SoulCycle 2020 PT Benefit Guide

WELCOME

SoulCycle started a revolution more than 13

years ago - and we haven’t stopped

building our communities since, outside

and in. As an important part of our

#SoulFam community, we strive to create

an environment where you feel rewarded for

your hard work and dedication to bringing

Soul to the People every single day. We see our

benefits program as one way we’re able to do

that, while supporting your overall health and

wellness.

This guide provides an overview of

the program for part time SoulCycle

employees. Please review it carefully

and use the guide to help you make

the most- informed decisions. You’ll

definitely get the greatest value from

your benefits by educating yourself!

ADDITIONAL BENEFITS

WELL-BEING

WEALTH

NOTICES

RESOURCES

SmartBEN SmartBEN Assist

Contacts

SmartBen contains your benefits,

LOGIN Go to ENROLL.SMARTBEN.COM and enter your username and password:

personalized communications

Username: First initial+last name+last 4 digits of SSN+SC (ex: jsmith4893SC) Password: Date of birth as MMDDYYYY (ex: 06211981)

and decision making tools to help you efficiently manage your benefits.

NAVIGATE From your custom home page you can navigate through your benefit tools.

ENROLL Click on BEGIN ENROLLMENT from the main menu. Items with red lights will show you which benefits need your attention.

MANAGE Deciding how to manage your benefits and elections is a personal decision. Use the decision making tools to make the best choices for you.

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ADDITIONAL BENEFITS

WELL-BEING

WEALTH

NOTICES

RESOURCES

SmartBEN SmartBEN Assist

Contacts

Assist

SmartBen Assist is a one-stop contact center to help you and your family members with benefits inquiries.

HELP STARTS HERE SmartBen Assist is an employee benefits resource center that provides comprehensive support for benefits questions and enrollment activities throughout the year.

WEBSITE

www.smartben.com

For service that’s confidential and responsive, contact:

877.260.7563 SoulCycle@SmartBenAssist.com

COMPLETELY CONFIDENTIAL! Your dedicated SmartBen Assist advocates understand your benefit plans and are able to answer benefit questions. A majority of inquiries are resolved the same day and all calls adhere to privacy best practices. For escalated claims-specific issues, you and your family members can contact Aurora Vasil at Brio Benefit Consulting by calling 646-790-7982 or emailing avasil@briobenefits.com.

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2020 HIGHLIGHTS

ADDITIONAL BENEFITS

WELL-BEING

WEALTH

NOTICES

RESOURCES

CONTACTS

SmartBEN SmartBEN Assist

Contacts

TRANSIT AND PARKING Benefit Resource Inc. 800.473.9595 BENEFITRESOURCE.COM

401(k) PLAN Empower Retirement 888.411.4015 EMPOWER-RETIREMENT.COM

EMPLOYEE ASSISTANCE PLAN Mutual of Omaha 800.316.2796 MUTUALOFOMAHA.COM HEARING DISCOUNT PROGRAM AMPLIFONUSA.COM/MUTUALOFOMAHA 888.534.1747 WORLDWIDETRAVELASSISTANCE Mutual of Omaha 800.856.9947 (inside the U.S.) 312.935.3658 (outside the U.S. - call collect)

LEGAL ASSISTANCE Rocket Lawyer 877.881.0947 GO.ROCKETLAWYER.COM/SOULCYCLE

STUDENT LOANASSISTANCE CommonBond 800.975.7812 CBPARTNER.CO/SOULCYCLE

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2020 HIGHLIGHTS

ADDITIONAL BENEFITS

RESOURCES

WEALTH

NOTICES

WELL-BEING

LiveHealth Hearing EAP

LIVEHEALTH

LIVEHEALTH 888.548.3432 LIVEHEALTHONLINE.COM

When you need to see a doctor, use LiveHealth Online to have a video visit with a board-certified doctor, 24/7 on your smartphone, tablet or computer with a webcam. It’s easy to use and more convenient than a trip to urgent care.

SIGNUP

• Visit livehealthonline.com or

WHO IS ELIGIBLE? All SoulCycle employees are eligible, even if you are not eligible for benefits or choose not to enroll in the health plan.

download the free mobile app

BENEFITS

Sign up for free and get: •

Immediate, 24/7 access to doctors.

• Prescriptions sent to the pharmacy of your choice, • if needed. • Medical care for common health conditions like the flu, • a cold, sinus infection, pink eye and more!

