2025 E MPLOYEE BENEFITS GUIDE
WELCOME TO YOUR BENEFIT ENROLLMENT GUIDE 2025 PLAN YEAR
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. Baft Development Services LLC DBA Jan Pro provides each employee up to a $500 monthly contribution to use towards your group healthcare benefits, only if you elect coverage. The rates reflected in this guide are the total cost per pay period for your coverage. The monthly contribution from your employer is not included in these rates. Keep in mind that the benefits you select during this enrollment will be effective June 1 st , 2025 and will continue through May 31 st , 2026. Baft Development Services LLC DBA Jan Pro 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, 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.
ADDITIONAL INFORMATION
WHO IS AN ELIGIBLE DEPENDENT? You can enroll the following dependents in our group benefit plans: • Your legal spouse • Your natural, adopted, or stepchildren living with you, or any other children whom you have legal guardianship, up to age 26 • Unmarried children of any age if disabled and claimed as a dependent on your federal income taxes ELIGIBILITY: As a Baft Development Services LLC DBA Jan Pro employee, you may be eligible for enrollment in a variety of insurance products. Full-time employees may participate in the benefits package on the 1 st of the month following 60 days of employment.
WHEN YOU CAN ENROLL IN BENEFITS:
• During your initial new hire eligibility period • During the annual Open Enrollment period for a June 1 st effective date
If you fail to enroll within the time frame given for the new hire eligibility or annual enrollment window, you will not be able to elect benefits again until the next Open Enrollment period, and you will not have coverage, unless you experience a qualified life event. Please make your elections on time, or you may experience a delay in using your benefits.
QUALIFYING LIFE 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 Life events include: • Marriage, divorce, or legal separation • Death of spouse or other dependent • Birth or adoption of a child • You or your spouse experience a work event that effects your benefits • A dependent’s eligibility status changes due to age, student status, marital status, or employment • Relocation into or outside of your plan’s service area 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.
HOW TO ENROLL
Step 1: Creating your Employee Navigator Account
Welcome Email:
• You will receive a Welcome email from Employee Navigator • Click on the “Registration Link” in the email • Create an account with username and password of your choice
• Go to https://www.employeenavigator.com/benefits/Account/Register • Enter [First Name], then [Last Name] • Enter your Company Identifier [Baft-JanPro] • PIN: Last four of your SSN • Enter your birthdate: MM/DD/YYYY • Click “Next” to continue • When prompted, your username will be as follows: [First Name].[Last Name] Option 2:
Step 2: Complete HR Tasks
• Once your account is set up, you will be taken to your employee homepage.
• On the homepage, click the “Complete HR Tasks” to begin your new hire tasks first.
• The first few tasks require you to put in demographic information and e-sign for online acknowledgment.
T I P If you hit “Dismiss, complete later” you’ll be taken to your Home Page. You’ll still be able to start enrollments again by clicking “Start Enrollments”
Step 3: Benefit Elections
• To enroll dependents in a benefit, click the checkbox next to the dependent’s name under “Who am I enrolling?” If you do not click on their name(s), they will not get the insurance. • Below your dependents you can view your available plans and the cost per pay period. To elect a benefit, click Select Plan underneath the plan cost.
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Step 4: Forms
• If you have elected benefits that require a beneficiary designation, Primary Care Physician or completion of an Evidence of Insurability form, you will be prompted or required to complete.
Step 5: Review & Confirm Elections
• Review the benefits you selected on the enrollment summary page to make sure they are correct then click “Sign & Agree” to complete your enrollment. Print a summary of your elections for your records.
T I P If you miss a step you’ll see Enrollment Not Complete in the progress bar with the incomplete steps highlighted. Click on any incomplete steps in the drop down bar to complete them. ALL STEPS MUST BE COMPLETED! Step 6: HR Tasks (if applicable) • To complete any required HR tasks, click “Start Tasks”. If your HR department has not assigned any tasks, you’re finished!
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MEDICAL COVERAGE
Baft Development Services LLC DBA Jan Pro offers the following plans through UnitedHealthcare.
