CLASS 1
BENEFITS GUIDE 2023 PLAN YEAR
TABLE OF CONTENTS
I ntroduction . . . . . . . . . . . . . . . . . . . . . . . Medical . . . . . . . . . . . . . . . . . . . . . . . . . . . Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basic Life AD&D . . . . . . . . . . . . . . . . . . . Disability . . . . . . . . . . . . . . . . . . . . . . . . . Supplemental Products . . . . . . . . . . . . . Member Claims Advocate . . . . . . . . . FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . Legal Notices . . . . . . . . . . . . . . . . . . . . Medicare Part D. . . . . . . . . . . . . . . . . COBRA. . . . . . . . . . . . . . . . . . . . . . . . . Exchange Notices. . . . . . . . . . . . . . . . Contact Information. . . . . . . . . . . . . .
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Infratech Corporation is proud to offer you a comprehensive benefits package for the 2023 - 2024 plan year. Keep in mind that new enrollment and changes will become effective February 1st, 2023.
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2 INFRATECH CORPORATION 2023 BENEFITS GUIDE
About Deductions
In preparation of your enrollment, please have the following information readily available for you and your dependent(s): • Date(s) of birth • Social Security Number(s): Mandatory • Full name, relationship, and Social Security Number(s) for Life Beneficiary(ies). (Beneficiaries must be at least 18 years old or you will be required to name a guardian for him/her.) Information Needed for Enrollment Premiums for medical, dental and vision plans are all deducted on a pre-tax basis because they are covered under Section 125 of the Internal Revenue Code. Once you elect benefits you will not be approved to make changes to your election or drop coverage until the next Open Enrollment period, unless you have a qualifying event. Voluntary life insurance premiums are deducted on a post-tax basis and may be changed outside of the Open Enrollment period.
Eligibility Information
Qualifying Life Events
As an employee of Infratech Corporation you may be eligible for
Qualifying events are events that cause an individual to lose his or her group health coverage. The type of qualifying event determines who the qualified beneficiaries are for that event and the period of time that a plan must offer continuation of coverage.
enrollment in a variety of insurance products. Full-time employees may participate in the benefits package on date of hire. You may enroll your eligible dependents for coverage once you are eligible. Your eligible dependents include:
Qualifying events include:
• Marriage • Divorce or legal separation • Birth or adoption of a child • Death of spouse or dependent child • Change in employment status • Loss of other coverage • Entitlement to Medicare or Medicaid • Child turning 26 years old
• Your legal spouse • Your children up to age 26 (as identified in the plan document)
*Once your elections are effective, they will remain in effect through the plan year.
You must notify Human Resources within 30 days of the qualifying life event. Depending on the type of event, you may be asked to provide proof of the event. If you do not contact Human Resources within 30 days of the qualifying event, you will have to wait until the next annual enrollment period to make changes.
3 INFRATECH CORPORATION 2023 BENEFITS GUIDE
Medical and Pharmacy Coverage
Infratech Corporation offers the following Medical plans
through Cigna and offers “in and out-of-network” benefits.
