2023 Employee Benefit Guide
Benefits for 2023
Table of Contents
• Overview of Benefits Programs
3
• Medical Benefits
5
• Dental Benefits
11
• Vision Benefits
12
• Life Insurance
13
• Short-term Disability Insurance
14
• Health Savings Account (HSA)
15
• Employee Assistance Program
16
• Telemedicine
17
• Pet Insurance
18
• Online Enrollment
19
• Legal Notices
20
• Contact Page
36
• Notes Page
37
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
2
Benefits for 2023 Overview of Benefits Programs
CHANGES AND QUALIFYING EVENTS
When Coverage Begins and Ends
› Your coverage under the benefits plans will end if you no longer meet the eligibility requirements, your contributions are discontinued, or the Group Insurance Policy is terminated.
Qualifying Events
› Eligible employees may enroll or make changes to their benefits elections during the annual open enrollment period. As with most benefits, once you elect an option you are bound to that choice for the entire plan year unless you experience a “Qualifying Event” . These may include, but are not limited to: • Changes in employment status • Changes in current insurance coverage status • Changes in legal marital status • Changes in number of dependents • Taking an unpaid leave of absence • Dependent satisfies or ceases to satisfy eligibility requirement • Family Medical Leave Act (FMLA) leave. • A COBRA-qualifying event • Entitlement to Medicare or Medicaid • A change in the place of residence of the employee, resulting in the current carrier not being available
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
3
NY Kids Club provides an array of benefits that can help you enjoy increased well-being, deal with an unexpected illness or accident, build and protect your financial security, balance your personal and professional life and meet everyday needs. These benefits are affordable, comprehensive and competitive. The table below summarizes the benefits available to eligible staff and their dependents. These benefits are described in greater detail in this booklet. › Full-Time employees working 30+ hours/week are eligible to enroll in all benefits › Part-Time employees working 20+ hours/week are eligible to enroll in all benefits except Medical and Employer Paid Life Insurance Benefits for 2023 Overview of Benefits Programs
BENEFITS AT-A-GLANCE
PLAN
CARRIER
Medical
Dental
Vision
Short Term Disability
Life/AD&D
Telemedicine
Employee Assistance Program
Pet Insurance
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
4
Medical Benefits for 2023
SUMMARY OF COVERAGE
Oxford – Plan 1 – EPO HSA Low Plan
Plan Provisions
In-Network
Network
Liberty
Annual Deductible (Individual/Family)
$5,500 / $11,000
Out-of-Pocket Maximum (Includes Coinsurance, & Deductible)
$6,350 / $12,700
Preventive Care
100% no deductible
Primary Physician Office Visit
70% after deductible
Specialist Office Visit
70% after deductible
Inpatient Hospital Services
70% after deductible
Outpatient Hospital Services
70% after deductible
Urgent Care
70% after deductible
Emergency Room Care
70% after deductible
Retail Prescription Drugs (30-day supply)
Tier 1 – Generic
$15 copay after deductible
Tier 2 – Formulary Brand
$35 copay after deductible
Tier 3 – Non-Formulary Brand
$75 copay after deductible
Available for employees working 30+ hours/week * For illustrative purposes only. Please refer to your plan documents for all plan details
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
5
Medical Benefits for 2023
SUMMARY OF COVERAGE
Oxford – Plan 2 – EPO HSA High Plan
Plan Provisions
In-Network
Network
Liberty
Annual Deductible (Individual/Family)
$2,850 / $5,700
Out-of-Pocket Maximum (Includes Coinsurance, & Deductible)
$4,000 / $8,000
Preventive Care
100% no deductible
Primary Physician Office Visit
90% after deductible
Specialist Office Visit
90% after deductible
Inpatient Hospital Services
90% after deductible
Outpatient Hospital Services
90% after deductible
Urgent Care
90% after deductible
Emergency Room Care
90% after deductible
Retail Prescription Drugs (30-day supply)
Tier 1 – Generic
$15 copay after deductible $35 copay after deductible
Tier 2 – Formulary Brand
