Acom 2023 Benefit Guide - Class 2 - All Other Eligible Empl…

CLASS 2 - ALL ELIGIBLE EMPLOYEES: BI-WEEKLY

benefits guide

2023 PLAN YEAR

Introduction

Welcome! Acom Integrated Solutions is proud to offer you a comprehensive benefits package for the upcoming plan year. This enrollment guide will assist you in determining the coverage levels that will provide you and your family with the protection that gives you peace of mind. This guide explains each type of coverage, gives suggestions about how to effectively use your benefits, and provides examples to help you determine your benefit and payroll deduction amounts.

We encourage you to take the time to review the enrollment guide prior to enrollment.

Keep in mind that the benefits you select during this enrollment will be effective May 1 st , 2023 and will continue through April 30 th , 2024.

Additional Information

What’s changing? For the upcoming plan year, we are changing our carrier for the Medical benefits from Humana to Cigna and offering 2 plans. Humana is exiting the market and Cigna was the most competitive option.

What’s the deadline to make changes? April 30 th 2023.

During the Enrollment period, you have the opportunity to elect, change, or waive benefits offered for the upcoming plan year. Please remember that changes to your benefits will only be accepted during the Open Enrollment period unless you experience a “Qualifying Event” as defined by the Internal Revenue Service.

Please reach out if you have any questions or concerns!

MUNDI HORN HUMAN RESOURCES MANAGER

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About Deductions

Premiums for medical, dental, vision and HSA Contribution plans are all deducted on a pre-tax basis because they are covered under Section 125 of the Internal Revenue Code. Once you elect benefits you will not be approved to make changes to your election or drop coverage until the next Open Enrollment period, unless you have a qualifying event. Voluntary life and short-term disability insurance premiums are deducted on a post-tax basis and may be changed outside of the Open Enrollment period.

Information Needed for Enrollment

In preparation of your enrollment, please have the following information readily available for you and your dependent(s): • Date(s) of birth • Social Security Number(s): Mandatory • Full name, relationship, and Social Security Number(s) for Life Beneficiary(ies). (Beneficiaries must be at least 18 years old or you will be required to name a guardian for him/her.)

All Eligibility

Qualifying Life Events

As an Acom employee, you may be eligible for enrollment in a variety of insurance products. Full-time employees may participate in the benefits package on the 1st of the month following 60 days of employment. You may enroll your eligible dependents for coverage once you are eligible. Your eligible dependents include:

Qualifying events are events that cause an individual to lose his or her group health coverage. The type of qualifying event determines who the qualified beneficiaries are for that event and the period of time that a plan must offer continuation of coverage.

Qualifying events include:

• Marriage • Divorce or legal separation • Birth or adoption of a child • Death of spouse or dependent child • Change in employment status • Loss of other coverage • Entitlement to Medicare or Medicaid • Child turning 26 years old

• Your legal spouse • Your children up to age 26 (as identified in the plan document)

*Once your elections are effective, they will remain in effect through the plan year.

You must notify Human Resources within 30 days of the qualifying life event. Depending on the type of event, you may be asked to provide proof of the event. If you do not contact Human Resources within 30 days of the qualifying event, you will have to wait until the next annual enrollment period to make changes.

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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 [ACOM] • PIN: Last four of your SSN • Enter your birthdate: MM/DD/YYY • 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 and Pharmacy Coverage

Acom offers the following plans through Cigna. Please reference the Summary Plan Description for more details. Insurance Carrier: Cigna Medical Insurance Medical Plan: HDHP w/ HSA Plan $6,350 Deductible Open Access Plus Plan $6,000 Deductible

