BENEFITS GUIDE
An overview of the wide array of benefits provided by Private Prep, to help you enjoy increased well-being and financial security
PREPARED BY BRIO BENEFITS FOR PRIVATE PREP
TABLE OF CONTENTS
▪
Introduction
4
▪ Overview of Benefits Programs
6
▪
Employee Contribution Costs
8
▪
Medical Benefits
9
▪ Health Savings Account (HSA)
11
▪
Dental Benefits
16
▪
Vision Benefits
18
▪ Long-Term Disability Insurance
20
▪ Flexible Spending Account (FSA)
22
▪
Commuter Benefits
23
▪
401(K) Retirement Plan
24
▪
Enrollment
26
▪
Contact Page
28
▪
Legal Notices
29
▪
Legal Notices – COBRA
35
▪
Legal Notices – FMLA
36
▪ Legal Notices – Medicare Part D Creditable
37
▪ Legal Notices – Market Exchange
39
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TABLE OF CONTENTS I
WE’VE GOT YOU COVERED
Private Prep is proud to offer a comprehensive benefits package for you and your family. This program is designed to take great care of you when you need it.
Make sure to explore your options to help you make the selections that best meet your needs.
INTRO & OVERVIEW
INTRODUCTION
For the 2024 plan year, Private Prep has worked hard to offer a competitive total rewards package that includes valuable and competitive benefits plans. These programs reflect our commitment to keeping our staff healthy and secure. We understand that your situation is unique, and Private Prep is offering an overall benefits package that can be shaped and molded by you to fit your needs. As an employee of Private Prep , enjoying your work and making valuable contributions to business are equally vital. The health, satisfaction and security of you and your family are important, not only to your well-being, but ultimately, in terms of achieving the goals of our organization. This benefits booklet is a summary description of your Private Prep benefit plans. If there is a discrepancy between these summaries and the written legal plan documents, the plan documents shall prevail. This booklet and plan summaries do not constitute a contract of employment. We hope this benefits booklet, along with our additional communication and decision-making tools, will help you make the best health care choices for you and your family.
UPDATE ON HEALTH CARE REFORM
Effective January 1, 2019 the Tax Cuts and Jobs Act (TJCA) repealed the individual mandate to maintain health insurance or be responsible for a “shared responsibility payment”. We hope to keep offering these benefits as a valuable part of your total compensation in the future. However, because we offer you coverage that satisfies all the health reform requirements, you will not qualify for any federal assistance to purchase an individual or family policy on the open market (the “marketplace”).
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INTRODUCTION I
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OVERVIEW OF BENEFITS
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 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
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PRIVATE PREP BENEFITS GUIDE
OVERVIEW I
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OVERVIEW OF BENEFITS
Private Prep 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 every day 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.
BENEFITS AT-A-GLANCE
Coverage
Carrier
Health
Dental
Vision
Long-Term Disability
Health Savings Account (HSA)
Flexible Spending Account (FSA)
Commuter Benefits
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OVERVIEW I
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EMPLOYEE CONTRIBUTION COSTS
Medical Plans (Bi-Weekly)
Low Plan 2024
Mid Plan 2024
High Plan 2024
Coverage
Employee Only
$61.40
$227.09
$352.47
Employee + Spouse
$408.96
$740.32
$991.08
Employee + Child(ren)
$339.45
$637.68
$863.36
Employee + Family
$756.52
$1,253.56
$1,629.71
Dental Plans (Bi-Weekly)
DHMO Plan 2024
DPPO 11E Plan* 2024
DPPO 12C Plan* 2024
Coverage
Employee Only
$5.13
$17.33
$21.88
Employee + Spouse
$10.12
$34.57
$43.62
Employee + Child(ren)
$13.75
$44.93
$56.74
Employee + Family
$18.74
$62.16
$78.48
*Your contribution cost for the Dental PPO plan is dependent on your geographic location
Vision Plan (Bi-Weekly)
Coverage
Vision Plan 2024
Employee Only
$2.20
Employee + Spouse
$4.18
Employee + Child(ren)
$4.40
Employee + Family
$6.48
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OVERVIEW I
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MEDICAL