Tier 3 – Non-Formulary Brand
$75 copay after deductible
Available for employees working 30+ hours/week * For illustrative purposes only. Please refer to your plan documents for all plan details
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
6
Benefits for 2023
Medical
SUMMARY OF COVERAGE
Oxford – Plan 3 – PPO Low Plan - $3,000 Deductible
Plan Provisions
In-Network
Out-of-Network
Network
Liberty
Annual Deductible (Individual/Family)
$3,000 / $6,000
$6,000 / $12,000
Out-of-Pocket Maximum (Includes Coinsurance, & Deductible)
$6,000 / $12,000
$12,000 / $24,000
Lifetime Maximum
Unlimited
100%no deductible
Preventive Care
50% after deductible
Primary Physician Office Visit
$30copay
50% after deductible
Specialist Office Visit
$50copay
50% after deductible
70%after deductible 70%after deductible
Inpatient Hospital Services
50% after deductible
Outpatient Hospital Services
50% after deductible
Urgent Care
$50 copay
50% after deductible
Emergency Room Care
70% after deductible
Retail Prescription Drugs (30-day supply)
Tier 1 – Generic
$15copay
$15copay
Tier 2 – Formulary Brand
$35copay
$35copay
Tier 3 – Non-Formulary Brand
$75copay
$75copay
Available for employees working 30+ hours/week * For illustrative purposes only. Please refer to your plan documents for all plan details
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
7
Benefits for 2023
Medical
SUMMARY OF COVERAGE
Oxford – Plan 4 – PPO High Plan - $500 Deductible
Plan Provisions
In-Network
Out-of-Network
Network
Liberty
Annual Deductible (Individual/Family)
$500 / $1,000
$1,000 / $2,000
Out-of-Pocket Maximum (Includes Medical & RX Copays, Coinsurance, & Deductible)
$3,500 / $7,000
$6,000 / $12,000
Preventive Care
100% deductible waived
60% after deductible
Primary Physician Office Visit
$25 copay
60% after deductible
Specialist Office Visit
$40 copay
60% after deductible
Inpatient Hospital Services
80% after deductible
60% after deductible
Outpatient Hospital Services
80% after deductible
60% after deductible
Urgent Care
$40 copay
60% after deductible
Emergency Room Care
$200 copay
Retail Prescription Drugs (30-day supply)
$15copay
$15copay
Tier 1 – Generic
$35copay
$35copay
Tier 2 – Formulary Brand
$75copay
$75copay
Tier3 – Non-Formulary Brand
Available for employees working 30+ hours/week * For illustrative purposes only. Please refer to your plan documents for all plan details
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
8
Benefits for 2023
Medical
Employee Contributions
Medical Costs Per Pay Period (Bi-Weekly)
Plan 1 EPO HSA Low Plan
Plan 2 EPO HSA High Plan
Plan 3 PPO LOW Plan
Plan 4 PPO HIGH Plan
Coverage
Employee Only
$86.28
$149.06
$191.40
$261.59
Employee+ Spouse
$435.05
$554.19
$643.08
$790.50
Employee+ Child(ren)
$324.07
$425.28
$499.37
$622.21
Family
$736.25
$904.07
$1,033.18
$1,247.28
Available for employees working 30+ hours/week * For illustrative purposes only. Please refer to your plan documents for all plan details
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
9
Benefits for 2023
Medical
KEY TERMS TO REMEMBER
OUT-OF-POCKET MAXIMUM This is the total amount you can pay out of pocket each calendar year before the plan pays 100 percent of covered expenses for the rest of the calendar year. Most expenses that meet provider network requirements count toward the annual out-of-pocket maximum, including expenses paid to the annual deductible*, copays and coinsurance. *Except for Grandfathered medical plans
ANNUAL DEDUCTIBLE The amount you have to pay each year before the plan starts paying a portion of medical expenses. All family members’ expenses that count toward a health plan deductible accumulate together in the aggregate; however, each person also has a limit on their own individual accumulated expenses (the amount varies by plan).
COPAYS AND COINSURANCE These expenses are your share of cost paid for covered health care services. Copays are a fixed dollar amount, and are usually due at the time you receive care. Coinsurance is your share of the allowed amount charged for a service, and is generally billed to you after the health insurance company reconciles the bill with the provider.