Insurance Carrier:
Cigna Medical Insurance
Medical Plan:
$1,500 / 80% Buy-Up Plan
$3,500 / 100% Base Plan
$5,000 / 100% HDHPQ Plan
In-Network: Office Visit Copay - Primary Care
$30
$30
Plan pays 100%
Office Visit Copay - Specialist Care
$60
$60
Plan pays 100%
Urgent Care Copay
$75
$75
Plan pays 100%
Emergency Room Care
$350
$350
Plan pays 100%
Preventative Visit Copay
$0
Plan pays 100%
Plan pays 100%
Diagnostic Testing & Blood Work
Plan pays 80%
Plan pays 100%
Plan pays 100%
Imaging
Plan pays 80%
Plan pays 100%
Plan pays 100%
Coinsurance
80%
100%
100%
Employee Deductible
$1,500
$3,500
$5,000
Family Deductible
$4,500
$10,500
$10,000
Employee Out-of-Pocket Max
$4,500 (includes deductible)
$7,900 (includes deductible)
$6,900 (includes deductible)
Family Out-of-Pocket Max
$9,000 (includes deductible)
$15,800 (includes deductible)
$13,800 (includes deductible)
Inpatient Hospital
Plan pays 80%
Plan pays 100%
Plan pays 100%
Outpatient Hospital or Facility
Plan pays 80%
Plan pays 100%
Plan pays 100%
Out-of-Network: Coinsurance
60%
70%
70%
Employee Deductible
$4,500
$10,000
$10,000
Family Deductible
$13,500
$20,000
$20,000
Employee Out-of-Pocket Max
$13.500
$23,700
$20,700
Family Out-of-Pocket Max
$27,000
$47,400
$41,400
Prescription Drugs: ( 30 Day Supply) Tier 1 - Generic
$15
$15
$15
Tier 2 - Preferred
$45
$45
$35
Tier 3 - Non-Preferred
$85
$85
$60
Tier 4 - Specialty
25% Coinsurance up to $300
25% Coinsurance up to $300
25% Coinsurance up to $300
Employee Weekly Deduction Employee Only
$40.36
$39.40
$5.00
Employee + Spouse
$142.84
$140.01
$50.00
Employee + Child(ren)
$115.52
$112.97
$40.00
Family
$167.81
$163.77
$70.00
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Dental Coverage
Good dental care is critical to your overall well-being. With Guardian Dental Insurance, you can get the attention your teeth need - at a cost you can afford. To get the most from your benefits and reduce out-of-pocket costs, choose an in-network provider by utilizing our large national network. These providers have agreed to file your claims and uphold the highest quality standards. You can find in-network providers at guardiananytime.com
Insurance Carrier:
Guardian Dental Insurance
Plan Type:
Low Plan
High Plan
Calendar Year Deductible Calendar Year Maximum
$50 Individual / $150 Family $50 Individual / $150 Family
$1,000
$3,000
Preventive Services
100%
100%
Basic Services Major Services
80% 50% 50%
80% 50% 50%
Orthodontia (dependent children only) Employee Weekly Deduction Employee Only
$6.53
$7.52
Employee + Spouse Employee + Child(ren)
$12.90 $18.07 $24.45
$14.87 $20.82 $28.18
Family
5 INFRATECH CORPORATION 2023 BENEFITS GUIDE
Vision Coverage
You can help protect your eyesight by visiting an eye doctor regularly. Vision insurance includes an annual comprehensive eye exam with an eye care doctor. Taking care of your eyes today can lead to a better quality of life later. Seeing an in-network eye care provider can reduce your expenses with savings on frames, lenses, contacts, eye exams and more. You can find vision providers at guardiananytime.com
Insurance Carrier:
Guardian Vision Insurance
Plan Type:
Davis Vision In-Network
Exam Copay
$10 Copay
Lenses - Single lined
$10 Copay
Lenses - Bifocal lined
$10 Copay
Lenses - Trifocal
$10 Copay
Lenses - Lenticular
$10 Copay
Frames
$ 135 Allowance; then 20% off remaining balance
Elective Contact Lenses (in place of lenses & frame) Medically Necessary Contacts
$135 Allowance; then 15% off remaining balance
Covered in full
Frequency for Exam / Lenses / Frames
12 months / 12 months / 24 months
Employee Weekly Deduction
Employee Only
$1.76
Employee + Spouse
$2.97
Employee + Child(ren)
$3.03
Family
$4.79
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Basic Life and AD&D Insurance Coverage
Infratech Corporation provides all Full Time employees with Basic Life and Accidental Death & Dismemberment at no cost to employees.
Insurance Carrier: Basic Life w/ AD&D Eligibility Requirement
Mutual of Omaha Basic Life w/AD&D Insurance
All Full Time Employees
Employee: $15,000 Spouse: $6,000 Dependent Child(ren): 14 days and older $3,500 / Less than 14 days $0
Life Insurance Benefit
Guarantee Issue
Yes
Accidental Death & Dismemberment Benefit (AD&D)
Same as Basic Life Amount
Voluntary Term Life Insurance Coverage
As a supplemental benefit, Infratech Corporation allows eligible employees to purchase additional life insurance coverage for yourself and your dependents. This coverage is paid for by you and is offered through Mutual of Omaha. Rates for the voluntary term life insurance are based on age, and volume, and benefits are subject to applicable age reductions.