MEDICAL PLAN
SUMMARY OF COVERAGE
EPO Low Plan
EPO Mid Plan
EPO High Plan
(Cigna Network)
In-Network ONLY Plans
Deductible (Individual / Family)
$2,000 / $4,000
$1,000 / $2,000
None
Co-Insurance
100%
90%
100%
Out of Pocket Maximum (Individual / Family)
$5,550 / $11,100
$4,000 / $8,000
$2,500 / $5,000
Office Visit: Primary Care/Specialist
Deductible, $30 / $50 Deductible, $40 / $70
$30 / $50
$200 Copay, After Deductible $50 Copay, After Deductible
Emergency Room
$250 Copay
$100 Copay
Urgent Care
$75 Copay
$50 Copay
Lab: Deductible X-Ray: 10% After Deductible You pay 10% After Deductible You pay 10% After Deductible
Lab/X-Ray
Deductible
No Charge
$300 Copay, After Deductible $250 Copay, After Deductible
Inpatient Hospital
$500 Copay
Outpatient Hospital
$250 Copay
Included in Medical Deductible
$100 / $200 (Individual / Family)
Rx Deductible
None
Rx Copays
Retail (30 daysupply) Mail Order (90 daysupply)
$10 / $35 / $70 After Deductible $20 / $70 / $140 After Deductible
$15* / $35 / $75 After Deductible $38* / $88 / $150 After Deductible
$15 / $30 / $50
$38 / $75 / $125
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MEDICAL PLAN I
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HEALTH SAVINGS ACCOUNT (HSA)
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. BY ENROLLING IN THE HDHP MEDICAL PLAN, YOU COULD BE ELIGIBLE TO SAVE MONEY ON A PRE-TAX BASIS BY CONTRIBUTING TO A HEALTH SAVINGS ACCOUNT TO PAY FOR FUTURE MEDICAL EXPENSES 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. Funds roll over year to year and accumulate over time. Once your HSA is established with WEX, money is contributed to your account by you, Campbell & Co. 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.
WHY IS IT A GOOD IDEA TO HAVE AN HSA?
Tax-free earnings Your interest and any investment earnings grow tax-free
Tax-free deposits The money you contribute to your HSA isn’t taxed (up to the IRS annual limit)
Tax-free withdrawals Money used toward eligible health care expenses isn’t taxed – now or in the future
Setting aside pre-tax dollars into your HSA you pay fewer taxes and increase your take- home pay by your tax savings. You save money on eligible expenses that you are paying for out of your pocket. The amount you save depends on your tax bracket. For example, if you are in the 30 percent tax bracket, you can save $30 on every $100 spent on eligible health care expenses.
2024 IRS Maximum Contribution Limits for HSA
Employee Only Enrollment
$4,150
Family Enrollment
$8,300
Employees Age 55 and up
$1,000 additional “catch - up” contribution
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PRIVATE PREP BENEFITS GUIDE
HSA I
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MEDICAL PLAN
KEY TERMS TO REMEMBER
ANNUAL DEDUCTIBLE
OUT-OF POCKET MAXIMUM
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).
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
COPAYS AND COINSURANCE
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.
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 providers.
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MEDICAL PLAN I
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MEDICAL PLAN
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 Private Prep, 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?
Below is a list of common services that are included in the plans offered this year:
“AN OUNCE OF PREVENTION IS WORTH A POUND OF CURE”
• 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 • Routine Digital Rectal Exam
• Routine Colorectal Cancer Screening • Routine Prostate Test
• Routine Lab Procedures • Routine Mammograms • Routine Pap Smear • Smoking Cessation Programs
• Testing for HPV and HIV • Routine Colonoscopy
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MEDICAL PLAN I
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MEDICAL PLAN
Allied Member Portal
Simply log in at www.alliedbenefit.com to:
Once you are enrolled, you’ll have access to your own personalized member portal on: AlliedBenefit.com
Manage your claims
•
Check your deductible status
•
Review your benefits, copays and coinsurance amounts
•
Allied’s member portal allows you to navigate your benefits and proactively manage your healthcare on your own time.
• Get a digital copy of your insurance card
And much more…
•
Visit www.alliedbenefit.com/Access/RequestWebAccount
or scan the QR code to register your account.