PLAN TYPES
› EPO/PPO – A network of doctors, hospitals and other health care providers › HMO – A network that requires you to select a Primary Care Physician (PCP) who coordinates your health care › POS – Combines aspects of a PPO and HMO › HDHP – A plan that has higher annual deductibles in exchange for lower premiums.
10
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
Medical Benefits for 2023
Understanding the full value of covered benefits allows you to take responsibility for maintaining good health and incorporating healthy habits into your lifestyle. Some examples include getting regular physical examinations, mammograms and immunizations. Through the plans offered by NY Kids Club , all covered individuals and family members are eligible to receive routine wellness services like these, at no cost; all copays, coinsurance, and deductibles are waived.
WHICH PREVENTIVE CARE SERVICES ARE COVERED?
The US Preventive Services Task Force maintains a regular list of recommended services that all Affordable Care Act (i.e., Health Care Reform) compliant insurance plans should cover at 100% for in-network providers. Below is a list of common services that are included in the plans offered this year:
› Routine Physical Exam › Well Baby and Child Care › Well Woman Visits › Immunizations › Routine Bone Density Test › Routine Breast Exam › Routine Gynecological Exam
› Screening for Gestational Diabetes › Obesity Screening and Counseling › Routine Digital Rectal Exam › Routine Colonoscopy › Routine Colorectal Cancer Screening › Routine Prostate Test
› Routine Lab Procedures › Routine Mammograms
› Routine Pap Smear › Smoking Cessation
“An ounce of prevention is worth a pound of cure”
› Health Education/Counseling Services › Health Counseling for STDs and HIV › Testing for HPV and HIV › Screening and Counseling for Domestic Violence
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
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Benefits for 2023
Dental Coverage
SUMMARY OF COVERAGE
Guardian
Plan Option
PPO
DHMO
Plan Provisions
InNetwork
Out of Network
InNetwork
Deductible Individual / Family
$50 / $150
n/a
Deductible period
Calendar year
Calendar Year Maximum $1,000
$1,000
Unlimited
Orthodontia Lifetime Maximum
n/a
$1,500 - $2,800
Orthodontia Age Limit
n/a
Adult & Child
Reimbursement Basis
Unit 1 - Preventive Care
100%
100%
Fee Schedule
Unit 2 - Basic Services
80%
80%
Fee Schedule
Unit 3 - Major Services
50%
50%
Fee Schedule
Unit 4 - Orthodontia
n/a
n/a
Fee Schedule
Available for employees working 20+ hours/week * For illustrative purposes only. Please refer to your plan documents for all plan details
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
12
Benefits for 2023
Vision Coverage
SUMMARY OF COVERAGE
Guardian
Network
PPO
Frequency of Service Exam
every 12 months every 12 months every 12 months every 12 months
Materials
Lenses /Contacts
Frames
Exam
$10copay $25copay
Materials Benefits EyeExam
In-Network
Out-of-Network
100%
up to$40
$150 max + 20% off balance
Frames
up to$45
Lenses – Single Lenses – Bifocal Lenses – Trifocal Lenses – Lenticular
100% 100% 100% 100% 100%
up to$40 up to$60 up to$80 up to$80 up to$210
Lenses - Contact(necessary) Lenses - Contact(elective)
Up to $150maximum up to $150
Lasik
Discounts available
n/a
Available for employees working 20+ hours/week * For illustrative purposes only. Please refer to your plan documents for all plan details
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
13
Benefits for 2023
Dental & Vision
Employee Contributions
DENTAL
Dental EmployeeContributions (Bi-Weekly)
DPPO
DHMO
Employee
$13.02
$6.36
Employee + Spouse
$26.45
$12.72
Employee + Child(ren)
$29.54
$17.46
Family
$45.48
$22.52
VISION
Vision Employee Contributions (Bi-Weekly)
Employee
$2.34
Employee + Spouse
$4.45
Employee + Child(ren)
$5.23
Family
$7.34
Available for employees working 20+ hours/week *For illustrative purposes only. Please refer to your plan documents for all plan details
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
14
Benefits for 2023
Life Insurance
SUMMARY OF COVERAGE
LIFE/AD&D
Plan Features
Employee Life Benefit Amount
Flat $10,000
AD&D Benefit
Flat $10,000
The following shows how much benefits are reduced at certain ages:
Age Band
Benefit Reduction
65-69
65%
70 +
50%
*Employer Paid Life Insurance is for Full-Time Employees ONLY
VOLUNTARY LIFE/AD&D
Employee Voluntary Life/AD&D Benefit Increments
$10,000
Benefit Maximum
5x Annual Salary up to $500,000
Guarantee Issue
$150,000
Spouse Voluntary Life/AD&D
Benefit Increments
$5,000
Benefit Maximum
100% of Employee Amount up to $500,000
Child Voluntary Life/AD&D Benefit Increments
