2019 Benefits at a Glance
PLAN YEAR:
January 15, 2014 – December 31, 2014
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CONTENTS &
CONTACT INFORMATION
Refer to this list when you need to contact one of your benefit vendors. For general information contact Human Resources.
HUMAN RESOURCES
shancock@naa.comor ddorey@naa.com
BROKER PARTNER - M.E. WILSON COMPANY
Katie Miller 813-984-3602 kmiller@mewilson.com
MEDICAL
page 3
Cigna 866-4942111 www.mycigna.com
VIRTUAL VISIT AND PHARMACY
page 4
MDLive 888-726-3117 www.mdliveforcigna.com AmWell 855-667-6722 www.amwellforcigna.com
HEALTH SAVINGS ACCOUNT (H.S.A)
page 5
Optum Health Bank 866-2234-8913 www.optumhealthbank.com
DENTAL
page 6
Guardian 800-541-7846 www.guardiananytime.com
VISION
page 7
Guardian 800-541-7846 www.guardiananytime.com BASIC LIFE INSURANCE, EMPLOYEE ASSISTANCE PROGRAM, & WORLDWIDE TRAVEL ASSISTANCE page 8 Mutual of Omaha 800-877-5176 (Life) www.mutualofomaha.com www.mutualofomaha.com/EOI (for online EOI) 800-316-2796 (EAP) www.mutualofomaha.com/eap Mutual of Omaha (AXA) (Travel Assistance)
Within the U.S.: 800-856-9947 Outside the U.S.: 312-935-3658
VOLUNTARY LIFE INSURANCE
page 9-10
DISABILITY INSURANCE
page 11-12
Mutual of Omaha 800-877-5176 www.mutualofomaha.com
DISCLOSURE NOTICES
page 13
BENEFIT INFORMATION
Benefit
Who pays the cost?
National Aviation Academy pays for a portion towards the employee cost for medical coverage.
YOUR BENEFITS PLAN
Medical
National Aviation Academy offers a variety of benefits allowing you the opportunity to customize a benefits package that meets your personal needs. In the following pages, you’ll learn more about the benefits offered. You’ll also see how choosing the right combination of benefits can help protect you and your family’s health and finances – and your family’s future.
National Aviation Academy offers dental coverage on a voluntary basis.
Dental
National Aviation Academy offers vision coverage on a voluntary basis.
Vision
National Aviation Academy provides all eligible employees with life and AD&D coverage.
Life and AD&D
National Aviation Academy offers additional life coverage on a voluntary basis.
Voluntary Life
National Aviation Academy offers short term disability coverage on a voluntary basis.
Short TermDisability
National Aviation Academy offers short term disability coverage on a voluntary basis.
Long TermDisability
PRE-TAX BENEFITS
CHOOSING YOUR BENEFITS
The premium for elected coverages are taken from your paycheck automatically. There are two ways that the money can be taken out, pre-tax or post –tax.
WHY DO I PAY FOR BENEFITS WITH BEFORE-TAX MONEY?
There is a definite advantage to paying for some benefits with before-tax money. Taking the money out before your taxes are calculated lowers the amount of your pay that is taxable. Therefore, you pay less in taxes.
WHICH BENEFIT PREMIUMS ARE TAKEN BEFORE TAX?
BEFORE tax –
Medical, Dental, and Vision
AFTER tax –
$
$
Life, and Disability
$
1
ELIGIBILITY All Regular full-time employees are eligible to join the National Aviation Academy Benefits once the waiting period has been satisfied, coverage will begin on the 1 st of the month following 60 days from your date of hire. “Regular Full-Time Employees” must be regularly scheduled and working at least 30 hours per week. You may also enroll your dependents in the Benefits Plan when you enroll.
WHO’S AN ELIGIBLE DEPENDENT?
