2025 E MPLOYEE BENEFITS GUIDE
WELCOME TO YOUR BENEFIT ENROLLMENT GUIDE 2025 PLAN YEAR
Foley Products Company is proud to offer you a comprehensive benefits package for the upcoming plan year. This enrollment guide will assist you in determining the coverage levels that will provide you and your family with the protection that gives you peace of mind. This guide explains each type of coverage, gives suggestions about how to effectively use your benefits, and provides examples to help you determine your benefit and payroll deduction amounts. We encourage you to take the time to review the enrollment guide prior to enrollment. The Open Enrollment period will begin on December 2 nd and end on December 9 th . Keep in mind that the benefits you select during this enrollment will be effective January 1 st , 2025 and will continue through December 31 st , 2025.
Please note: This benefit guide contains the basic information about your benefits program. It does not cover every detail; but it does provide a general description of each benefit plan. Every effort has been made to ensure that the information is accurate. However, this guide is not an insurance policy. If there is any question as to coverage, benefit eligibility, or interpretation, the insurance contract and the Certificate of Coverage you receive from the insurance carrier will govern the administration of your benefits. If you would like additional or specific information, please contact the Human Resources Department.
ADDITIONAL INFORMATION
ELIGIBILITY:
Benefits are available to full-time employees working a minimum of 30 hours per week. • Medical/Rx benefits are effective on the 1st day of the month following 60 days of continuous service • Dental benefits are effective on the 1st day of the month following 60 days of continuous service • Vision benefits are effective on the 1st day of the month following 60 days of continuous service • Basic Life/AD&D and Voluntary Life benefits are effective on the 1st day of the month following 180 days of continuous service • The Flexible Spending Account is offered to new hires, effective 1st day of month following 60 days of continuous service.
ABOUT DEDUCTIONS:
Under Section 125 of the Internal Revenue Service (IRS) code, you are allowed to pay certain group insurance premiums with tax-free dollars. This means your premium deductions are taken before Federal Income, State Income, and Social Security taxes are calculated, saving you 28% or more, depending on your tax bracket. Please make your benefit elections carefully, including the choice to waive coverage. Your pretax elections will remain in effect unless you experience an IRS approved qualified life event.
WHO IS AN ELIGIBLE DEPENDENT?
• Your legal spouse not working full-time and eligible for benefits through their employer. • Your child(ren) are covered to age 26 (medical/dental/vision insurance only) • Your child(ren) are covered six (6) months to age 19, 26 years if full-time student (life insurance only)
QUALIFYING LIFE EVENTS are events that cause an individual to lose his or her group health coverage. The type of qualifying event determines who the qualified beneficiaries are for that event and the period of time that a plan must offer continuation of coverage. Qualifying Life events include: • Marriage, divorce, or legal separation • Death of spouse or other dependent • Birth or adoption of a child • You or your spouse experience a work event that effects your benefits • A dependent’s eligibility status changes due to age, student status, marital status, or employment • Relocation into or outside of your plan’s service area
You must notify Human Resources within 30 days of the qualifying life event. Depending on the type of event, you may be asked to provide proof of the event. If you do not contact Human Resources within 30 days of the qualifying event, you will have to wait until the next annual enrollment period to make changes.
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ENROLLMENT
ENROLLMENT
Welcome to Your Employee Benefits Supersite! https://www.mybensite.com/foleyproducts/
Step 1: Know Your Benefit Options We believe that employees are our greatest resource. We offer a competitive benefit package for you and your family, and the support system to help you make great decisions. Review your Benefits Supersite and know your options: Benefit summaries
New Member Login Create Account: Verify employee last name, date of birth and last 4 digits of Social Security Number. Email: An email address is required. If you do not have one, click on the Gmail or Yahoo links to establish a free email account. Your email becomes your username . Password: Create and confirm your password to complete registration.
Side-by-side comparisons Insurance carrier information Member service information Provider search directories Forms and plan documents
Step 2: Benefit Shopping Click Enroll Now to shop and elect benefits:
Existing Member Login In the Employee Login section, enter your email address and password, then check the box to agree to website terms and conditions.
