Campbell & Co 2024 Benefit Guide

BENEFITS GUIDE

An overview of the wide array of benefits provided by Campbell & Company, to help you enjoy increased well-being and financial security

PREPARED BY BRIO BENEFITS FOR CAMPBELL & COMPANY

TABLE OF CONTENTS

▪

Introduction

▪ Overview of Benefits Programs

▪

Medical Benefits

▪ Health Savings Account (HSA)

▪

Dental Benefits

▪

Vision Benefits

▪

Life Insurance

▪

Disability Insurance

▪ Flexible Spending Account (FSA)

▪

HealthJoy

▪

Online Enrollment

▪

Legal Notices

▪

Legal Notices - COBRA

▪

Legal Notices - FMLA

▪

Notes Page

CAMPBELL & COMPANY BENEFITS GUIDE

TABLE OF CONTENTS I

WE’VE GOT YOU COVERED

Campbell & Company is proud to offer a comprehensive benefits package for you and your family. This program is designed to take great care of you when you need it. Make sure to explore your options to help you make the selections that best meet your needs.

INTRO & OVERVIEW

INTRODUCTION

For the 2024 plan year, Campbell & Company has worked hard to offer a competitive total rewards package that includes valuable and competitive benefits plans. These programs reflect our commitment to keeping our staff healthy and secure. We understand that your situation is unique, and Campbell & Company is offering an overall benefits package that can be shaped and molded by you to fit your needs. As an employee of Campbell & Company enjoying your work and making valuable contributions to business are equally vital. The health, satisfaction and security of you and your family are important, not only to your well-being, but ultimately, in terms of achieving the goals of our organization. This benefits booklet is a summary description of your Campbell & Company benefit plans. If there is a discrepancy between these summaries and the written legal plan documents, the plan documents shall prevail. This booklet and plan summaries do not constitute a contract of employment. We hope this benefits booklet, along with our additional communication and decision-making tools, will help you make the best health care choices for you and your family.

CAMPBELL & COMPANY BENEFITS GUIDE

INTRODUCTION I

OVERVIEW OF BENEFITS

CHANGES AND QUALIFYING EVENTS

WHEN COVERAGE BEGINS AND ENDS

Your coverage under the benefits plans will end if you no longer meet the eligibility requirements, your contributions are discontinued or the Group Insurance Policy is terminated.

QUALIFYING EVENTS

• Eligible employees may enroll or make changes to their benefits elections during the annual open enrollment period. As with most benefits, once you elect an option you are bound to that choice for the entire plan year unless you experience a “Qualifying Event” . These may include, but are not limited to: • Changes in employment status • Changes in legal marital status • Changes in number of dependents • Taking an unpaid leave of absence • Dependent satisfies or ceases to satisfy eligibility requirement • Family Medical Leave Act (FMLA) leave. • A COBRA-qualifying event • Entitlement to Medicare or Medicaid • A change in the place of residence of the employee, resulting in the current carrier not being available

CAMPBELL & COMPANY BENEFITS GUIDE

OVERVIEW I

MEDICAL

MEDICAL PLAN

SUMMARY OF COVERAGE

Plan 1 (HSA)

Plan 2 (HSA)

Plan 3 (PPO)

Plan 4 (PPO)

In Network

Deductible (Single / Family)

$1,600 / $3,200 $2,250 / $4,500

$500 / $1,000 $7,350 / $14,700

Out of Pocket Maximum (Single / Family)

$3,450 / $6,900 $3,450 / $6,900

$3,500 / $7,000 $8,150 / $16,300

Coinsurance

N/A

Preventive Care

100% Covered 100% Covered 100% Covered 100% Covered

Primary Care

Deductible + $25

$25 (no deductible)

$40 (no deductible)

Specialist Visit

Deductible + $75

$75 (no deductible)

Deductible + $80

Inpatient Hospital

Deductible + $250 Deductible + $250 Deductible + 0% Deductible + $500

Emergency Room (copay waived if admitted)

Deductible + $500 Deductible + $500

$500 Copay

Deductible + $500

Rx Copays (Retail)

$10 / $50 / $80

$10 / $50 / $80 $10 / $45 /0 $75 $10 / $50 / $80

Rx Copays (Mail Order)