Insurance Carrier:
UnitedHealthcare Medical Insurance
Medical Plan:
$1,000 Copay Plan
$3,500 Copay Plan
In-Network: Primary Care Visits
$25 Copay $75 Copay $50 Copay
$25 Copay $75 Copay $50 Copay
Specialist Care Visits
Urgent Care
Emergency Room Care
Deductible met; then 20% Coinsurance
Deductible met; then 20% Coinsurance
Preventative Visit Copay Diagnostic Testing (X-Ray / Blood Work)
$0
$0
Deductible met; then 20% Coinsurance
Deductible met; then 20% Coinsurance
Deductible met; then 20% Coinsurance
Deductible met; then 20% Coinsurance
Advanced Imaging
80%
80%
Plan Coinsurance
$1,000 $2,000 $4,500 $9,000
$3,500 $7,000 $8,150 $16,300
Employee Deductible
Family Deductible
Employee Out-of-Pocket Max
Family Out-of-Pocket Max
Deductible met; then 20% Coinsurance Deductible met; then 20% Coinsurance
Deductible met; then 20% Coinsurance Deductible met; then 20% Coinsurance
Inpatient Hospital
Outpatient Hospital or Facility
Out-of-Network Plan Coinsurance
50%
50%
Employee Deductible
$2,000 $4,000 $9,000 $18,000
$7,000
Family Deductible
$14,000 $16,300 $32,600
Employee Out-of-Pocket Max
Family Out-of-Pocket Max
Prescription Drugs 30-day supply Tier 1 - Generic
$10 Copay $35 Copay $75 Copay $250 Copay
$10 Copay $35 Copay $75 Copay $250 Copay
Tier 2 - Preferred
Tier 3 - Non-Preferred
Tier 4 - Specialty
Employee Bi-Weekly Deduction Employee Only
$294.72 $598.62 $543.37 $847.26
$240.17 $484.04 $439.70 $683.58
Employee + Spouse Employee + Child(ren)
Family
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DENTAL BENEFITS
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.
To find an in-network provider, visit uhc.com/find-a-doctor
Insurance Carrier:
UnitedHealthcare Dental Insurance
Base Plan You pay:
Plan Type:
Calendar Year Deductible
$50 Individual / $150 Family
Calendar Year Maximum
$1,000
Preventive Services
100%
Basic Services
80%
Major Services
50%
Orthodontia (dependent children only)
N / A
Out-of-Network Reimbursement
90th Usual & Customary
Employee Bi-Weekly Deduction Employee Only
$17.79
Employee + Spouse
$35.58
Employee + Child(ren)
$39.48
Family
$60.16
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VISION BENEFITS
You can help protect your eyesight by visiting an eye doctor regularly. Taking care of your eyes today can lead to a better quality of life later.
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.
To find an in-network provider, visit uhc.com/find-a-doctor
Insurance Carrier:
UnitedHealthcare Vision Insurance
In-Network You pay:
Out-of-Network You are reimbursed:
Eye Exam every 12 months
$10 Copay
Up to $40
Lenses every 12 months • Single Vision
$25 Copay $25 Copay $25 Copay $25 Copay
Up to $40 Up to $60 Up to $80 Up to $80
• Bifocal • Trifocal • Lenticular
Frames every 12 months
$150 Allowance + 30% off balance
Up to $45
$105 Allowance Medically Necessary: Covered in full
Up to $80 Medically Necessary: up to $210
Contacts every 12 months
Employee Bi-Weekly Deduction
Employee Only
$2.79
Employee + Spouse
$5.30
Employee + Child(ren)
$6.22
Family
$8.75
*Contacts benefit is in lieu of eyeglass frames and lens benefit.
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BASIC LIFE W/AD&D INSURANCE COVERAGE
Baft Development Services LLC DBA Jan Pro provides all Full-Time employees with Basic Life and Accidental Death & Dismemberment at no cost to you.