Step-by-step enrollment guidance Cost per paycheck is displayed for each benefit elected Add and manage covered dependents Update beneficiaries Review and submit final elections Print your Benefit Confirmation Statement (BCS) for your records
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MEDICAL / PRESCRIPTION INSURANCE Your medical benefits feature Point of Service (POS) Plans: a High Deductible Health Plan and a Traditional Copay plan. All POS Plans allow you to direct your own care and access both in-network and out-of-network providers. To maximize your benefits, you should try to select an in-network provider.
RETAIL PRESCRIPTIONS
Drugs have the lowest copay. This tier will contain low cost and preferred medications that may be generic, single source brand-name drugs1, or multi-source brand-name drugs2. Drugs will have a higher copay than those In tier 1. This tier will contain preferred medications that may be generic, single source brand-name drugs1, or multi-source brand-name drugs2. Drugs will have a higher copay than those on tier 2. This tier will contain non-preferred and high-cost medications. This will include medications considered generic, single source brand-name drugs1 and multi-source brand-name drugs2.
Tier 1
Tier 2
Tier 3
Tier 4
Specialty Drugs.
MAIL ORDER PRESCRIPTIONS You have the option of ordering pharmacy maintenance medications through the mail. This benefit offers the convenience of home delivery as well as lower copays. Mail order prescriptions are available through Cigna. Please call the customer service number on your ID card to see if your prescriptions are eligible for this service. Please contact customer service if you have benefit questions, eligibility or claim questions. Customer Service support is available Monday through Friday from 8:00 am to 5:00 pm at 800.997.1654. You may also manage your medical benefits through the Cigna website, www.myCigna.com. You may access this site 24 hours a day to check your claims, find a provider, order an ID card and more. SPOUSAL AFFIDAVIT You will need to complete a spousal affidavit annually to confirm your spouse does not have access to coverage through their employer. The affidavit must be completed for employees electing either Employee & Spouse or Family medical coverage.
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MEDICAL
Foley Products Company offers the following plans through Cigna. Please reference the Summary Plan Description for more details.
Insurance Carrier:
Cigna Medical Insurance
Medical Plan:
HSA
Gold
In-Network: Office Visit Copay - Primary Care
Deductible; then 100% Coinsurance
$25 Copay $50 Copay $60 Copay
Office Visit Copay - Specialist Care Deductible; then 100% Coinsurance
Urgent Care Copay Emergency Room Care (waived if admitted) Preventative Visit Copay
Deductible; then 100% Coinsurance
Deductible; then 100% Coinsurance
$150 Copay; then 80% Coinsurance
100% Coinsurance; No Deductible
100% Coinsurance; No Deductible
Coinsurance
100%
80%
Employee Deductible Family Deductible
$3,500 $7,000 $6,300 $12,600
$2,500 $7,500 $5,000 $10,000
Employee Out-of-Pocket Max Family Out-of-Pocket Max
Inpatient Hospital
Deductible; then 100% Coinsurance Deductible; then 100% Coinsurance
Deductible; then 80% Coinsurance $150 Copay; Deductible; then 80%
Outpatient Hospital or Facility
Out-of-Network: Coinsurance
70%
60%
Employee Deductible Family Deductible
$7,000 $14,000 $18,900 $37,800
$5,000 $15,000 $15,000 $30,000
Employee Out-of-Pocket Max Family Out-of-Pocket Max
Prescription Drugs: (30 Day Supply) Tier 1 - Generic
Deductible; then 100% Coinsurance Deductible; then 100% Coinsurance Deductible; then 100% Coinsurance Deductible; then 100% Coinsurance
$15 Copay $40 Copay $75 Copay
Tier 2 - Preferred
Tier 3 - Non-Preferred
Tier 4 - Specialty
20% Coinsurance
RATES:
Weekly $37.00 $83.00 $78.00 $127.00
Monthly $160.00 $361.33 $339.54 $550.88
Weekly $71.00 $142.00 $133.00 $216.00
Monthly $306.45 $613.48 $576.14 $937.25
Employee Only
Employee + Spouse Employee + Child(ren)
Family
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HEALTH SAVINGS ACCOUNT (HSA)
HEALTH SAVINGS ACCOUNT (HSA) The High Deductible Health Care Plan (HDHP) offers a Health Savings Account (HSA). Foley Products Company will contribute the below amounts to your HSA account and you can make additional pre-tax contributions
