BENEFITS GUIDE 2023 PLAN YEAR
TABLE OF CONTENTS
Loop Recruiting is proud to offer you a comprehensive benefits package for the 2023 - 2024 plan year. Keep in mind that new enrollment and changes will become effective April 1 st , 2024.
I ntroduction . . . . . . . . . . . . . . . . . . . . . . Medical . . . . . . . . . . . . . . . . . . . . . . . . . . Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . Basic Life AD&D . . . . . . . . . . . . . . . . . . FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Legal Notices . . . . . . . . . . . . . . . . . . . . Medicare Part D. . . . . . . . . . . . . . . . . . COBRA. . . . . . . . . . . . . . . . . . . . . . . . . . Exchange Notices. . . . . . . . . . . . . . . . . Contact Information. . . . . . . . . . . . . . .
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LOOP RECRUITING 2023 BENEFITS GUIDE
Premiums for medical, dental and vision plans are all deducted on a pre-tax basis because they are covered under Section 125 of the Internal Revenue Code. Once you elect benefits you will not be approved to make changes to your election or drop coverage until the next Open Enrollment period, unless you have a qualifying event. About Deductions
In preparation of your enrollment, please have the following information readily available for you and your dependent(s): • Date(s) of birth • Social Security Number(s): Mandatory • Full name, relationship, and Social Security Number(s) for Life Beneficiary(ies). (Beneficiaries must be at least 18 years old or you will be required to name a guardian for him/her.) Information Needed for Enrollment
Eligibility Information
Qualifying Life Events
As an Loop Recruiting employee, you may be eligible for enrollment in a variety of insurance products. Full-time employees may participate in the benefits package after 60 days of employment. You may enroll your eligible dependents for coverage once you are eligible. Your eligible dependents include:
Qualifying events are events that cause an individual to lose his or her group health coverage. The type of qualifying event determines who the qualified beneficiaries are for that event and the period of time that a plan must offer continuation of coverage.
Qualifying events include:
• Marriage • Divorce or legal separation • Birth or adoption of a child • Death of spouse or dependent child • Change in employment status • Loss of other coverage • Entitlement to Medicare or Medicaid • Child turning 26 years old
• Your legal spouse • Your children up to age 26 (as identified in the plan document)
*Once your elections are effective, they will remain in effect through the plan year.
You must notify Human Resources within 30 days of the qualifying life event. Depending on the type of event, you may be asked to provide proof of the event. If you do not contact Human Resources within 30 days of the qualifying event, you will have to wait until the next annual enrollment period to make changes.
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LOOP RECRUITING 2023 BENEFITS GUIDE
Medical and Pharmacy Coverage
Loop Recruiting offers the following plans through AllState Benefits and offers “in and out-of-network” benefits.
Insurance Carrier:
AllState Benefits Medical Insurance Cigna OAP Open Access Plan Network
Medical Plan:
In-Network: Office Visit Copay - Primary Care
$40 Copay
Office Visit Copay - Specialist Care
$60 Copay
Urgent Care Copay
$75 Copay
Emergency Room Care
20% Coinsurance; after deductible
Preventative Visit Copay
$0
Diagnostic Testing & Blood Work
20% Coinsurance; after deductible
Imaging
20% Coinsurance; after deductible
Coinsurance
20%
Employee Deductible
$3,000
Family Deductible
$6,000
Employee Out-of-Pocket Max
$7,900
Family Out-of-Pocket Max
$15,800
Inpatient Hospital
20% Coinsurance; after deductible
Outpatient Hospital or Facility
20% Coinsurance; after deductible
Out-of-Network: Coinsurance
50%
Employee Deductible
$6,000
Family Deductible
$12,000
Employee Out-of-Pocket Max
$23,700
Family Out-of-Pocket Max
$47,400
Prescription Drugs: ( 30 Day Supply) Tier 1 - Generic
$20 Copay
Tier 2 - Preferred
$50 Copay
Tier 3 - Non-Preferred
$75 Copay
Tier 4 - Specialty
20% Coinsurance
Bi-Weekly Payroll Deduction Employee Only
$71.84
$294.54 $208.34 $402.33
Employee + Spouse Employee + Child(ren)
Family
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LOOP RECRUITING 2023 BENEFITS GUIDE
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LOOP RECRUITING 2023 BENEFITS GUIDE
Dental Coverage
Regular dental exams can help you and your dentist detect problems in the early stages when treatment is simpler and costs are lower. Your PPO dental plan is through Sun Life and offers “in and out-of-network” benefits.