$2,000
Benefit Maximum
100% of Employee Amount up to $10,000
Available for employees working 20+ hours/week * For illustrative purposes only. Please refer to your plan documents for all plan details
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
15
Benefits for 2023
Short Term Disability Insurance
SUMMARY OF COVERAGE
Plan Features
Employee Benefit Amount
60% of salary
Maximum Benefit Amount
$1,000 per week
Elimination Period
7 days injury / 7 days sickness
Benefit Duration
13 Weeks
Available for employees working 20+ hours/week * For illustrative purposes only. Please refer to your plan documents for all plan details
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
16
Benefits for 2023
Health Savings Account (HSA)
FOR 2023 NY Kids Club IS OFFERING A HEALTH SAVINGS ACCOUNT (HSA) FOR PLANS 3 & 4.. THIS IS HOW AN HSA WORKS:
A health savings account (HSA) is a health care account and savings account in one. The main purpose of this account is to offset the cost of a qualifying high deductible health plan (HDHP) and provide savings for your out-of-pocket eligible health care expenses – those you and your tax dependents may have now, in the future, and during your retirement. This is a “portable” account. You own your HSA! It’s included in your employee benefits package, but after you set up your account, it’s yours to keep, even if you change jobs or retire. Once your HSA is established, money is contributed to your account by you, NY Kids Club or friends and family, and you can then use your HSA dollars tax-free to pay for eligible health care expenses. You save money on expenses you’re already paying for, like doctors’ office visits, prescription drugs, and much more. Best of all, you decide how and when to use your HSA dollars.
HOW THE HSA WORKS:
TheIRSregulationsallowyou,viatheHSA, to contribute on a pre ‐ tax basis $3,850 for single coverage and $7,750 for employee and dependent coverage. In the year you turn 55, you are entitled to contribute an additional $1,000. If you are on Medicare, the IRS does not allow pre ‐ tax contributions. Employees who are enrolled in Medicare are not eligible to participate in the HSA as of the firstdayof the month theyturn65and enroll in Medicare. If you are 65 and not enrolled in Medicare, you can still participate inthe HSA. If you are enrolled as a family, make an HSA contribution and turn 65 and enroll in Medicareduring the year,your contribution will be adjusted in the month you turn 65 and are enrolled in Medicare. You are not required to participate in the HSA plan if you enroll in the HDHP. However, it is a significant tax savings benefit to consider. Please keep in mind that the HSA concept is a long-term commitment and carries over from year to year. This means there is a full rollover of unused funds to the next calendar year. HSA funds roll over from year to year and accumulate in your account. There is no “use -it-or- lose- it” rule with HSAs, and you decide how and when to use your HSA funds, which can be used for eligible expenses you have now, in the future, or during retirement. And when you have a certain balance in your HSA, investment opportunities are available.
Refer to your HSA documentation for more information.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
17
Benefits for 2023
Employee Assistance Program
Confidential Emotional Support Our highly trained clinicians will listen to your concerns and helpyouoryourfamilymembers withanyissues,including: • Anxiety, depression, stress
• Grief, lossand life adjustments • Relationship/marital conflicts
Work-Life Solutions Our specialists provide qualified referrals and resources for just about anything on your to-do list, such as: • Finding child and elder care • Hiring movers or home repair contractors • Planning events, locating pet care Legal Guidance Talk to our attorneys for practical assistance with your most pressing legal issues, including: • Divorce,adoption,family law,wills,trusts andmore Need representation? Get afree 30-minute consultation and a 25% reduction in fees. Financial Resources Our financial experts can assist with awide range of issues. Talk to us about: • Retirement planning, taxes • Relocation, mortgages, insurance • Budgeting, debt, bankruptcy and more Online Support GuidanceResources ® Online is your 24/7 link to vital information, tools and support. Log on for: • Articles, podcasts, videos, slideshows • On-demand trainings • “Ask the Expert” personal responses to your questions
Your ComPsych GuidanceResources program offers someone to talk to and resources to consult whenever and wherever you need them.
