OPEN ENROLLMENT benefits guide
2022 PLAN YEAR
Introduction
Dear Employee
J&L Ventures, LLC offers a comprehensive suite of benefits to promote health and financial security for you and your family. This guide provides you with a summary of your benefits.
Please review it carefully so you can choose the coverage that’s right for you.
About Deductions
TABLE OF CONTENTS Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Member Advocate . . . . . . . . . . . . . . . . . . . . . 4 Medical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Basic Life AD&D . . . . . . . . . . . . . . . . . . . . . . . 8 Disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Election Forms . . . . . . . . . . . . . . . . . . . . . . . 12 Legal Notices . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Medicare Part D. . . . . . . . . . . . . . . . . . . . . . 17 COBRA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Exchange Notices. . . . . . . . . . . . . . . . . . . . . . 19 Contact Information. . . . . . . . . . . . . . . . . . . .22
Premiums for Medical, Dental, and Vision coverage will be deducted on a pre - tax basis because it is covered under your Cafeteria Plan under Section 125 of the Internal Revenue Service Code. Once you elect to enroll in this plan, you will not be allowed to drop or change your election until the Company’s next Annual Enrollment unless you have a Qualifying Event.
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All Eligibility
As a J&L Ventures, LLC employee, you may be eligible for enrollment in a variety of insurance products. You may enroll your eligible dependents for coverage once you are eligible. Your eligible dependents include:
• 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 may only change coverage within 30 days of a qualifying life event.
Information Needed for Enrollment
In preparation of your enrollment, please have the following information readily available for you and your dependent(s):
Qualifying Life Events 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 coverage.
• Date(s) of birth
• Social Security Number(s): Mandatory
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. • 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.)
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
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M ember C laims A dvocate
Employee Benefit Assistants You Can Count on
J&LVentures, LLC 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
Seth Knight - sknight@knightrawls.com Leigh Drawdy - ldrawdy@knightrawls.com Resa Carter - rcarter@knightrawls.com Anna Meadows - ameadows@knightrawls.com (706) 323-1600
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Medical and Pharmacy Coverage
J&L Ventures, LLC offers the following plans through Anthem Blue Cross Blue Shield. Please reference the Summary Plan Description for more details. Insurance Carrier: Anthem Blue Cross Blue Shield Medical Insurance Medical Plan Number: High Copay Plan Low Copay Plan In-Network: Office Visit Copay - Primary Care $25 Copay per visit Deductible; then 30% Coinsurance Office Visit Copay - Specialist Care $50 Copay per visit Deductible; then 30% Coinsurance Urgent Care Copay $60 Copay per visit Deductible; then 30% Coinsurance Emergency Room Care $150 Copay; then 20% Coinsurance $250 Copay; then 30% Coinsurance Preventative Visit Copay $0 $0 Diagnostic Testing & Blood Work $0 $0 Imaging Deductible; then 20% Coinsurance Deductible; then 30% Coinsurance Coinsurance 80% 70% Employee Deductible $1,500 $2,500 Family Deductible $4,500 $7,500 Employee Out-of-Pocket Max $7,150 $7,150 Family Out-of-Pocket Max $14,300 $14,300 Inpatient Hospital Deductible; then 20% Coinsurance Deductible; then 30% Coinsurance Outpatient Hospital or Facility Deductible; then 20% Coinsurance Deductible; then 30% Coinsurance Out-of-Network: Coinsurance 50% 50% Employee Deductible $4,500 $7,500 Family Deductible $13,500 $22,500 Employee Out-of-Pocket Max $21,450 $21,450 Family Out-of-Pocket Max $42,900 $42,900 Prescription Drugs: ( 30 Day Supply) Rx Deductible $300 Individual / $600 Family $1,000 Individual / $2,000 Family Tier 1 - Generic $30 $15 Tier 2 - Preferred Deductible met; then $55 Copay Deductible met; then $50 Copay Tier 3 - Non-Preferred Deductible met; then $90 Copay Deductible met; then 20% Coinsurance Tier 4 - Specialty Pay at appropriate tier Deductible met; then 20% Coinsurance Employee Bi-Weekly Deduction Employee Only $68.00 $53.00 Employee + Spouse $140.00 $110.00 Employee + Child(ren) $130.00 $99.00 Family $218.00 $167.00
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Dental Coverage
Regular dental exams can help you and your dentist detect problems in the early stages when treatment is simpler and costs are lower.
Keeping your teeth and gums clean and healthy will prevent most tooth decay and periodontal disease, and is an important part of maintaining your medical health.
Your PPO dental plan is through Anthem BlueCross BlueShield and offers “in and out-of-network” benefits.