Insurance Carrier:
Mutual of Omaha Voluntary Life w/AD&D Insurance
Voluntary Life w/ AD&D Eligibility Requirement Employee Benefit Amounts Employee
All Full Time Employees
5x Annual Earnings up to $500k in increments of $25k
Spouse
100% of employee’s benefit up to $250k 100% of employee’s benefit up to $10k
Child(ren)
Guarantee Issue* Employee
$100k
Dependent Child(ren)
100% of employee’s benefit 100% of employee’s benefit
*Guarantee Issue applies only to new hires.
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Disability Coverage
The goal of Infratech’s Disability Insurance Plan is to provide you with income replacement should you be unable to work due to a non- work-related illness or injury. The company provides employees with the option to purchase voluntary “Short and Long Term Disability” income benefits. Both the short term and long term disability coverages are offered through Mutual of Omaha.
Insurance Carrier:
Mutual of Omaha Short-Term Disability Insurance
Plan Type:
Voluntary
Eligibility Requirement Benefit Percentage Maximum Weekly Benefit
All Full Time Employees
50%
$1,500
Elimination Period - Accident
0 Days
Elimination Period - Sickness
8 Days
Pre-Existing Condition
3 / 6
Benefit Duration
13 Weeks Maximum
Insurance Carrier:
Mutual of Omaha Long-Term Disability Insurance
Plan Type:
Voluntary
Eligibility Requirement Benefit Percentage Maximum Monthly Benefit
All Full Time Employees
60%
$2,500 90 Days 2 Years 12 / 12 SSNRA
Elimination Period
Own Occupation Definition
Pre-Existing Condition
Benefit Duration
8 INFRATECH CORPORATION 2023 BENEFITS GUIDE
Accident Insurance
Voluntary Accident Insurance
Don’t let an accident catch you off guard. Protect your family’s finances with Accident Insurance from United of Omaha Life Insurance Company. An accident insurance policy supplements your medical coverage and provides a cash benefit for injuries you or an insured family member sustain from an accident. This benefit can be used to pay out-of- pocket medical expenses, help supplement your daily living expenses and cover unpaid time off work. As an active employee of Infratech Corporation, you may purchase this coverage for yourself and your family members, and premiums can be deducted from your paycheck. It’s a simple and affordable way
for your family to receive added financial protection. Coverage guidelines and benefits are outlined below.
This insurance offers financial protection by paying a cash benefit if you or an insured dependent are injured as a result of a covered accident. Unless otherwise stated, the benefit amount payable is the same for you and your insured dependent(s).
ELIGIBILITY - ALL ELIGIBLE EMPLOYEES Eligibility Requirement
You must be actively working a minimum of 30 hours per week to be eligible for coverage. To be eligible for coverage, your dependents must be able to perform normal activities, and not be confined (at home, in a hospital, or in any other care facility), and any child(ren) must be under age 26. In order for your spouse and/or children to be eligible for coverage, you must elect coverage for yourself. The premiums for this insurance are paid in full by you.