Things to know regarding HSAs: A Health Savings Account (HSA) is similar in many ways to a Flexible Spending Account (FSA) or Health Reimbursement Arrangement (HRA) – except you get to keep the money in the account. The HSA is a cash account. You may use the cash available in your account at any time. HSA funds – both employee and company money – are completely yours and is 100% vested. If unused, the money rolls over or carries forward from one year to the next. Employee and company money goes into the account tax free. As long as used for eligible expenses, the money comes out tax free. SAVE YOUR RECEIPTS! You may change your contribution election at any time during the year. Any interest income or investment income grows tax-free. To cover yourself or a family member under an HSA, you must be in a qualified High Deductible Health Plan (HDHP) and cannot: • Be Medicare eligible • Be able to be claimed under someone else’s taxes • Be covered by a traditional-style health plan (PPO, HMO, etc.) • Participate in a FSA plan HSAs and coverage of adult children under age 26: While the Patient Protection and Affordable Care Act (PPACA) allows parents to add their adult children (up to age 26) to their health plans, the IRS has not changed its definition of a dependent for health savings accounts. If account holders can’t claim a child as a dependent on their tax returns, then they can’t spend HSA dollars on services provided to that child. According to the IRS definition, a dependent is a qualifying child who: • Has same principal place of abode as the covered employee for more than one-half of taxable year. • Has not provided over one-half of their own support during taxable year. • Is not yet age 19 (or if a student; not yet age 24) at the end of the tax year, or is permanently and totally disabled.
The IRS determines HSA rules and annual maximums, which may increase each year. For 2025 the annual total contribution maximums, including the employer contributions, are: Single Coverage: $4,300 With Dependents: $8,550 Additional amount if over 55: $1,000
HSA funds may be used for:
Employees participating in the HDHP/HSA plan will receive the following company contributions in 2025: Coverage Level Annual / Monthly Contribution* Single Coverage $500 / $41.67 Employee + Spouse $1,000 / $83.33 Employee + Child(ren) $1,000 / $83.33 Employee + Family $1,000 / $83.33 *Annual contribution assumes participation for the full calendar year. Employees enrolling in the HDHP/HSA plan mid-year will receive the contribution for the period enrolled on the plan. By IRS rules, HSA funds used for non-eligible expenses are subject to ordinary income tax and an additional 20% penalty. Once you turn 65, an HSA account works similar to an IRA, subject only to ordinary income tax for non tax-free withdrawals. • Medical out-of-pocket expenses, Dental & Vision expenses • Over-the-Counter drugs (with a note / prescription from your doctor) • COBRA premiums if you leave the company • Retiree medical coverage
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HEALTH SAVINGS ACCOUNT (HSA)
WHICH PLAN IS RIGHT FOR YOU?
Below are cost illustrations of the POS Plans. Review these to decide what plan is best for you.
The HSA account is your own responsibility, and eligibility and compliance are between you and the IRS.
ANNUAL COST EXAMPLE OF EMPLOYEE ONLY COVERAGE FOR A HEALTHY INDIVIDUAL
HDHP
POS
Monthly Deductions, annualized
$1,920.00
$3,677.40
Preventive Care Visit
No Cost
No Cost
Sick Visits - 2
$100.00 x 2 = $200.00
$25.00 x 2 = $50.00
$40.00 x 12 = $480.00 (Tier 2 before deductible)
Monthly Prescription
$25.00 x 12 = $300.00
Total Expenses
$2,420.00
$4,207.40
Less Company HSA Contribution
($500.00)
-0-
Total Out of Pocket Expenses
$1,920.00
$4,207.40
ANNUAL COST EXAMPLE OF FAMILY COVERAGE FOR A HEALTHY FAMILY
HDHP
POS
Monthly Deductions, annualized
$6,610.56
$11,247.00
Preventive Care Visit
No Cost
No Cost
Sick Visits - 8
$100.00 x 8 = $800.00
$25.00 x 2 = $200.00
Monthly Prescription
$50.00 x 12 = $600.00
$40.00 x 12 = $480.00
Total Expenses
$8,010.56
$11,927.00
Less Company HSA Contribution
($1,000.00)
-0-
Total Out of Pocket Expenses
$7,010.56
$11,927.00
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CIGNA VIRTUAL CARE
Life is demanding. It’s hard to find time to take care of yourself and your family members as it is, never mind when one of you isn’t feeling well. That’s why your health plan through Cigna includes access to minor medical and behavioral/mental health virtual care. Whether it’s late at night and your doctor or therapist isn’t available or you just don’t have the time or energy to leave the house, you can: › Access care from anywhere via video or phone. › Get minor medical virtual care 24/7/365 – even on weekends and holidays. › Schedule a behavioral/mental health virtual care appointment online in minutes. › Connect with quality board-certified doctors and pediatricians as well as licensed counselors and psychiatrists. › Have a prescription sent directly to your local pharmacy, if appropriate.