Contact Your GuidanceResources ® Program TDD: 800.697.0353 Online: guidanceresources.com App: GuidanceResources ® Now Copyright © 2016 ComPsych Corporation. All rights reserved.
Available for ALL EMPLOYEES * For illustrative purposes only. Please refer to your plan documents for all plan details
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
18
Benefits for 2023
Telemedicine
Teladoc allows you 24 hour access to doctors by phone anywhere in the US and guarantees a call back within 1 hour and will prescribe medication over the phone for all non-narcotic prescriptionsat no cost to you . The plan covers you and all your dependents for only $4.62 per paycheck ! From the convenience of work or home or even while on vacation, you can schedulea call or virtual visit with a board certified physician 24/7 for conditions such as: • Cold and Flu Symptoms • Bronchitis • Respiratory Infection • Sinus problems • Allergies • Urinary Tract Infection and more! Toset up a Teladoc visit, you will need to log on to www.MyBenefitsWork.com, click Teladoc and the “Use this Benefit” button. Follow the prompts to set up your account and complete your or your dependents medical history before requesting a visit.
Available for employees working 20+ hours/week
* For illustrative purposes only. Please
refer to your plan documents for all plan details
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
19
Benefits for 2023
Pet Insurance
2 Enrollment Plan Options Pin Paws and Pin Paws Plus
Pet Cloud - Online account/app that
keeps all pet's info in one place
PawPinner - Tracks your pet and
notifies you if someone finds your pet
WhiskerDoc - 24/7 Pet Telehealth
Rx Valet - Discounts on Rx &
Preventives
Wigglepon -Pet-centric discounts
(BarkBox, Pet Food, Toys, etc.)
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
20
Benefits for 2023
Online Enrollment Overview
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
21
Legal Notices Benefits for 2023
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that addresses the privacy and security of certain individually identifiable health information, called protected health information (or PHI). You have certain rights with respect to your PHI, including a right to see or get a copy of your health and claims records and other health information maintained by a health plan or carrier. For a copy of the Notice of Privacy Practices, describing how your PHI may be used and disclosed and how you get access to the information, contact Human Resources.
Women’s Health and Cancer Rights Act Enrollment Notice
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Woman’s Health and Cance r Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:
1. All stages of reconstruction of the breast on which mastectomy was performed. 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses. 3. Treatment of physical complications of the mastectomy, including lymphedema.
These will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this benefits plan. If you would like more information on WHCRA benefits, call your plan administrator. .
Newborns’ and Mothers’ Health Protection Act Disclosure
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Patient Protection Notice
Your carrier generally may require the designation of a primary care provider. You have the right to designate any primary care provider who participates in your network and who is available to accept you or your family members. Until you make this designation, your carrier may designate one for you. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the plan administrator. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from your 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 your network who specializes in obstetrics or gynecology. The health care professional, 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, contact the plan administrator.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
22
Legal Notices Benefits for 2023
HIPAA Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request en rollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. If you or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or b ecome eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must request enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistance subsidy. To request special enrollment or to obtain more information about the plan's special enrollment provisions, contact the plan administrator.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
23
Legal Notices Benefits for 2023
Premium Assistance Under Medicaid and t he Children’s Health Insurance Program (CH IP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit 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” o pportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2022. Contact your State for more information on eligibility –
ALABAMA-Medicaid
CALIFORNIA-Medicaid
Website: http://myalhipp.com/ Phone: 1-855-692-5447
Website: Health Insurance Premium Payment (HIPP) Programhttp://dhcs.ca.gov/hipp Phone: 916-445-8322 Fax: 916-440-5676 Email: hipp@dhcs.ca.gov
ALASKA-Medicaid