Dependent Eligibility Requirement
Premium Payment PLAN INFORMATION
INFORMATION / AMOUNT(S) Non-occupational (Off-job only)
Coverage Type Express Benefit
$100
Not Included
Annual Benefit Maximum (ABM)
Included
Portability
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45106
G000B59Y
Accident Insurance
BENEFITS AMOUNTS Initial Care & Emergency 1 – Most treatment / service required within 72 hours of accident; Once per accident per insured person Emergency Room $200 Urgent Care Center $125 Initial Physician Office Visit $100 Ambulance Up to $1,500 Specified Injuries 1,2 Fractures (Surgical / Non-surgical) Up to $8,000/Up to $4,000 Dislocations (Surgical / Non-surgical) Up to $10,000/Up to $5,000 Lacerations Up to $1,000 Burns Up to $20,000 Dental Up to $400 Hospital, Surgical & Diagnostic 1,3 Admission $1,500 Daily Confinement (Up to 365 days per accident) $300 per day ICU Confinement (Up to 15 days per accident) $600 per day Rehab. Facility Confinement (Up to 30 days per accident) $150 per day Surgical Up to $2,000 Diagnostic Up to $300 Follow-Up Care 1 – Treatment / service required within 365 days of accident; Medical device is once per accident per insured person Physician Follow-Up Office Visit $75; Up to 6 per accident Therapy Services $25; Up to 6 per accident Medical Device $100 Prosthetic Device(s) $750; Up to 2 per accident Additional Benefits 1 – Benefits are payable within 365 days of accident Transportation (Up to 3 trips per accident) $300 per trip Lodging (Up to 30 nights per accident) $125 per night Childcare (Up to 30 days per accident) $20 per day Catastrophic Benefits 1 ,4 – Benefits are payable within 365 days of accident; Once per accident per insured person Principal Sum (PS) You: $25,000
Spouse: $10,000 Child(ren): $5,000
Common Carrier Accidental Death Transportation of Remains Dismemberment & Paralysis Reasonable Modifications
300% of PS Up to $5,000
Up to 100% of PS Up to 10% of PS
Coma
50% of PS
SERVICES Hearing Discount Program
The Hearing Discount program provides you and your family discounted hearing products, including hearing aids and batteries. Call 1-888-534-1747 or visit www.amplifonusa.com/mutualofomaha to learn more.
1 Additional limitations apply as described in the certificate. 2 Fractures and dislocations require treatment within 90 days of accident, burns and lacerations within 72 hours of an accident, and dental care within 30 days. If an insured person sustains both a fracture and dislocation as the result of the same accident, the maximum amount payable is up to 200% of the amount payable for the injury with the highest applicable benefit amount. 3 Daily confinement must begin with 90 days of accident and ICU confinement within 30 days. Surgical treatment timeframes vary. If applicable, diagnostic services must be received within 90 days of accident. Except for confinement benefits, most benefits are payable once per accident per insured person. If any surgery occurs concurrently with an open reduction for a fracture or dislocation of the same bone or joint as a result of the same accident, only the highest applicable benefit is payable. 4 The principal sum for you and your spouse reduces by 50% when you reach the age of 70.
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Critical Illness Insurance
Voluntary Critical Illness Insurance
As an active employee of Infratech Corporation, you can give your family the extra security they need to lessen the financial impact of a serious illness by purchasing Critical Illness insurance through United of Omaha Life Insurance Company. A critical illness insurance policy provides a lump-sum cash benefit upon diagnosis of a critical illness like a heart attack, stroke or cancer. The benefit can be used to pay out-of-pocket expenses or to supplement your daily cost of living. How much insurance is enough? Even if you have the best health insurance plan, it will not cover 100 percent of medical expenses. You also need to consider other expenses associated with the recovery process – time off work, travel to treatment centers, home modifications – that may quickly deplete your savings. Coverage guidelines and benefits are outlined in the chart below.
ELIGIBILITY - ALL ELIGIBLE EMPLOYEES Eligibility Requirement
You must be actively working a minimum of 30 hours per week to be eligible for coverage. To be eligible for coverage, your dependents must be able to perform normal activities, and not be confined (at home, in a hospital, or in any other care facility), and any child(ren) must be under age 26. In order for your spouse and/or children to be eligible for coverage, you must elect coverage for yourself. The premiums for this insurance are paid in full by you. Child insurance is automatic. A separate premium is not required.