•
Your legal spouse
• Your married or unmarried natural children, step-children living with you, legally adopted child(ren) and any other child(ren) for whom you have legal guardianship, up to age 26
A dependent who is older than 26 years of age, but less than 30 years of age may be eligible for medical benefits. Please contact Human Resources for more information.
WHEN CAN YOU ENROLL?
You can sign up for Benefits at any of the following times:
• As a new hire, at your initial eligibility date.
• During the annual open enrollment period. (January 1 st of each year.)
• Within 30 days of a qualified family-status change.
If you do not enroll at one of the above times, you may enroll during the next annual open enrollment period.
MAKING CHANGES
Generally, you can only change your benefit choices during the annual benefits enrollment period. However, you may be able to change your benefit choices during the plan year if you have a change in status including:
•
• Change in your work status that affects your benefits
Your marriage
•
• Change in residence that affects your eligibility for coverage
Your divorce
•
• Change in your child’s eligibility for benefits
Birth or adoption of an eligible child
•
• Receiving QualifiedMedical Child Support Order (QMCSO)
Death of your spouse or covered child
• Change in your spouse’s work status that affects your benefits
You must submit documentation as proof of life event to Human Resources within 30 days. The IRS allows changes to be made within 60 days for those eligible for Medicaid or CHIP under HIPAA Special Enrollment Rights. If you fail to do so you will be required to wait until the next annual enrollment period to make benefit changes unless you hav e another family status change.
WHEN DOES COVERAGE END?
Coverage will stop as of the end of the month in which you are no longer employed with National Aviation Academy..
2
MEDICAL INSURANCE
National Aviation Academy offers medical coverage through Cigna. You have three plan options to choose from. To find participating providers go to www.cigna.com and click on “Find a Doctor”, then follow the prompts to complete the search within the “Open Access Plus (OAP)” network. The chart below provides a briefly overview of the medical plan offered.
MID COPAY PLAN
HIGH COPAY PLAN
H.S.A. PLAN
IN-NETWORK
Open Access Plus (OAP)
DEDUCTIBLE (your first dollar cost for covered in-network claims) Deductible (Individual / Family)
$2,500 / $5,000
$2,000 / $4,000
$1,000 / $3,000
COINSURANCE (Coinsurance is a cost sharingon claims that comes once you’vemet your deductible. The cost sharing is betweenyou and Cigna.) (Cigna / Member) 80% / 20% 80% / 20%
80% / 20%
OUT OF POCKET MAXIMUM (once met all in-network covered services are covered by the plan) MaximumOut-of-Pocket (Individual / Family) $6,500 / ($7,350) $13,000
$6,000 / $12,000
$3,500 / $7,000
Maximum Includes
Deductible, Coinsurance, Prescription Costs & Copays
PREVENTIVE CARE Wellness, Immunizations, Mammography, Colonoscopy, etc.
Covered 100%, no cost to you
OFFICE VISITS Referral Required
No
Virtual Visits
$45 - $49
$30 Copay
$25 Copay
Office Visits (Illness/Injury)
Covered 80% after deductible
$30 Copay
$25 Copay
Specialist Visits
Covered 80% after deductible
$55 Copay
$45 Copay
HOSPITAL SERVICES Inpatient Hospital
Covered 80% after deductible
Covered 80% after deductible
Covered 80% after deductible
Outpatient Surgery
Covered 80% after deductible
Covered 80% after deductible
Covered 80% after deductible
Emergency Room
Covered 80% after deductible
$300 Copay
$200 Copay
Urgent Care
Covered 80% after deductible
$60 Copay
$50 Copay
DIAGNOSTIC TESTING Lab
Covered 80% after deductible
Covered 100%
Covered 100%
X-Ray
Covered 80% after deductible
$50 Copay
Covered 100%
Advanced Imaging
(MRI, CAT, PET, etc.)
Covered 80% after deductible
$300 Copay
$200 Copay
Medical deductible first, then
PRESCRIPTIONS
Retail (30 day supply) Tier 1 / 2 / 3
$10 / $50 / $80
$10 / $30 / $50 / 20% to $250
$10 / $30 / $50 / 20% to $250
H.S.A compatible?