In-Network: Office Visit Copay - Primary Care

Deductible; then 100% Coinsurance

$25 Copay

Office Visit Copay - Specialist Care

Deductible; then 100% Coinsurance

$50 Copay

Urgent Care Copay

Deductible; then 100% Coinsurance

$75 Copay

Emergency Room Care

Deductible; then 100% Coinsurance

$350 Copay

Preventative Visit Copay

Diagnostic Testing & Blood Work

Deductible; then 100% Coinsurance

Imaging

Deductible; then 100% Coinsurance

Coinsurance

100%

Employee Deductible

$6,350

$6,000

Family Deductible

$6,350

$12,000

Employee Out-of-Pocket Max

$6,350

$7,900

Family Out-of-Pocket Max

$12,700

$15,800

Inpatient Hospital

Deductible; then 100% Coinsurance

Outpatient Hospital or Facility

Deductible; then 100% Coinsurance

Out-of-Network: Coinsurance

70%

Employee Deductible

$10,000

Family Deductible

$10,000

$20,000

Employee Out-of-Pocket Max

$21,550

$23,700

Family Out-of-Pocket Max

$43,100

$47,400

Prescription Drugs: ( 30 Day Supply) Tier 1 - Generic

Deductible; then 100% Coinsurance

$15 Copay

Tier 2 - Preferred

Deductible; then 100% Coinsurance

$30 Copay

Tier 3 - Non-Preferred

Deductible; then 100% Coinsurance

$50 Copay

Employee Bi-Weekly Deduction Employee Only

$71.29 $306.96 $246.08 $395.87

$84.99 $337.46 $274.45 $439.02

Employee + Spouse Employee + Child(ren)

Family

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HSA Coverage

Your eligibility

In order to open and fund an HSA, you must meet the

following requirements: • You are enrolled in Acoms High Deductible Plan (HDHP) • Are not covered under another medical plan such as Medicare, Tricare or a spouse’s medical plan (not an HDHP) which provides similar coverage; and • Cannot be claimed as a dependent on another person’s insurance policy or tax return.

Qualified Health Care Expenses

Each time you have a medical, dental or vision expense you decide if you want to pay with money from your HSA. “Qualified Medical Expenses” are determined by the US Treasury, 213(d) expenses, and detailed in IRS Publication 502. Some examples include but are not limited to:

•

Expenses that apply toward your deductible

2023 IRS Calendar Year Contribution Limit

• • • • • •

Prescription expenses Contact lens fitting

Acom contributes annually to your HSA: EE: $600 / ES: $760 / EC: $780 / FAM: $1020 The amount you may contribute to your HSA is based on your HDHP medical plan’s tier. 2023 If you cover just yourself on the plan: $3,850 If you cover yourself and a spouse or dependents: $7,750 Age 55+ Catch-Up: $1,000

Orthodontia Acupuncture Artificial teeth Eye glasses

Whose Medical Expenses Can You Use Your HSA Funds on?

When You Can Begin Contributing

Generally your:

You may begin funding your HSA when your medical HDHP

•

Legally married spouse. Domestic partners are not covered under the tax code. Permanently and totally disabled dependent of any age. Dependent under the age of 19 at the end of calendar year or a full-time student under the age of 24 at the end of the calendar year who also: Lived with you more than 1/2 the calendar year, and Didn’t provide over 1/2 his/her own support in the calendar year, and Didn’t file a joint tax return, other than to claim a refund

benefits begin.

You are able to contribute as little or as much (up to the IRS limit) as you wish out of each paycheck and this election may be changed at any time throughout the year.

•

When You Cannot Contribute

If you terminate HDHP medical plan coverage (or employment) with Acom, you may no longer contribute to your HSA through Acom payroll deduction. You own the HSA so your balance can be carried over year after year and the funds you contributed always belong to you.

•

Benefits of an HSA

Tax Savings! An HSA provides triple tax savings: (1) tax deductions when you contribute to your account (2) tax-free investment earnings (3) tax-free withdrawals for qualified medical expenses

•

Qualifying relative. See IRS Publication 502 for more information.

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Health Reimbursement Arrangement

Acom offers a Health Reimbursement Arrangement (HRA) that funds a portion of the calendar year deductible for you and your covered family members if you elected the Cigna Copay Plan. The actual deductible on this plan is $6,000 for an individual and $12,000 for family coverage. Under this HRA, the employee responsibility is the first $2,500 and the company will then reimburse up to $3,500 of the remaining calendar year deductible for an individual. Where there are two or more eligible dependents, the HRA will reimburse the second calendar year deductible for the same amount as the first should your dependent(s) meet the second calendar year deductible.