Insurance Carrier:
Anthem BlueCross BlueShield Dental Insurance
Plan Type:
Dental Plan 130
Calendar Year Deductible Calendar Year Maximum
$50 / Individual; maximum of $150 family
$1,000
Preventive Services
100%
Basic Services Major Services
80% 50% 80%
Endo/Perio
Orthodontic Lifetime (dependent chil- dren only) Out-of-Network Reimbursement Employee Bi-Weekly Deduction Employee Only
$1,000
N / A
$2.52 $4.80 $6.52 $9.00
Employee + Spouse Employee + Child(ren)
Family
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Vision Coverage
The vision plan covers routine eye exams and also pays for all or a portion of the cost of glasses or contact lenses if you need them.
Your PPO vision plan is through Anthem BlueCross BlueShield and offers “in and out-of-network” benefits.
To find an in-network provider, visit bcbsga.com
Insurance Carrier:
Anthem BlueCross BlueShield Vision Insurance
Plan Type:
Blue ViewVision
In-Network $10 Copay $20 Copay $20 Copay $20 Copay
Out-of-Network $30 allowance $25 allowance $40 allowance $55 allowance
Exam Services
Lenses - Single lined Lenses - Bifocal lined
Lenses - Trifocal
$ 130 allowance; then 15% off any remaining balance
Contacts / Lenses
$105 allowance
$130 allowance; then 20% off any remaining balance
Frames
$45 allowance
Frequency for Exam / Lenses / Frames Employee Bi-Weekly Deduction Employee Only
12 months / 12 months / 24 months
$1.65 $2.76 $2.52 $4.46
Employee + Spouse Employee + Child(ren)
Family
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Basic Life and AD&D Insurance Coverage
J&L Ventures, LLC provides all Full Time employees with Basic Life and Accidental Death & Dismemberment coverage.
Insurance Carrier:
Anthem Life Basic Life Insurance
Basic Life w/ AD&D Eligibility Requirement Life Insurance Benefit
All Full Time Employees Based on Occupation Class
Guarantee Issue
Yes
Accidental Death & Dismemberment Benefit (AD&D)
Same as Basic Life Amount
Dependent Life
$10,000
Voluntary Term Life Insurance Coverage
As a supplemental benefit, J&L Ventures, LLC 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 Anthem Life. Rates for the voluntary term life insurance are based on age, and volume, and benefits are subject to applicable age reductions.
Insurance Carrier:
Anthem Life Voluntary Life Insurance
Voluntary Life w/ AD&D Eligibility Requirement Employee Benefit Amounts Employee
All Full Time Employees
minimum of $10,000 / up to $500,000 in increments of $10,000 minimum of $5,000 / 100% of employees benefit, up to $250,000 minimum of $5,000 / 100% of employees benefit, up to $250,000
Spouse
Child(ren)
Guarantee Issue Employee
5 times annual income, up to $150,000 100% of employees benefit, up to $75,000 100% of employees benefit, up to $75,000
Spouse
Child(ren)
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Disability Insurance Coverage
The goal of J&LVentures 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 the option to purchase voluntary “Short and Long Term Disability” income benefits.
Both the short term and long term disability coverages are offered through Anthem Life.
Insurance Carrier:
Anthem Life Short-Term Disability Insurance
Plan Type:
Voluntary
Eligibility Requirement
All Full Time Employees
Benefit Percentage
60%
Waiting Period - Accident Waiting Period - Sickness Maximum Weekly Benefit Pre-Existing Condition
14 Days 14 Days $1,000
3/12
Benefit Duration
11 Weeks
Insurance Carrier:
Anthem Life Long-Term Disability Insurance
Plan Type:
Voluntary
Eligibility Requirement
All Full Time Employees
Waiting Period
90 Days
Benefit Percentage
60%
Maximum Monthly Benefit
$5,000 SSNRA 2 Years
Benefit Duration
Own Occupation Definition Partial Disability Benefit
99% during Own Occ; then 85%
Mental Disorders Drug & Alcohol
24 Months per Lifetime 24 Months per Lifetime
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Medicare
We’ve got your Medicare plan!
If you’re approaching 65 — whether you’ll retire or keep working — Anthem may have a quality, affordable Medicare plan for you. } Choose from a wide range of Medicare Advantage or Medicare Supplement plans.* } Get expert help to find the right plan for your health, lifestyle and budget. } Ask how you could save money by moving your eligible spouse to Medicare, too!
TIP! Get a customized plan recommendation. When it comes to choosing the right Medicare plan, Anthem members have an advantage. Your history with us matters. Our exclusive PlanMatch tool uses your information — including costs, doctors, where you receive care and may include your prescriptions — to recommend a plan for you. There’s nothing to look up or type in. Go to www.anthem.com/movetomedicare to find the right Medicare plan quickly, easily and confidently.