Convenient? Yes. Costly? No.
Medical virtual care for minor conditions costs less than ER or urgent care center visits, and maybe even less than an in-office primary care provider visit.
al/Mental health virtual care unselors and psychiatrists can diagnose, escribe most medications for nonemergency mental health conditions, such as:
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Minor medical virtual care Board-certified doctors and pediatricians can diagnose, treat and prescribe most medications for minor medical conditions, such as:
Behavioral/Mental health virtual care Licensed counselors and psychiatrists can diagnose, treat and prescribe most medications for nonemergency behavioral/mental health conditions, such as:
› Insect bites › Joint aches
› Addictions › Bipolar disorders › Child/Adolescent issues › Depression › Eating disorders › Grief/Loss › Life changes › Men’s issues › Panic disorders › Parenting issues
› Postpartum depression › Relationship and marriage issues › Stress › Trauma/PTSD › Women’s issues
› Nausea › Pink eye › Rashes › Respiratory infections › Shingles › Sinus infections › Skin infections › Sore throats › Urinary tract infections
Offered by Cigna Health and Life Insurance Company or its affiliates.
nect with an MDLIVE virtual er, visit myCigna.com, locate alk to a doctor or nurse 24/7” and click “Connect Now.” ate a Cigna Behavioral Health er, visit myCigna.com, go to Care & Costs” and enter al counselor” under “Doctor by or call the number on the back r Cigna ID card 24/7.
MDLIVE providers can also conduct virtual wellness screenings.
Connect with virtual care your way. › Contact your in-network provider or counselor › Talk to an MDLIVE medical provider on demand on myCigna.com › Schedule an appointment with an MDLIVE provider or licensed therapist on myCigna.com › Call MDLIVE 24/7 at 888.726.3171
To connect with an MDLIVE virtual provider, visit myCigna.com, locate the “Talk to a doctor or nurse 24/7” callout and click “Connect Now.” To locate a Cigna Behavioral Health provider, visit myCigna.com, go to “Find Care & Costs” and enter “Virtual counselor” under “Doctor by Type,” or call the number on the back of your Cigna ID card 24/7.
nsible for any treatment provided to their patients. Video chat may not be ble in all areas or under all plan types. A primary care provider referral is
9
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of a covered condition. Not all prescription drugs are covered. Product
CIGNA ONE GUIDE
ENJOY EASIER SERVICE
Now that your Cigna One Guide team is by your side
Ready to answer all your health plan questions. And so much more. Let’s face it, understanding and using your health plan isn’t always easy. Well, not to worry. Your Cigna One Guide® team is ready and waiting to help. It’s our highest level of personal support available.
Get care › Find an in-network health care provider, lab or urgent care center › Connect with health coaches, pharmacists and more › Connect with dedicated,
Simply call us, click-to-chat on myCigna.com or use the myCigna ® App . You’ll automatically be connected with a One Guide representative who will help guide you where you need to go. Helping you save money. And stay healthy. Your Cigna One Guide team can help you: Understand your plan › Learn how your coverage works › Get answers to your health care or plan questions
Click, call or chat. Your personal guide is ready and waiting to help.
one-on-one support for complex health situations
myCigna.com myCigna App 800.Cigna24
Save and earn › Earn incentives (if provided by your employer) › Get cost estimates to avoid surprises
Offered by Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, or their affiliates. The Apple logo is a trademark of Apple Inc., registered in the U.S. and other countries. App Store is a registered service mark of Apple Inc. Google Play is a trademark of Google LLC. Amazon, Kindle, Fire and all related logos are trademarks of Amazon.com, Inc. or its affiliates. The downloading and use of the myCigna mobile app is subject to the terms and conditions of the app and the online store from which it is downloaded. Standard mobile phone carrier and data usage charges apply. 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, review your plan documents or 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 (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. 903505 b 01/20 © 2020 Cigna. Some content provided under license.