Health Reimbursement Arrangement (HRA) Illustration Employee Only Illustration

Plan Arrangement

Funding $2,500

Employee pays first $2,500

HRA pays next $3,500 to equal $6,000 plan deductible

$3,500

Coinsurance now pays at 100% (except for copays of any type) Employee is liable for $1,900 in copays to equal out-of-pocket max

$6,000 $7,900 $4,400

Employee out-of-pocket maximum equals $4,400

Employee + Dependent(s) Illustration

Plan Arrangement

Funding $5,000 $7,000 $12,000 $15,800 $8,800

Employee pays first $5,000

HRA pays next $7,000 to equal $12,000 plan deductible Coinsurance now pays at 100% (except for copays of any type) Employee is liable for $3,800 in copays to equal out-of-pocket max

Employee out-of-pocket maximum equals $8,800

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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 Sun Life and offers “in and out-of-network” benefits.

Insurance Carrier:

Sun Life Dental Insurance

Plan Type:

Basic

Enhanced

Calendar Year Deductible Calendar Year Maximum

$50 Individual / $150 Family $50 Individual / $150 Family

$1,000

$2,000

Preventive Services

100%

Basic Services Major Services

80% 50%

90% 60%

Orthodontia (dependent children only) Out-of-Network Reimbursement

N / A

$1,000

90th UCR

Employee Bi-Weekly Deduction Employee Only

$6.76

$13.79 $26.57 $37.19 $47.02

Employee + Spouse Employee + Child(ren)

$15.80 $15.54 $22.27

Family

time insured continuously under a dental plan benefits provided for only these services Less than 6 months Preventive Services At least 6 months but less than 12 months Preventive Services and fillings under Basic Services At least 12 months Preventive, Basic, Major and Ortho Services

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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 Sun Life and offers “in and out-of-network” benefits.

To find an in-network provider, visit www.vsp.com/eye-doctor

Insurance Carrier:

Sun Life Vision Insurance

Plan Type:

In-Network

Out-of-Network

Exam Services

$10 $60

up to $30 up to $31 up to $25 up to $50 up to $60 up to $100

Contact Lens Exam Copay Lenses - Single lined Lenses - Bifocal lined Lenses - Trifocal lined Lenses - Lenticular lined

$10 Copay $10 Copay $10 Copay $10 Copay

$150 Retail Allowance; then 20% off remaining balance

Frames

up to $80

Elective Contact Lenses (in place of lenses & frames)

$150 Retail Allowance

up to $128

Medically Necessary Contacts

$10 Copay

up to $210

Frequency: Exam / Lenses / Frames

once every: 12 months / 12 months / 12 months

Employee Bi-Weekly Deduction Employee Only

$4.23 $8.24 $7.64

Employee + Spouse Employee + Child(ren)

Family

$11.65

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Basic Life and AD&D Coverage

Acom provides all Full Time employees with Basic Life and Accidental Death & Dismemberment coverage.

Insurance Carrier:

Sun Life Basic Life Insurance

Basic Life w/ AD&D Eligibility Requirement Life Insurance Benefit

All Full Time Employees

$20,000

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, Acom 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 Sun Life. Rates for the voluntary term life insurance are based on age, and volume, and benefits are subject to applicable age reductions.

Insurance Carrier:

Sun Life Voluntary Life Insurance

Voluntary Life w/ AD&D Eligibility Requirement Employee Benefit Amounts Employee

All Full Time Employees

5x Annual Earnings to $500k in increments of $10k 100% of Employee to $150k in increments of $5k

Spouse

Child(ren)

100% of Employee to $10k

Guarantee Issue Employee

$100k

Spouse Children

$25k $10k

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Disability Coverage

The goal of Acom’s Disability Insurance Plan is to provide you with income replacement should you be unable to work due to a non- work-related illness or injury. The company provides employees with the option to purchase voluntary “Short and Long Term Disability” income benefits. Both the short term and long term disability coverages are offered through Sun Life. Rates will be automatically calculated and shown in Employee Navigator during enrollment process.