COLORADO-Health First Colorado (Colorado’s Medicaid
Program)&ChildHealth Plan Plus(CHP+)
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
Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943 /State Relay711 CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan- plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711Health Insurance Buy-In Program (HIBI): https://www.colorado.gov/pacific/hcpf/health- insurance-buy-program HIBI Customer Service: 1-855-692-6442
ARKANSAS-Medicaid
FLORIDA-Medicaid
Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.c om/hipp/index.html Phone: 1-877-357-3268
Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
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Legal Notices Benefits for 2023
GEORGIA-Medicaid
MAINE-Medicaid
GA HIPP Website: https://medicaid.georgia.gov/health- insurance-premium-payment-program-hipp Phone: 678-564-1162, Press 1 GA CHIPRA Website: https://medicaid.georgia.gov/programs/third-party-liability/childrens- health-insurance-program-reauthorization- act-2009-chipra Phone: (678) 564-1162, Press 2
Enrollment Website: https://www.maine.gov/dhhs/ofi/applications-forms Phone: 1-800-442-6003 TTY: Maine relay 711
Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms
Phone: -800-977-6740. TTY: Maine relay 711
INDIANA-Medicaid
MASSACHUSETTS-Medicaid and CHIP
Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: https://www.in.gov/medicaid/ Phone 1-800-457-4584
Website: https://www.mass.gov/masshealth/pa Phone: 1-800-862-4840 TTY: (617) 886-8102
IOWA-Medicaid and CHIP (Hawki)
MINNESOTA-Medicaid
Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563 HIPP Website: https://dhs.iowa.gov/ime/members/medicaid-a-to- z/hipp HIPP Phone: 1-888-346-9562
Website: https://mn.gov/dhs/people-we-serve/children-and-families/health- care/health-care-programs/programs-and-services/other- insurance.jsp Phone: 1-800-657-3739
KANSAS-Medicaid
MISSOURI-Medicaid
Website: https://www.kancare.ks.gov/ Phone: 1-800-792-4884
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005
KENTUCKY-Medicaid
MONTANA-Medicaid
Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov
Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084 Email: HHSHIPPProgram@mt.gov
KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718
Kentucky Medicaid Website: https://chfs.ky.gov
LOUISIANA-Medicaid
NEBRASKA-Medicaid
Website: dhh.louisiana.gov/index.cfm/subhome/1/n/331 or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618- 5488 (LaHIPP)
Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
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Legal Notices Benefits for 2023
NEVADA-Medicaid
SOUTH CAROLINA-Medicaid
Medicaid Website:http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900
Website: https://www.scdhhs.gov Phone: 1-888-549-0820
NEW HAMPSHIRE-Medicaid
SOUTH DAKOTA-Medicaid
Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345,ext 5218
Website: http://dss.sd.gov Phone: 1-888-828-0059
NEW JERSEY-Medicaid and CHIP
TEXAS-Medicaid
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
Website: http://gethipptexas.com/ Phone: 1-800-440-0493
NEW YORK-Medicaid
UTAH-Medicaid and CHIP
Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831
Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669
NORTH CAROLINA-Medicaid
VERMONT-Medicaid
Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100
Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427
NORTH DAKOTA-Medicaid
VIRGINIA-Medicaid and CHIP
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825
Website: https://www.coverva.org/en/famis-select https://www.coverva.org/en/hipp Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-800-432-5924
OKLAHOMA-Medicaid and CHIP
WASHINGTON-Medicaid
Website: http://www.insureoklahoma.org Phone: 1-888-365-3742
Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022
OREGON-Medicaid
WEST VIRGINIA-Medicaid and CHIP
Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075
Website: https://dhhr.wv.gov/bms/ http://mywvhipp.com/ Medicaid Phone: 304-558-1700 CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
PENNSYLVANIA-Medicaid
WISCONSIN-Medicaid and CHIP
Website: https://www.dhs.pa.gov/Services/Assistance/Pages/HIPP- Program.aspx Phone: 1-800-692-7462
Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002
RHODE ISLAND-Medicaid and CHIP
WYOMING-Medicaid
Website: https://health.wyo.gov/healthcarefin/medicaid/programs- and-eligibility/ Phone: 1-800-251-1269
Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
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Legal Notices Benefits for 2023
To see if any other states have added a premium assistance program since July 31, 2022, or for more information on special enrollment rights, contact either:
U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)
U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565
PaperworkReduction 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 collection displays 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 four minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, 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.