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MYCIGNA
EASY TO REGISTER. EASY TO USE. Get to know the full value of myCigna.
From programs that help improve your health to tools that help manage your health spending, there’s so much you can do on myCigna.com or the myCigna® app.
Find in-network doctors, hospitals and medical services
Manage and track claims
See cost estimates for medical procedures
Compare quality of care information for doctors and hospitals
Access a variety of health and wellness tools and resources
The myCigna website and app both have an easy, interactive health assessment to help you learn more about your health and what you can do to improve it.
Register today You can register online or through the app.
Feel better-protected
1. Go to the myCigna.com website or launch the myCigna app and select “Register Now” 2. Enter your requested information 3. Confirm your identity 4. Create your security information and provide your primary email address 5. Review and submit
Cigna is as committed to helping protect your health information as we are to protecting your health and well-being. That’s why we take certain steps to enhance the security of your personal health information on the myCigna website and app.
› Enhanced registration › Two-step authentication
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DENTAL
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 dental plan is through Cigna and offers “in and out-of-network” benefits.
Insurance Carrier:
Cigna Dental Insurance
Plan Type:
Basic
Calendar Year Deductible
$50 Individual / $150 Family
Calendar Year Maximum
$1,000
Preventive Services
100%
Basic Services
80%
Major Services
50%
Orthodontia
$50 Annual Deductible; then 50% Coinsurance
RATES:
Weekly
Monthly
Employee Only
$2.61
$11.30
Employee + Spouse
$5.83
$25.25
Employee + Child(ren)
$4.98
$21.59
Family
$8.32
$36.04
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VISION
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.
You can feel more confident with dental insurance that encourages routine cleanings and checkups. Dental insurance helps protect your teeth for a lifetime.
Your vision plan is through Cigna and offers “in and out-of-network” benefits.
Insurance Carrier:
Cigna Vision Insurance
In-Network $20 Copay $20 Copay $20 Copay $20 Copay
Out-of-Network $45 allowance $25 allowance $40 allowance $55 allowance
Vision Exam
Lenses - Single lined Lenses - Bifocal lined Lenses - Trifocal lined
$130 allowance; then 20% discount
Frames
$45 allowance
Contacts (in lieu of glasses) • Elective • Therapeutic Allowance
$130 allowance then 15% discount Covered in Full
$105 allowance $210 allowance
Frequency: Exam / Lenses / Frames
once every: 12 months / 12 months / 12 months
RATES:
Weekly
Monthly
Employee Only
$1.57 $2.74 $2.98 $4.54
$6.79
Employee + Spouse Employee + Child(ren)
$11.87 $12.90 $19.69
Family
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LIFE AND VOLUNTARY LIFE INSURANCE
LIFE INSURANCE PROVIDED BY UNUM The company provides full-time employees basic life and accidental death and dismemberment benefits at no cost to the employee. VOLUNTARY LIFE INSURANCE PROVIDED BY UNUM You may purchase additional life insurance for yourself, your spouse, or your child(ren). You must purchase coverage for yourself order to purchase coverage for a dependent, and you may not purchase more for your dependent(s) than you purchase for yourself. Guaranteed Issue (GI) is limited to employees in their New Hire eligibility window. Evidence of Insurability (EOI) will be required for newly elected amounts above the GI or for elections at Annual Enrollment. Rates are age-banded and based on the amount of coverage elected. Benefits begin to reduce at age 65. The voluntary life benefit is in addition to the basic life coverage the Company provides. The voluntary life plan is 100% employee paid.
