTE: you will not need to wait for the updates to reflect within the system. You may proceed with enrollment.) Once confirmed and/or changes have been made please click “I Agree”, located at the bottom of the page and “Continue”.

** Any fields marked with an asterisk are required.**

FINALIZE ENROLLMENT

Once you’ve completed your review and changes click the “I agree, and I'm finished with my enrollment. “ then hit “Save my Enrollment!”

Once completed you may email yourself confirmation of your enrollment, if email was entered in the Family Profile Information. Otherwise you may print the confirmation by clicking on the “Print” icon located on the right hand side of the page.

LOG OFF

Although the online portal is secure and your information is encrypted during transit, it’s important you log off once you’ve completed your session. To do so, click the “LOG OUT” icon in the upper right-hand corner of the enrollment site.

For security purposes the system will automatically logout if left idle for 30+ minutes.

BENEFIT INFORMATION

Benefit

Who pays the cost?

McKibbon Hospitality pays for a portion towards the employee and dependent cost for medical coverage.

YOUR BENEFITS PLAN

Medical

McKibbon Hospitality 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.

McKibbon Hospitality offers dental coverage on a voluntary basis.

Dental

McKibbon Hospitality offers vision coverage on a voluntary basis.

Vision

Life

McKibbon Hospitality offers life coverage on a voluntary basis.

McKibbon Hospitality offers short term disability coverage on a voluntary basis.

Short TermDisability

McKibbon Hospitality pays 100% of the cost for long term disability coverage.

Long TermDisability

Accident

McKibbon Hospitality offers accident coverage on a voluntary basis.

PRE-TAX BENEFITS

CHOOSING YOUR BENEFITS

The premium for elected coverages is taken from your paycheck automatically. There are two ways that the money can be taken out, pre-tax or post –tax.

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

There is a definite advantage to paying for some benefits with pre-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.

WHICH BENEFIT PREMIUMS ARE TAKEN BEFORE TAX?

PRE tax –

Medical, Dental, and Vision

POST tax –

Life, Disability, and Accident

ELIGIBILITY

All salaried full-time employees are eligible to join the McKibbon Hospitality Benefits once the waiting period has been satisfied. Coverage will begin on the 31 st day from your date of hire. Salaried 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.

WHO’S AN ELIGIBLE DEPENDENT?

•

Your legal spouse

• Your married or unmarried natural children, step-children living with you, legally adopted child(ren) and any other child(ren) for whom you have legal guardianship, up to age 26

A dependent who is older than 26 years of age, but less than 30 years of age may be eligible for medical benefits. Please contact Benefits@mckibbon.com for more information.

WHEN CAN YOU ENROLL?

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

• As a new hire, at your initial eligibility date. You must enter your election via Paylocity no later than 7 days from your date of hire.

• During the annual open enrollment period in 2019

• 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.

MAKING CHANGES

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

•

• Change in your work status that affects your benefits

Your marriage

•

• Change in residence that affects your eligibility for coverage

Your divorce

•

• Change in your child’s eligibility for benefits

Birth or adoption of an eligible child

•

• Receiving QualifiedMedical Child Support Order (QMCSO)

Death of your spouse or covered child

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

You must submit documentation as proof of life event to Benefits@mckibbon.comwithin 30 days. The IRS allows changes to be made within 60 days for those eligible for Medicaid or CHIP under HIPAA Special Enrollment Rights. If you fail to do so you will be required to wait until the next annual enrollment period to make benefit changes unless you hav e another family status change.

WHEN DOES COVERAGE END?

Coverage will stop on the last day of the month of your last day employed by McKibbon.

MEDICAL INSURANCE

McKibbon Hospitality offers medical coverage through United Healthcare (UHC). You have four plan options to choose from. To find participating providers go to www.myuhc.com and click on “Find a Doctor”, then follow the prompts to complete the search within the “Choice Plus” network. The chart below provides a brief overview of the medical plans offered.

BUY-UP PLAN #1

BUY-UP PLAN #2

HDHP H.S.A. PLAN

BASE PLAN

IN-NETWORK

Choice Plus

DEDUCTIBLE (your first dollar cost for covered in-network claims) Deductible (Individual / Family) $6,600 / $13,200

$2,500 / $5,000

$4,500 / $9,000

$3,500 / $7,000

COINSURANCE (your responsibility on claims costs once you’vemet the deductible) 20% 20% OUT OF POCKET MAXIMUM (once met all in-network covered services are covered by the plan) MaximumOut-of-Pocket (Individual / Family) $7,130 / $14,260 $6,350 / $12,700

20%

$5,000 / $10,000

$5,000 / $6,850

Maximum Includes

Deductible, Coinsurance, Prescription Costs & Copays

PREVENTIVE CARE Wellness, Immunizations, Mammography, Colonoscopy, etc.

