2024 EMPLOYEE BENEFITS GUIDE
WELCOME TO YOUR BENEFIT ENROLLMENT GUIDE 2024 PLAN YEAR
Emsere - Fully Equipped is proud to offer you a comprehensive benefits package for the upcoming plan year. This enrollment guide will assist you in determining the coverage levels that will provide you and your family with the protection that gives you peace of mind. This guide explains each type of coverage, gives suggestions about how to effectively use your benefits, and provides examples to help you determine your benefit and payroll deduction amounts. We encourage you to take the time to review the enrollment guide prior to enrollment. The Open Enrollment period will begin on January 17 th and end on January 22 nd . Keep in mind that the benefits you select during this enrollment will be effective February 1 st , 2024.
2 EMSERE - FULLY EQUIPPED 2024 BENEFITS GUIDE Please note: This benefit guide contains the basic information about your benefits program. It does not cover every detail; but it does provide a general description of each benefit plan. Every effort has been made to ensure that the information is accurate. However, this guide is not an insurance policy. If there is any question as to coverage, benefit eligibility, or interpretation, the insurance contract and the Certificate of Coverage you receive from the insurance carrier will govern the administration of your benefits. If you would like additional or specific information, please contact the Human Resources Department.
About Deductions
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. Voluntary life insurance premiums are deducted on a post-tax basis and may be changed outside of the Open Enrollment period.
Information Needed for Enrollment
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.)
Eligibility Information
Qualifying Life Events
As an employee of Emsere you may be eligible for enrollment in a variety of insurance products. New hire employees may participate in the benefits package on the 1st of the month following date of hire. 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.
3 EMSERE - FULLY EQUIPPED 2024 BENEFITS GUIDE
Medical and Pharmacy Coverage
Emsere offers the following Medical plans through Cigna and offers “in and out-of-network” benefits.
Insurance Carrier:
Cigna Medical Insurance
Medical Plan: In-Network: Employee Deductible
Gold PPO Plan
Silver HSA Plan
$1,000
$3,000
Family Deductible
$2,000
$6,000
Coinsurance
90%
80%
Employee Out-of-Pocket Max
$4,000 (includes deductible)
$6,000 (includes deductible)
Family Out-of-Pocket Max
$8,000 (includes deductible)
$12,000 (includes deductible)
Office Visit Copay - Primary Care
$20 Copay
Deductible; then 20% Coinsurance
Office Visit Copay - Specialist Care
$50 Copay
Deductible; then 20% Coinsurance
Urgent Care Copay
$75 Copay
Deductible; then 20% Coinsurance
Emergency Room Care
$250 Copay; then 10% Coinsurance
Deductible; then 20% Coinsurance
Preventative Visit Copay
$0
$0
Independent Facility Lab: $75 Independent Facility X-ray: $150 All Other Places : Ded/Coins
Diagnostic Testing & Blood Work
Deductible; then 20% Coinsurance
Imaging
$150 Copay
Deductible; then 20% Coinsurance
Inpatient Hospital
Deductible; then 10% Coinsurance
Deductible; then 20% Coinsurance
Outpatient Hospital or Facility
Deductible; then 10% Coinsurance
Deductible; then 20% Coinsurance
Out-of-Network: Coinsurance
70%
60%
Employee Deductible
$2,500
$5,000
Family Deductible
$5,000
$10,000
Employee Out-of-Pocket Max
$8,000
$6,000
Family Out-of-Pocket Max
$16,000
$12,000
Prescription Drugs: ( 30 Day Supply) Tier 1 - Generic
$0
$0
Tier 2 - Preferred
$35
$35
Tier 3 - Non-Preferred
$50
$50
Tier 4 - Specialty
$100
$100
Employee Bi-Weekly Deduction Employee Only
$23.00
$0.00
Employee + Spouse
$217.00
$177.00
Employee + Child(ren)
$210.00
$195.00
Family
$281.00
$233.00
4 EMSERE - FULLY EQUIPPED 2024 BENEFITS GUIDE
Health Savings Account (HSA)
HEALTH SAVINGS ACCOUNT (HSA) The High Deductible Health Care Plan (HDHP) offers a Health Savings Account (HSA). Emsere will contribute the below amounts to your HSA account and you can make additional pre-tax contributions