OMB Control Number 1210-0137 (expires 1/31/2023)
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
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Legal Notices Benefits for 2023
Genetic Information Nondiscrimination Act (GINA) Disclosures Genetic Information Nondiscrimination Act of 2008
The Genetic Information Nondiscrimination Act of 2008 (“GINA”) protects employees against discrimination based on their
genetic information. Unless otherwise permitted, your Employer may not request or require any genetic information from you
or your family members.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II
from requesting or requiring genetic information of an individual or family member of the individual, except as specifically
allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to
this request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical hist ory,
the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member
sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family
member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2023 Employee Benefit Guide
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Legal Notices Benefits for 2023
USERRA Notice Your Rights Under USERRA A. The Uniformed Services Employment and Reemployment Rights Act
USERRA protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake military service or certain types of service in the National Disaster Medical System. USERRA also prohibits employers from discriminating against past and present members of the uniformed services, and applicants to the uniformed services. B. Reemployment Rights You have the right to be reemployed in your civilian job if you leave that job to perform service in the uniformed service and: • You ensure that your employer receives advance written or verbal notice of your service; • You have five years or less of cumulative service in the uniformed services while with that particular employer; • You return to work or apply for reemployment in a timely manner after conclusion of service; and • You have not been separated from service with a disqualifying discharge or under other than honorable conditions. If you are eligible to be reemployed, you must be restored to the job and benefits you would have attained if you had not been absent due to military service or, in some cases, a comparable job. C. Right to Be Free from Discrimination and Retaliation If you: • Are a past or present member of the uniformed service; • Have applied for membership in the uniformed service; or • Are obligated to serve in the uniformed service; then an employer may not deny you o Initial employment; o Reemployment; o Retention in employment; o Promotion; or o Any benefit of employment because of this status. In addition, an employer may not retaliate against anyone assisting in the enforcement of USERRA rights, including testifying or making a statement in connection with a proceeding under USERRA, even if that person has no service connection. If you leave your job to perform military service, you have the right to elect to continue your existing employer-based health plan coverage for you and your dependents for up to 24 months while in the military. • Even if you do not elect to continue coverage during your military service, you have the right to be reinstated in your employer's health plan when you are reemployed, generally without any waiting periods or exclusions (e.g., pre-existing condition exclusions) except for service-connected illnesses or injuries. D. Health Insurance Protection •
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
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Legal Notices Benefits for 2023
E. Enforcement •
The U.S. Department of Labor, Veterans' Employment and Training Service (VETS) is authorized to investigate and resolve complaints of USERRA violations. For assistance in filing a complaint, or for any other information on USERRA, contact VETS at 1-866-4-USA-DOL or visit its Web site at http://www.dol.gov/vets. An interactive online USERRA Advisor can be viewed at http://www.dol.gov/elaws/userra.htm. • If you file a complaint with VETS and VETS is unable to resolve it, you may request that your case be referred to the Department of Justice or the Office of Special Counsel, as applicable, for representation. • You may also bypass the VETS process and bring a civil action against an employer for violations of USERRA. The rights listed here may vary depending on the circumstances. The text of this notice was prepared by VETS, and may be viewed on the Internet at this address: http://www.dol.gov/vets/programs/userra/poster.htm. Federal law requires employers to notify employees of their rights under USERRA, and employers may meet this requirement by displaying the text of this notice where they customarily place notices for employees. U.S. Department of Labor, Veterans' Employment and Training Service, 1-866-487-2365.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
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Legal Notices Benefits for 2023
COBRA
Model General Notice of COBRA Continuation Coverage Rights (For use by single-employer group health plans)
** Continuation Coverage Rights Under COBRA**
Introduction
You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has import ant
information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice
explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to
protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may
cost less than COBRA continuation coverage.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of1985
(COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage
would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you shouldreview
the Plan’s Summary Plan Description or contact the Plan Administrator.
You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an
individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualifyfor lower
costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for
another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept la te enrollees.
What is COBRA continuation coverage?
COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This isalso
called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA co ntinuation
coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children coul d
become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event.
If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the followin g qualifying
events:
• Your hours of employment are reduced, or
• Your employment ends for any reason other than your gross misconduct.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
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