Doctors using LiveHealth Online typically charge $59 or less per visit, depending on your health plan.

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2020 HIGHLIGHTS

ADDITIONAL BENEFITS

RESOURCES

WEALTH

NOTICES

WELL-BEING

LiveHealth

Hearing

EAP

HEARINGDISCOUNT PROGRAM

AMPLIFON HEARING HEALTH CARE 888.534.1747

AMPLIFONUSA.COM/ MUTUALOFOMAHA

Through a partnership with Amplifon Hearing Health Care,SoulCycle provides hearing aid benefits and discounted hearing screening services to ouremployees.

The national network of credentialed hearing care professionals and clinics are dedicated to helping you hear better with custom hearing solutions from the leading manufacturers at negotiated low prices.

PROGRAMBENEFITS

About 36 million Americans have a hearing loss, according to the Center for Disease Control and Prevention .

• Low price guarantee on hearingaids • Discount on hearing testing and diagnostics • Continuous care: One year free follow-up, three year warranty and two years freebatteries • Risk Free 60-day trial period with money back guarantee • ...and more

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2020 HIGHLIGHTS

ADDITIONAL BENEFITS

RESOURCES

WEALTH

NOTICES

WELL-BEING

LiveHealth

Hearing EAP

EMPLOYEEASSISTANCE PROGRAM (EAP)

MUTUAL OF OMAHA 888.316.2796 MUTUALOFOMAHA.COM/EAP

Life’s not always easy. Sometimes a personal or

The EAP provides you and your family:

• Experienced EAP Staff • Master’s level professionals who can provide assistance for a variety of personal and professional matters • Emotional well-being • Family and relationships • Legal and financial • Health lifestyles • Work and Life transitions

• Work/Life balance • Substance abuse • Dependent and elder care assistance and referral services • Access to a library of educational articles, handouts and resources via website WHAT TO EXPECT Information gathered by the EAP is confidential – the EAP with SoulCycle about your situation unless there is a risk of others. Your EAP benefits are provided through SoulCycle. There is no cost to you for utilizing EAP services. If additional resources are needed, your EAP will help locate appropriate providers in your area.

professional issue can get in the way of maintaining a healthy, productive life.

EAPBENEFITS

• Unlimited telephone access to EAP professionals 24 hours a day, seven days a week • Telephone assistance and referral • Service for employees and eligible dependents • Legal assistance and financial services • Will Preparation • Legal library and online forms

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ADDITIONAL BENEFITS

RESOURCES WELL-BEING

WEALTH

NOTICES

401(K) PLAN

EMPOWER RETIREMENT 888.411.4015 EMPOWER-RETIREMENT.COM

401(K) In order to help you save for retirement, SoulCycle offers eligible employees the opportunity to voluntarily contribute to the SoulCycle 401(k) Plan. You are eligible to enroll on the 1 st of the month following 30 days of employment.

NEED HELP UNDERSTANDINGHOWMUCH TO CONTRIBUTE? HighTower Fiduciary Plan Advisors is a team of advisors that SoulCycle has selected to provide fiduciary advice to you as a participant in SoulCycle’s retirementplan.

HIGHTOWER 443.578.3201 401KADVISOR@HTFPA.COM

Eligible employees may enroll online anytime at EMPOWER- RETIREMENT.COM or by callingEmpower Retirement directly at 888.411.4015. You may defer up to 100% of your annual earnings to a maximum amount determined by the IRS each year ($19,500 in 2020). Employees who are or will become age 50 or older are eligible to defer an additional sum of money to the plan ($6,500 in 2020). If you are interested in enrolling in this catch-up provision, please contact theBenefits Department. All contributions can be made on a pre-tax basis. You direct how your contributions are invested with a wide range of fund options. SoulCycle provides a discretionary match, after one year of employment. The match is currently equal to 50% of the first 3% of your deferral contributions to a maximum deferral rate of 1.5%. The match may be provided to all eligible employees who are actively employed at the endof the plan year (December 31 st ).