Dependent Eligibility Requirement
Premium Payment
BENEFIT CATEGORY 1
CONDITION
% OF CI PRINCIPAL SUM
Heart Attack, Heart Transplant, Stroke, ALS (Lou Gehrig's), Advanced Alzheimer's, Advanced Parkinson's Heart Valve Surgery, Coronary Artery Bypass, Aortic Surgery
100%
Heart/Circulatory/Motor Function
25%
11 INFRATECH CORPORATION 2023 BENEFITS GUIDE G000B59Y
45105
Critical Illness Insurance
Major Organ Transplant/Placement on UNOS List, End-Stage Renal Failure Cerebral Palsy, Structural Congenital Defects, Genetic Disorders, Congenital Metabolic Disorders, Type 1 Diabetes Acute Respiratory Distress Syndrome (ARDS)
100%
Organ
25% 100% 100% 50% 25%
Childhood/Developmental *benefits only available to children
Cancer (Invasive)
Cancer
Bone Marrow Transplant
Carcinoma in Situ, Benign Brain Tumor
COVERAGE GUIDELINES 2
MINIMUM $10,000
MAXIMUM $10,000
GUARANTEE ISSUE 3
$10,000 $10,000
For You Elect in $10,000 increments Spouse Elect in $10,000 increments
$10,000
100% of employee’s CI Principal Sum, up to $10,000
25% of employee’s CI Principal Sum, up to $5,000
$3,000
Child(ren) *benefit for each child
ADDITIONAL BENEFITS Policy Benefit Maximum
The maximum payout amount is 300% of the CI Principal Sum amount for each insured person. If the policy benefit maximum is reached for an insured person, the coverage will terminate. Dependents will remain insured if you continue to satisfy the eligibility requirements of the policy. Once benefits have been paid for a Critical Illness, no additional benefits are payable for that same Critical Illness for each insured person. Benefits are still payable for any other Critical Illness in the same benefit category, for each insured person. The reoccurrence benefit is equal to 100% of the Critical Illness principal sum. When insurance ends, you have the right to continue group Critical Illness insurance for yourself and your dependents.
Additional Occurrence Benefit
Reoccurrence Benefit
Portability
CONDITIONS & LIMITATIONS Benefit Waiting Period
There is no benefit waiting period.
SERVICES Hearing Discount Program
The Hearing Discount Program provides you and your family discounted hearing products, including hearing aids and batteries. Call 1-888-534-1747 or visit www.amplifonusa.com/mutualofomaha to learn more. Advocacy services give an employee who has been diagnosed with a medical condition access to skilled clinicians and nurses for personalized, problem- solving assistance in a one-on-one setting. Call 1-866-372-5577 Monday – Friday 7 A.M. to 7 P.M. CST or email careadvocates@gilsbar.com for assistance.
Advocacy
1 Payment of a partial benefit reduces the remaining amount payable in a category . 2 The amount of insurance for your spouse and child(ren) will be rounded to the next higher multiple of $1,000, if not already an even multiple of $1,000. 3 Subject to any reductions, Guarantee Issue is available to new hires. Amounts over the Guarantee Issue will require a health application/evidence of insurability. For late entrants, all amounts will require a health application/evidence of insurability. Amounts over the Guarantee Issue and/or not meeting minimum participation levels will require a health application/evidence of insurability.
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Employee Benefit Assistants You Can Count on M ember C laims A dvocate
Infratech Corporation provides you and your family members a complimentary member claims service to help with claims, billing, missing ID cards and more. give member claims advocate a call if : • You received a provider bill or EOB and feel the claim was processed incorrectly • You are at the doctor or pharmacy and having trouble with your coverage • You need to confirm if a provider is In-Network • You are missing your ID card Y ou can reach the M ember C laims A dvocate team by phone or email
Monday through Friday, 8:30 AM EST - 5:00 PM EST
Billy Eissler - beissler@yatesins.com Jonathan Massey - jmassey@yatesins.com (404) 633-4321
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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-Pocket maximum? The Medical Out-of-Pocket maximum is the maximum amount a member must pay during the policy year for covered essential health benefits. The OOP includes a member’s deductible and any coinsurance member responsibility. The Pharmacy OOP includes only pharmacy co-pays. The Medical OOP does NOT include monthly premiums, or billing from out-of-network providers. What is an in-network vs out-of-network provider? Cigna contracts with a wide range of doctors, as well as specialists, hospitals, labs, radiology facilities and pharmacies. These are the providers that are considered “in your network”. Specifically, each of these providers has agreed to accept Cigna’s contracted rate for your medical care and services rendered. The contracted rate includes both Cigna’s share of the cost, and the member’s. Your share may be in the form of a co-payment, deductible, or co-insurance. For example, Cigna’s contracted rate for a primary care visit might be $125. The Plan has a $25 co-payment for the visit; the member will pay $25 of the cost and your insurance plan will pay the remaining $100. An “out-of-network” provider is a medical doctor or facility that is not in contract with Cigna. This means that the provider may charge members higher rates for medical services and care, outside of the standard “in-network” rates. For example, a out-of- network provider may charge $200 for a primary care visit. Cigna may pay an adjustment of an out-of-network benefit of $80 dollars to the provider, so the member may be balance-billed for the remaining $120 cost of the visit.