Yes
No
No
OUT-OF-NETWORK 1
All plans have out of network benefits, please refer to plan summaries for details. Semi Monthly Cost for Coverage
Employee Only
$79.50
$167.50
$198.50
Employee + Spouse
$400.50
$637.50
$711.50
Employee + Child(ren)
$270.50
$453.50
$513.50
Employee + Family
$579.50
$887.50
$986.50
1 Charges are subject to balance billing
This chart is intended only to highlight the benefits available and should not be relied upon to fully determine your coverage. If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage. 3
TELEHEALTH VIRTUAL VISITS
If you are enrolled in the medical insurance through Cigna you have access to Virtual visits through MDLive and/or AmWell. Virtual visits allow you to see and talk to a doctor from a mobile device or computer without an appointment. A majority of visits take between 10-15 minutes, and virtual visits are a part of your health benefits. Through a virtual visit, doctors can diagnose and treat a vast range of non-emergency medical conditions and provide services such as writing a prescription, if needed. This includes: • Allergies • Bladder infection • Bronchitis • Cold/cough • Fever • Migraine/headaches • Pink eye • Seasonal flu • Sinus problems • Sore throat • Stomach ache
Download the MDLive and/or AmWell apps today! Once your enrolled in the Cigna medical plan go in a register your account(s). Once registered you’ll have access to virtual visits whenever needed!
Contact MDLive at 888-726-3171 and AmWell at 855-667-9722., download the apps today!
Virtual visits are subject the same copay as our primary care physician, saving you time and money! If you are on the H.S.A plan virtual visits are just $45 with MDLive and $49 with AMWell!
PHARMACY
90 DAY SUPPLIES FOR MAINTENANCE MEDICATIONS
Cigna’s pharmacy program CIGNA 90 NOW allows you to fill a 90 day supply of maintenance medications at participating retail pharmacies or through Cigna's Home Delivery Pharmacy.
To use CIGNA 90 NOW simply get a 90 day prescription from your doctor and take it to the CIGNA 90 NOW participating
pharmacy of your choice, this include:
• • • • • •
CVS (including Target and Navarro)
Walmart
Kroger
Access Health
Good Neighbor Pharmacies
Cardinal Health
By using Cigna’s Home Delivery Pharmacy you won’t have to go to the pharmacy to pick up your medication. Cigna will delivery these to your door and standard shipping is always free. Contact 800-285-4812 with questions on Cigna’s Home Delivery Pharmacy or visit www.cigna.com/home-delivery-pharmacy
$$ $$$ $
WAYS TO SAVE!
A wide range of generic medications are offered at low cost at your local pharmacy.
Specific generic drugs are available at Target, Wal-Mart, and/or CVS for $4 for a 30-day supply and $10 for a 90-day supply !
Certain antibiotics are available at Publix for FREE !
4
HEALTH SAVINGS ACCOUNT (H.S.A)
Employees enrolling in the H.S.A Medical Plan are eligible to open and contribute to a Health Savings Account (H.S.A). With an H.S.A you have the ability to put money side, through payroll deductions, to help pay for H.S.A eligible expenses. The H.S.A is with Optum Health Bank.
2019 IRS Annual MaximumHSA Contribution Limits
Employee Only
$3,500
Family
$7,000
Additional $1,000 annually catch-up amounts for available for employees 55 years or older
WHAT ARE THE BENEFITS OF A H.S.A?
•
The money you put aside is PRE-TAX
• The H.S.A is a bank account in your name. If you retire or should you leave National Aviation Academy you take this account with you.
• The account rolls over year to year. You will not have to forfeit any unused funds.
• You will receive a debit card upon opening an H.S.A for quick and easy utilization of the fund.
• The list of eligible expenses is vast! These expenses include things covered under the medical, dental, and vision coverage – as well as some items that aren't!