Contact Allied at 1-800-288-2078 Monday – Thursday 8:30m-8:00pm, Friday 9:00am – 6:00pm, or Saturday 10:00am – 1:00pm EST
*For illustrative purposes only. Please refer to your plan documents for all plan details
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MEDICAL PLAN I
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MEDICAL PLAN
SmithRx Programs
*For illustrative purposes only. Please refer to your plan documents for all plan details
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MEDICAL PLAN I
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DENTAL
DENTAL PLANS
SUMMARY OF COVERAGE
Plan Features
DHMO Plan
DPPO Plan
IN NETWORK COVERAGE
None
$50
Individual Deductible
None
$150
Family Deductible
100%
100%
Preventive Care
80%
80%
Basic Procedures
50%
50%
Major Procedures
None
$1,000
Calendar Year Max
$5
N/A
Office Visit Copay
Not Covered
Not Covered
Orthodontia
OUT OF NETWORK COVERAGE
$50
Individual Deductible
Not Covered
$150
Family Deductible
$1,000
Calendar Year Max
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PRIVATE PREP BENEFITS GUIDE
DENTAL PLAN I
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VISION
VISION PLAN
SUMMARY OF COVERAGE
Plan Features
Vision Plan
IN NETWORK
OUT OF NETWORK
$20 copay
Up to $20
Vision Exam
Lenses
Single Bifocal Trifocal Polycarbonate (adults & children)
$20copay $20 copay $20 copay Up to $40
Up to $15 Up to $30 Up to $60 Not Covered
$105 allowance
Up to $50
Frames
$105 allowance + 15% off remaining No Charge, after $20 copay
Up to $175 Up to $200
Elective Contact Lenses Medically Necessary
Frequency Limit (Months) Exam
Every 12 Months Every 12 Months Every 24 Months Every 12 Months
Lenses Frames Contacts
Up to 15% Off
No discounts
Laser Vision Correction
To find an in-network provider, visit www.aetnavision.com or call (877) 973-3238 . Aetna utilizes the EyeMed network
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PRIVATE PREP BENEFITS GUIDE
VISION PLAN I
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DISABILITY
DISABILITY PLAN VOLUNTARY LONG TERM
SUMMARY OF COVERAGE
Plan Features
Employee Benefit Amount
60% of base salary
Maximum Benefit Amount
$6,000 per month
Elimination Period
90 days
Benefit Duration
SSNRA (Social Security Normal Retirement Age)
LONG TERM DISABILITY RATES
Age Bracket
Rates per $100 of coverage
<25
$0.09 $0.13 $0.20 $0.24 $0.27 $0.35 $0.47 $0.53 $0.57 $0.60
25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69
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PRIVATE PREP BENEFITS GUIDE
DISABILITY – LONG TERM I
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FLEXIBLE SPENDING ACCOUNT (FSA)
Private Prep is offering a Flexible Spending Account (FSA) through Discovery for 2024.
This is how an FSA works:
• You contribute into an FSA directly from your paycheck before taxes are taken out. • Then use your pre-tax FSA funds throughout the plan year to pay for eligible health care or dependent care expenses. • You save money on expenses you’re already paying for.
You can contribute up to $3,200 per year in pre-tax dollars into an FSA. Refer to your FSA documentation for more details.
DEPENDENT CARE FSA ELIGIBLE EXPENSES
HEALTH FSA ELIGIBLE EXPENSES
• Medical expenses: co-pays, co- insurance, and deductibles • Dental expenses: exams, cleanings, X- rays, and braces • Vision expenses: exams, contact lenses and supplies, eyeglasses, and laser eye surgery • Professional services: physical therapy, chiropractor, and acupuncture • Prescription drugs and insulin • Over-the-counter health care items: bandages, pregnancy test kits, blood pressure monitors, etc.
• Care for your child who is under age 13 • Before and after-school care • Baby sitting and nanny expenses • Day care, nursery school, and preschool • Summer day camp • Care for a relative who is physically or mentally incapable of self-care and lives in your home
You cannot enroll in the FSA if you have an HSA.
Refer to your FSA documentation for more information.
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PRIVATE PREP BENEFITS GUIDE
FSA I
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COMMUTER BENEFITS
Contribute pre-tax dollars for the cost of commuting! Must be working to use these accounts
Transit Expenses 2024 Maximum $315 per month, for common carrier including Uber Pool and Lyft Line
Parking Expenses 2024 Maximum $315 per month
▪ Transit is a monthly election. Employees can change their pre-tax deductions at anytime during the plan year, based on their current month’s expenses. Unused funds roll over into the next year provided they stay enrolled in the plan. ▪ Save on your commute by contributing pretax dollars towards transit expenses. These plans are administered by WEX, and funds can be accessed via your FSA card.