Covered 100%, no cost to you

OFFICE VISITS Referral Required

No $49

Virtual Visits

$10 Copay

Office Visits (Illness/Injury)

Covered 80% after deductible

$50 Copay

$45 Copay

$35 Copay

Covered 80% after deductible

Specialist Visits

$75 Copay

$60 Copay

HOSPITAL SERVICES Inpatient Hospital

Covered 80% after deductible Covered 80% after deductible Covered 80% after deductible Covered 80% after deductible

Covered 80% after deductible

Covered 80% after deductible Covered 80% after deductible

Outpatient Surgery

Covered 80% after deductible

Covered 80% after deductible Covered 80% after deductible

Emergency Room

$500 Copay

Urgent Care

$75 Copay

DIAGNOSTIC TESTING Lab & X-Ray Advanced Imaging (MRI, CAT, PET, etc.)

Covered 80% after deductible

Covered 100%

Covered 80% after deductible

Covered 80% after deductible Covered 80% after deductible

PRESCRIPTIONS

Your medical deductible applies first then, $10 / $35 / $60 Yes

Retail (30 day supply) Tier 1 / 2 / 3 / 4

$20 / $50 / $100 / $200

Medicare (Part D) Creditable

Yes

OUT-OF-NETWORK 1

Refer to plan summary for details . Copies can be found within forms library on the Benefits Portal.

$114.56 $293.38 $263.23 $365.10

Employee Only

$ 81.65

$121.92

$161.40

Employee + Spouse

$216.50

$312.23

$350.96

Employee + Child(ren)

$197.50

$280.15

$298.32

Employee + Family

$236.57

$388.55

$447.15

4 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. Reminder: You are not able to drop coverage outside of open enrollment unless you experience a qualified life event (QLE). Examples of QLEs are provided on page 3 of this guide. If you later decide the cost of the plan is too expensive, you will not be able to drop the coverage or change plans as this is not a QLE. Please note these rules and restriction are set and regulated by the IRS, not McKibbon Hospitality. 1 Charges are subject to balance billing

HEALTH SAVINGS ACCOUNT (H.S.A.)

Employees enrolling in the HDHP H.S.A Medical Plan are eligible to open and contribute to a Health Savings Account (H.S.A). With a H.S.A you have the ability to put money side, through payroll deductions, to help pay for H.S.A eligible expenses. The H.S.A is with Optum Health Bank.

WHAT ARE THE BENEFITS OF A H.S.A?

•

The money you put aside is PRE-TAX

• The H.S.A is a bank account in your name. If you retire or should you leave McKibbon Hospitality you take this account with you.

• The account rolls over year to year. You will not have to forfeit any unused funds.

• You will receive a debit card upon opening a H.S.A for quick and easy utilization of the fund.

• The list of eligible expenses is vast! These expenses include things covered under the medical, dental, and vision coverage – as well as some items that aren't!

2019 IRS Annual MaximumHSA Contribution Limits

Employee Only

$3,500

Family

$7,000

Additional $1,000 annually catch-up amounts for available for employees 55 years or older

WHAT ARE ELIGIBLE EXPENSES UNDER THE H.S.A?

Examples of eligible services include, but are not limited to the following:

• • • • • • • • • •

Acupuncture

• • •

Glasses

• • • • • • •

Batteries for hearing aids

Chiropractic services

Prescription Drugs

Long-term care Nursing home

Alcohol and drug dependency treatment

Prescription sunglasses

Ambulance

• Over the Counter Drugs (when ordered by a doctor) • Laser eye surgery • Radial keratotomy • Fertility enhancements • Hearing aids • Batteries for hearing aids • Long-term care

Maternity Expenses Organ transplants Physical therapies Speech therapies

Artificial limbs Contact lenses

Contact lens solution

Copays

• Smoking-cessation programs and products • Vasectomy • Wheelchairs

Deductible expenses

Dental expenses

VIRTUAL VISITS

Virtual visits allow you to see and talk to a doctor from a mobile device or computer without an appointment. A majority of visits take between 10-15 minutes, and virtual visits are a part of your health benefits.

