Presentation Title

2025 Mid-Year Education

Presented by Brio Benefits

Qualifying Life Events (QLEs) & Special Enrollments (SEPs)

Qualifying Life Events (QLEs) are specific situations that allow employees and their dependents to enroll, make changes, or cancel their health insurance coverage outside of the standard open enrollment period. When a QLE occurs, employees are granted a Special Enrollment Period (SEP) of 30 days from the start of your event.

Loss of other coverage (Loss of dependent status)

Birth or adoption of a child

Marriage or divorce

Termination of Medicaid or change in income that affects your subsidy eligibility.

Permanent move to an area that affects your current health plan.

Becoming a U.S. citizen or lawfully present resident

Your Medical Plans

California Only Health Maintenance Organization (HMO)

Cigna HMO (Southern California Network)

Coinsurance

Cigna pays 100%

HMO health plan offers a local network of doctors and hospitals for you to choose from. ✓ In-Network PCP is required ✓ Referrals to a specialist are need except for OB/GYNs ✓ Out-of-network coverage is permitted for emergency care only, as defined by the plan.

Deductible Individual / Family

$500 / $1,000

Out-of-pocket Max Individual / Family

$3,000 / $6,000

Preventative Care

Covered at 100%

Office Visit PCP/Specialist

$20 Copay

Emergency Room $200 Copay

Waived if Admitted

Urgent Care

$25 Copay

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

Rx Copays

$10 / $25 / $45

High-Deductible Health Plan (HDHP) vs Traditional Plans

HDHP

TRADITIONAL

Preventive Services covered at 100% before deductible is met.

Preventive Services covered at 100% before the deductible is met.

Lower monthly premiums

Higher monthly premiums

Copays apply for Rx, office, ER & Urgent Care. All other medical services must meet the deductible before coinsurance applies.

Non-preventative and Rx deductibles must be meet before Rx copays and medical coinsurance applies.

Can contribute to an HSA

Cannot contribute to an HSA

Lower deductible & out- of-pocket maximums

Higher deductible & out- of-pocket maximums

Gersh Plan Example HDHP vs Traditional

Open Access Plus HDHP / HSA Plan

Services

New - Open Access Plus PPO Plan

Plan Pays 90% / You Pay 10%

Coinsurance

Plan Pays 70% / Your Pay 30%

$2,000 / $4,000 Individual in a Family Max: $3,300

Deductible

$2,500 / $5,000

$4,000 / $8,000

Out-of-Pocket Max (Individual/Family)

$5,000 / $10,000

No Charge

Preventative Care

No Charge

10% after Deductible

Office Visit PCP / Specialist

$30 Copay / $50 Copay

10% after Deductible

Emergency Room

$350 Copay then 30% after deductible

$10 / $40 / $60

Rx Copays

$15 / $35 / $70

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

With Gersh Contributions Health Savings Account (HSA)

An HSA is available to those with a High-Deductible Health Plan (HDHP) and allows funds to be saved tax-free, with unused money rolling over from year to year.

Gersh Contributes

$750 | $1,500

+ You Contribute

$ ______________________________________ ≤ IRS Contribution Limit $4,300 | $8,550

* Gersh contributions are prorated based on your date of hire.

Flexible Saving Accounts (FSA) Dependent Care FSA

Use-it- or-lose-it MUST enroll annually or be termed. Pre-Tax Savings Account

Care for your dependent who is under age 13*

✓ Before and after school care ✓ Babysitting and nanny expenses ✓ Daycare, nursery school, and preschool ✓ Summer day camp Care for your spouse or a relative who is physically or mentally incapable of self-care and lives in your home.

* You and your spouse must be working or looking for work to utilize funds.

Medical In-Network vs Out-of-Network(OON)

Medical In-Network vs Out-of-Network (OON)

In-Network

Out-of-Network

Providers have agreed to accept discounted rates for covered services that cannot be exceeded.

There are no discounted rates for covered service. Providers can charge full price.

Rates

Cost sharing is available through copays, lower coinsurance %, deductibles and OOP maximums.

There are no copays, and you will be responsible for a higher coinsurance %, deductibles and OOP maximums. You will be responsible for filing your OON claim for potential reimbursement.

Cost

Claims are filed by your provider.

Claims

For emergency services , as defined by your plan documents, plans are legally required to process claims and member responsibility at in-network rates.

Dental & Vision Plans

Gersh Plan Example DHMO vs DPPO

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

DHMO

DPPO

In-Network

Out-of-Network

Annual Deductible Individual | Family

None

$50 | $150

Calendar Year Plan Max

Unlimited

$2,500 per person

100% Deductible Waived

Preventive Care Benefits

100% Deductible Waived

$5 Copay

Refer to Copay Schedule

100% Deductible Waived

You pay 20% after deductible

Basic Services

Refer to Copay Schedule

You pay 40% after deductible

You pay 50% after deductible

Major Services

Orthodontia (Child | Adult)

$1,104 to $5,425

50% up to $2,000 Lifetime Maximum

Gersh Vision Plan

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

In Network

Out-of-Network

Eye exam (1 per calendar year)

$10 Copay

Up to $45 reimbursement

Lenses (Single / Bifocal / Trifocal / Lenticular) (1 per calendar year)

Covered at 100% after $10 Copay

Up to ($32 / $55 / $65 / $80) reimbursement

Frame allowance (1 per calendar year)

$130 Allowance

Up to $71 reimbursement

Elective Contacts (1 per calendar year)

$130 Allowance

Up to $105 reimbursement

Medically Necessary Contacts (1 per calendar year)

Covered at 100%

Up to $210 reimbursement

Your Responsibility

Deductibles

A deductible is the amount you pay for most eligible medical services or medications before your health plan begins to share in the cost of covered services.