Things to know regarding HSAs: A Health Savings Account (HSA) is similar in many ways to a Flexible Spending Account (FSA) or Health Reimbursement Arrangement (HRA) – except you get to keep the money in the account. The HSA is a cash account. You may use the cash available in your account at any time. HSA funds – both employee and company money – are completely yours and is 100% vested. If unused, the money rolls over or carries forward from one year to the next. Employee and company money goes into the account tax free. As long as used for eligible expenses, the money comes out tax free. SAVE YOUR RECEIPTS! To cover yourself or a family member under an HSA, you must be in a qualified High Deductible Health Plan (HDHP) and cannot: • Be Medicare eligible • Be able to be claimed under someone else’s taxes • Be covered by a traditional-style health plan (PPO, HMO, etc.) • Participate in a FSA plan HSAs and coverage of adult children under age 26: While the Patient Protection and Affordable Care Act (PPACA) allows parents to add their adult children (up to age 26) to their health plans, the IRS has not changed its definition of a dependent for health savings accounts. If account holders can’t claim a child as a dependent on their tax returns, then they can’t spend HSA dollars on services provided to that child. According to the IRS definition, a dependent is a qualifying child who: • Has same principal place of abode as the covered employee for more than one-half of taxable year. • Has not provided over one-half of their own support during taxable year. • Is not yet age 19 (or if a student; not yet age 24) at the end of the tax year, or is permanently and totally disabled.
The IRS determines HSA rules and annual maximums, which may increase each year. For 2024 the annual total contribution maximums, including the employer contributions, are: Single Coverage: $4,150 With Dependents: $8,300 Additional amount if over 55: $1,000 Health Savings Account & Flexible Spending Account FSA Employer Contribution Per Pay Period / Annual HSA Employer Contribution Per Pay Period / Annual EE & EE+SP $0 EE & EE+SP $50 ($1,300) EE / CH & Family $50 ($1,300) EE / CH & Family $75 ($1,950)
HSA funds may be used for:
• Medical out-of-pocket expenses, Dental & Vision expenses • Over-the-Counter drugs (with a note / prescription from your doctor) • COBRA premiums if you leave the company • Retiree medical coverage By IRS rules, HSA funds used for non-eligible expenses are subject to ordinary income tax and an additional 20% penalty. Once you turn 65, an HSA account works similar to an IRA, subject only to ordinary income tax for non tax-free withdrawals.
5 EMSERE - FULLY EQUIPPED 2024 BENEFITS GUIDE
Dental Coverage
Good dental care is critical to your overall well-being. With Guardian Dental Insurance, you can get the attention your teeth need - at a cost you can afford. To get the most from your benefits and reduce out-of-pocket costs, choose an in-network provider by utilizing our large national network. These providers have agreed to file your claims and uphold the highest quality standards. You can find in-network providers at guardiananytime.com
Insurance Carrier:
Guardian Dental Insurance
Plan Type:
Low Plan
High Plan
Calendar Year Deductible Calendar Year Maximum
$50 Individual / $150 Family $50 Individual / $150 Family
$1,750
$2,500
Preventive Services
100%
100%
Basic Services Major Services
80% 50% N/A
80% 50% 50%
Orthodontia (dependent children only)
Endo / Perio
Major
Major
Employee Bi-Weekly Deduction Employee Only
$0.00
$0.00
Employee + Spouse Employee + Child(ren)
$12.25 $17.78 $10.28
$13.76 $23.09 $40.34
Family
6 EMSERE - FULLY EQUIPPED 2024 BENEFITS GUIDE
Vision Coverage
You can help protect your eyesight by visiting an eye doctor regularly. Vision insurance includes an annual comprehensive eye exam with an eye care doctor. Taking care of your eyes today can lead to a better quality of life later. Seeing an in-network eye care provider can reduce your expenses with savings on frames, lenses, contacts, eye exams and more. You can find vision providers at guardiananytime.com
Insurance Carrier:
Guardian Vision Insurance
Plan Type:
VSP In-Network
Exam Copay
$10 Copay
Lenses - Single lined
$25 Copay
Lenses - Bifocal lined
$25 Copay
Lenses - Trifocal
$25 Copay
Lenses - Lenticular
$25 Copay
Frames
$ 150 Allowance
Elective Contact Lenses (in place of lenses & frame) Medically Necessary Contacts