Through a virtual visit, doctors can diagnose and treat a vast range of non-emergency medical conditions and provide services such as writing a prescription, if needed. This includes:

• • • • •

Allergies

• • • • • •

Migraine/headaches

Bladder infection

Pink eye

Bronchitis Cold/cough

Seasonal flu

Sinus problems

Fever

Sore throat

Stomach ache

Access virtual visits :

Log in to myuhc.com and choose from provider sites where you can register for a virtual visit. After registering and requesting a visit you will pay your portion of the service cost and then you will enter a virtual waiting room. Payment for service cost can be remitted via credit card. During your visit you will be able to talk to a doctor about your health concerns, symptoms and treatment options.

Virtual visits are subject to a $10 copay on the Base, Buy-Up #1, and Buy-Up #2 plans, saving you time and money! If you’re on the HDHP H.S.A plan your cost is $49 !

PRESCRIPTIONS & WAYS TO SAVE

Ask your doctor or pharmacist if your brand medication has a generic or lower cost alternative.

SAVING ON PRESCRIPTIONS

A wide range of generic medications are offered at low cost at your local pharmacy. Specific generic drugs are available at Target, Wal-Mart, and/or CVS for $4 for a 30-day supply and $10 for a 90-day supply ! Certain antibiotics are available at Publix for FREE !

90 DAY SUPPLY FOR MAINTENANCE MEDICATIONS

There are 2 ways to save – 1. Using UHC’s OptumRX Mail Order program can save you time and money ! A 90 day supply of your medication is delivered to your door and you are reminded when a refill is needed. The cost to use mail order is 2.5 times the retail cost, that means you save 50% on the 3 rd month’s copay! The program is calledMail Services Member Select.

2. UHC’s OptumRX Preferred90 allows you to fill a 90 day supply of your maintenance medications at CVS for 2.5 times the retail cost, that means you save 50% on the 3 rd month’s copay!

IMPORTANT INFO FOR MAINTENANCE MEDICATIONS! UHC requires you to choose to fill your maintenance medication(s) through either OptumRX Mail Services Member Select or a retail pharmacy. They will send you a letter asking you to make a decision to enroll in mail order OR dis-enroll in the program. UHC allows you 2 retail pharmacy fills of your maintenance medication before you must choose. If you do not take action after the second retail fill, you may pay more for your medication until you make a decision.

Q: How do you inform UHC of your decision to enroll in mail order or dis-enroll to fill your Rx at a retail pharmacy?

A: You may go online to www.myuhc.comor call the member services number, located on the back of your ID card.

DENTAL INSURANCE

McKibbon Hospitality offers dental coverage through United Healthcare. The Dental PPO Plan allows you to use in-network or out-of-network providers. Find in-network providers on www.myuhc.com by clicking on “Find Dentist” and searching within the “Options PPO 30” network. If out-of-network dentists are used, you will be responsible for paying the difference between United Healthcare’s allowed amount and what the dentist may charge, also known as “balance billing”. The chart below provides a brief overview of the plan.

DPPO PLAN

In-Network

Calendar Year Deductible (applies to basic & major services only)

Individual

$50

Family

$150

Annual Maximum (per covered member)

Per covered member

$1,000

Preventive Services

Exams, Cleanings, & Fluoride

Covered in full

Basic Services

Fillings, Simple Extractions, Oral surgeries, Periodontics, & Endodontics

Covered 70% after deductible

Major Services

Crowns, Bridges, & Dentures

Covered 50% after deductible

Out-of Network 1

Calendar Year Deductible

$50 / $150

Schedule of Services: Preventive

Covered 100% Covered 70% after deductible Covered 50% after deductible

Basic Major

Annual Maximum (pre covered member)

$ 1,000

80 th Usual & Customary Charges

Basis of Payment

Bi-Weekly Cost for Coverage

$10.31

Employee Only

$25.97

Employee + Spouse

$24.67

Employee + Child(ren)

$38.95

Employee + Family

1 Subject to balance billing. Please refer to your plan document for specific details. Copies can be found within forms library on the Benefits Portal.

VISION INSURANCE

McKibbon Hospitality offers vision coverage through United Healthcare. The United Healthcare vision plan allows you the flexibility to see any provider. To search in-network providers visit www.myuhcvision.com and search based on your location. When you utilize an out-of-network provider you pay expenses at the time of service and file a claim for reimbursement. Below is a list of the reimbursement schedule.