When can I change my beneficiary information for my Basic Life Insurance? Any time! It is important that all beneficiary information be kept up-to-date. You may need to change it after a marriage, divorce, or birth of a child. You can go into Employee Navigator at anytime to update your beneficiary.
Term
Definition
Network Office Visit (PCP) The “per visit” co-pay cost for a primary care or standard network doctor.
The “per visit” co-pay cost for a specialized doctor (cardiologist, OB/GYN,
Specialist Office Visit
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
14 INFRATECH CORPORATION 2023 BENEFITS GUIDE
Legal Notices
Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free or Low-Cost Health Coverage to Children and Families If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www. healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www. insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2021. Contact your State for more information on eligibility –
ALABAMA - Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447 ALASKA - Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: Customer Service@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default. aspx ARKANSAS - Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447) COLORADO - Medicaid Website: http://www.colorado.gov/hcpf Customer Contact Center: 1-800-221-3943 KANSAS - Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512 KENTUCKY - Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570 LOUSIANA - Medicaid Website: http://dhh.louisiana.gov/index.cfm/ subhome/l/n/331 Phone: 1-888-695-2447
FLORIDA - Medicaid Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268 GEORGIA - Medicaid Website: http://dch.georgia.gov/medicaid - click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507 INDIANA - Medicaid Healthy Indiana Plan for Low-Income Adults 19-64 Website: http://www.hip.in.gov Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone: 1-800-403-0864 IOWA - Medicaid Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 MAINE - Medicaid Website: http://maine.gov/dhhs/ofi/public-assistance/ index.html Phone: 1-800-442-6003 TTY: Maine relay 711
MASSACHUSETTS - Medicaid and CHIP Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120 MINNESOTA - Medicaid Website: http://mn.gov/dhs/ma/ Phone: 1-800-657-3739
15 INFRATECH CORPORATION 2023 BENEFITS GUIDE
Legal Notices
MISSOURI - Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
RHODE ISLAND - Medicaid Website: http://www.eohhs.ri.gov/ Phone: 401-462-5300 SOUTH CAROLINA - Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 SOUTH DAKOTA - Medicaid
Phone: 573-751-2005 MONTANA - Medicaid Website: http://dphhs.mt.gov/ MontanaHealthcarePrograms/HIPP
Phone: 1-800-694-3084 NEBRASKA - Medicaid
Website: http://www.dhhs.ne.gov/Children_Family_ Services/AccessNebraska/Pages/accessnebraska_ index.aspx Phone: 1-855-632-7633 NEVADA - Medicaid Website: http://dwss.nv.gov/ Phone: 1-800-992-0900 NEW HAMPSHIRE - Medicaid Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 NEW JERSEY - Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/ medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 NEW YORK - Medicaid Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA - Medicaid Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100 NORTH DAKOTA - Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825 OKLAHOMA - Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 OREGON - Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075 PENNSYLVANIA - Medicaid Website: http://www.dhs.pa.gov/hipp Phone: 1-800-692-7462
Website: http://dss.sd.gov Phone: 1-888-828-0059 TEXAS - Medicaid Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 UTAH - Medicaid and CHIP Medicaid Website: http://health.utah.gov/medicaid CHIP Website: http://health.utah.gov/chip
Phone: 1-877-543-7669 VERMONT - Medicaid Website: http://www.greenmountaincare.org Phone: 1-800-250-8427 VIRGINIA - Medicaid and CHIP Medicaid & CHIP Website: http://www.coverva.org/programs_premi - um_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282 WASHINGTON - Medicaid Website: http://www.hca.wa.gov/free-or-low-costhealth-care/pro - gram-administration/premiumpayment- program Phone: 1-800-562-3022 ext. 15473 WEST VIRGINIA - Medicaid Website: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/ default.aspx Phone: 1-877-598-5820, HMS Third Party Liability WISCONSIN - Medicaid and CHIP Website: http://www.dhs.wisconsin.gov/publications/p1/p10095.pdf
Phone: 1-800-362-3002 WYOMING - Medicaid Website: http://wyequalitycare.acs-inc.com/ Phone: 307-777-7531