HighTower Fiduciary Plan Advisors also provides the following services to you as a planparticipant:

YOUR 401(K)

You can enroll and make changes

• Answer questions on the available investments • Provide educational webinars on retirement topics • Assists in developing an investment strategy • Provide in-person, group and 1-on-1 meetings • Provide phone support for 1-on-1 investmentadvice • Provide newsletters and Financial Wellnessprograms If you have a question that you would like to discuss with HighTower Fiduciary Plan Advisors or you would like to schedule a meeting with one of their advisors, contact them at 443.578.3201, or send your questionsto 401KADVISOR@HTFPA.COM

to your retirement plan at any time

during the year after you are eligible

to participate.

ENROLL

• Go to EMPOWER-RETIREMENT.COM

• Click on LOGIN

• Click on INDIVIDUAL

• Click on RETIREMENT PLAN

• Click on REGISTER

• Enter your SSN, home zip code, last name, date of birth and the numeric portion of your street address

• Click CONTINUE

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ADDITIONAL BENEFITS

RESOURCES

WELL-BEING

WEALTH

NOTICES

Transit and Parking

Legal and Student Loan

Travel

ADDITIONAL BENEFITS

BENEFIT RESOURCES INC. 800.473.9595 BENEFITRESOURCE.COM

TRANSIT AND PARKING SoulCycle has set up a plan that lets you setaside pre-tax dollars to pay for qualified employment-related transportation and commuter parking expenses. Toparticipate in the plan, you simply estimate your qualified transportation expenses for the year, and enroll online indicating your estimated monthly expense(s). This amount may be changed on a monthly basis. There is a monthly limit of $270 for transit and $270 for parking. There will be an appropriate deduction amount pre-tax from your first paycheck of the month to credit your Parking and/or Transit Reimbursement account. You can then use the funds from these accounts to pay for your eligible transportation expenses by paying with your BRI Benefits Card. Upon termination, you have 90 days to submit claims for expenses incurred while actively employed.

There are two qualified transportation benefits:

• Qualified Parking: Expenses for parking at or near SoulCycle’s business premises or parking at or near a location from which you commute to work by mass transit, vanpooling, carpool, etc. • Transit Passes and Vanpooling: Expenses for any pass, fare card or similar item that entitles you to transportation on a mass transit system to and from work or for the cost of transportation between your place of residence and place of employment in a commuter vehicle that has a seating capacity of 6 persons or more (not including the driver) where at least 80% of the mileage used for the year is for the purpose of transporting employees to their place of employment.

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2020 HIGHLIGHTS

ADDITIONAL BENEFITS

RESOURCES

WELL-BEING

WEALTH

NOTICES

Transit and Parking

Legal and Student Loan

Travel

ADDITIONAL BENEFITS

WORLDWIDE TRAVEL ASSISTANCE ID NUMBER: 99ØØMOO2 800.856.9947 (IN THE U.S.) 312.935.3658 (OUTSIDE THE U.S.)

WORLDWIDE TRAVEL ASSISTANCE Experiencing an emergency while traveling can be especially difficult. Knowing who to call for medical problems, currency exchange issues or lost luggage is critical. Take comfort in knowing that Travel Assistance travels with you worldwide, offering access to a network of professionals who can help you with local medical referrals or provide other emergency assistance services in foreign locations.

EMERGENCY TRAVEL SUPPORT SERVICES Provides 24/7 access to telephone translation and interpreter services:

• Locating legal services • Baggage • Emergency payment and cash

MEDICAL ASSISTANCE

PRE-TRIP ASSISTANCE Minimize travel hassles by calling us pre-departure for:

• Locating medical providers and referrals • Communication on your medical status with family, physicians, employer, travel company and consulate • Emergency evacuation if adequate medical facilities are not available, including payment of covered expenses • Transportation home for further treatment – in the event of death, assist in the return of mortal remains • Transportation arrangements for the visit of a family member or friend if your hospitalization is more than seven calendar days • Return home for dependent children if your hospitalization is more than seven calendar days IDENTITY THEFT Your Travel Assistance benefit automatically includes Identity Theft Assistance, coordinated at no additional cost. Whether at home or traveling, this benefit provides education, prevention and recovery information to help you protect your identity.

• Information regarding passport, visa or other required documentation for foreign travel • Travel, health advisories and inoculation requirements for foreign countries • Domestic and international weather forecasts • Daily foreign currency exchange rates • Consulate and embassy locations

IMMEDIATE ATTENTION FOR EMERGENCIES WHILE TRAVELING

While traveling more than 100 miles from home you may access Travel Assistance services 24/7 by calling the toll-free number for immediate help from a travel assistance professional.