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TRANSIT & PARKING I
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401(k) PLAN
401(k) PLAN HIGHLIGHTS
Private Prep offers a 401(k) plan through Principal Getting into the plan • Once you are age 21 and complete 1,000 hours of service within a 12-month period you are eligible to join in the plan • You will be automatically enrolled in the Plan on the first day of the month coinciding with the date on which the eligibility requirements are met. Elective deferrals in the amount of 3% of compensation will automatically be deducted from your compensation, unless you elect not to participate in the Plan or change your contributions. • Private Prep makes an employer contribution equal to no less than 3% of your salary. • The plan allows you to defer up to $22,500 in 2024. The plan also allows for catch- up contributions of $7,500 for participants over age 50 • You select the investment(s) that are right for you • Make sure to designate your beneficiary
If you have questions, please contact retirement@briobenefits.com
Receiving benefits from the plan •
Vesting refers to your "ownership" of a benefit from the Plan. You are always 100% vested in your Plan contributions and your rollover contributions, plus any earnings they generate. • You will be fully vested in your plan benefits when you have completed four years of service with us (working at least 1,000 hours per year) • You may take a loan from this plan • If you have certain financial hardship situations, you may be able to withdraw money from the plan • Visit www.principal.com for more detailed information about our plan
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401(k) I
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ENROLLMENT
ONLINE ENROLLMENT OVERVIEW
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PRIVATE PREP BENEFITS GUIDE
ONLINE ENROLLMENT
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CONTACTS
Line of Coverage
Carrier Name
Website
Phone Number
(800) 288-2078
Medical
Allied
www.alliedbenefit.com
Pharmacy
SmithRx
smithrx.com
(844) 454-0123
Dental
Aetna
www.aetnadental.com (800) 872-3862
Vision
Aetna
www.aetnavision.com (877) 973-3238
Disability
Mutual of Omaha www.mutualofomaha.com (800) 228-7104
HSA, FSA, Commuter
WEX
www.wexinc.com
(800) 492-0669
Brio Benefit Consulting Liza Conner Brio Benefits 929-554-8054 lconner@briobenefits.com
Panayiotis Constantine Brio Benefits 646-790-7979 pconstantine@briobenefits.com
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CONTACTS
PRIVATE PREP BENEFITS GUIDE
LEGAL NOTICES
LEGAL NOTICES
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
The Health Insurance Portability and Accountability Act of 1996 addresses how an employer can enforce eligibility and
enrollment for health care benefits, and ensures that protected health information which identifies you is kept private. You
have a right to inspect copy-protected health information that is maintained by and for the plan for enrollment, payment,
claims and case management. If you feel that protected health information about you is incorrect or incomplete, you may
ask your benefits administrator to amend the information. For a full copy of the Notice of Privacy Practices, describing how
protected health information about you may be used and disclosed and how you get access to the information, contact
Human Resources.
The HIPAA Privacy Rule was effective beginning April 14, 2003. The Privacy Rule is intended to safeguard protected health
information (PHI). The provisions of the Privacy Rule have a significant impact on those who deal with health information
and on all citizens with regard to their personal PHI. Our health insurance broker and all our contracted plans adhere to the
HIPAA Privacy Rule.
Medicaid and the Children’s Health Insurance Program (CHIP)
If you’re eligible for health coverage from Private Prep , but can’t afford the premiums, some states have premium -
assistance programs that can help pay for coverage with funds from their Medicaid or CHIP programs. If you or your
dependents are already enrolled in Medicaid or CHIP, 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, once it is determined that you or your
dependents are eligible for premium assistance under either of these programs, the employer’s health plan is required to
permit you and your dependents to enroll in the plan - as long as you and your dependents are eligible, and not already
enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being
determined eligible for premium assistance.
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 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:
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.
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 child birth 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).
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PRIVATE PREP BENEFITS GUIDE
LEGAL NOTICES
LEGAL NOTICES
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 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.
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 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 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.
HIPAA Privacy Notice Please contact HR if you have any questions or need assistance obtaining a privacy notice.
Notice Extension Of Dependent Coverage To Age 26 And Enrollment Opportunity
Individuals whose coverage ended, or who were denied coverage (or were not eligible for coverage), because the
availability of dependent coverage of children ended before attainment of age 26 are eligible to enroll in medical, dental
and vision programs. For more information contact your plan administrator.
Notice Lifetime Limit No Longer Applies And Enrollment Opportunity
The lifetime limit on the dollar value of benefits under United Healthcare medical program does not apply. Enrollment
opportunities for individuals who previously lost coverage due to a lifetime limit are available. For more information contact
your plan administrator.