To see if any more States have added a premium assistance program since January 31, 2021, or for more information on special enrollment rights, you can contact either:
U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/ebsa 1-866-444-EBSA (3272)
U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565
16 INFRATECH CORPORATION 2023 BENEFITS GUIDE
Legal Notices
Important Notices about Medical Coverage
HIPAA Special Enrollment Rights
These benefits will be provided subject to the same deductibles and co-insurance applicable to other medical and surgical benefits provided under this plan. Our plan complies with these requirements. Benefits for these items generally are compatible to those provided under our plan for similar types of medical services and supplies. Of course, the extent to which any of these items is appropriate following mastectomy is a matter to be determined by consultation between the attending physician and the patient. Our plan neither imposes penalties (for example, reducing or limiting reimbursements) nor provides incentives to induce attending providers to provide care inconsistent with these requirements. If you would like more information on WHCRA benefits, call Yates LLC at (706) 323-1600.
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself or your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must enroll within 30 days after the marriage, birth, adoption, or placement for adoption. Effective April 1, 2009 special enrollment rights also exist in the following circumstances: • If you or your dependents experience a loss of eligibility for Medicaid or your State Children’s Health Insurance Program (SCHIP) coverage; or • If you or your dependents become eligible for premium assistance under an optional state of Medicaid or SCHIP program that would pay the employee’s portion of the health insurance premium. NOTE: In the two above listed circumstances only, you or your dependents will have sixty (60) days to request special enrollment in the group health plan coverage. An individual must request this special enrollment within sixty (60) days of the loss of coverage described at bullet one, and within sixty (60) days of when eligibility is determined as described in bullet two. Women’s Health and Cancer Rights Act of 1998 Annual Notice If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for all stages of reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses; and treatment of physical complications of the mastectomy, including lymphedema.
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, not withstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa. opr@dol.gov and reference the OMB Control Number 1210- 0137.
17 INFRATECH CORPORATION 2023 BENEFITS GUIDE
Medicare Part D
Medicare Part D Notice of Creditable Coverage
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Infratech Corporation and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your currant coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Infratech Corporation has determined that the prescription drug coverage offered by Sun Life Blue Cross Blue Shield plans are on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join a Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens to Your Current Coverage if You Join a Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Infratech Corporation coverage may or may not be affected. See pages 7-9 of the CMS Disclosure of Creditable Coverage to Medicare Part D Eligible Individuals Guidance (available at https://www.cms.hhs.gov/Creditable Coverage/ ), which outlines the prescription drug plan provisions / options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D. If you do decide to join a Medicare drug plan and drop your current Infratech Corporation coverage, be aware that you and your dependents may or may not be able to get this coverage
back. When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Infratech Corporation and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without a creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For further information, call Yates LLC at (706) 323- 1600. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Infratech Corporation changes. You may also request a copy of this notice at any time. More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Medicare Part D Notice of Creditable Coverage, cont. Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help. Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity. gov , or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium.