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2020 HIGHLIGHTS

ADDITIONAL BENEFITS

RESOURCES

WELL-BEING

WEALTH

NOTICES

Transit and Parking

Legal and Student Loan

Travel

ADDITIONAL BENEFITS

ROCKET LAWYER 877.881-0947 GO.ROCKETLAWYER.COM/ SOULCYCLE

ROCKET LAWYER Rocket Lawyer’s online legal assistance program provides you and your family with free resources while going through any of the following events:

COMMONBOND STUDENT LOAN REFINANCING SoulCycle has partnered with CommonBond to help you simplify your student loans – and save money!

COMMON BOND 800.975.7812 CBPARTNER.CO/SOULCYCLE

REFINANCING Refinancing means taking out a new loan – at a lower interest rate – to replace your old loans, helping you to pay down debt faster, or save money in the process.

• Getting Married

• Starting a Family • Buying a Home • Landlord/Tenant Issues

• Speeding Tickets • Estate Planning • Family / Elder Care • Estate Planning • And More!

SMARTER STUDENT LOANS CommonBond’s student loans help you pay for your, or your child's undergraduate or graduate education.

SIGNING-UP IS EASY By visiting cbpartner.co/soulcycle, you’re already well on your way to refinancing or taking out brand-new loans for education purposes. And – by signing up for CommonBond – you’re eligible for a $300 cash bonus when you refinance!

HOW TO ACCESS With Rocket Lawyer, you’ll have access to the following services: • Legal Documents Library: create and sign hundreds of legal documents such as wills, leases, and child care authorization forms • Attorney Q & A: submit a question and receive reliable legal advice within one business day • Attorney Phone Consultations: schedule a free, 30- minute phone call with a Rocket Lawyer attorney specializing in your issue • Attorney Discounts: save up to 40% on lawyers in your area

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ADDITIONAL BENEFITS

RESOURCES

WELL-BEING

WEALTH

NOTICES

NOTICES

In the event a covered employer lawfully (or inadvertently) acquires genetic information, the information must be kept in a separate file and treated as a confidential medical record, and may be disclosed to third parties only in very limited circumstances. SUMMARY OF MATERIAL MODIFICATION This Annual Open Enrollment Communication constitutes a Summary of Material Modifications (“SMM”) which describes changes to your health care program effective January 1, 2020. This SMM is a summary of the changes made to the program and the partial terms of SoulCycle medical plans. The SMM is not an official plan document. The actual terms of the plans are contained in the plan documents. In the event of any discrepancy, or any conflict between this SMM and the official plan documents, the official plan documents will govern. This SMM should be retained with your other benefits information. SPECIAL ENROLLMENT RIGHTS This notice is being provided to insure that you understand your right to apply for group health insurance coverage. You should read this notice even if you plan to waive coverage at this time. Loss of Other Coverage If you are declining coverage for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). Example: You waived coverage because you were covered under a plan offered by your spouse’s employer. Your spouse terminates their employment. If you notify your employer within 30 days of the date coverage ends, you and your eligible dependents may apply for coverage under our health plan. SoulCycle reserves the right to change, amend, or cease these benefits at any time.

• Reconstruction of the breast on which the mastectomy was performed; • Any necessary surgery and reconstruction of the other breast to produce a symmetrical appearance; • Prostheses; and Treatment of physical conditions related to the mastectomy, including lymphedema. Our medical plans comply with these requirements. Benefits for these items are similar to those provided under the plan for similar types of medical services and supplies. WOMEN’S HEALTHAND CANCER RIGHTS ACT Under the Women’s Health and Cancer Rights Act, group health plans must make certain benefits available to participants of health plans who have undergone a mastectomy. In particular, a plan must offer mastectomy patients benefits for: CONTINUED COVERAGE UNDER COBRA Under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), you and your covered dependents may be able to continue certain health care benefits if you lose your coverage as the result of certain qualifying events. Contact the Benefits Department for more information. HIPAA REGULATIONS HELP PROTECT YOUR PRIVACY The privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) help to ensure that your health care- related information stays private. New employees will receive a Privacy Practice Notice which outlines the ways in which the medical plan may use and disclose protected health information (PHI). The notice also describes your rights. For more information, contact the Benefits Department. GENETIC INFORMATION NON-DISCRIMINATION ACT - GINA GINA broadly prohibits covered employers from discriminating against an employee, individual, or member because of the employee’s “genetic information,” which is broadly defined in GINA to mean (1) genetic tests of the individual, (2) genetic tests of family members of the individual, and (3) the manifestation of a disease or disorder in family members of such individual. GINA also prohibits employers from requesting, requiring, or purchasing an employee’s genetic information. This prohibition does not extend to information that is requested or required to comply with the certification requirements of family and medical leave laws, or to information inadvertently obtained through lawful inquiries under, for example, the Americans with Disabilities Act, provided the employer does not use the information in any discriminatory manner.