Insurance Carrier:

Sun Life Short-Term Disability

Plan Type:

Voluntary

Plan Options

Basic

Enhanced

Benefit Percentage

60% of Weekly Earnings

Maximum Weekly Benefit

$1,500

Guaranteed Issue Amount

$1,500

Injury Elimination Period Sickness Elimination Period

14 days 14 days

0 days 7 days

Benefit Duration

11 weeks

13 weeks

3 month pre-existing / 12 month waiting period

Pre-existing Condition Limitation

Insurance Carrier:

Sun Life Long-Term Disability

Plan Type:

Employer Paid

Employee Classification

Class 2 - All Eligible Employees

Benefit Percentage

60%

Maximum Monthly Benefit

$10,000

Guaranteed Issue Amount

$10,000

Elimination Period

90 days 2 Years SSNRA Included

Own Occupation Coverage

Benefit Duration

Partial Disability Benefit

Mental & Nervous Limitation Drug & Alcohol Limitation Pre-Existing Condition Limitation

24 Months per Lifetime 24 Months per Lifetime

3 month pre-existing / 12 month waiting period

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401k Retirement Plan

Acom offers a retirement plan hosted by Voya to eligible employees. You are eligible for this benefit on the first of the month following 60 days of employment. Employees who are eligible to enroll will do so electronically through the Voya website with the information provided below: Initial Enrollment • VoyaRetirementPlans.com/EnrollmentCenter • Plan Number: 817598 • Verification Number: 81759899 Employer Contributions Acom matches 50% of the employee’s contribution up to 6% for a maximum match of 3% of compensation. The employer contribution is discretionary and can be changed at any time. Employees Currently Contributing to the 401k If you are currently contributing to your 401k and would like to make changes to your personal information, beneficiaries, or elections, please contact the Human Resources Department for instructions. If you would like to review your contributions or account information, please visit the website at www.voya.com. You will then use your username and password to access your account. Vesting See Summary Plan Description (SPD)

Additional Questions? Call the Plan Administrator Angela Demas at 703-750-6750 ext.102

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EAP

The Employee Assistance Program (EAP) is a benefit program in which we provide employees and their family members up to six free counseling sessions. This information is kept completely confidential. This program is intended to help employees deal with person problems that may adversely impact their work performance, health, and well-being. Through the EAP, individual, family, and group counseling is available to employees and dependents. Regardless of your location, our EAP will find a counselor for you from an extensive network of providers.

Some reasons employees seek counseling: • Depression • Anxiety • Stress • Grief & Loss • Trauma

To schedule an appointment, call an intake professional at (706) 649-6500. You will have to provide the name of your employer and let them know you are utilizing your EAP benefit.

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CHOOSE A PLAN WITH CONFIDENCE Cigna One Guide service can help. We understand how confusing and overwhelming it can be to review your health plan options. And we want to help by providing the resources you need to make a decision with confidence. That’s why Cigna One Guide® service is available to you now . Call a Cigna One Guide representative during preenrollment to get personalized, useful guidance. Your personal guide will help you: › Easily understand the basics of health coverage › Identify the types of health plans available to you › Check if your doctors are in-network to help you avoid unnecessary costs › Get answers to any other questions you may have about the plans or provider networks available to you The best part is, during the enrollment period, your personal guide is just a call away. Don’t wait until the last minute to enroll. Call 888.806.5094 to speak with a Cigna One Guide representative today.

After enrollment, the support continues for Cigna customers. Cigna One Guide service will be there to guide you through the complexities of the health care system, and help you avoid costly missteps. Our goal is a simpler health care journey for you and your family. Cigna One Guide service provides personalized assistance to help you: › Resolve health care issues › Save time and money › Get the most out of your plan › Find hospitals and health care providers in your plan’s network › Get cost estimates and avoid surprise expenses › Understand your bills Access Cigna One Guide – after enrollment – in the way that’s most convenient for you: myCigna.com or the myCigna® app Live chat Phone

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates. Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health benefit plans contain exclusions and limitations. For costs and complete details of coverage, see your plan documents. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company (CHLIC), Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc. (CHC-TN), and Cigna HealthCare of Texas, Inc. Policy forms: OK - HP-APP-1 et al., OR - HP-POL38 02-13, TN - HP-POL43/HC-CER1V1 et al. (CHLIC); GSA-COVER, et al. (CHC-TN). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. All pictures are used for illustrative purposes only. 901994 b 06/20 © 2020 Cigna. Some content provided under license.