Vision

In-Network

Routine Eye Exams

Every 12 months

$10 Copay

Lenses 2

Every 12 months

Single Vision Bifocal Trifocal Lenticular

$25 Copay Lens upgrades are available from 20%-60% of retail pricing.

Frames

Every 12 months

$25 Copay provides a $130 allowance PLUS 30% off cost over the allowance

Contact Lenses (in lieu of glasses)

Every 12 months

Elective Contact Lenses Selection Non-Selection

$25 Copay provides up to 4 boxes $25 Copay provides a $130allowance

Medically Necessary

Covered 100% after $25 Copay

Out-of-Network 1

Routine Eye Exams

Every 12 months Reimbursed up to $40 Every 12 months Reimbursed up to $40 Reimbursed up to $60 Reimbursed up to $80 Reimbursed up to $80 Every 12 months Reimbursed up to $45 Every 12 months Reimbursed up to $130 Reimbursed up to $210

Lenses 2 Single

Bifocal Trifocal Lenticular

Frames

Contact Lenses (in lieu of glasses) Elective Medically Necessary

Bi-Weekly Cost for Coverage

Employee Only

$3.12

Employee + Spouse

$5.92

Employee + Child(ren)

$6.94

Employee + Family

$9.77

1 Reimbursable amount, less applicable copay. 2 Lenses benefit listed are for a pair of lenses.

VOLUNTARY LIFE INSURANCE

McKibbon Hospitality offers employees the option to purchase voluntary life insurance. This coverage is through United Healthcare.

WHAT’S GUARANTEE ISSUE?

Guarantee Issue (GI) is the amount you can purchase as a newly eligible employee without having to provide evidence of good heath (Evidence of Insurability (EOI)). The GI is $100,000 or 5x your annual salary, whichever is less.

WHEN WOULD I NEED TO SHOW EVIDENCE OF GOOD HEALTH TO GET LIFE INSURANCE?

If you elect a benefit over GI as a new hire, a benefit outside of your newly eligible period, or an increase to your current benefit you will be required to provide Evidence of Insurability (EOI). Completed EOIs should be submitted to United Healthcare directly. The fax number is listed on the form. A copy of the EOI form can be found within the library of the Benefits Portal.

HOW MUCH LIFE INSURANCE CAN I PURCHASE?

You may purchase a benefit in increments of $10,000 for as little as $10,000 and as much as $500,000, or 5x your annual salary (whichever is less).

Cost for coverage (per $1,000)

Age

WHAT’S THE COST?

0-24

$0.055

25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74

$0.060 $0.080 $0.090 $0.118 $0.180 $0.314 $0.541 $0.753 $1.317 $2.713 $4.155

See the below chart to locate your age bracket. The rates shown are per $1,000 of life benefit. Simply find the bi-weekly cost for coverage using the calculation below.

/ 1,000 =

Step 1

Desired benefit

75 +

/ 26

= $

x $

x 12 = $

Step 2

Your age rate

Annual cost for coverage

Cost per paycheck

WHAT HAPPENS WHEN YOU TURN 65?

Age Reduction Schedule

When you reach 65 a reduction of benefits will apply as of the first of the new policy year. See table for reduction of original benefit based on age.

At age…

Your original benefit will reduced by …

65 70 75

35%

60% 75%

WHAT HAPPENS IF I LEAVE MCKIBBON HOSPITALITY?

If you were to leave McKibbon Hospitality your voluntary life coverage offers the option of portability or conversion. Portability is a continuation of voluntary group term life insurance, cost of coverage is based on current group rates (subject to change as of renewal). Portability is available to all employees enrolled in voluntary life under the age of 70. Under conversion, an individual flexible premium universal life policy may be purchased. The cost for coverage would be based on individual life amounts and will differs from the group rates (typically higher in cost). You have 30 days from the date of terminated coverage to apply.

This process is handled by UHC, please reach out to them directly at 877-683-8601.

VOLUNTARY SHORT TERM DISABILITY

McKibbon Hospitality offers you the option to purchase short term disability (STD) insurance. STD is insurance for your paycheck should you become disabled due to an off the job injury or illness for a period of time.

WHEN WOULD THE BENEFIT START?

Benefits would begin on the 30 th day from injury or illness.