Insurance Carrier:
Sun Life Dental Insurance
Plan Type:
PPO
Calendar Year Deductible Calendar Year Maximum
$50 Individual / $150 Family
$1,000
Preventive Services
100%
Basic Services Major Services
80% 50%
Out-of-Network Reimbursement Bi-Weekly Payroll Deduction Employee Only
90th Percentile Plan
$10.99 $21.49 $30.49 $40.49
Employee + Spouse Employee + Child(ren)
Family
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Vision Coverage
The vision plan covers routine eye exams and also pays for all or a portion of the cost of glasses or contact lenses if you need them. Your vision plan is through Sun Life and offers “in and out-of-network” benefits.
Insurance Carrier:
Sun Life Vision Insurance
In-Network $10 Copay $25 Copay $25 Copay $25 Copay
Out-of-Network
Exam Services
Up to $45 Up to $30 Up to $50 Up to $60 Up to $105 Up to $70
Lenses - Single lined Lenses - Bifocal lined Lenses - Trifocal Contacts / Lenses
$ 150 Allowance
Frames
$150 allowance; then 20% off any remaining balance
Frequency for Exam / Lenses / Frames Bi-Weekly Payroll Deduction Employee Only
12 months / 12 months / 24 months
$3.47 $7.44 $7.44
Employee + Spouse Employee + Child(ren)
Family
$11.41
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Basic Life Insurance Coverage
Loop Recruiting provides all Full Time employees with Basic Life and Accidental Death & Dismemberment at no cost to employees.
Insurance Carrier: Basic Life w/ AD&D Eligibility Requirement Life Insurance Benefit
Basic Life Insurance
All Full Time Employees
$25,000
Guarantee Issue
Yes
Accidental Death & Dismemberment Benefit (AD&D)
Same as basic life
12 LOOP RECRUITING 2023 BENEFITS GUIDE
Enrollment Form
SunLife One Sun Life Executive Park, Wellesley Hills, MA 02481 Group Enrollment Form
Sun Life Assurance Company of Canada One Sun Life Executive Park Wellesley Hills, MA 02481
New employee
Change
COBRA
Employer use (check one):
1. General Information Employer Name Loop Recruiting, LLC
Account / Policy Number 954258
Location
2. Employee Information Employee's Full Legal Name (First, M.I., Last)
Date of Birth
Male Female
Street Address
City
State
Zip Code
Occupation
Eligibility Class (if applicable) Social Security Number Phone Number
Date employed:
Full-Time Part-Time
Date: Date:
Return from layoff Date:
Rehire
Current Active Employment Type # of hours Full-Time
Earnings $ Hourly
Part-Time
Weekly
Monthly
Annually
Other:
3. Dependent Information Please complete this entire section if you are selecting dependent coverage. No employee can be insured as a dependent when he/she is also insured as an employee for any benefit under the same policy. If more space is needed, please add additional pages. Relationship Full legal name (First, M.I., Last) Gender Social Security number Date of birth Student Y/N Spouse Children
13 LOOP RECRUITING 2023 BENEFITS GUIDE
Enrollment Form
4. Benefit Elections You need to complete all sections of the enrollment form including electing or refusing insurance coverage below and sign it. This must be done either during the enrollment period or within 31 days of your eligibility date. Benefits completely paid by your employer ("non-contributory benefits") cannot be refused. Not all of the benefit options listed below will be necessarily available to you. Your employer will tell you which benefits are available and what your Maximum Guaranteed Issue amount is.
Elect Refuse Coverage
Dental:
Employee
Employee + Spouse
Employee + Child(ren) Employee + Family Were you covered under another dental plan within the last 31 days? .................... Yes No
If "Yes," provide the termination date: Reason for termination of coverage?
Vision:
Employee
Employee + Spouse Employee + Family
Employee + Child(ren)
Employer provided benefits --Your employer pays the premiums for the following benefits if you are eligible for them. Enrollment is automatic; no election is required.