NEWBORNS’ AND MOTHERS’ HEALTHPROTECTION ACT Under federal law, health care plans may not restrict any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal delivery, or less than 96 hours following a Cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother and with the mother’s consent, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). YOUR RIGHTS UNDER MICHELLE’S LAW Effective January 1, 2010, full-time students covered under the group health plan, that would otherwise lose eligibility under the plan because of a reduction in their full-time class status due to a medically necessary leave of absence from school, may be eligible to extend their coverage under the plan for up to one year, or to age 26, whichever occurs first. The child must be a dependent child of a plan participant and be enrolled in the company group health plan on the basis of being a student at a postsecondary educational institution immediately before the first day of the leave. MENTAL HEALTH PARITY Effective January 1, 2010, the company- sponsored medical plans were modified to cover mental health and substance abuse expenses subject to the same treatment limits, deductibles, copayments, co- insurance and out-of-pocket requirements that apply to other medical and surgical expenses. This change applies to both inpatient and outpatient services. USERRA protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake military service or certain types of service in the National Disaster Medical System. USERRA also prohibits employers from discriminating against past and present members of the uniformed services, and applicants to the uniformed services. The Act also states that if an employee leaves their job to perform military service, they have the right to elect to continue existing employer-based health plan coverage for the employee and their eligible dependents for up to 24 months while in the military. Even if the employee doesn’t elect to continue coverage during their military service, they have the right to be reinstated in their employer’s health plan when they are reemployed, generally without any waiting periods or exclusions (e.g. pre-existing condition exclusions) except for service-connected illnesses or injuries. UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA)

Marriage, Birth, or Adoption If you have a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 3 days after the marriage, birth, or placement for adoption.

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2020 HIGHLIGHTS

ADDITIONAL BENEFITS

RESOURCES

WELL-BEING

WEALTH

NOTICES

NOTICES

COLORADO: Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) Health First Colorado Website: www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1.800.221.3943/ State Relay 711 CHP+: https://www/colorado.gov/pacific/hcpf/Child-Health-Plan-Plus CHP+ Customer Service: 1.800.359.1991/ State Relay 711

TERMINATION OF HEALTHCOVERAGE FOR CAUSE, INCLUDING FRAUD OR INTENTIONAL MISREPRESENTATION

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 July 31, 2019. Contact your State for more information on eligibility.

SoulCycle reserves the right to terminate health care coverage for you and/or your dependent prospectively without notice for cause (as determined by the Plan Administrator), or if you and/or your dependent are otherwise determined to be ineligible for coverage under the plan. In addition, if you or your covered dependent commits fraud or intentional misrepresentation in an application for health coverage under the plan, in connection with a benefit claim or appeal, or in response to any request for information by SoulCycle or it’s delegees (including the Plan Administrator or a claims administrator), the Plan Administrator may terminate your coverage retroactively upon 30-days’ notice.

FLORIDA: Medicaid Web: www.flmedicaidtplrecovery.com/hipp/ Phone: 1.877.357.3268

GEORGIA: Medicaid Web: https://medicaid.georgia.gov/health-insurance-premium-payment- program-hipp Phone: 678.564.1162 ext 2131

Failure to inform any of such persons that you or your dependents are covered under another group health plan or knowingly providing false information in order to obtain or continue coverage for an eligible dependent are examples of actions that constitute fraud under the plan.

INDIANA: Medicaid Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1.877.438.4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1.800.403.0864

CHILDREN’S HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT OF 2009 (CHIP)

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. Signed into expand state CHIP eligibility to more children and expectant mothers with an extended 60-daytime frame to coordinate any changes to employer health elections in the event of gain or loss of eligibility and/or a subsidy under Medicaid or CHIP.