TIP! Find the right plan — just for you.
When it comes to choosing the right Medicare plan, we have a simple to use shopping tool. Go to https://shop.anthem.com/medicare, answer a few easy questions and find the Medicare plan that best suits your individual needs. You can even complete your enrollment online.
Call now: 1-888-271-9626 (TTY: 711) 8 a.m. to 8 p.m., 5 days a week
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FAQ
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? Anthem 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 Anthem’s contracted rate for your medical care and services rendered. The contracted rate includes both Anthem’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, Anthem’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 Anthem. 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. Anthem 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. You can go into Employee Navigator anytime to update your beneficiary.
Term
Definition
The “per visit” co-pay cost for a primary care or standard network doctor.
Network Office Visit (PCP)
The “per visit” co-pay cost for a specialized doctor (cardiologist, OB/GYN, orthopedic, gastrointestinal, etc.)
Specialist Office Visit
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 responsibilty, 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 Speciality Drugs are covered under a separate tier.
Network Deductible
Co-Insurance
Network Out-of-Pocket Maximum (OOP)
Prescription Drug Tiers and Monthly Co-Pays
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Election Forms
Employee Insurance Rates 2021/2022 Plan Year Effective October 1, 2021
J & L Ventures, LLC Employee Insurance Rates effective 10/01/2021 are shown below.
It is now Open Enrollment for J & L Ventures, LLC. Open Enrollment is an opportunity for you to review your current benefit plan elections to ensure they continue to meet your needs and those of your family. New enrollments and changes will become effective October 1 st .
If you do not enroll, or make any necessary changes during Open Enrollment, you will not be able to enroll again until the next annual open enrollment period unless you experience a Qualifying Event (QE).
Examples of a QE include: Open Enrollment, Other insurance, Marriage, Divorce, or legal separation, Adoption or birth of a child, Death of a spouse or child or Involuntary loss of coverage
ALL rates are shown on a weekly basis . **NOTE – Coverage for spouse is not allowed if insurance is available through spouse’s employer.
Group Health Insurance – High Benefit Plan Option $1,500 Individual / $4,500 Family Deductible 80% In Network Coinsurance $7,150 Individual / $14,300 Out of Pocket $25 PCP Copay / $50 SCP Copay $300 Individual / $600 Family Non-Generic Rx Deductible $5/$20/$45/$80/25% Rx Copays
I elect this benefit (please check)
Current Per Pay Period Costs
Employee Only
$ 68.00 $140.00 $130.00 $218.00
Employee + Spouse Employee + Child(ren)
Family
Group Health Insurance – Low Benefit Plan Option $2,500 Individual / $7,500 Family Deductible 70% In Network Coinsurance $7,150 Individual / $14,300 Out of Pocket $45 PCP Copay (4 Visit Max) $1,000 Individual / $2,000 Family Non-Generic Rx Deductible $5/$20/20% Rx Copays
I elect this benefit (please check)
Current Per Pay Period Costs
Employee Only
$ 53.00 $110.00 $ 99.00 $167.00
Employee + Spouse Employee + Child(ren)
Family
I Decline Medical Coverage
_____________
***No Medical Coverage***
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Election Forms
Dental Insurance Plan $50 Individual / $150 Family Deductible 100% Preventive / 80% Basic / 50% Major Coinsurance In Network $1000 Annual Maximum 50% Orthodontia / $1,000 Lifetime Max Per Pay Period Costs I elect this benefit (please check)
Employee Only
$ 2.52 $ 4.80 $ 6.52 $ 9.00
Employee + Spouse Employee + Child(ren)
Family
***No Dental Coverage***
I Decline Dental Coverage
_____________
Vision Insurance Plan $10 Exam Copay $130 Materials Allowance 12 /12/ 24 Contract
I elect this benefit (please check)
Per Pay Period Costs
Employee Only
$ 1.65 $ 2.76 $ 2.52 $ 4.46
Employee + Spouse Employee + Child(ren)
Family
I Decline Vision Coverage
_____________
***No Vision Coverage***
Life Insurance
Benefit
Pricing Determination Based on Job Classification One Unit per Household
Basic Life AD&D Dependent Life Voluntary Life
Based on Increments of $10,000
Voluntary Short Term Disability Voluntary Long Term Disability
Based on Income
Based on Income ___________________________________________________________________________________________________________ PLEASE READ CAREFULLY! I would like to ADD or CHANGE the following lines of coverage for 2021/2022 (check all that apply): DO NOT CHECK UNLESS YOU ARE REQUESTING A CHANGE OR ADDITION TO YOUR CURRENT COVERAGE Life _____ Dental _____ Vol Vision _____ Vol Life _____ Dep Life _____ Vol STD _____ Vol LTD_____ *Note – Evidence of insurability and/or new application may be required
__________________________________________
____________
Printed Name
Effective / Change Date
__________________________________________
_____________________
Signature
Date
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Legal Notices
Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free or Low-Cost Health Coverage to Children and Families
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2021. Contact your State for more information on eligibility –
ALABAMA - Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447 ALASKA - Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: Customer Service@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default. aspx ARKANSAS - Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447) COLORADO - Medicaid Website: http://www.colorado.gov/hcpf Customer Contact Center: 1-800-221-3943 KANSAS - Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512 KENTUCKY - Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570 LOUSIANA - Medicaid Website: http://dhh.louisiana.gov/index.cfm/ subhome/l/n/331 Phone: 1-888-695-2447