Employee Basic Life and Accidental Death & Dismemberment (AD&D)
5. Beneficiary Designation Information Primary Beneficiary Designation
On the lines below, list the individual(s) who should receive proceeds in the event of your death. You may specify as many individuals as you like, but the total proceeds must equal 100%. This is your primary beneficiary. Attach additional pages if necessary. If you do not name a beneficiary or if no beneficiary is alive at the time of your death, proceeds will be payable in accordance with your Group insurance policy. Designation applies to all coverages for which a beneficiary designation is required. Primary Beneficiary(ies)
Percent share of proceeds*
1 Name (First, M.I., Last)
Relationship to employee Social Security number
%
Address
Phone number
Date of birth
2 Name (First, M.I., Last)
Relationship to employee Social Security number
%
Address
Phone number
Date of birth
*Must equal 100%
14 LOOP RECRUITING 2023 BENEFITS GUIDE
GVMPEM-5627 (Rev 4/20)
Enrollment Form
Secondary Beneficiary Designation On the lines below, list the individual(s) who should receive the proceeds ONLY IF ALL of the individuals listed above are not living at the time of your death. This is your secondary (or contingent) beneficiary. The Secondary beneficiary is not paid if a primary beneficiary is alive at the time of your death. Attach additional pages if necessary. Secondary Beneficiary(ies)
Percent share of proceeds*
1 Name (First, M.I., Last)
Relationship to employee Social Security number
%
Address
Phone number
Date of birth
2 Name (First, M.I., Last)
Relationship to employee Social Security number
%
Address
Phone number
Date of birth
*Must equal 100%
6. Signature and authorization information
I understand that:
I am requesting coverage under a Group Insurance policy offered by my employer. This coverage will end when my employment terminates, subject to any portability or continuation provisions available under the Group Insurance policy.
My employer will deduct all or part of the premium for contributory coverage from my pay.
For Life insurance, Evidence of Insurability may be required for amounts over my Guarantee Issue for this enrollment. For Dental coverage, I understand that I will not be entitled to benefits until the expiration of any Late Entrant benefit waiting period specified in the certificate of insurance.
For Dental Insurance plans, I have the right to select any dental care provider of my choice.
The dental plan includes a pre-determination provision that will advise me in advance of the benefits I may be eligible for if the procedure is performed. Coverages include benefit waiting periods, limitations and exclusions that may affect my entitlement to benefits. If I am not actively at work due to injury, illness, layoff or leave of absence on the date that any initial or increased coverage is scheduled to start under the plan, such coverage will not start until the date I return to work. When required by the coverage, if my spouse or any of my dependent children are confined due to an injury or illness, as required by the coverage, on the date that any initial or increased coverage is scheduled to start under the plan, such coverage will not start until the date they are no longer confined and are able to perform their normal activities. By signing below, I am representing that the information I have provided is true and correct to the best of my knowledge and belief. X Employee Signature Today's Date To the Employee: Make a copy of this form for your records before submitting it to your employer. To the Employer: This original enrollment form should remain at the employer's site. Family status, coverage, or beneficiary changes should be recorded on another copy of the Enrollment Form.
15 LOOP RECRUITING 2023 BENEFITS GUIDE
GVMPEM-5627 (Rev 4/20)
Enrollment Form
Agent, Broker, and/or Enroller information: Agent name
Agent / Broker name
Enroller name
Contactus
Bymail SunLife
One Sun Life Executive Park Wellesley Hills, MA 02481
16 LOOP RECRUITING 2023 BENEFITS GUIDE
Customer Service 800-247-6875 M-F 8:00 a.m.-8:00 p.m., ET
www.sunlife.com/us
GVMPEM-5627 (Rev 4/20)
Frequently Asked Questions
What is included in the Medical Out-of-Pocket maximum? What is included in the Pharmacy Out- of-Pocket maximum? The Medical Out-of-Pocket maximum is the maximum amount a member must pay during the policy year for covered essential health benefits. The OOP includes a member’s deductible and any coinsurance member responsibility. The Pharmacy OOP includes only pharmacy co-pays. The Medical OOP does NOT include monthly premiums, or billing from out-of-network providers. What is an in-network vs out-of-network provider? Cigna contracts with a wide range of doctors, as well as specialists, hospitals, labs, radiology facilities and pharmacies. These are the providers that are considered “in your network”. Specifically, each of these providers has agreed to accept Cigna’s contracted rate for your medical care and services rendered. The contracted rate includes both Cigna’s share of the cost, and the member’s. Your share may be in the form of a co-payment, deductible, or co-insurance. For example, Cigna’s contracted rate for a primary care visit might be $125. The Plan has a $25 co-payment for the visit; the member will pay $25 of the cost and your insurance plan will pay the remaining $100. An “out-of-network” provider is a medical doctor or facility that is not in contract with Cigna. This means that the provider may charge members higher rates for medical services and care, outside of the standard “in-network” rates. For example, a out-of- network provider may charge $200 for a primary care visit. Cigna may pay an adjustment of an out-of-network benefit of $80 dollars to the provider, so the member may be balance-billed for the remaining $120 cost of the visit. When can I change my beneficiary information for my Basic Life Insurance? Any time! It is important that all beneficiary information be kept up-to-date. You may need to change it after a marriage, divorce, or birth of a child.