WHAT ARE ELIGIBLE EXPENSES UNDER THE H.S.A?
Examples of eligible services include, but are not limited to the following:
• • • • • • • • • • • • •
Acupuncture
• • • • • • • • •
Fertility enhancements
Chiropractic services
Hearing aids
Alcohol and drug dependency treatment
Batteries for hearing aids
Ambulance
Long-term care Nursing home
Artificial limbs Contact lenses
Maternity Expenses Organ transplants Physical therapies Speech therapies
Contact lens solution
Copays
Deductible expenses
Dental expenses
• Smoking-cessation programs and products • Vasectomy • Wheelchairs
Glasses
Prescription Drugs
Prescription sunglasses
• Over the Counter Drugs (when ordered by a doctor) • Laser eye surgery • Radial keratotomy
5
DENTAL INSURANCE
National Aviation Academy offers dental coverage through Guardian. The Dental PPO Plan allows you to use in-network or out-of-network benefits. Find in-network providers on www.guardiananytime.com by clicking on “Find Dentist” and searching within the “PPO” network. If out-of-network dentists are used, you will be responsible for paying the difference between Guardian’s allowed amount and what the dentist may charge, also known as “balance billing”. The chart below provides a brief overview of the plan.
BASE DPPO PLAN
HIGH DPPO PLAN
In-Network
Calendar Year Deductible (applies to basic & major services only)
Individual
$50
$50
Family
$150
$150
Annual Maximum (per covered member)
Per covered member
$1,000
$1,500
Preventive Services
Exams, Cleanings, & Fluoride
Covered in full
Covered in full
Basic Services
Fillings, Simple Extractions, Oral surgeries, Periodontics, & Endodontics
Covered 80% after deductible
Covered 80% after deductible
Major Services
Crowns, Bridges, & Dentures
Covered 50% after deductible
Covered 50% after deductible
Orthodontics
(Child only – 19 years and under)
Coverage Lifetime maximum
50% $1,000
None
Out-of Network 1
Calendar Year Deductible
$50 / $150
$50 / $150
Schedule of Services: Preventive
Covered 100% Covered 80% after deductible Covered 50% after deductible
Covered 100% Covered 80% after deductible Covered 50% after deductible
Basic Major
Annual Maximum (pre covered member)
$ 1,000
$ 1,500
Basis of Payment
Maximum Allowable Amount
Semi Monthly Cost for Coverage
$10.50
$12.90
Employee Only
$21.63
$23.15
Employee + Spouse
$21.50
$25.00
Employee + Child(ren)
$30.38
$39.25
Employee + Family
6 1 Subject to balance billing. Please refer to your plan document for specific details
VISION INSURANCE
National Aviation Academy offers vision coverage through Guardian. The Guardian vision plan provides you access to the Davis Vision network but allows you the flexibility to see any provider. To search in-network providers visit www.guardiananytime.com and search based on your location. When you utilize an out-of-network provider you pay expenses at the time of service and file a claim for reimbursement. Below is a list of the reimbursement schedule.
Davis Vision
In-Network
Routine Eye Exams
Every 12 months
$10 Copay
Lenses 2
Every 12 months
Single Vision Bifocal Trifocal Lenticular
$25 Copay Lens upgrades are additional cost, you may receive a discount at participating providers.
Frames
Every 24 months
$25 Copay provides a $120 allowance PLUS 20% off cost over the allowance
Contact Lenses (in lieu of glasses)
Every 12 months
Elective Contact Lenses
$120 allowance PLUS 15% off the overage
Medically Necessary
Covered 100%
Out-of-Network 1
Routine Eye Exams
Every 12 months Reimbursed up to $50 Every 12 months Reimbursed up to $48 Reimbursed up to $67 Reimbursed up to $86 Reimbursed up to $126 Every 24 months Reimbursed up to $55 Every 12 months Reimbursed up to $105 Reimbursed up to $210
Lenses 2 Single
Bifocal Trifocal Lenticular
Frames
Contact Lenses (in lieu of glasses) Elective Medically Necessary
Semi Monthly Cost for Coverage
Employee Only
$2.48
Employee + Spouse
$4.60
Employee + Child(ren)