If you are actively at work at least 30 hours per week, you may apply for coverage for:
Choose from $10,000 to $500,000 in $10,000 increments, up to 5 times your earnings. You can get up to $150,000. This is the amount of coverage you can qualify for with no medical underwriting. Get up to $500,000 of coverage in $5,000 increments. Spouse coverage cannot exceed 100% of the coverage amount you purchase for yourself. Your spouse can get up to $30,000 with no medical underwriting, if eligible (see delayed effective date). Get up to $10,000 of coverage in $2,000 increments if eligible (see delayed effective date). One policy covers all of your children until their 19th birthday - or until their 26th birthday if they are full-time students. The maximum benefit for children live birth to 6 months is $1,000.
You:
Your spouse:
Your children:
WHO CAN GET ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) COVERAGE?
Get up to $500,000 of AD&D coverage for yourself in $10,000 increments to a maximum of 5 times your earnings.
You:
Get up to $500,000 of AD&D coverage for your spouse in $5,000 increments, if eligible (see delayed effective date).
Your spouse:
Your children:
Get up to $10,000 of coverage for your children in $2,000 increments if eligible (see delayed effective date).
NO MEDICAL UNDERWRITING IS REQUIRED FOR AD&D COVERAGE.
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DISABILITY COVERAGE
VOLUNTARY SHORT TERM DISABILITY COVERAGE
If a covered illness or injury keeps you from working, Short Term Disability Insurance replaces part of your income while you recover. After you become disabled for 14 days, STD covers 60% of your weekly income, up to a maximum benefit of $1,000 per week. The weekly benefit may be reduced or offset by other sources of income. As long as you remain disabled, you can receive payments for up to 11 weeks.
Monthly Rates
Age
0-24 $0.187 25-29 $0.322 30-34 $0.442 35-39 $0.406 40-44 $0.383 45-49 $0.451 50-54 $0.602 55-59 $0.859 60-64 $1.113 65+ $1.352
VOLUNTARY LONG TERM DISABILITY COVERAGE
This coverage provides a monthly benefit if you have a covered illness or injury, and you can’t work for a few months — or even longer. If you are disabled, after 90 days, LTD covers 60% of your monthly income, up to a maximum of $6,000. The monthly benefit may be reduced or offset by other sources of income. As long as you remain disabled, you can receive benefits up to the Social Security (SS) normal retirement age.
Monthly Rates
Age
0-24 $0.20 25-29 $0.26 30-34 $0.45 35-39 $0.74 40-44 $1.26 45-49 $1.75 50-54 $2.36 55-59 $2.84 60-64 $2.80 65-69 $2.41 70+ $1.96
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FSA & SUPPLEMENTAL INSURANCE
FLEXIBLE SPENDING ACCOUNTS PROVIDED BY
The Flexible Spending Account (FSA) gives you the option to use pre-tax dollars to be reimbursed for out- of-pocket health care expenses that are not covered by a health, dental or vision insurance policy. You have the option to enroll in the Medical Expense FSA or the Dependent Care FSA. Please see the following information to determine which FSA best fits your needs. The Medical Expense FSA allows you to pay for medical, dental, vision and other “health and welfare” expense with pre-tax dollars. For example, you can use the money in this account to pay for your copays or deductible, as well as the cost for items that are not covered by your insurance, but are approved by the IRS (see IRS publications 502 and 969). You may elect to set aside up to $3,300 per year into your Medical Expense FSA. Please note, if you do not use the entire amount that you have elected to set aside within the calendar year, you can only rollover up to $500 to the next plan year. Dependent Care FSA allows you to use your pre-tax dollars to pay for qualified dependent care. A qualified dependent is under the age of 13, or a spouse/dependent who is disabled and cannot care for themselves and live with for more than 6 months of the year. You can contribute up to $5,000 per family per year ($2,500 if you are married and do not file a joint tax return) in the Dependent Care FSA. To see a full list of qualified Dependent Care FSA expenses see IRS publication 503. GROUP ACCIDENT COVERAGE PROVIDED BY UNUM Accident Insurance provides a set benefit amount based on the type of injury you have and the type of treatment you need. It covers accidents that occur off the job. And it includes a range of incidents, from common injuries to more serious events. It can help you with out-of-pocket costs that your medical plan doesn’t cover, like co-pays and deductibles. Every year, each family member who has Accident coverage can also receive $50 for getting a covered Be Well screening test. Rates Weekly Monthly Employee $2.04 $8.82 Employee + Spouse $3.69 $15.98 Employee + Child(ren) $5.09 $22.05 Family $6.74 $29.21 GROUP HOSPITAL COVERAGE PROVIDED BY UNUM Group Hospital Insurance helps covered employees and their families cope with the financial impacts of a hospitalization. You can receive benefits when you’re admitted to the hospital for a covered accident, illness or childbirth. Rates Weekly Monthly Employee $2.63 $11.39 Employee + Spouse $6.33 $27.46 Employee + Child(ren) $3.96 $17.14 Family $7.66 $33.21
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SUPPLEMENTAL INSURANCE
GROUP CRITICAL ILLNESS PROVIDED BY UNUM
If you’re diagnosed with an illness that is covered by this insurance, you can receive a lump sum benefit payment. You can use the money however you want.