2X Retail

Out of Network

Deductible

$10,000 / $30,000 $10,000 / $30,000 $2,000 / $6,000 $22,060 / $66,150

Coinsurance

50%

Max Out of Pocket

2x Deductible 2x Deductible 5x Deductible $42,050/$126,150

Employee Contributions (Monthly)

Coverage

Plan 1

Plan 2

Plan 3

Plan 4

Employee Only

$97.50

$61.08

$243.76

$17.53

Employee + Spouse

$411.66

$308.01

$835.52

$37.12

Employee + Child(ren)

$327.74

$245.41

$663.57

$29.14

Employee + Family

$566.37

$423.41

$1,152.50

$50.36

CAMPBELL & COMPANY BENEFITS GUIDE

MEDICAL PLAN I

* For illustrative purposes only. Please refer to your plan documents for all plan details

MEDICAL PLAN

KEY TERMS TO REMEMBER

ANNUAL DEDUCTIBLE

OUT-OF POCKET MAXIMUM

The amount you have to pay each year before the plan starts paying a portion of medical expenses. All family members’ expenses that count toward a health plan deductible accumulate together in the aggregate; however, each person also has a limit on their own individual accumulated expenses (the amount varies by plan).

This is the total amount you can pay out of pocket each calendar year before the plan pays 100 percent of covered expenses for the rest of the calendar year. Most expenses that meet provider network requirements count toward the annual out-of-pocket maximum, including expenses paid to the annual deductible*, copays and coinsurance *Except for Grandfathered medical plans

COPAYS AND COINSURANCE

PLAN TYPES

• PPO – A network of doctors, hospitals, and other health care providers • HDHP/HSA – A plan that has higher annual deductibles in exchange for lower premiums.

These expenses are your share of cost paid for covered health care services. Copays are a fixed dollar amount, and are usually due at the time you receive care. Coinsurance is your share of the allowed amount charged for a service, and is generally billed to you after the health insurance company reconciles the bill with the providers.

CAMPBELL & COMPANY BENEFITS GUIDE

MEDICAL PLAN I

MEDICAL PLAN

Understanding the full value of covered benefits allows you to take responsibility for maintaining good health and incorporating healthy habits into your lifestyle. Some examples include getting regular physical examinations, mammograms and immunizations. Through the plans offered by Campbell & Company , all covered individuals and family members are eligible to receive routine wellness services like these, at no cost; all copays, coinsurance, and deductibles are waived.

WHICH PREVENTIVE CARE SERVICES ARE COVERED?

The US Preventive Services Task Force maintains a regular list of recommended services that all Affordable Care Act (i.e. Health Care Reform) compliant insurance plans should cover at 100% for in-network providers. Below is a list of common services that are included in the plans offered this year:

“AN OUNCE OF PREVENTION IS WORTH A POUND OF CURE”

• Routine Physical Exam • Well Baby and Child Care • Well Woman Visits • Immunizations • Routine Bone Density Test • Routine Breast Exam • Routine Gynecological Exam • Screening for Gestational Diabetes • Obesity Screening and Counseling • Routine Digital Rectal Exam • Routine Colonoscopy

• Routine Colorectal Cancer Screening • Routine Prostate Test

• Routine Lab Procedures • Routine Mammograms • Routine Pap Smear • Smoking Cessation Programs

• Health Education/Counseling Services • Health Counseling for STDs and HIV • Testing for HPV and HIV • Screening and Counseling for Domestic Violence

CAMPBELL & COMPANY BENEFITS GUIDE

MEDICAL PLAN I

MEDICAL & PHARMACY REMINDERS

Meritain administers your medical plan. They handle the following: • Medical Claims • ID Cards • Service Issues Your network will be the Aetna Choice POS II network • Meritain uses Aetna’s network, BUT your provider must send claims to Meritain at the address on the back of your ID card to avoid delays in processing • To find an in-network provider, visit http://www.aetna.com/docfind/custom/mymeritain/

Important Note for Mail Order and Specialty drugs:

• If you wish to receive your prescription(s) by mail, you will need to fill them through Optum Mail Order Pharmacy . Call Capital Rx at (888) 832-2779 and follow the prompts for “medications delivered to your home” or ask your doctor to send an electronic prescription to Optum Home Delivery. • All specialty medications will need to be filled through Optum Specialty Pharmacy . You can contact Capital Rx Customer Care at (888) 832- 2779 and follow the prompts to “specialty pharmacy” or ask your doctor to send an electronic prescription to Optum Specialty Pharmacy. • You can also go online to www.optum.com/pharmacy-services.html to get started

CAMPBELL & COMPANY BENEFITS GUIDE

MEDICAL PLAN I

HEALTH SAVINGS ACCOUNT (HSA)

A health savings account (HSA) is a health care account and savings account in one. The main purpose of this account is to offset the cost of a qualifying high deductible health plan (HDHP) and provide savings for your out-of-pocket eligible health care expenses – those you and your tax dependents may have now, in the future, and during your retirement. BY ENROLLING IN THE HDHP MEDICAL PLAN, YOU COULD BE ELIGIBLE TO SAVE MONEY ON A PRE-TAX BASIS BY CONTIRBUTING TO A HEALTH SAVINGS ACCOUNT TO PAY FOR FUTURE MEDICAL EXPENSES This is a “portable” account. You own your HSA! It’s included in your employee benefits package, but after you set up your account, it’s yours to keep, even if you change jobs or retire. Funds roll over year to year and accumulate over time. Once your HSA is established, money is contributed to your account by you, Campbell & Company or friends and family, and you can then use your HSA dollars tax-free to pay for eligible health care expenses. You save money on expenses you’re already paying for, like doctors’ office visits, prescription drugs, and much more. Best of all, you decide how and when to use your HSA dollars.

WHY IS IT A GOOD IDEA TO HAVE AN HSA?

Tax-free earnings Your interest and any investment earnings grow tax-free

Tax-free deposits The money you contribute to your HSA isn’t taxed (up to the IRS annual limit)

Tax-free withdrawals Money used toward eligible health care expenses isn’t taxed – now or in the future

Setting aside pre-tax dollars into your HSA you pay fewer taxes and increase your take- home pay by your tax savings. You save money on eligible expenses that you are paying for out of your pocket. The amount you save depends on your tax bracket. For example, if you are in the 30 percent tax bracket, you can save $30 on every $100 spent on eligible health care expenses.

2024 IRS Maximum Contribution Limits for HSA

Employee Only Enrollment

$4,150

Family Enrollment

$8,300

Employees Age 55 and up

$1,000 additional “catch - up” contribution

CAMPBELL & COMPANY BENEFITS GUIDE

HSA I

DENTAL

DENTAL PLANS

SUMMARY OF COVERAGE

Key Features

Cigna Dental

In Network

Out of Network

Annual Deductible Individual | Family

$50 | $150

Calendar Year Plan Max

$1,500 per person

Preventive Care Benefits

No Charge

Basic Services

You pay 0%

You pay 20%

Major Services

You pay 40%

You pay 50%

Orthodontia

Not Covered

Dental Costs included in Meritain Medical Costs

CAMPBELL & COMPANY BENEFITS GUIDE

DENTAL PLAN I

* For illustrative purposes only. Please refer to your plan documents for all plan details

VISION

VISION PLAN

SUMMARY OF COVERAGE

Vision Benefit

In Network

Frequency

Eye Exam

$10 copay

Once every 12 months

Lenses Single Bifocal Trifocal

$25 Copay

Once every 12 months

Frames

Plan pays up to $150

Once every 24 months

Contacts

Elective

Plan pays up to $150

Once every 12 months

Medically Necessary

Covered in full after $25 Copay

Vision Costs included in Meritain Medical Costs

CAMPBELL & COMPANY BENEFITS GUIDE

VISION PLAN I

* For illustrative purposes only. Please refer to your plan documents for all plan details

LIFE

SUMMARY OF COVERAGE

Basic Life / AD&D

Plan Features

Basic Life & AD&D

Employee Benefit Amount

Flat $50,000

The following shows how much benefits are reduced at certain ages:

Age Band

Benefit Reduction

65%

50%

CAMPBELL & COMPANY BENEFITS GUIDE

LIFE INSURANCE I

* For illustrative purposes only. Please refer to your plan documents for all plan details