IOWA: Medicaid Web: http://dhs.iowa.gov/hawki Phone: 1.800.257.8563

ALABAMA: Medicaid Web: http://myalhipp.com/ Phone: 1.855.692.5447

KANSAS: Medicaid Web: www.kdheks.gov/hcf Phone: 1.785.296.3512

ALASKA: Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1.866.251.4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

KENTUCKY: Medicaid Web: chfs.ky.gov Phone: 1.800.635.2570

LOUISIANA: Medicaid Web: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1.888.695.2447 MAINE: Medicaid Web: www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1.800.442.6003 TTY: Maine relay 711

ARKANSAS: Medicaid Web: http://myarhipp.com/ Phone: 1.855.MyARHIPP (855.692.7447)

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ADDITIONAL BENEFITS

RESOURCES

WELL-BEING

WEALTH

NOTICES

NOTICES

NORTH CAROLINA: Medicaid Web: https://medicaid.ncdhhs.gov Phone: 919.855.4100

MASSACHUSETTS: Medicaid and CHIP Web: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1.800.862.4840

VERMONT: Medicaid Web: http://www.greenmountaincare.org Phone: 1.800.250.8427

MINNESOTA: Medicaid Web: http://mn.gov/dhs/people-we-serve/seniors/health-care/health- care-programs/programs-and-services/other-insurance.jsp Phone: 1.800.657.3739 MISSOURI: Medicaid Web: www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573.751.2005 MONTANA: Medicaid Web: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1.800.694.3084

NORTH DAKOTA: Medicaid Web: www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1.844.854.4825

VIRGINIA: Medicaid and CHIP Medicaid Web: www.coverva.org/programs_premium_ assistance.cfm Medicaid Phone: 1.800.432.5924 CHIP Web: www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1.855.242.8282

OKLAHOMA: Medicaid and CHIP Web: www.insureoklahoma.org Phone: 1.888.365.3742

WASHINGTON: Medicaid Web: https://www.hca.wa.gov/ Phone: 1.800.562.3022 ext.15473

OREGON: Medicaid Web: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1.800.699.9075

WEST VIRGINIA: Medicaid Web: www.dhhr.wv.gov/bms Phone: 1.877.598.5820, HMS Third Party Liability

PENNSYLVANIA: Medicaid Web:

NEBRASKA: Medicaid Web: http://www.ACCESSNebraska.ne.gov

http://www.dhs.pa.gov/provider/medicalassistance/ healthinsurancepremiumpaymenthippprogram/index.htm Phone: 1.800.692.7462 RHODE ISLAND: Medicaid and CHIP Web:http://www.eohhs.ri.gov/ Phone: 855.697.4347, or 401.462.0311 (Direct Rite Share Line)

WISCONSIN: Medicaid and CHIP Web: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1.800.362.3002

Phone: 1.855.632.7633 Lincoln: 402.473.7000 Omaha: 402.595.1178

WYOMING: Medicaid Web: https://wyequalitycare.acs-inc.com/ Phone: 307.777.7531

NEVADA: Medicaid Medicaid Web: https://dhcfp.nv.gov Phone: 1.800.992.0900

SOUTH CAROLINA: Medicaid Web: www.scdhhs.gov Phone: 1.888.549.0820

Tosee if any more States have added a premium assistance program since July 31, 2019, or for more information on special enrollment rights, contact either:

NEW HAMPSHIRE: Medicaid Web: www.dhhs.nh.gov/oii/hipp.htm Phone: 603.271.5218 Toll free number for the HIPP program: 1.800.852.3345 ext 5218 NEW JERSEY:Medicaid and CHIP Medicaid Web: www.state.nj.us/humanservices/dmahs/clients/ medicaid/ Medicaid Phone: 609.631.2392 CHIP Web: www.njfamilycare.org/index.html CHIP Phone: 1.800.701.0710

SOUTH DAKOTA: Medicaid Web: http://dss.sd.gov Phone: 1.888.828.0059

U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1.866.444.EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare &Medicaid Services www.cms.hhs.gov 1.877.267.2323, Menu Option 4, Ext. 61565

TEXAS: Medicaid Web: www.gethipptexas.com Phone: 1.800.440.0493

UTAH: Medicaid and CHIP Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1.877.543.7669

NEW YORK: Medicaid Web: https://www.health.ny.gov/health_care/medicaid/ Phone: 1.800.541.2831

OMB Control Number 1210-0137 (expires 12/31/2019)

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