$150 Allowance
Covered in full
Frequency for Exam / Lenses / Frames
12 months / 12 months / 24 months
Employee Bi-Weekly Deduction
Employee Only
$0.00
Employee + Spouse
$2.13
Employee + Child(ren)
$2.22
Family
$4.90
7 EMSERE - FULLY EQUIPPED 2024 BENEFITS GUIDE
Basic Life and AD&D Insurance Coverage
Emsere 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
Guardian Basic Life w/AD&D Insurance
All Full Time Employees
Life Insurance Benefit
$100,000
Guarantee Issue
Yes
Accidental Death & Dismemberment Benefit (AD&D)
Same as Basic Life Amount
Voluntary Term Life Insurance Coverage
As a supplemental benefit, Emsere allows eligible employees to purchase additional life insurance coverage for yourself and your dependents. This coverage is paid for by you and is offered through Guardian. Rates for the Voluntary Term Life Insurance are based on age, and volume, and benefits are subject to applicable age reductions. An EOI is required for elections made above the Guarantee Issue amount.
Insurance Carrier:
Guardian Voluntary Life w/AD&D Insurance
Voluntary Life w/ AD&D Eligibility Requirement Employee Benefit Amounts Employee
All Full Time Employees
Up to $100k in increments of $10k
Spouse
100% of employee’s benefit up to $150k
Child(ren)
Up to $10k in increments of $2k
Guarantee Issue* Employee
$100k
Dependent Child(ren)
100% of employee’s benefit 100% of employee’s benefit
*Guarantee Issue applies only to new hires.
8 EMSERE - FULLY EQUIPPED 2024 BENEFITS GUIDE
Disability Coverage
The goal of Emsere’s Disability Insurance Plan is to provide you with income replacement should you be unable to work due to a non- work-related illness or injury. The company provides employees with “Short and Long-Term Disability” income benefits. Both the Short-Term and Long-Term Disability coverages are offered through Guardian.
Insurance Carrier:
Guardian Short-Term Disability Insurance
Plan Type:
Employer Paid
Eligibility Requirement Benefit Percentage Maximum Weekly Benefit
All Full Time Employees
60%
$1,500
Elimination Period - Accident
7 Days
Elimination Period - Sickness
7 Days
Pre-Existing Condition
3 / 6
Benefit Duration
12 Weeks Maximum
Insurance Carrier:
Guardian Long-Term Disability Insurance
Plan Type:
Employer Paid
Eligibility Requirement Benefit Percentage Maximum Monthly Benefit
All Full Time Employees
60%
$7,500 90 Days 2 Years 12 / 12 SSNRA
Elimination Period
Own Occupation Definition
Pre-Existing Condition
Benefit Duration
9 EMSERE - FULLY EQUIPPED 2024 BENEFITS GUIDE
Accident Insurance Accident Insurance
An accidental injury can seriously cost you Help protect yourself from unexpected medical costs
If you and your family are active, chances are, you’re no stranger to a hospital emergency room. Even with medical insurance, a fall while bicycle riding or your child’s sprained ankle at soccer practice can cost you a bundle in out-of-pocket expenses. Are you financially prepared for all of the medical and non-medical costs of treatment and recovery from a serious injury? Financial support to help get you back on your feet • No matter what kind of medical coverage you have, you may have out-of-pocket costs that could really set you back financially. • Guardian® pays you cash benefits based on covered injuries, treatments and services. • Payments go directly to you, and can help pay for other expenses, like traveling to the hospital, childcare and lost income from missed work. • “Child Organized Sport” benefit pays you an extra 20% cash benefit for each accident when the dependent child is injured while playing an organized sport. 1 An example of how Accident Insurance works 2 While Sue was hiking in a local park, she fell and tore cartilage in her knee. She went to the hospital emergency room for treatment and stayed overnight. The doctor gave her a brace and scheduled her for a follow up visit. See how Accident Insurance offset Sue’s expenses: Ambulance $150 Knee Brace $125 Hospital Admission $1,000 X-Ray $30 Emergency Room Visit $175 Knee Cartilage Tear $500 Hospital Confinement (1 Day) $225 6 Follow-Up Visits $300 Medical Resonance Imaging (MRI) $150 Total cash benefit paid for covered services: $2,655 Accident Insurance with Guardian is easy • No health questions to answer and convenient payroll deductions.