18 INFRATECH CORPORATION 2023 BENEFITS GUIDE
COBRA
What is COBRA continuation health coverage? The Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions amend the Employee Retirement Income Security Act, the Internal Revenue Code and the Public Health Service Act to require group health plans to provide a temporary continuation of group health coverage that otherwise might be terminated. What does COBRA do? COBRA requires continuation coverage to be offered to covered employees, their spouses, former spouses, and dependent children when group health coverage would otherwise be lost due to certain specific events. COBRA continuation coverage is often more expensive than the amount that active employees are required to pay for group health coverage, since the employer usually pays part of the cost of employees’ coverage and all of that cost can be charged The law generally applies to all group health plans maintained by private-sector employers with 20 or more employees, or by state or local governments. The law does not apply to plans sponsored by the Federal Government or by churches and certain church-related organizations. In addition, many states have laws similar to COBRA, including those that apply to health insurers of employers with less than 20 employees (sometimes called mini-COBRA). Check with your state insurance commissioner’s office to see if such coverage is available to you. Who is entitled to continuation coverage under COBRA? In order to be entitled to elect COBRA continuation coverage, your group health plan must be covered by COBRA; a qualifying event must occur; and you must be a qualified beneficiary for that event. Plan Coverage COBRA covers group health plans sponsored by an employer (private-sector or state/local government) that employed at least 20 employees on more than 50 percent of its typical business days in the previous calendar year. Both full- and part-time employees are counted to determine whether a plan is subject to COBRA. Each part-time employee counts as a fraction of a full-time employee, with the fraction equal to the number of hours that the part-time employee worked divided by the hours an employee must work to be considered full time. Qualified Beneficiaries A qualified beneficiary is an individual covered by a group health plan on the day before a qualifying event occurred that caused him or her to lose coverage. Only certain individuals can become qualified beneficiaries due to a qualifying event, and the type of qualifying event determines who can become a qualified beneficiary when it happens. A qualified beneficiary must be a covered employee, the employee’s spouse or former to individuals receiving continuation coverage. What group health plans are subject to COBRA?
spouse, or the employee’s dependent child. In certain cases involving the bankruptcy of the employer sponsoring the plan, a retired employee, the retired employee’s spouse or former spouse, and the retired employee’s dependent children may be qualified beneficiaries. In addition, any child born to or placed for adoption with a covered employee during a period of continuation coverage is automatically considered a qualified beneficiary. An employer’s agents, independent contractors, and directors who participate in the group health plan may also be qualified beneficiaries. Are there alternatives for health coverage other than COBRA? If you become entitled to elect COBRA continuation coverage when you otherwise would lose group health coverage under a group health plan, you should consider all options you may have to get other health coverage before you make your decision. There may be more affordable or more generous coverage options for you and your family through other group health plan coverage (such as a spouse’s plan), the Health Insurance Marketplace, or Medicaid. If you become entitled to elect COBRA continuation coverage when you otherwise would lose group health coverage under a group health plan, you should consider all options you may have to get other health coverage before you make your decision. There may be more affordable or more generous coverage options for you and your family through other group health plan coverage (such as a spouse’s plan), the Health Insurance Marketplace, or Medicaid. Under the Health Insurance Portability and Accountability Act (HIPAA), if you or your dependents are losing eligibility for group health coverage, including eligibility for continuation coverage, you may have a right to special enroll (enroll without waiting until the next open season for enrollment) in other group health coverage. For example, an employee losing eligibility for group health coverage may be able to special enroll in a spouse’s plan. A dependent losing eligibility for group health coverage may be able to enroll in a different parent’s group health plan. To have a special enrollment opportunity, you or your dependent must have had other health coverage when you previously declined coverage in the plan in which you now want to enroll. You must request special enrollment within 30 days from the loss of your job- based coverage. Losing your job-based coverage is also a special enrollment event in the Health Insurance Marketplace). The Marketplace offers “one-stop shopping” to find and compare private health insurance options. In the Marketplace, you could be eligible for a tax credit that lowers your monthly premiums and cost-sharing reductions (amounts that lower your out-of- pocket costs for deductibles, coinsurance and co-payments), and you can see what your premium, deductibles, and out-of- pocket costs will be before you make a decision to enroll.
19 INFRATECH CORPORATION 2023 BENEFITS GUIDE
Exchange Notices
New Health Insurance Marketplace Coverage Options and Your Health Coverage
Form Approved OMB No. 1210-0149 (expires 6-30-2023)
PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance : the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment based health coverage offered by your employer. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014. Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. 1 Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact . The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.
1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by
the plan is no less than 60 percent of such costs.
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