Term
Definition
Network Office Visit (PCP) The “per visit” co-pay cost for a primary care or standard network doctor.
The “per visit” co-pay cost for a specialized doctor (cardiologist, OB/GYN,
Specialist Office Visit
orthopedic, gastrointestinal, etc.)
The amount of money a member owes for any In-network health care services before co-insurance coverage begins. These are generally services that are NOT covered under a standard co-pay (inpatient surgery, outpatient surgery, MRI, etc.) Deductibles run on a calendar year basis. After any applicable deductible is met, the remaining cost of any in-network health care service is divided between the insurance carrier and the member. A 70% / 30% network co-insurance would divide the cost of a service with 70% paid by the insurance carrier and 30% paid by the member. These are generally services that are NOT covered under a standard co-pay (inpatient surgery, outpatient surgery, MRI, etc.) The maximum amount a member must pay during the policy year for covered essential health benefits. The OOP includes a member’s deductible, any co-insurance member responsibility, primary care and specialist office visit co-pays, ER or Urgent Care co-pays, and prescription co-pays / costs. The OOP does NOT include monthly premiums, billing from out-of-network providers, or spending for non-essential health benefits. The cost of a one month supply of a prescription drug. All covered drugs are designated into tiered levels based on drug usage, cost, and clinical effectiveness. Tier 1 usually includes generics, while Tier 2 generally includes preferred brand name medications. Tier 3 typically includes non-preferred brand name medications, Tier 4 usually includes higher cost drugs and Specialty Drugs are covered under a separate tier.
Network Deductible
Co-Insurance
Network Out-of-Pocket Maximum (OOP)
Prescription Drug Tiers and Monthly Co-Pays
17 LOOP RECRUITING 2023 BENEFITS GUIDE
Legal Notices
Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free or Low-Cost Health Coverage to Children and Families 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” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at 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 January 31, 2021. Contact your State for more information on eligibility –
ALABAMA - Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447 ALASKA - Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: Customer Service@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default. aspx ARKANSAS - Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447) COLORADO - Medicaid Website: http://www.colorado.gov/hcpf Customer Contact Center: 1-800-221-3943 KANSAS - Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512 KENTUCKY - Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570 LOUSIANA - Medicaid Website: http://dhh.louisiana.gov/index.cfm/ subhome/l/n/331 Phone: 1-888-695-2447
FLORIDA - Medicaid Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268 GEORGIA - Medicaid Website: http://dch.georgia.gov/medicaid - click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507 INDIANA - Medicaid 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 IOWA - Medicaid Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 MAINE - Medicaid Website: http://maine.gov/dhhs/ofi/public-assistance/ index.html Phone: 1-800-442-6003 TTY: Maine relay 711
MASSACHUSETTS - Medicaid and CHIP Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120 MINNESOTA - Medicaid Website: http://mn.gov/dhs/ma/ Phone: 1-800-657-3739
18 LOOP RECRUITING 2023 BENEFITS GUIDE
Legal Notices
MISSOURI - Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
RHODE ISLAND - Medicaid Website: http://www.eohhs.ri.gov/ Phone: 401-462-5300 SOUTH CAROLINA - Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 SOUTH DAKOTA - Medicaid
Phone: 573-751-2005 MONTANA - Medicaid Website: http://dphhs.mt.gov/ MontanaHealthcarePrograms/HIPP
Phone: 1-800-694-3084 NEBRASKA - Medicaid
Website: http://www.dhhs.ne.gov/Children_Family_ Services/AccessNebraska/Pages/accessnebraska_ index.aspx Phone: 1-855-632-7633 NEVADA - Medicaid Website: http://dwss.nv.gov/ Phone: 1-800-992-0900 NEW HAMPSHIRE - Medicaid Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 NEW JERSEY - Medicaid and CHIP 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 NEW YORK - Medicaid Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA - Medicaid Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100 NORTH DAKOTA - Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825 OKLAHOMA - Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 OREGON - Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075 PENNSYLVANIA - Medicaid Website: http://www.dhs.pa.gov/hipp Phone: 1-800-692-7462
Website: http://dss.sd.gov Phone: 1-888-828-0059 TEXAS - Medicaid Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 UTAH - Medicaid and CHIP Medicaid Website: http://health.utah.gov/medicaid CHIP Website: http://health.utah.gov/chip