Choose $10,000, $20,000 or $30,000 of coverage with no medical underwriting to qualify if you apply during this enrollment.
You:
Spouses can only get 100% of the employee coverage amount as long as you have purchased coverage for yourself. Children from live birth to age 26 are automatically covered at no extra cost. Their coverage amount is 50% of yours. They are covered for all the same illnesses plus these specific childhood conditions: cerebral palsy, cleft lip or palate, cystic fibrosis, Down syndrome, spina bifida, type 1 diabetes, sickle cell anemia and congenital heart disease. The diagnosis must occur after the child’s coverage effective date.
Your spouse:
Your children:
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ADDITIONAL INFORMATION
401(K) PLAN ADMINISTERED BY EMPOWER/MERRILL LYNCH Upon completion of 60 days of continuous employment, employees qualify to participate in our 401(k) plan on the 1st day of the following month. Upon qualifying, all employees will be enrolled with an initial contribution level of 3% of their pay, unless they opt out of the enrollment. Newly eligible participants will be mailed a Summary Plan Description of the plan, educational materials, and online enrollment instructions. For every $1.00 you contribute to the plan, the Company contributes $0.50 up to the first 8%. EMPLOYEE ASSISTANCE PROGRAM PROVIDED BY UNUM Your EAP is designed to help you lead a happier and more productive life at home and at work. Call for confidential access to a Licensed Professional Counselor* who can help you. You can get up to three visits available at no additional cost to you with a Licensed Professional Counselor. EAP services are available to all eligible partners and employees, their spouses or domestic partners, dependent children, parents and parents-in-law. A Licensed Professional Counselor can help you with:
• Stress, depression, anxiety • Relationship issues, divorce • Anger, grief, loss • Job stress, work conflicts • Family, parenting problems
Help is easy to access:
Phone support: 1-800-854-1446 Online support: unum.com/lifebalance
CIGNA TOTAL BEHAVIORAL HEALTH Finding a path to feeling better mentally and emotionally can feel overwhelming. Even on the best days, taking that next step is difficult without special support. As a Cigna HealthcareSM customer, you have access to so much to help you, including digital resources, aid with stress and anxiety, therapy, coaching and care for more complex behavioral health needs. Cigna has many convenient options to address your unique mental health needs — including face-to-face, phone and video appointments, as well as virtual providers that use secure messaging. Get immediate care and support, 24/7/365. The Cigna licensed clinicians provide consultations in the moment to help you with a care plan or to talk about what you’re going through. Visit myCigna.com and click the Wellness tab, then select Mental Health Support or chat 9am-8pm ET 800-997-1654
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FREQUENTLY ASKED QUESTIONS
What is included in the Medical Out-of-Pocket maximum? What is included in the Pharmacy Out-of-Pock- et 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 provid- ers 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 mem- bers higher rates for medical services and care, outside of the standard “in-network” rates. For example, a out-of-network provider may charge $200 for a primary care visit. Cigna may pay an adjustment of an out-of-network benefit of $80 dollars to the provider, so the member may be balance-billed for the remaining $120 cost of the visit.
When can I change my beneficiary information for my Basic Life Insurance? Any time! It is important that all beneficiary information be kept up-to-date. You may need to change it after a marriage, divorce, or birth of a child.