UnitedHealthcare Basic Life w/AD&D Insurance
Eligibility Requirement
All Full-Time Employees
Life Insurance Benefit
$20,000
Guarantee Issue
Yes
Accidental Death & Dismemberment Benefit (AD&D)
Same as Basic Life Amount
UHC WELLNESS
UnitedHealthcare Level Funded Welcome to Wellness
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UHC WELLNESS
Level Funded Wellness Get started with Level Funded Wellness, programs included in your health plan and designed to help you with a healthier lifestyle — all at no extra cost to you.
Motion Rewards for meeting program walking goals Use a wearable activity tracker to track steps, reach goals and earn rewards
HealthiestYou ™ Virtual Care
Virtual care from your mobile device or computer Talk with medical doctors who can diagnose, treat and prescribe medication
24/7 Virtual Visits Connect with a doctor 24/7 Speak to a doctor by phone* or video when you want care — anytime, anywhere
Rally Your personalized health journey Complete a health survey, choose and complete missions, join and complete challenges and earn rewards
* Data rates may apply.
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UHC WELLNESS
Earn rewards with Motion With UnitedHealthcare Motion®, every step moves you closer to hitting program goals and earning rewards. All you have to do is sign up, slip on a tracker and get moving — no gym required. With Motion, you get a wearable activity tracker and a set of 3 daily goals. Meet the goals, and you may earn rewards every day — up to $1,095* a year. Get started Visit unitedhealthcaremotion.com to set up your account. Download the UnitedHealthcare Motion app. Get moving Step 1: Simply put on your activity tracker in the morning.
Step 2: Sync your tracker to your personal account. It will regularly send your information to a secure place online.
Step 3: Check your progress regularly and track your earnings at unitedhealthcaremotion.com or on the Motion app.
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UHC WELLNESS
Get rewards Motion rewards you for meeting 3 daily goals. This may maximize your health benefits and helps you get FIT.
Daily goal
Potential benefits
Reward
Frequency 6 brief walks over the course of a day, at least 1 hour apart. (For each walk, need 300 steps within 5 minutes.) Intensity 1 brisk walk of 3,000 steps within 30 minutes or 30 minutes performing other eligible activities. Tenacity At least 10,000 steps in a day. (The activity devices will reset at midnight local time.)
May reduce risk factors for metabolic and cardiac health May reduce risk factors for cardiovascular, metabolic, bone and mental health conditions, as well as cancer May increase energy expenditures and can help manage weight
$1
$1
$1
Participation 2,500+ steps per day with no FIT rewards.
May encourage those who do not regularly hit their FIT goals to continue being active
$.25
Total possible per day
$3.00
When you get FIT every day, you and your covered spouse may each earn up to $1,095* per calendar year. We’ll help you get started by giving you $55 just for registering at unitedhealthcaremotion.com . You can use the credit toward an activity tracker — or if you already have a compatible tracker, you can save the credit for reimbursement of your out-of-pocket medical expenses. Key features: • Plan participants and eligible spouses may be reimbursed up to $1,095* or 30% of the cost of plan participant-only coverage (or family coverage if dependents are covered) for available incentives under all programs combined as applicable, whichever is less, each calendar year • Quarterly reimbursements for expenses are applied to the out-of-pocket limit calendar year spend • 50% plan year rollover of unreimbursed rewards for those on a non-HSA plan • $55 registration credit can be used toward purchase of an activity tracker or saved for quarterly reimbursements. The unused credit will be deposited into the plan participant’s HSA (if plan participant has this set up). Considerations: • Point tracking does not start until after your effective date • Every quarter, all earned credits will be deposited into your health savings account (HSA) to be used at your discretion • Plan participants and spouses on a high deductible health plan are required to provide UnitedHealthcare Motion with their HSA bank information at the time of registration to receive reimbursement HSA contribution limits for 2022: Plan participants are responsible for ensuring that they do not exceed the 2022 HSA contribution limits imposed by the IRS. For 2022, the maximum contribution is $3,650 for individual coverage and $7,300 for family coverage. If you are age 55 or older, you may be eligible for an additional $1,000 catch-up contribution. Please seek your own tax advice.