FLORIDA - Medicaid Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268 GEORGIA - Medicaid Website: http://dch.georgia.gov/medicaid - click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507 INDIANA - Medicaid Healthy Indiana Plan for Low-Income Adults 19-64 Website: http://www.hip.in.gov Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone: 1-800-403-0864 IOWA - Medicaid Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 MAINE - Medicaid Website: http://maine.gov/dhhs/ofi/public-assistance/ index.html Phone: 1-800-442-6003 TTY: Maine relay 711
MASSACHUSETTS - Medicaid and CHIP Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120 MINNESOTA - Medicaid Website: http://mn.gov/dhs/ma/ Phone: 1-800-657-3739
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Legal Notices
MISSOURI - Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
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://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
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 NEWYORK - 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 RHODE ISLAND - Medicaid
Phone: 1-877-543-7669 VERMONT - Medicaid Website: http://www.greenmountaincare.org Phone: 1-800-250-8427 VIRGINIA - Medicaid and CHIP Medicaid & CHIP Website: http://www.coverva.org/programs_premi- um_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282 WASHINGTON - Medicaid Website: http://www.hca.wa.gov/free-or-low-costhealth-care/pro- gram-administration/premiumpayment- program Phone: 1-800-562-3022 ext. 15473 WEST VIRGINIA - Medicaid Website: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/ Pages/default.aspx Phone: 1-877-598-5820, HMS Third Party Liability WISCONSIN - Medicaid and CHIP Website: http://www.dhs.wisconsin.gov/publications/p1/p10095.pdf
Phone: 1-800-362-3002 WYOMING - Medicaid Website: http://wyequalitycare.acs-inc.com/ Phone: 307-777-7531
To see if any more States have added a premium assistance program since January 31, 2021, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/ebsa 1-866-444-EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565
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Legal Notices Important Notices about Medical Coverage
HIPPA 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 RightsAct of 1998Annual 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.
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 Knight - Rawls 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.
These benefits will be provided subject to the same
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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 J&L Ventures, LLC 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. J&L Ventures, LLC has determined that the prescription drug coverage offered by Anthem plans are on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join a Medicare Drug Plan ? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens to Your Current Coverage if You Join a Medicare Drug Plan? If you decide to join a Medicare drug plan, your current J&L Ventures, LLC 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 themwhen they become eligible for Medicare Part D. If you do decide to join a Medicare drug plan and drop your current J&L Ventures, LLC 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 J&L Ventures, LLC 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 Knight - Rawls 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 J&L Ventures, LLC 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.
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COBRA
What is COBRAcontinuation 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 youmay 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 youmay 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 (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 copayments), and you can see what your premium, deductibles, and out-of-pocket costs will be before you make a decision to enroll.
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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 employmentbased 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.
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Exchange Notices
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 complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application. 3. Employer name 4. Employer Identification Number (EIN)
J&L Ventures, LLC.
J&L Ventures, LLC.
5. Employer address 3 Villa Drive NW
6. Employer phone number
(706)232-2064
8. State
9. ZIP code
7. City
GA
30165
Rome
10. Who can we contact about employee health coverage at this job?
Susan Baker
11. Phone number (if different from above)
12. Email address
susan.baker@bevsouth.us
(706)232-2064
Here is some basic information about health coverage offered by this employer: • As your employer, we offer a health plan to: All employees. Eligible employees are:
X
Full-time (40 hours a week)
Some employees. Eligible employees are:
• With respect to dependents:
X
We do offer coverage. Eligible dependents are:
We do not offer coverage.
If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages.
** 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 monthly premiums.
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Exchange Notices
The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for employers, but will help ensure employees understand their coverage choices.
13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months? Yes (Continue) 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue) No (STOP and return this form to employee) X
14. Does the employer offer a health plan that meets the minimum value standard*? Yes (Go to question 15) No (STOP and return form to employee)
X
15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don't know, STOP and return form to employee. X 60.10
16. What change will the employer make for the new plan year? Employer won't offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)
a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month
Monthly
Quarterly
Yearly
• 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 (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
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