Term Definition Network Office Visit (PCP) The “per visit” co-pay cost for a primary care or standard network doctor.
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
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LEGAL NOTICES
Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free or Low-Cost Health Coverage to Children and Families
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow. gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer- sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2022. Contact your State for more information on eligibility –
ALABAMA - Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447 ALASKA - Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: Customer Service@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default. aspx ARKANSAS - Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447) COLORADO - Medicaid Website: http://www.colorado.gov/hcpf Customer Contact Center: 1-800-221-3943 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 KANSAS - Medicaid Website: http://www.kdheks.gov/hcf/
FLORIDA - Medicaid Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268 GEORGIA - Medicaid Website: http://dch.georgia.gov/medicaid - click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507 INDIANA - Medicaid Healthy Indiana Plan for Low-Income Adults 19-64 Website: http://www.hip.in.gov Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone: 1-800-403-0864 IOWA - Medicaid Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 MAINE - Medicaid Website: http://maine.gov/dhhs/ofi/public-assistance/ index.html Phone: 1-800-442-6003 TTY: Maine relay 711
MASSACHUSETTS - Medicaid and CHIP Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120 MINNESOTA - Medicaid Website: http://mn.gov/dhs/ma/ Phone: 1-800-657-3739
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LEGAL NOTICES
MISSOURI - Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
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://dss.sd.gov Phone: 1-888-828-0059 TEXAS - Medicaid Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 UTAH - Medicaid and CHIP Medicaid Website: http://health.utah.gov/medicaid CHIP Website: http://health.utah.gov/chip
Website: http://www.dhhs.ne.gov/Children_Family_ Services/AccessNebraska/Pages/accessnebraska_ index.aspx Phone: 1-855-632-7633 NEVADA - Medicaid Website: http://dwss.nv.gov/ Phone: 1-800-992-0900 NEW HAMPSHIRE - Medicaid Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 NEW JERSEY - Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/ medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 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
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_premium_as- sistance.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/program-ad- ministration/premiumpayment- program Phone: 1-800-562-3022 ext. 15473 WEST VIRGINIA - Medicaid Website: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/ default.aspx Phone: 1-877-598-5820, HMS Third Party Liability WISCONSIN - Medicaid and CHIP Website: http://www.dhs.wisconsin.gov/publications/p1/p10095.pdf
Phone: 1-800-362-3002 WYOMING - Medicaid Website: http://wyequalitycare.acs-inc.com/ Phone: 307-777-7531
To see if any more States have added a premium assistance program since January 31, 2022, or for more information on special enrollment rights, you can contact either:
U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/ebsa 1-866-444-EBSA (3272)
U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565
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LEGAL NOTICES
Important Notices about Medical Coverage
HIPPA Special Enrollment Rights If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself or your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must enroll within 30 days after the marriage, birth, adoption, or placement for adoption. Effective April 1, 2009 special enrollment rights also exist in the following circumstances: • If you or your dependents experience a loss of eligibility for Medicaid or your State Children’s Health Insurance Program (SCHIP) coverage; or • If you or your dependents become eligible for premium assistance under an optional state of Medicaid or SCHIP program that would pay the employee’s portion of the health insurance premium. NOTE: In the two above listed circumstances only, you or your dependents will have sixty (60) days to request special enrollment in the group health plan coverage. An individual must request this special enrollment within sixty (60) days of the loss of coverage described at bullet one, and within sixty (60) days of when eligibility is determined as described in bullet two. Women’s Health and Cancer Rights Act of 1998 Annual Notice If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy- related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for all stages of reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses; and treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and co-insurance applicable to other medical and surgical benefits
provided under this plan. Our plan complies with these requirements. Benefits for these items generally are compatible to those provided under our plan for similar types of medical services and supplies. Of course, the extent to which any of these items is appropriate following mastectomy is a matter to be determined by consultation between the attending physician and the patient. Our plan neither imposes penalties (for example, reducing or limiting reimbursements) nor provides incentives to induce attending providers to provide care inconsistent with these requirements. If you would like more information on WHCRA benefits, call Yates at (706) 323-1600.
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub. L. 104- 13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, not withstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.
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