HOW MUCH WOULD THE BENEFIT PAY? The benefit would pay 60% of your weekly pre-disability earnings to a maximum of $1,000.00 per week.

HOW LONG WILL THE BENEFIT PAY?

The benefit would pay out to a maximum of 9 weeks or until you no longer meet the definition of disability, whichever occurs first.

EXAMPLE: Sue makes $40,000 annually. She become temporarily disabled and goes out on short term disability. She would receive a weekly benefit of $461.54 (60% of her weekly earnings) per week, up to 9 weeks or until she is no longer disabled (whichever is first).

PRE-EXISITING CONDITIONS ARE EXCLUDED. If you had a pre-existing condition within the 3 months prior to coverage becoming effective, you would not be eligible to claim for any disability resulting from that condition if the disability occurs within 12 months of the start of coverage.

WHEN WOULD I NEED TO SHOW EVIDENCE OF GOOD HEALTH TO GET STD INSURANCE?

If you elect coverage outside your newly eligible period you will be required to provide Evidence of Insurability (EOI). Completed EOIs should be submitted to United Healthcare directly. The fax number is listed on the form.

LONG TERM DISABILITY

McKibbon Hospitality provides you with long term disability (LTD) insurance. LTD is also insurance for your paycheck should you become disabled off the job.

McKibbon Hospitality pays 100% of the cost for LTD coverage. This benefit is at NO COST TO YOU.

WHEN WOULD THE BENEFIT START?

Benefits would begin on the 90 th day from injury or illness.

HOW MUCH WOULD THE BENEFIT PAY?

The benefit would pay 60% of your monthly pre-disability earnings to a maximum of $6,000.00 per month.

HOW LONG WILL THE BENEFIT PAY?

The benefit would pay out until Social Security Normal Retirement Age.

ACCIDENT INSURANCE

McKibbon Hospitality offers accident coverage through United Healthcare. Accident coverage provides direct payment for set injuries and services associated with an off the job accident. There are two accident plans available.

BASE PLAN

ENHANCED PLAN

Accidental Death & Dismemberment Life

$20,000

One hand or foot / Both hands or feet or combo One finger or toe / Two + fingers or toes or combo

$10,000 / $20,000

$2,000 / $4,000

Accidental Death Common Carrier

$80,000 Child benefit is 50% of employee/spouse

Initial Care Ground Ambulance / Air Ambulance Emergency Room Treatment / Physician Office or Urgent Care

$200 / $1,200 $100 / $40

Hospital Care Hospital Confinement / Admission Hospital ICU Confinement / Admission Follow Up Care Major Diagnostic Exam Follow up Physician Visit / Physical Therapy Medical Appliances Prosthetic (one / two or more) Rehabilitation Unit

$800 / $160 $2,500 / $500

$160 $40 / $30 $140 $500 / $1,00 $80 $280 $100 - $1,000 $500 - $8,000 $140 / $10,000 $80 - $200 $200

Common Injuries Blood, Plasma, Platelets Adnominal / Thoracic Surgery Burns

Concussion / Coma Dental Emergency Eye Surgery

Dislocations Surgical reduction type: (Hip/Knee/Ankle/Foot/Collarbone/Lower Jaw/Shoulder/Elbow/Wrist/Hand/Toe/Finger)

$80 - $3,200

Fractures Surgical reduction type:

(Skull/Hip/Vertebrae/Pelvis/Leg/Face/Upper Jaw/ Arm/Shoulder blade/Collarbone/Vertebral process/ Hand/Wrist/Kneecap/Foot/Ankle/Rib/Coccyx/Finger/Toe) Lacerations No stitches, staples or glue / Not more than 5cm Greater than 5cm but not more than 15 cm / 15cm +

$80 - $4,000

$30 / $50 $200 / $400

Paralysis

$400 - $10,000

Tendons / Ligaments / Rotator / Knee Cartilage

Exploratory / Surgery to repair one / more than one

$140 / $400 / $800

Organized Sporting Activity Injury Family Child Daycare (Per day, 30 day max) Family Lodging (per day) Transportation(special treatment, 100+ miles away)

$28 $140 $400

Bi-Weekly Cost for Coverage

$1.98

$4.56

Employee Only

$2.66

$6.54

Employee + Spouse

$2.33

$6.54

Employee + Child(ren)

$3.01

$8.51

Employee + Family

Benefits under the Accident coverage are only payable if it is a result of an accident . For example:

 (Payable) a broken leg due to a fall is a injury as a result of an accident X (NOT payable) a hospitalization due to kidney stones

EMPLOYEE ASSISTANCE PROGRAM

When you enroll in the medical insurance you automatically have access to United Healthcare’s Employee Assistance Program (EAP). The EAP program is a confidential resource available 24/7 to help you deal with a variety of life stages and/or concerns. These include but are not limited to the following:

• • • • •

Depression, stress and anxiety Relationship difficulties Financial and legal advice Family issues and parenting Child and elder care support

• • • • •

Dealing with domestic violence Substance abuse and recovery

Work-related issues

Grief

Eating disorders

Visit www.liveandworkwell.com

Call the toll-free number located on the back of your health plan ID card.

Username: RESOURCES Password: RESOURCES

Care24® Ser vices

Care24 provides you with Support Services as well as the Care24 Nurseline to help you when needed. These service are at NO COST TO YOU and available 24/7!

Support Services – The service offers you a wide range of health and well-being information through a toll-free telephone number. These services and health information include: • Health coaching • Emotional support • Connection to legal and financial services • End of Life care and support • Grief counseling

Nurseline – Care24 also has a Nurseline, which is a trustworthy resource for health information. When calling in you will speak directly to an experienced registered nurse or master’s-level counselor at any time.

When you don’t know where to go, give Care24’s Nurseline a call!

You may also find the following online, via Care24:

• Audio library for access to recorded health and well-being messages • Information on Oral health

Visit myuhc.com

1-888-887-4114

ID CARDS

NEW ENROLLEES

To utilize your medical and dental coverage prior to receiving your ID card you may simply give your provider your Social Security Number (SSN) as an alternate ID, as opposed to your member ID. Please note you will not receive a physical vision ID card by mail, UHC Vision is paperless. When making a vision appointment let the provider know you are a UHC vison member, they can use your SSN to verify benefits.

UHC IS DIGITAL

You may access your digital card via www.myuhc.com and www.myuhcvision.com as well as Health4Me – UHC’s mobile app . Please note, if you are registering prior to receiving your ID card with member ID, you may register using your SSN.

TERMS TO KNOW

When you enroll in coverage you become a UHC member. A member of UHC gets access to their network of providers (doctors and facilities) – these are in-network providers. UHC members receive Discounted Rates with these in-network providers. Discounted Rate

Copays

Copays are set dollar amounts you pay for specific services. These cost are typically collected at the time of service. EX: you have a $50 copay for a visit to your primary care physician.

Services not subject to a copay are subject to your deductible. You pay first dollar costs for claims subject to your deductible and you receive the Discounted Rate for all covered claims with an in-network provider. Deductible

Coinsurance

Coinsurance is a cost share. Once you meet the deductible UHC will share in the cost of your claims. The percent of the cost for the claim you are responsible for. The amounts you pay in coinsurance apply to your out of pocket maximum.

Out-of-Pocket

This amount is the maximum amount you will pay towards covered services on the plan for the calendar year. This amount includes the amounts you pay in deductible, coinsurance, copays, and prescription copays.

REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES

Required Annual Employee Disclosure Notices THE NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT OF 1996

The Newborns’ and Mothers’ Health Protection Act of 1996 prohibits group and individual health insurance policies from restrictingbenefits for any hospital lengthof 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 attendinghealth care provider may, in consultation with the mother, discharge the mother or newborn child prior to the expiration of such minimum length of stay.

Further, a health insurer or healthmaintenance organizationmay not:

1. Deny to the mother or newborn child eligibility, or continued eligibility, to enroll or to renew coverageunder the terms of the plan, solely to avoid providing such length of stay coverage;

2. Provide monetary payments or rebates to mothers to encouragesuch mothers to accept less than the minimum coverage;

3. Provide monetary incentives to an attendingmedical provider to induce such provider to provide care inconsistent with such lengthof stay coverage;

4. Require a mother to give birth in a hospital; or

5. Restrict benefits for any portion of a period within a hospital lengthof 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.

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 newMedicare 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 informationon your benefits enrollment form when enrolling into benefits.

WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998

The Women’s Health and Cancer Rights Act of 1998 requires McKibbon Hospitality Hospitality to notify you, as a participant or beneficiary of the McKibbon Hospitality Hospitality 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 consultationwith your attending physician for:

1. All stages of reconstruction of the breast on which the mastectomy was performed;

2. Surgery and reconstructionof the other breast to produce a symmetrical appearance; and

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

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 Certificateof 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.

REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES continued

Required Annual Employee Disclosure Notices continued

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

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 healthplan is not subject to most of HIPAA’s privacy requirements.

I. No access to protected health information (PHI) except for summary health informationfor limited purposeand 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.

II.

Insurer for group health plan will provide privacy notice

The insurer for the group healthplan 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.

III.

No intimidatingor retaliatory acts

The group health plan shall not intimidate, threaten, coerce, discriminateagainst, 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.

IV.

No Waiver

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.

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 (includinga 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 healthcare professionals, however, may be required to comply with certain procedures, including obtaining prior authorizationfor certain services, following a pre-approved treatment plan or procedures for making referrals. For a list of participating healthcare professionals who specialize in obstetrics or gynecology, or for informationon 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 applicationmay invalidate your coverage. The carrier has the right to rescind coverage on the basis of fraud or misrepresentation.

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Required Annual Employee Disclosure Notices continued

CHILDREN’S HEALTH INSURANCE PROGRAMREAUTHORIZATION 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 eligiblefor State premium assistance. Please note that premium assistance is not available in all states. If you or your children are eligiblefor 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 eligiblefor these premium assistance programs but you may be able to buy individual insurance coverage through the Health InsuranceMarketplace. 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 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 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 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 coveragewithin 60 days of beingdetermined 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 planpremiums. The following list of states is current as of July 31, 2016. Contact your Statefor more information on eligibility –

ALABAMA – Medicaid

FLORIDA – Medicaid

Website: http://myalhipp.com/ Phone: 1-855-692-5447

Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268

ALASKA – Medicaid

GEORGIA – Medicaid

The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: http://dch.georgia.gov/medicaid - Click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507

ARKANSAS – Medicaid

INDIANA – Medicaid

Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.hip.in.gov Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1-800-403-0864

COLORADO – Medicaid

IOWA – Medicaid

Medicaid Website: http://www.colorado.gov/hcpf Medicaid Customer Contact Center: 1-800-221-3943

Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562

KANSAS – Medicaid

NEW HAMPSHIRE – Medicaid

Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218

KENTUCKY – Medicaid

NEW JERSEY – Medicaid and CHIP

Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

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

LOUISIANA – Medicaid

NEW YORK – Medicaid

Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831

REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES continued

Required Annual Employee Disclosure Notices continued

MAINE – Medicaid

NORTH CAROLINA – Medicaid

Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711

Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP

NORTH DAKOTA – Medicaid

Website: http://www.mass.gov/MassHealth Phone: 1-800-462-1120

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

MINNESOTA – Medicaid

OKLAHOMA – Medicaid and CHIP

Website: http://mn.gov/dhs/ma/ Phone: 1-800-657-3739

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

MISSOURI – Medicaid

OREGON – Medicaid

Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

MONTANA – Medicaid

PENNSYLVANIA – Medicaid

Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

Website: http://www.dhs.pa.gov/hipp Phone: 1-800-692-7462

NEBRASKA – Medicaid

RHODE ISLAND – Medicaid

Website:http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/ Pages/accessnebraska_index.aspx Phone: 1-855-632-7633

Website: http://www.eohhs.ri.gov/ Phone: 401-462-5300

NEVADA – Medicaid

SOUTH CAROLINA – Medicaid

Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900

Website: http://www.scdhhs.gov Phone: 1-888-549-0820

SOUTH DAKOTA – Medicaid

WASHINGTON – Medicaid

Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: http://www.hca.wa.gov/free-or-low-cost-health-care/program- administration/premium-payment-program Phone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid

WEST VIRGINIA – Medicaid

Website: http://gethipptexas.com/ Phone: 1-800-440-0493

Website: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspx Phone: 1-877-598-5820, HMS Third Party Liability

UTAH – Medicaid and CHIP

WISCONSIN – Medicaid and CHIP

Website: Medicaid: http://health.utah.gov/medicaid CHIP: http://health.utah.gov/chip Phone: 1-877-543-7669

Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002

VERMONT– Medicaid

WYOMING – Medicaid

Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531

VIRGINIA – Medicaid and CHIP Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282

To see if any other states have added a premium assistance program since July 31, 2016, or for more information on special enrollment rights, contact either: U.S. Department of Labor U.S. Department of Healthand Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 Paperwork Reduction Act Statement 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 collectiondisplays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control 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 with 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 seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collectionof information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

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