Questions about Motion
Call 1-855-256-8669 | Email unitedhealthcaremotion@uhc.com
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*Or $1,150 if not applying registration credit toward an activity tracker.
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UHC WELLNESS
Virtual care from your mobile devices! HealthiestYou – Your one-stop shop for all things virtual healthcare. All 4 services are available to all family members in your household, even those not taking medical coverage with UnitedHealthcare Level Funded. HealthiestYou may help you save time, money and avoid unnecessary in person doctor visits for non-life threatening illnesses. Doctors may prescribe medication when necessary as well. Your virtual care services include: Get well. HealthiestYou virtual care.
Back/neck care Get help to relieve your back and neck pain through guided videos with a certified health coach Mental Health Connect with a psychiatrist/therapist for support for anxiety, stress, depression, family difficulties, etc. (For 18+ only) Dermatology Communicate with a Dermatologist through the HealthiestYou app via message center for skin conditions (acne, eczema, shingles, psoriasis, etc.) General medical Consult with a doctor 24/7 in all 50 states for minor illnesses (cold, flu, sinus infection, pink eye, UTI, allergies, etc.)
HealthiestYou Expert Medical Services If you’re dealing with a difficult diagnosis or questioning a treatment plan, you need to be sure. Have your medical case reviewed at no additional cost to you by a leading expert and get a second opinion on conditions like cancer, orthopedic problems, digestive system issues, chronic illnesses and more. 1. Contact HealthiestYou via app or phone 2. Provide details about your medical history 3. Get results and recommendations in a personalized report at no additional cost
1-866-703-1259
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UHC WELLNESS
Download the app to connect to doctors by phone or video 24/7, shop the lowest cost prescriptions, and much more 1. Download the app Search “HealthiestYou” in the app store or on Google Play 2. Set up your account Once you’ve downloaded the app, select “Register,” then choose “Employee” as your membership type 3. Enter basic contact information Type in your last name, date of birth, and ZIP code 4. Type in your security information Enter a valid email address, password, the best number for our doctors to reach you, your preferred language, and accept terms and conditions
Questions about HealthiestYou virtual care? Do you have a question on how to set up the member website? Need help downloading or using the app? We’re happy to help. Contact us using the information below.
Call: 1-866-703-1259 | Send us an email at: help@healthiestyou.com
Search “HealthiestYou” in the App Store® or Google Play® to download. HealthiestYou.com Download the app.
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UHC WELLNESS
See a doctor 24/7 with Virtual Visits 24/7 Virtual Visits let you and your covered family members connect with a doctor whenever you want care — from anywhere. Care is at your fingertips on myuhc.com® or the UnitedHealthcare® app — and you can choose a phone or video visit.
Use 24/7 Virtual Visits for common, nonemergency conditions like: • Allergies • Bronchitis • Eye infections • Flu • Headaches/migraines • Rashes • Sore throats • Stomachaches • And more
With 24/7 Virtual Visits, doctors can diagnose a wide range of common medical conditions — and even may prescribe medications, if needed.** Through your UnitedHealthcare Level Funded plan, your cost for a 24/7 Virtual Visit is $0.*** Get started Visit myuhc.com/virtualvisits or download the UnitedHealthcare app. To register by phone, call 1-855-615-8335 . When you request your visit, you can choose to speak to a doctor on the phone or have a video visit.
Questions about Virtual Visits
See the 24/7 Virtual Visits FAQ on myuhc.com or call the member number on your health plan ID card
** Certain prescriptions may not be available, and other restrictions may apply. *** The Designated Virtual Visit Provider’s reduced rate for a 24/7 Virtual Visit is subject to change at any time.
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UHC WELLNESS
Reach healthier goals with Rally Rally® encourages a healthier lifestyle and is designed to help you make changes to your daily routine, set goals and track your progress all to help encourage a healthier lifestyle. You'll get fun, personalized recommendations to help you move more and eat better, which may improve your health.