Accident Insurance is a smart choice for: • Families with an active lifestyle • Your children while playing organized sports 1 • Anyone concerned about covering out of pocket medical expenses
• Helps protect your savings when the unexpected occurs. • Take the coverage with you if you change jobs or retire.
Learn more about Accident Insurance at guardianlife.com
The Guardian Life Insurance Company of America New York, NY guardianlife.com
1. Child must be insured by the plan on the date the accident occurred and must be 18 years of age or younger. 2. For illustrative purposes only. See your plan for specific coverage amounts and details. Guardian Accident Insurance is underwritten and issued by The Guardian Life Insurance Company of America, New York, NY. Products are not available in all states. Policy limitations and exclusions apply. Optional riders and/or features may incur additional costs. Plan documents are the final arbiter of coverage. This policy provides Accident insurance only. It does not provide basic hospital, basic medical or major medical insurance as defined by the New York State Department of Financial Services. IMPORTANT NOTICE –THIS POLICY DOES NOT PROVIDE COVERAGE FOR SICKNESS. GUARDIAN® is a registered service mark of The Guardian Life Insurance Company of America®. ©Copyright 2020 The Guardian Life Insurance Company of America.Policy Form #GP-1-ACC-18, GP-1-AC-BEN-12, et al.; GP-1-LAH-12R.
2020-93592 (02-22)
10 EMSERE - FULLY EQUIPPED 2024 BENEFITS GUIDE
Critical Illness Insurance
Critical Illness Insurance
Help employees focus on recovery during a critical illness, not finances. Treatment of critical illnesses such as cancer, heart attack, and stroke can lead to unexpected expenses that create an additional financial cost. Critical Illness insurance is an affordable way to address growing medical costs — covered benefits go directly to the employee and can be used for any purpose.
• Travel to treatment centers in another city • Expenses like groceries, rent and mortgage • Co-pays • Experimental treatments Half of all full-time workers have less than $2,500 saved for a medical emergency. 1 Critical Illness insurance pays a lump-sum amount upon diagnosis of over 40 illnesses. It also provides a wide range of payouts ($1,000 to $50,000) that employers can customize to help meet their employees’ needs. Choose from these optional benefits: • Automatic Increase • Cancer Death Benefit • Wellness Benefit for Preventive Services • Recovery Supplement • Occupational HIV/Hepatitis • Hospitalization Admission Benefit — up to $500 per day for an accident or non-critical illness • Infectious Contagious Disease
Critical illness insurance covers more than 40 illnesses • No lifetime maximum for all covered illnesses • Children are covered at no additional cost • Optional Rider: Pays a benefit for Alzheimer’s for covered employee’s parents
11 EMSERE - FULLY EQUIPPED 2024 BENEFITS GUIDE
Critical Illness Insurance
The plan is simple. Take a look at the following example of ‘Jane’, who has a benefit of $10,000. 2 • Jane is diagnosed with thyroid cancer • She is in remission for 15 months, and then diagnosed with lymph node cancer • Six years later, she has a heart attack
Condition
Formula
Benefit Payment
Thyroid Cancer (1st Occurrence) Lymph Node Cancer (2nd Occurence)
100% x $10,000 50% x $10,000 100% x $10,000
$10,000 $5,000 $10,000 $25,000
Heart Attack
Total
Guardian® covers the first occurrence while a member is covered under the plan. Recurrence of the same condition is covered after 12 symptom and treatment free months (does not include maintenance medications or follow up visits.) First occurrence of related conditions is covered after 3 months. First occurrence of unrelated conditions are covered immediately. Speak to your Guardian representative for more details.