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MADE EASY BENEFITS EDUCATION

With Cigna’s Virtual Benefits Education Website, your employees can review benefits options online, at their convenience. While smaller businesses* may have different needs, they all have one thing in common. They’re powered by busy, productive employees. How can you get everyone on the same page when it comes to open enrollment? Simple. With Cigna’s Virtual Benefits Education Website , your employees will have access to details about the benefits being offered to them. Advantages for you. › We’ll personalize your benefits education website to match the specific Cigna administered benefits your company will offer, which may include medical, dental and vision. › You can save time and increase productivity by simply sharing the website link so employees can review the benefit options you’re offering. Now your employees can: › Conveniently review and compare Cigna-administered plan options you have chosen for them. › Watch informative videos (sample topics: “How Health Savings Accounts work” and “How to get prescriptions filled”). › Have “Virtual Assistants” guide them through the website and help explain the different benefits being offered. › Get support anytime by calling Cigna’s toll-free line. Reach out to your Cigna representative for more information

› More convenient than

in-person open enrollment meetings

› Tailored to the specific Cigna-administered plan options you select › Employees can review benefit options 24/7, on their computer, tablet, or smart phone › Includes medical, dental, and vision

[YOUR COMPANY NAME HERE] has chosen Cigna for your healthcare benefits. This website will help you understand your benefits and other important information you should know as you get ready to enroll. You can also learn about Cigna programs and who to call if you need additional assistance. Click on the video to meet Bill and Jill – virtual benefit assistants who can help you navigate.

Your customized website will include the name of your company.

Offered by: Cigna Health and Life Insurance Company or its affiliates. *In most states, Cigna offers group insurance coverage to employers with more than 50 full-time employees, as well as administrative services for self-funded plans with as few as 25 full-time employees. Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health benefit plans contain exclusions and limitations. For costs and details of coverage, contact a Cigna representative. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. CHLIC policy forms: Medical: OK - HP-APP-1 et al., OR - HP-POL38 02-13, TN - HP-POL43/HC-CER1V1 et al. (CHLIC); GSA-COVER, et al. (CHC-TN); Dental: OK – HP-POL99/HP-POL-388, POL115; OR - HP-POL68/HP-POL352, HP-POL121 04-10; TN – HP-POL69/HC-CER2V1/HP-POL389, et al., HP-POL134/HC-CER17V1 et al. 946124 05/20 © 2020 Cigna. Some content provided under license.

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GET MORE

From your health benefits.

Understanding the benefits your employer is providing can help you save time and money when seeking care. Good news – your employer has chosen Cigna to be your health plan partner. With Cigna you have access to a wealth of resources to ensure you get the right care at the right time and for the lowest cost under your plan. To help you get the most out of your health plan, you’ll first need to understand how to access all of the great resources available to you. That’s where the Cigna Virtual Benefits Education Website comes in. The Virtual Benefits Education Website includes: › Videos on getting the most from your plan, understanding your pharmacy benefits, and determining which virtual and digital care options you can access. This section also includes a handy dictionary to help you understand some of the most common health care terms. › Details on the benefits and coverage including what it will cost you to receive care. › Information on resources and programs Cigna offers, including how to access our One Guide® concierge service. Reach out to your Human Resources department for more information

› Informative videos › Virtual assistants guide you through the website. › Support anytime by calling Cigna’s toll-free line

Offered by: Cigna Health and Life Insurance Company or its affiliates. Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health benefit plans contain exclusions and limitations. For costs and details of coverage, contact a Cigna representative. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. CHLIC policy forms: Medical: OK - HP-APP-1 et al., OR - HP-POL38 02-13, TN - HP-POL43/HC-CER1V1 et al. (CHLIC); GSA-COVER, et al. (CHC-TN); Dental: OK – HP-POL99/HP-POL-388, POL115; OR - HP-POL68/HP-POL352, HP-POL121 04-10; TN – HP-POL69/HC-CER2V1/HP-POL389, et al., HP-POL134/HC-CER17V1 et al. 947596 a 12/20 © 2020 Cigna. Some content provided under license.