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PRIVATE PREP BENEFITS GUIDE
LEGAL NOTICES
LEGAL NOTICES
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 a nd you’re el igible 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 el igible for Medicaid or CHIP, you w on’t be eligible for these premi um 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 e mployer plan if you aren’t alr e ady enrolled. This is called a “special enrollm e nt” 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 July 31, 2018. Contact your State for more information on eligibility –
ALABAMA – Medicaid
FLORIDA – Medicaid
Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268
Website: http://myalhipp.com/ Phone: 1-855-692-5447
ALASKA – Medicaid
GEORGIA – Medicaid
Website: http://dch.georgia.gov/medicaid - Click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507
The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: myakhipp.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
ARKANSAS – Medicaid
INDIANA – Medicaid
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: http://www.indianamedicaid.com Phone 1-800-403-0864
Website: http://myarhipp.com/
Phone: 1-855-MyARHIPP (855-692-7447)
COLORADO – Health First Colorado (Colorado’s Medicaid Progra m) &
IOWA – Medicaid
Child Health Plan Plus (CHP+)
Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711
Website: http://dhs.iowa.gov/hawk-i Phone: 1-800-257-8563
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LEGAL NOTICES
LEGAL NOTICES
KANSAS – Medicaid
NEW HAMPSHIRE – Medicaid
Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512
Website: https://www.dhhs.nh.gov/ombp/nhhpp/ Phone: 603-271-5218 Hotline: NH Medicaid Service Center at 1-888-901-4999
KENTUCKY – Medicaid
NEW JERSEY – Medicaid and CHIP
Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/med icaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710
Website: https://chfs.ky.gov Phone: 1-800-635-2570
LOUISIANA – Medicaid
NEW YORK – Medicaid
Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447
Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831
MAINE – Medicaid
NORTH CAROLINA – Medicaid
Website: https://dma.ncdhhs.gov/ Phone: 919-855-4100
Website: http://www.maine.gov/dhhs/ofi/public- assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711
MASSACHUSETTS – Medicaid and CHIP
NORTH DAKOTA – Medicaid
Website: http://www.mass.gov/eohhs/gov/departments/massh ealth/ Phone: 1-800-862-4840
Website: http://www.nd.gov/dhs/services/medicalserv/medicai d / Phone: 1-844-854-4825
MINNESOTA – Medicaid
OKLAHOMA – Medicaid and CHIP
Website: https://mn.gov/dhs/people-we-serve/seniors/health- care/health-care-programs/programs-and- services/other-insurance.jsp 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/HI PP Phone: 1-800-694-3084
Website: http://www.dhs.pa.gov/provider/medicalassistance/he althinsurancepremiumpaymenthippprogram/index.htm
Phone: 1-800-692-7462
NEBRASKA – Medicaid
RHODE ISLAND – Medicaid
Website: http://www.ACCESSNebraska.ne.gov Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-1178
Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347
NEVADA – Medicaid
SOUTH CAROLINA – Medicaid
Medicaid Website: https://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900
Website: https://www.scdhhs.gov Phone: 1-888-549-0820
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SOUTH DAKOTA – Medicaid
WASHINGTON – Medicaid
WASHINGTON – Medicaid Website: http://www.hca.wa.gov/free-or-low-cost- health-care/program-administration/premium-payment- program Phone: 1-800-562-3022 ext. 15473
SOUTH DAKOTA - Medicaid
Website: http://dss.sd.gov Phone: 1-888-828-0059
TEXAS – Medicaid
WEST VIRGINIA – Medicaid
Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
Website: http://gethipptexas.com/ Phone: 1-800-440-0493
UTAH – Medicaid and CHIP
WISCONSIN – Medicaid and CHIP
Medicaid Website: https://medicaid.utah.gov/ CHIP Website: 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: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531
Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427
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.cf m CHIP Phone: 1-855-242-8282
To see if any other states have added a premium assistance program since July 31, 2018, or for more information on special enrollment rights, contact either:
U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565
U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)
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, 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 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 dol.gov and reference the OMB Control Number 1210-0137.