DISABILITY

SUMMARY OF COVERAGE

NEW! Short Term Disability

Plan Features

Short Term Disability

60% of Weekly Earnings

Employee Benefit Amount

$1,500/week

Maximum Benefit Amount

Elimination Period (Accident & Sickness)

7 days

Up to 25 weeks

Benefit Duration

Long-Term Disability

Plan Features

Long Term Disability

60% of Monthly Earnings

Employee Benefit Amount

$10,000/month

Maximum Benefit Amount

180 days

Elimination Period (Accident)

Social Security Normal Retirement Age

Benefit Duration

CAMPBELL & COMPANY BENEFITS GUIDE

DISABILITY – SHORT TERM I

* For illustrative purposes only. Please refer to your plan documents for all plan details

FLEXIBLE SPENDING ACCOUNTS (FSA)

Campbell & Company is offering a Flexible Spending Account (FSA) for 2024. This is how an FSA works:

• You set aside up to $3,200 annually for your FSA from your paycheck before taxes are taken out. • Then use your pre-tax FSA funds throughout the plan year to pay for eligible health care or dependent care expenses. • You save money on expenses you’re already paying for. • This account is “use it or lose it” meaning all unspent funds are forfeited and do not rollover.

DEPENDENT CARE FSA ELIGIBLE EXPENSES

HEALTH FSA ELIGIBLE EXPENSES

• Medical expenses: co-pays, co-insurance, and deductibles • Dental expenses: exams, cleanings, X-rays, and braces • Vision expenses: exams, contact lenses and supplies, eyeglasses, and laser eye surgery • Professional services: physical therapy,

• Care for your child who is under age 13 • Before and after-school care • Baby sitting and nanny expenses • Day care, nursery school, and preschool • Summer day camp • Care for a relative who is physically or mentally incapable of self-care and lives in your home

chiropractor, and acupuncture • Prescription drugs and insulin

• Over-the-counter health care items: bandages, pregnancy test kits, blood pressure monitors, etc.

COMMUTER ACCOUNTS ▪

Flex Transit is a monthly election. Employees can change their pre-tax deductions at anytime during the plan year, based on their current month’s expenses. Unused funds roll over into the next year provided they stay enrolled in the plan. ▪ Save on your commute by contributing pretax dollars towards transit expenses. These plans are administered by HealthEquity, and funds can be accessed via your FSA card.

The 2024 monthly maximum contribution to Transit and Parking FSA accounts is $315. Totaling $630/per month for both .

CAMPBELL & COMPANY BENEFITS GUIDE

FSA I

* For illustrative purposes only. Please refer to your plan documents for all plan details

TELEMEDICINE

HealthJoy A Better Employee Benefits Experience

BENEFITS WALLET

HEALTHCARE CONCIERGE

RX SAVINGS REVIEW

APPOINTMENT BOOKING

HSA / FSA SUPPORT

PROVIDER RECS

With 24/7 access to our dedicated healthcare concierge team, visits, and care navigation tools, you never have to walk alone. HealthJoy helps you locate in-network doctors, find extra savings on your prescriptions, and navigate your benefits. Our mobile app and dedicated member support team are always on hand to help make it easier to stay healthy and well. HealthJoy is the virtual access point for all your healthcare navigation and employee benefits needs. We’re provided free by your employer to help understand and make the most of your benefits. We connect you and your family with the right benefits at the right moment in your care journey, saving you time, money, and frustration.

HealthJoy is completely free for ALL EMPLOYEES

Chat with HealthJoy today by logging into the HealthJoy app or call (877) 500-3212

CAMPBELL & COMPANY BENEFITS GUIDE

TELEMEDICINE

ENROLLMENT

EASE – ENROLLMENT OVERVIEW

CAMPBELL & COMPANY BENEFITS GUIDE

ONLINE ENROLLMENT

LEGAL NOTICES

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that addresses the privacy and security of certain individually identifiable health information, called protected health information (or PHI). You have certain rights with respect to your PHI, including a right to see or get a copy of your health and claims records and other health information maintained by a health plan or carrier. For a copy of the Notice of Privacy Practices, describing how your PHI may be used and disclosed and how you get access to the information, contact Human Resources.

Women’s Health and Cancer Rights Act Enrollment Notice

If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Woman’s Health and Cance r Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

1. All stages of reconstruction of the breast on which mastectomy was performed. 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses. 3. Treatment of physical complications of the mastectomy, including lymphedema.