Contact your Guardian Group sales representative for more information.
The Guardian Life Insurance Company of America New York, NY guardianlife.com
In New York Critical Illness is known as Specified Disease. 1 The Guardian Workplace Benefits Study SM : Ninth Annual, 2020. 2 Example is for illustrative purposes only and is not intended to represent the actual benefit amounts for this product. Guardian’s Critical Illness Insurance is underwritten and issued by The Guardian Life insurance Company of America, New York, NY. Products are not available in all states. Policy limitations and exclusions apply. Optional riders and/or features may incur additional costs. Plan documents are the final arbiter of coverage. This policy provides limited benefits health insurance only. It does not provide basic hospital, basic medical or major medical insurance as defined by the New York State Department of Financial Services. Critical Illness Policy Form No. GP-1-CI-14, GP-1-LAH-12R. GUARDIAN® is a registered service mark of The Guardian Life Insurance Company of America® ©Copyright 2020 The Guardian Life Insurance Company of America.
2021-117062 (2/23)
2
12 EMSERE - FULLY EQUIPPED 2024 BENEFITS GUIDE
Employee Benefit Assistants You Can Count on M ember C laims A dvocate
Emsere provides you and your family members a complimentary member claims service to help with claims, billing, missing ID cards and more.
give member claims advocate a call if : • You received a provider bill or EOB and feel the claim was processed incorrectly • You are at the doctor or pharmacy and having trouble with your coverage • You need to confirm if a provider is In-Network • You are missing your ID card Y ou can reach the M ember C laims A dvocate team by phone or email
Monday through Friday, 8:30 AM EST - 5:00 PM EST
Billy Eissler - beissler@yatesins.com Cheryl Janis - cjanis@yatesins.com (404) 633-4321
13 EMSERE - FULLY EQUIPPED 2024 BENEFITS GUIDE
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, 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.
Specialist Office Visit
Network Deductible
Co-Insurance
Network Out-of-Pocket Maximum (OOP)
Prescription Drug Tiers and Monthly Co-Pays
14 EMSERE - FULLY EQUIPPED 2024 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, 2022. 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
15 EMSERE - FULLY EQUIPPED 2024 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, 2022, 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
16 EMSERE - FULLY EQUIPPED 2024 BENEFITS GUIDE
Legal Notices
Important Notices about Medical Coverage
HIPAA Special Enrollment Rights 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. 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. 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.
17 EMSERE - FULLY EQUIPPED 2024 BENEFITS GUIDE
Medicare Part D
Medicare Part D Notice of Creditable Coverage Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Emsere 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. Emsere 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? Ifyou decide to join a Medicare drug plan, your current Emsere 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 Emsere coverage, be aware that you and your dependents may or may not be able to get this coverage back. 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 Emsere 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 Emsere 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.