It is an out-of-pocket cost that the insured must remit either monthly or annually.

Individual Deductible vs Family Deductible

A family deductible is the maximum amount that a family needs to meet for coinsurance to kick in for everyone in the family. Family Deductible Plans - costs for all your family members throughout the plan year are added together and applied toward the family deductible. Family Plans with Individual Deductibles (Embedded Deductible) - an overall family deductible and each family member also has their own individual deductible

An individual deductible is the amount one person needs to meet for coinsurance to kick in.

Copay vs Coinsurance

You’ve met your annual deductible of $2,000 and have to visit the ER later in the year.

Copays

Coinsurance

Paid each time you visit your doctor or pharmacy.

Paid for services and medicines if you’ve met your deductible.

The hospital bills $20,000. Cigna allows $12,000 of the charge.

Fixed dollar amount.

Actual dollar amount varies.

May count towards your deductible.

Paid after you meet your deductible.

Cigna will pay $10,800. ($12,000 x 90%)

Paid at the time of service.

Billed by the provider who you will pay directly.

You will pay your coinsurance, $1,200 ($12,000 x 10%)

Out-of-Pocket Maximum (OOP) Out-of-pocket maximum is a cap, or limit, on the amount of money you will need to pay for covered health care services in a plan year.

Deductibles

Copays

Coinsurance

OOP Max

Out-of-Network (OON) Balance Billing

Out-of- Network

In-Network

Open Access Plus PPO IN: 70% | OUT: 50%

You need a procedure and visit a surgery center.

Your EOB has become available in your member portal so you can now view your patient responsibility.

Two weeks later you receive a bill from your provider.

Explanation of Benefits (EOBs)

Explanation of Benefits (EOB)

An EOB is a statement from your health insurance plan describing what costs it will cover for medical care or products you’ve received.

Money Saved In-network

OOP Medical Expenses

Cost Of Care

➢ Where your claim was sent and processed.

➢ Where the EOB is being sent. ➢ What the EOB is. ➢ Office visit information.

➢ Who the claim is for (Dependent or Subscriber).

➢ Who the patient saw. ➢ What the service cost. ➢ How much you saved with insurance. ➢ What you may owe.

Continue to Pg. 2

➢ Glossary of terms

➢ Instructions for claims appeals

➢ Contacts for claims assistance

Continue to Pg. 3

➢ Breakdown of service codes, what was owed, paid, and your responsibility.

➢ What’s left of your responsibility.

➢ Information for appeals and explanation of charges.

Your Resources

Your Cigna ID Card

1 st Day of coverage Your Employer & Group #

Your elected plan

Copay and coinsurance info Deductible and Out-of- Network info

Your member ID and name

Rx information

MyCigna.com and Cigna Mobil Find Care and Costs Search for in-network providers, procedures, cost estimates, and more.

Manage Spending Accounts Review your spending account balances, contributions, and withdrawals, all in one place.

View Claims See a list of your most recent claims, their status, and reimbursements.

Access Your Digital ID Cards Get on-the-go access to your digital ID card or proof of coverage wherever you are, from the web or mobile app.

Enhanced Resources for Cigna Members

Lifestyle Benefits ✓ Cigna Healthy Rewards ® to save money on health and wellness products and services. ✓ Online coaching programs help you maintain a healthy lifestyle ✓ Personal health coaches to help improve your health and wellness Programs to help you better manage stress, quit tobacco or lose weight ✓ Simple, online health assessment designed to help you live a healthier life Mental Health Benefits ✓ Free Veteran Support Line available 24/7/365 to all veterans by calling 855.244.6211 ✓ Talkspace ✓ Headspace Medical Services ✓ Price Assure by Cigna through GoodRx ✓ Answers by Cigna for Amazon Alexa ✓ MD Live- Telemedicine services

HealthJoy

A Better Employee Benefits Experience

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

You also have access to unlimited MeMd for Virtual Medical Care and Virtual Mental Health at no cost!

BENEFITS WALLET

HEALTHCAR E CONCIERGE

RX SAVINGS REVIEW

APPOINTMEN T BOOKING

HSA / FSA SUPPORT

PROVIDER RECS

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

Questions? Contact HR:

▪

Lourdes Clarke

Carrier Contact Information

lclarke@gersh.com

•

212-634-8161

•

Benefit

Provider

Phone

Website

▪

Nicole Dosso

NDosso@gersh.com

•

Medical

Cigna

(800) 244-6224

myCigna.com

212-634-8117

•

Dental (PPO / DHMO)

Cigna

(800) 595-7114

myCigna.com

Vision

Cigna

(866) 939-3633

myCigna.com

Glossary of Terms

Life / AD%D and LTD

Mutual of Omaha

(800) 877-5176

MutualOfOmaha.com

Accident, Critical Illness, Hospital Indemnity

Cigna

(800) 754-3207

SuppHealthClaims.com

Download App on Smart Phone

Telemedicine / Health Wallet

HealthJoy

(877) 500-3212

Employee Assistance Program Health Savings Account (HSA) Flexible Spending Account (FSA) (LFSA) and Commuter Benefits Family Planning & Women’s Health EAP

Mutual of Omaha

(800) 316-2796

MutualOfOmaha.com

HSA Bank

(800) 244-6224

My.Cigna.com

WEX

(866) 451-3399

WexInc.com

Carrot

Thank You!

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