These will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this benefits plan.

Newborns’ and Mothers’ Health Protection Act Disclosure

Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Patient Protection Notice

Your carrier generally may require the designation of a primary care provider. You have the right to designate any primary care provider who participates in your network and who is available to accept you or your family members. Until you make this designation, your carrier may designate one for you. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the plan administrator. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from your carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in your network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the plan administrator.

CAMPBELL & COMPANY BENEFITS GUIDE

LEGAL NOTICES

HIPAA Special Enrollment Notice

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request en rollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. If you or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or b ecome eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must request enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistance subsidy. To request special enrollment or to obtain more information about the plan's special enrollment provisions, contact the plan administrator.

CAMPBELL & COMPANY BENEFITS GUIDE

LEGAL NOTICES

Premium Assistance Under Medicaid and t he Children’s Health Insurance Program (CH IP)

If you or your children are eligible for Medicaid or CHIP 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” o pportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2023. Contact your State for more information on eligibility –

ALABAMA-Medicaid

CALIFORNIA-Medicaid

Website: http://myalhipp.com/ Phone: 1-855-692-5447

Website: Health Insurance Premium Payment (HIPP) Program

http://dhcs.ca.gov/hipp Phone: 916-445-8322 Fax: 916-440-5676 Email: hipp@dhcs.ca.gov

ALASKA-Medicaid

COLORADO-Health First Colorado (Colorado’s Medicaid

Program)&ChildHealth Plan Plus(CHP+)

The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/State Relay 711 CHP+: https://hcpf.colorado.gov/child-health-plan-plus CHP+ Customer Service: 1-800-359-1991/State Relay 711 Health Insurance Buy-In Program (HIBI): https://www.mycohibi.com/ HIBI Customer Service: 1-855-692-6442

ARKANSAS-Medicaid

FLORIDA-Medicaid

Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery. c om/hipp/index.html Phone: 1-877-357-3268

Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

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LEGAL NOTICES

GEORGIA-Medicaid

MAINE-Medicaid

GA HIPP Website: https://medicaid.georgia.gov/health- insurance-premium-payment-program-hipp Phone: 678-564-1162, Press 1 GA CHIPRA Website: https://medicaid.georgia.gov/programs/third-party- liability/childrens- health-insurance-program-reauthorization- act-2009-chipra Phone: (678) 564-1162, Press 2

Enrollment Website: https://www.mymaineconnection.gov/benefits/s/?language= en_US Phone: 1-800-442-6003 TTY: Maine relay 711

Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms

Phone: -800-977-6740. TTY: Maine relay 711

INDIANA-Medicaid

MASSACHUSETTS-Medicaid and CHIP

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: https://www.in.gov/medicaid/ Phone 1-800-457-4584

Website: https://www.mass.gov/masshealth/pa Phone: 1-800-862-4840 TTY: 711 Email: masspremassistance@accenture.com

IOWA-Medicaid and CHIP (Hawki)

MINNESOTA-Medicaid

Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563 HIPP Website: https://dhs.iowa.gov/ime/members/medicaid-a-to- z/hipp HIPP Phone: 1-888-346-9562

Website: https://mn.gov/dhs/people-we-serve/children-and- families/health- care/health-care-programs/programs-and- services/other- insurance.jsp Phone: 1-800-657-3739

KANSAS-Medicaid

MISSOURI-Medicaid

Website: https://www.kancare.ks.gov/ Phone: 1-800-792-4884 HIPP Phone: 1-800-967-4660

Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

KENTUCKY-Medicaid

MONTANA-Medicaid

Kentucky Integrated Health Insurance Premium Payment Program (KI- HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov/agencies/dms

Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084 Email: HHSHIPPProgram@mt.gov

LOUISIANA-Medicaid

NEBRASKA-Medicaid

Website: dhh.louisiana.gov/index.cfm/subhome/1/n/331 or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618- 5488 (LaHIPP)

Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178

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LEGAL NOTICES

NEVADA-Medicaid

SOUTH CAROLINA-Medicaid

Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900

Website: https://www.scdhhs.gov Phone: 1-888-549-0820

NEW HAMPSHIRE-Medicaid

SOUTH DAKOTA-Medicaid

Website: https://www.dhhs.nh.gov/programs-services/medicaid/health- insurance-premium-program Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext. 5218