Phone: 1-877-543-7669 VERMONT - Medicaid Website: http://www.greenmountaincare.org Phone: 1-800-250-8427 VIRGINIA - Medicaid and CHIP Medicaid & CHIP Website: http://www.coverva.org/programs_premi- um_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282 WASHINGTON - Medicaid Website: http://www.hca.wa.gov/free-or-low-costhealth-care/pro- gram-administration/premiumpayment- program Phone: 1-800-562-3022 ext. 15473 WEST VIRGINIA - Medicaid Website: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/ default.aspx Phone: 1-877-598-5820, HMS Third Party Liability WISCONSIN - Medicaid and CHIP Website: http://www.dhs.wisconsin.gov/publications/p1/p10095.pdf
Phone: 1-800-362-3002 WYOMING - Medicaid Website: http://wyequalitycare.acs-inc.com/ Phone: 307-777-7531
To see if any more States have added a premium assistance program since January 31, 2021, or for more information on special enrollment rights, you can contact either:
U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/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
19 LOOP RECRUITING 2023 BENEFITS GUIDE
Legal Notices
Important Notices about Medical Coverage
HIPAA Special Enrollment Rights
These benefits will be provided subject to the same deductibles and co-insurance applicable to other medical and surgical benefits provided under this plan. Our plan complies with these requirements. Benefits for these items generally are compatible to those provided under our plan for similar types of medical services and supplies. Of course, the extent to which any of these items is appropriate following mastectomy is a matter to be determined by consultation between the attending physician and the patient. Our plan neither imposes penalties (for example, reducing or limiting reimbursements) nor provides incentives to induce attending providers to provide care inconsistent with these requirements. If you would like more information on WHCRA benefits, call Yates LLC at (706) 323-1600.
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 or your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment 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 result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must enroll within 30 days after the marriage, birth, adoption, or placement for adoption. Effective April 1, 2009 special enrollment rights also exist in the following circumstances: • If you or your dependents experience a loss of eligibility for Medicaid or your State Children’s Health Insurance Program (SCHIP) coverage; or • If you or your dependents become eligible for premium assistance under an optional state of Medicaid or SCHIP program that would pay the employee’s portion of the health insurance premium. NOTE: In the two above listed circumstances only, you or your dependents will have sixty (60) days to request special enrollment in the group health plan coverage. An individual must request this special enrollment within sixty (60) days of the loss of coverage described at bullet one, and within sixty (60) days of when eligibility is determined as described in bullet two. Women’s Health and Cancer Rights Act of 1998 Annual Notice If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for all stages of reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses; and treatment of physical complications of the mastectomy, including lymphedema.
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 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, not withstanding 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 collection of 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.
20 LOOP RECRUITING 2023 BENEFITS GUIDE
Medicare Part D
Medicare Part D Notice of Creditable Coverage
When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Loop Recruiting and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without a creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For further information, call Yates LLC at (706) 323- 1600. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Loop Recruiting changes. You may also request a copy of this notice at any time. More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Medicare Part D Notice of Creditable Coverage, cont. Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help. Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity. gov , or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium.
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Loop Recruiting and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your currant coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Loop Recruiting has determined that the prescription drug coverage offered by Cigna plans are on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join a Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens to Your Current Coverage if You Join a Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Loop Recruiting coverage may or may not be affected. See pages 7-9 of the CMS Disclosure of Creditable Coverage to Medicare Part D Eligible Individuals Guidance (available at https://www.cms.hhs.gov/Creditable Coverage/ ), which outlines the prescription drug plan provisions / options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D. If you do decide to join a Medicare drug plan and drop your current Loop Recruiting coverage, be aware that you and your dependents may or may not be able to get this coverage back.
21 LOOP RECRUITING 2023 BENEFITS GUIDE
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