OMB Control Number 1210-0137
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COBRA
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
The right to COBRA continuation coverage was created by federal law, so that you and your covered dependents
may continue your employer-sponsored benefits coverage at full cost (plus an administrative fee). After a qualifying
event, COBRA continuation coverage must be offered to each qualified beneficiary. You, your spouse and your
dependent children could become qualified beneficiaries if coverage under the Plan is lost as a result of a
qualifying event. If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage for either of
these reasons: • Your hours of employment are reduced • Your employment ends for any reason other than your gross misconduct
If you’re the spouse/dependent of a Private Prep employee, you’ll become a qualified beneficiary if you lose your
coverage under the Plan for any of these reasons:
• Your spouse/parent dies • Your spouse’s/parent’s hours of employment are reduced • Your spouse’s/parent’s employment ends for reasons other than his or her gross misconduct • Your spouse/parent is retired and becomes entitled to Medicare benefits • You are divorced or legally separated from your spouse • Child is no longer eligible for coverage under the Plan as a dependent child
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FAMILY MEDICAL LEAVE ACT (FMLA)
Family Medical Leave Act (FMLA)
FMLA requires covered employers to provide up to 12 weeks of unpaid, job-protected leave to eligible employees for the
following events:
• Incapacity due to pregnancy, pre-natal medical care or child birth • To care for an employee’s child after birth, or placement for adoption or foster care • To care for an employee’s spouse, son or daughter, or parent, who has a serious health condition; or • A serious health condition that makes an employee unable to perform the employee’s job
Eligible employees with a spouse, son, daughter or parent on active duty or call-to-active-duty status in the National Guard
or Reserves in support of contingency operation may use their 12-week leave entitlement to address certain qualifying
exigencies. Qualifying exigencies may include attending certain military events, arranging for alternative childcare,
addressing certain financing and legal arrangements, attending certain counseling sessions and attending post-
deployment reintegration briefings. During FMLA leave, the employer must maintain the employee’s health coverage under any “group health plan” on the
same terms as if the employee had continued to work. Upon return from FMLA leave, most employees must be restored to
their original or equivalent positions with equivalent pay, benefits and other employment terms. Use of FMLA leave cannot
result in the loss of any employment benefit that accrued prior to the start of an employee’s leave.
Employees are eligible if they have worked for a covered employer for at least one year, for 1,250 hours over the previous
12 months and if at least 50 employees are employed by the employer within 75 miles.
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MEDICARE PART D
Important Notice from Private Prep About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about your current
prescription drug coverage with Private Prep 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 thisnotice.
There are two important things you need to know about your current coverage and Medicare’s prescription drug
c1.overage: 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 monthlypremium.
2. Private Prep has determined that the prescription drug coverage offered by Oxford 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 15 th to December7 th .
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible
for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current Private Prep coverage will not be affected.
If you do decide to join a Medicare drug plan and drop your current Private Prep coverage, be aware that you and
your dependents will be able to get this coverage back.
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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 Private Prep and don’t join a Medicare drug plan
within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare
drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up 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
For More Information About This Notice Or Your Current Prescription Drug Coverage… Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.
Contact Adrienne de la Fuente for further information. 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 Private Prep changes. You also may request
a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You”
handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by
Medicare drug plans.
- Visit www.medicare.gov For more information about Medicare prescription drug coverage:
- 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).
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Form Approved OMB No. 1210-0149 (expires 5-31-2020)
New Health Insurance Marketplace Coverage Options and Your Health Coverage
PART A: General Information When key parts of the healthcare law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment – based health coverage offered by your employer. What is the Health InsuranceMarketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one – stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014 in yourarea. Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your householdincome.. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost – sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. Ifthe cost of a planfrom your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer,thenyoumay losethe employercontribution(ifany)to the employer – offered coverage. Also, this employer contribution, as well as your employee contribution to employer – offered coverage, is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after – tax basis. How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description. The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in yourarea.
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PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to completean application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplaceapplication.
4. Employer Identification Number (EIN)
3. Employer name
5. Employer address
6. Employer phone number
7.City
8. State
9. ZIP code
10. Who can we contact about employee health coverage at this job?
11. Phone number (if different fromabove)
12. Emailaddress
Here is some basic information about health coverage offered bythis employer: ● As your employer, we offer a health planto: □ All employees. Eligible employeesare: □ Some employees. Eligible employees are:
● With respect todependents: □
We do offer coverage. Eligible dependents are: □ We do not offercoverage.
□ If checked, this coverage meets the minimum value standard, and the cost of this coverage to you isintended to be affordable, based on employeewages.
^^ Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid – year, or if you have other income losses, you may still qualify for a premium discount. If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthlypremiums.
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