Website: http://dss.sd.gov Phone: 1-888-828-0059

NEW JERSEY-Medicaid and CHIP

TEXAS-Medicaid

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

Website: Health Insurance Premium Payment (HIPP) Program | Texas Health and Human Services Phone: 1-800-440-0493

NEW YORK-Medicaid

UTAH-Medicaid and CHIP

Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

NORTH CAROLINA-Medicaid

VERMONT-Medicaid

Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100

Website:Health Insurance Premium Payment (HIPP) Program | Department of Vermont Health Access Phone: 1-800-250-8427

NORTH DAKOTA-Medicaid

VIRGINIA-Medicaid and CHIP

Website: https://www.hhs.nd.gov/healthcare Phone: 1-844-854-4825

Website: https://coverva.dmas.virginia.gov/learn/premium- assistance/famis-select https://coverva.dmas.virginia.gov/learn/premium-assistance/health- insurance-premium-payment-hipp-programs Medicaid/CHIP Phone: 1-800-432-5924

OKLAHOMA-Medicaid and CHIP

WASHINGTON-Medicaid

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022

OREGON-Medicaid

WEST VIRGINIA-Medicaid and CHIP

Website: http://healthcare.oregon.gov/Pages/index.aspx Phone: 1-800-699-9075

Website: https://dhhr.wv.gov/bms/ http://mywvhipp.com/ Medicaid Phone: 304-558-1700 CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

PENNSYLVANIA-Medicaid and CHIP

WISCONSIN-Medicaid and CHIP

Website: https://www.dhs.pa.gov/Services/Assistance/Pages/HIPP- Program.aspx Phone: 1-800-692-7462 CHIP Website: Children's Health Insurance Program (CHIP) (pa.gov) CHIP Phone: 1-800-986-KIDS (5437)

Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002

RHODE ISLAND-Medicaid and CHIP

WYOMING-Medicaid

Website: https://health.wyo.gov/healthcarefin/medicaid/programs- and-eligibility/ Phone: 1-800-251-1269

Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)

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To see if any other states have added a premium assistance program since July 31, 2023, or for more information on special enrollment rights, contact either:

U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/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

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately four 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, 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.

OMB Control Number 1210-0137 (expires 1/31/2026)

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Genetic Information Nondiscrimination Act (GINA) Disclosures Genetic Information Nondiscrimination Act of 2008

The Genetic Information Nondiscrimination Act of 2008 (“GINA”) protects employees against discrimination based

on their genetic information. Unless otherwise permitted, your Employer may not request or require any genetic

information from you or your family members.

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by

GINA Title II from requesting or requiring genetic information of an individual or family member of the individual,

except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic

information when responding to this request for medical information. “Genetic information,” as defined by GINA,

includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the

fact that an individual or an individual’s family member sought or received genetic services, and genetic

information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an

individual or family member receiving assistive reproductive services.

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USERRA Notice Your Rights Under USERRA A. The Uniformed Services Employment and Reemployment Rights Act

USERRA protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake military service or certain types of service in the National Disaster Medical System. USERRA also prohibits employers from discriminating against past and present members of the uniformed services, and applicants to the uniformed services. B. Reemployment Rights You have the right to be reemployed in your civilian job if you leave that job to perform service in the uniformed service and: • You ensure that your employer receives advance written or verbal notice of your service; • You have five years or less of cumulative service in the uniformed services while with that particular employer; • You return to work or apply for reemployment in a timely manner after conclusion of service; and • You have not been separated from service with a disqualifying discharge or under other than honorable conditions. If you are eligible to be reemployed, you must be restored to the job and benefits you would have attained if you had not been absent due to military service or, in some cases, a comparable job. C. Right to Be Free from Discrimination and Retaliation If you: • Are a past or present member of the uniformed service; • Have applied for membership in the uniformed service; or • Are obligated to serve in the uniformed service; then an employer may not deny you o Initial employment; o Reemployment; o Retention in employment; o Promotion; or o Any benefit of employment because of this status. In addition, an employer may not retaliate against anyone assisting in the enforcement of USERRA rights, including testifying or making a statement in connection with a proceeding under USERRA, even if that person has no service connection. If you leave your job to perform military service, you have the right to elect to continue your existing employer-based health plan coverage for you and your dependents for up to 24 months while in the military. • Even if you do not elect to continue coverage during your military service, you have the right to be reinstated in your employer's health plan when you are reemployed, generally without any waiting periods or exclusions (e.g., pre-existing condition exclusions) except for service- connected illnesses or injuries. D. Health Insurance Protection •