See your Rally Age Start by taking an interactive health survey to see your Rally Age, that may help you assess your health. Based on your Rally Age, you’ll get personal recommendations called “missions” to help you reach your health goals. Accept your missions Missions are custom-picked activities designed to help you eat better, and get active. Choose the missions you want to work on and level up to more challenging missions when you’re ready.
Take on a challenge Use the Rally app to track your activity and compete with other Rally participants to earn extra rewards.
Earn rewards You’ll earn Rally coins for completing your health survey, missions and challenges — even just for logging in once a day. You can use the coins to enter drawings for chances to earn rewards, get discounts or trigger a donation to a charity.
Get started Register at werally.com/client/allsavers/register | Access Rally anytime at werally.com or myuhc.com For questions about registration, call us at 1-844-334-4944
Questions about Rally
Visit our support page rally-support.force.com/customer Email the Rally support team support@werally.com
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M ember C laims A dvocate
Employee Benefit Assistants You Can Count on
Baft Development Services LLC DBA Jan Pro 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
Charlie McDaniel - cmcdaniel@yatesins.com Leigh Drawdy - ldrawdy@yatesins.com (706) 323-1600
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 phar- macy 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? UnitedHealthcare 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 UnitedHealth- care’s contracted rate for your medical care and services rendered. The contracted rate includes both UnitedHealthcare’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, UnitedHealthcare’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 UnitedHealthcare. 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-net- work provider may charge $200 for a primary care visit. UnitedHealthcare 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
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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, 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
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LEGAL NOTICES
MISSOURI - Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: 1-800-692-7462 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/cli- ents/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
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
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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 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.
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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 Baft Development Services LLC DBA Jan Pro 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 current 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. Baft Development Services LLC DBA Jan Pro has determined that the prescription drug coverage offered by UnitedHealthcare 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 Baft Development Services LLC DBA Jan Pro 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 Baft Development Services LLC DBA Jan Pro 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 Baft Development Services LLC DBA Jan Pro 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 Baft Development Services LLC DBA Jan Pro 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.ssa.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 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 (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.
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EXCHANGE NOTICES
Health Insurance Marketplace Coverage Options and Your Health Coverage
Form Approved OMB No. 1210-0149 (expires 12-31-2026)
PART A: General Information Even if you are offered health coverage through your employment, you may have other coverage options through the Health Insurance Marketplace (“Marketplace”).To assist you as you evaluate options for you and your family, this notice provides some basic information about the Health Insurance Marketplace. 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 in your geographic area. Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium and other out-of-pocket costs, but only if your employer does not offer coverage, or offers coverage that is not considered affordable for you and doesn’t meet certain minimum value standards (discussed below). The savings on your premium that you're eligible for depends on your household income. You may also be eligible for a tax credit that lowers your costs. Does Employment-Based Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that is considered affordable for you and meets certain minimum value standards, you will not be eligible for a tax credit, or advance payment of the tax credit, for your Marketplace coverage and may wish to enroll in your employment-based health plan. However, you may be eligible for a tax credit, and advance payments of the 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 is considered affordable for you or meet minimum value standards. If your share of the premium cost of all plans offered to you through your employment is more than 9.12% 1 of your annual household income, or if the coverage through your employment does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit, and advance payment of the credit, if you do not enroll in the employment-based health coverage. For family members of the employee, coverage is considered affordable if the employee’s cost of premiums for the lowest-cost plan that would cover all family members does not exceed 9.12% of the employee’s household income. .12 Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered through your employment, then you may lose access to whatever the employer contributes to the employment-based coverage. Also, this employer contribution -as well as your employee contribution to employment-based coverage- is generally excluded from income for federal and state income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. In addition, note that if the health coverage offered through your employment does not meet the affordability or minimum value standards, but you accept that coverage anyway, you will not be eligible for a tax credit. You should consider all of these factors in determining whether to purchase a health plan through the Marketplace.
1 Indexed annually; see https://www.irs.gov/pub/irs-drop/rp-22-34.pdf for 2023. 2 An employer-sponsored or other employment-based 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. For purposes of eligibility for the premium tax credit, to meet the “minimum value standard,” the health plan must also provide substantial coverage of both inpatient hospital services and physician services.
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