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M ember C laims A dvocate

Employee Benefit Assistants You Can Count on

Acom 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 Resa Carter - rcarter@knightrawls.com (706) 323-1600

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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? Cigna contracts with a wide range of doctors, as well as specialists, hospitals, labs, radiology facilities and pharmacies. These are the providers that are considered “in your network”. Specifically, each of these providers has agreed to accept Cigna’s contracted rate for your medical care and services rendered. The contracted rate includes both Cigna’s share of the cost, and the member’s. Your share may be in the form of a co-payment, deductible, or co-insurance. For example, Cigna’s contracted rate for a primary care visit might be $125. The Plan has a $25 co-payment for the visit; the member will pay $25 of the cost and your insurance plan will pay the remaining $100. An “out-of-network” provider is a medical doctor or facility that is not in contract with Cigna. This means that the provider may charge members higher rates for medical services and care, outside of the standard “in-network” rates. For example, a out-of- network provider may charge $200 for a primary care visit. Cigna may pay an adjustment of an out-of-network benefit of $80 dollars to the provider, so the member may be balance-billed for the remaining $120 cost of the visit. When can I change my beneficiary information for my Basic Life Insurance? Any time! It is important that all beneficiary information be kept up-to-date. You may need to change it after a marriage, divorce, or birth of a child. You can go into Employee Navigator anytime to update your beneficiary.

Term

Definition

Network Office Visit (PCP)

The “per visit” co-pay cost for a primary care or standard network doctor.

Specialist Office Visit

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.

Network Deductible

Co-Insurance

Network Out-of-Pocket Maximum (OOP)

Prescription Drug Tiers and Monthly Co-Pays

19 Acom Integrated Solutions 2023 Enrollment Guide

Legal Notices

Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free or Low-Cost Health Coverage to Children and Families If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www. healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www. insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2021. Contact your State for more information on eligibility –

ALABAMA - Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447 ALASKA - Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: Customer Service@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default. aspx ARKANSAS - Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447) COLORADO - Medicaid Website: http://www.colorado.gov/hcpf Customer Contact Center: 1-800-221-3943 KANSAS - Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512 KENTUCKY - Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570 LOUSIANA - Medicaid Website: http://dhh.louisiana.gov/index.cfm/ subhome/l/n/331 Phone: 1-888-695-2447

FLORIDA - Medicaid Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268 GEORGIA - Medicaid Website: http://dch.georgia.gov/medicaid - click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507 INDIANA - Medicaid Healthy Indiana Plan for Low-Income Adults 19-64 Website: http://www.hip.in.gov Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone: 1-800-403-0864 IOWA - Medicaid Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 MAINE - Medicaid Website: http://maine.gov/dhhs/ofi/public-assistance/ index.html Phone: 1-800-442-6003 TTY: Maine relay 711

MASSACHUSETTS - Medicaid and CHIP Website: http://www.mass.gov/MassHealth

Phone: 1-800-462-1120 MINNESOTA - Medicaid Website: http://mn.gov/dhs/ma/ Phone: 1-800-657-3739

20 Acom Integrated Solutions 2023 Enrollment Guide

Legal Notices

MISSOURI - Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

RHODE ISLAND - Medicaid Website: http://www.eohhs.ri.gov/ Phone: 401-462-5300 SOUTH CAROLINA - Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 SOUTH DAKOTA - Medicaid

Phone: 573-751-2005 MONTANA - Medicaid Website: http://dphhs.mt.gov/ MontanaHealthcarePrograms/HIPP