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E. Enforcement •

The U.S. Department of Labor, Veterans' Employment and Training Service (VETS) is authorized to investigate and resolve complaints of USERRA violations. For assistance in filing a complaint, or for any other information on USERRA, contact VETS at 1-866-4-USA-DOL or visit its Web site at http://www.dol.gov/vets. An interactive online USERRA Advisor can be viewed at http://www.dol.gov/elaws/userra.htm. • If you file a complaint with VETS and VETS is unable to resolve it, you may request that your case be referred to the Department of Justice or the Office of Special Counsel, as applicable, for representation. • You may also bypass the VETS process and bring a civil action against an employer for violations of USERRA. The rights listed here may vary depending on the circumstances. The text of this notice was prepared by VETS, and may be viewed on the Internet at this address: http://www.dol.gov/vets/programs/userra/poster.htm. Federal law requires employers to notify employees of their rights under USERRA, and employers may meet this requirement by displaying the text of this notice where they customarily place notices for employees. U.S. Department of Labor, Veterans' Employment and Training Service, 1-866-487-2365.

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COBRA

Model General Notice of COBRA Continuation Coverage Rights (For use by single-employer group health plans)

** Continuation Coverage Rights Under COBRA**

Introduction

You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has import ant

information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice

explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to

protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may

cost less than COBRA continuation coverage.

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985

(COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage

would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review

the Plan’s Summary Plan Description or contact the Plan Administrator.

You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an

individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower

costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for

another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept la te enrollees.

What is COBRA continuation coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also

called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA co ntinuation

coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children coul d

become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event.

If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the followin g qualifying

events:

• Your hours of employment are reduced, or

• Your employment ends for any reason other than your gross misconduct.

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COBRA

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because o f the

following qualifying events:

•

Your spouse dies;

• Your spouse’s hours of employment are reduced;

• Your spouse’s employment ends for any reason other than his or her gross misconduct;

• Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or

• You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying

events:

•

The parent-employee dies;

• The parent- employee’s hours of employment are reduced;

• The parent- employee’s employment ends for any reason other than his or her gross misconduct;

• The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);

• The parents become divorced or legally separated; or

• The child stops being eligible for coverage under the Plan as a “dependent child.”

When is COBRA continuation coverage available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a

qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:

• The end of employment or reduction of hours of employment;

•

Death of the employee;

• The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

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COBRA

For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibi lity

for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs.

How is COBRA continuation coverage provided?

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each

of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage.

Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation

coverage on behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment

termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage,

may permit a beneficiary to receive a maximum of 36 months of coverage.

There are also ways in which this 18-month period of COBRA continuation coverage can be extended:

Disability extension of 18-month period of COBRA continuation coverage

If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan

Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation

coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA

continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage.

Second qualifying event extension of 18-month period of continuation coverage

If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent

children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is

properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting

COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B,

or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This

extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the

Plan had the first qualifying event not occurred.

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COBRA

Are there other coverage options besides COBRA Continuation Coverage?

Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the

Health Insurance Marketplace, Medicare, Medicaid, Children’s Health Insurance Program (CHIP) , or other group health plan coverage

options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than

COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov .

Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?

In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial

enrollment period, you have an 8-month special enrollment period 1 to sign up for Medicare Part A or B, beginning on the earlier of

• The month after your employment ends; or

• The month after group health plan coverage based on current employment ends.

If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment p enalty

and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in

Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage. However, if

Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage may not be discontinued on account

of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.

If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA

continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.

For more information visit https://www.medicare.gov/medicare-and-you.

If you have questions

Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified

below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the

Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office

of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit

www.dol.gov/agencies/ebsa . (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s

website.) For more information about the Marketplace, visit www.healthcare.gov .

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