18 EMSERE - FULLY EQUIPPED 2024 BENEFITS GUIDE
COBRA
What is COBRA continuation health coverage? The Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions amend the Employee Retirement Income Security Act, the Internal Revenue Code and the Public Health Service Act to require group health plans to provide a temporary continuation of group health coverage that otherwise might be terminated. What does COBRA do? COBRA requires continuation coverage to be offered to covered employees, their spouses, former spouses, and dependent children when group health coverage would otherwise be lost due to certain specific events. COBRA continuation coverage is often more expensive than the amount that active employees are required to pay for group health coverage, since the employer usually pays part of the cost of employees’ coverage and all of that cost can be charged to individuals receiving continuation coverage. What group health plans are subject to COBRA? The law generally applies to all group health plans maintained by private-sector employers with 20 or more employees, or by state or local governments. The law does not apply to plans sponsored by the Federal Government or by churches and certain church-related organizations. In addition, many states have laws similar to COBRA, including those that apply to health insurers of employers with less than 20 employees (sometimes called mini-COBRA). Check with your state insurance commissioner’s office to see if such coverage is available to you. Who is entitled to continuation coverage under COBRA? In order to be entitled to elect COBRA continuation coverage, your group health plan must be covered by COBRA; a qualifying event must occur; and you must be a qualified beneficiary for that event. Plan Coverage COBRA covers group health plans sponsored by an employer (private-sector or state/local government) that employed at least 20 employees on more than 50 percent of its typical business days in the previous calendar year. Both full-and part-time employees are counted to determine whether a plan is subject to COBRA. Each part-time employee counts as a fraction of a full-time employee, with the fraction equal to the number of hours that the part-time employee worked divided by the hours an employee must work to be considered full time. Qualified Beneficiaries A qualified beneficiary is an individual covered by a group health plan on the day before a qualifying event occurred that caused him or her to lose coverage. Only certain individuals can become qualified beneficiaries due to a qualifying event, and the type of qualifying event determines who can become a qualified beneficiary when it happens. A qualified beneficiary
must be a covered employee, the employee’s spouse or former spouse, or the employee’s dependent child. In certain cases involving the bankruptcy of the employer sponsoring the plan, a retired employee, the retired employee’s spouse or former spouse, and the retired employee’s dependent children may be qualified beneficiaries. In addition, any child born to or placed for adoption with a covered employee during a period of continuation coverage is automatically considered a qualified beneficiary. An employer’s agents, independent contractors, and directors who participate in the group health plan may also be qualified beneficiaries. Are there alternatives for health coverage other than COBRA? If you become entitled to elect COBRA continuation coverage when you otherwise would lose group health coverage under a group health plan, you should consider all options you may have to get other health coverage before you make your decision. There may be more affordable or more generous coverage options for you and your family through other group health plan coverage (such as a spouse’s plan), the Health Insurance Marketplace, or Medicaid. If you become entitled to elect COBRA continuation coverage when you otherwise would lose group health coverage under a group health plan, you should consider all options you may have to get other health coverage before you make your decision. There may be more affordable or more generous coverage options for you and your family through other group health plan coverage (such as a spouse’s plan), the Health Insurance Marketplace, or Medicaid. Under the Health Insurance Portability and Accountability Act (HIPAA), if you or your dependents are losing eligibility for group health coverage, including eligibility for continuation coverage, you may have a right to special enroll (enroll without waiting until the next open season for enrollment) in other group health coverage. For example, an employee losing eligibility for group health coverage may be able to special enroll in a spouse’s plan. A dependent losing eligibility for group health coverage may be able to enroll in a different parent’s group health plan. To have a special enrollment opportunity, you or your dependent must have had other health coverage when you previously declined coverage in the plan in which you now want to enroll. You must request special enrollment within 30 days from the loss of your job-based coverage. Losing your job-based coverage is also a special enrollment event in the Health Insurance Marketplace). The Marketplace offers “one-stop shopping” to find and compare private health insurance options. In the Marketplace, you could be eligible for a tax credit that lowers your monthly premiums and cost- sharing reductions (amounts that lower your out-of-pocket costs for deductibles, coinsurance and co-payments), and you can see what your premium, deductibles, and out-of-pocket costs will be before you make a decision to enroll.
19 EMSERE - FULLY EQUIPPED 2024 BENEFITS GUIDE
Exchange Notices
New Health Insurance Marketplace Coverage Options and Your Health Coverage
Form Approved OMB No. 1210-0149 (expires 6-30-2023)
PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance : the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment based health coverage offered by your employer. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014. Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. 1 Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact . The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.
1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by
the plan is no less than 60 percent of such costs.
20 EMSERE - FULLY EQUIPPED 2024 BENEFITS GUIDE
Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24yatesknightrawls.employeenavigator.com
Made with FlippingBook - professional solution for displaying marketing and sales documents online