Phone: 1-800-694-3084 NEBRASKA - Medicaid

Website: http://www.dhhs.ne.gov/Children_Family_ Services/AccessNebraska/Pages/accessnebraska_ index.aspx Phone: 1-855-632-7633 NEVADA - Medicaid Website: http://dwss.nv.gov/ Phone: 1-800-992-0900 NEW HAMPSHIRE - Medicaid Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 NEW JERSEY - Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/ medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 NEW YORK - Medicaid Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA - Medicaid Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100 NORTH DAKOTA - Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825 OKLAHOMA - Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 OREGON - Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075 PENNSYLVANIA - Medicaid Website: http://www.dhs.pa.gov/hipp Phone: 1-800-692-7462

Website: http://dss.sd.gov Phone: 1-888-828-0059 TEXAS - Medicaid Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 UTAH - Medicaid and CHIP Medicaid Website: http://health.utah.gov/medicaid CHIP Website: http://health.utah.gov/chip

Phone: 1-877-543-7669 VERMONT - Medicaid Website: http://www.greenmountaincare.org Phone: 1-800-250-8427 VIRGINIA - Medicaid and CHIP Medicaid & CHIP Website: http://www.coverva.org/programs_premi- um_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282 WASHINGTON - Medicaid Website: http://www.hca.wa.gov/free-or-low-costhealth-care/pro- gram-administration/premiumpayment- program Phone: 1-800-562-3022 ext. 15473 WEST VIRGINIA - Medicaid Website: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/ default.aspx Phone: 1-877-598-5820, HMS Third Party Liability WISCONSIN - Medicaid and CHIP Website: http://www.dhs.wisconsin.gov/publications/p1/p10095.pdf

Phone: 1-800-362-3002 WYOMING - Medicaid Website: http://wyequalitycare.acs-inc.com/ Phone: 307-777-7531

To see if any more States have added a premium assistance program since January 31, 2021, or for more information on special enrollment rights, you can contact either:

U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/ebsa 1-866-444-EBSA (3272)

U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565

21 Acom Integrated Solutions 2023 Enrollment Guide

Legal Notices

Important Notices about Medical Coverage

HIPPA Special Enrollment Rights

These benefits will be provided subject to the same deductibles and co-insurance applicable to other medical and surgical benefits provided under this plan. Our plan complies with these requirements. Benefits for these items generally are compatible to those provided under our plan for similar types of medical services and supplies. Of course, the extent to which any of these items is appropriate following mastectomy is a matter to be determined by consultation between the attending physician and the patient. Our plan neither imposes penalties (for example, reducing or limiting reimbursements) nor provides incentives to induce attending providers to provide care inconsistent with these requirements. If you would like more information on WHCRA benefits, call Yates at (706)323-1600.

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself or your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must enroll within 30 days after the marriage, birth, adoption, or placement for adoption. Effective April 1, 2009 special enrollment rights also exist in the following circumstances: • If you or your dependents experience a loss of eligibility for Medicaid or your State Children’s Health Insurance Program (SCHIP) coverage; or • If you or your dependents become eligible for premium assistance under an optional state of Medicaid or SCHIP program that would pay the employee’s portion of the health insurance premium. NOTE: In the two above listed circumstances only, you or your dependents will have sixty (60) days to request special enrollment in the group health plan coverage. An individual must request this special enrollment within sixty (60) days of the loss of coverage described at bullet one, and within sixty (60) days of when eligibility is determined as described in bullet two. Women’s Health and Cancer Rights Act of 1998 Annual Notice If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for all stages of reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses; and treatment of physical complications of the mastectomy, including lymphedema.

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, not withstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa. opr@dol.gov and reference the OMB Control Number 1210- 0137.

22 Acom Integrated Solutions 2023 Enrollment Guide

Medicare Part D

Medicare Part D Notice of Creditable Coverage

When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Acom 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 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 Acom changes. You may also request a copy of this notice at any time. More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Medicare Part D Notice of Creditable Coverage, cont. Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help. Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity. gov , or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium.

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Acom 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. Acom has determined that the prescription drug coverage offered by Cigna plans are on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join a Medicare Drug Plan ? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens to Your Current Coverage if You Join a Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Acom 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 Acom coverage, be aware that you and your dependents may or may not be able to get this coverage back.

23 Acom Integrated Solutions 2023 Enrollment Guide

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