$4.64
Employee + Family
$7.49
1 Reimbursable amount, less applicable copay. 2 Lenses benefit listed are for a pair of lenses.
7
BASIC LIFE AND AD&D INSURANCE
National Aviation Academy provides all benefits eligible employees with $30,000 of Life and AD&D insurance, this benefit is 100% paid for by National Aviation Academy.
EMPLOYEE ASSISTANCE PROGRAM (EAP)
All eligible employees are automatically provided access to Mutual of Omaha’s Employee Assistance Program (EAP). The EAP program is a confidential resource available 24/7 to help you deal with a variety of life stages and/or concerns. These include but are not limited to the following:
• • • • •
Depression, stress and anxiety Relationship difficulties Financial and legal advice Family issues and parenting Child and elder care support
• • • • •
Dealing with domestic violence Substance abuse and recovery
Work-related issues
Grief
Eating disorders
The program also includes up to 3 face to face visits with a counselor, per household per calendar year.
Call 1-800-316-2796
Visit www.mutualofomaha.com/eap
WORLDWIDE TRAVEL ASSISTANCE
Benefits eligible employees also have access to Mutual of Omaha’s Worldwide Travel Assistance program, provided through AXA Assistance USA. This resource is available to you and your dependents for any single trip more than 100 miles from home.
WHAT WILL THEY HELP WITH?
Pre-Trip Assistance •
Medical Assistance Services •
Immunization requirements
Locating legal services and medical providers • Help with replacing corrective lenses and medical devices
•
Passport and visa requirements
•
Travel/tourist advisories
•
Embassy/consular referrals
Medical Emergency Transportation •
•
Foreign exchange rates
Emergency evacuation
• Coordination of transportation for family to join hospitalized member, return of companion or child(ren)
Travel Assistance Services •
Emergency travel arrangements
• Document replacement (credit cards, airline tickets, etc.)
Within the U.S. call toll free: 1-800-856-9947 Outside the U.S. call collect : 312-935-3658
8
VOLUNTARY LIFE INSURANCE
National Aviation Academy offers employees the option to purchase additional life insurance on a voluntary basis. This coverage is through Mutual of Omaha.
HOW MUCH LIFE INSURANCE CAN I PURCHASE?
You may purchase a benefit for as little as $10,000 and as much as $100,000, not to exceed 5x your annual salary.
AT YOUR ANNUAL OPEN ENROLLMENT….
If you currently have voluntary life insurance for yourself, you may elect a $10,000 increase in benefit (not to exceed the guaranteed issues amount) at open enrollment WITHOUT having to provide Evidence of Insurability (EOI).
WHAT IS GUARANTEED ISSUE AMOUNT (GI)?
The Guaranteed Issue (GI) amount is the amount is $50,000, not to exceed 5x your annual salary. When you are newly eligible for coverage you may elect up to this amount without having to provide Evidence of Insurability (EOI).
WHEN WOULD I NEED TO SHOW EVIDENCE OF INSURABILITY TO GET LIFE INSURANCE?
If you elect a benefit over GI as a new hire, a benefit outside of your newly eligible period, or an increase over $10,000 to your current benefit you will be required to provide Evidence of Insurability (EOI). You may complete EOI via EOI form or online at www.MutualofOmaha.com/EOI.
WHAT HAPPENS WHEN YOU TURN 65?
When you reach 65 a reduction of benefits will apply as of the first of the new policy year. When you turn 65 you original benefit reduces to 65%, when you turn 70 it reduces to 50%.
IF YOU PURCHASE LIFE INSURANCE FOR YOURSELF, YOU MAY ALSO PURCHASE LIFE INSURANCE FOR YOUR SPOUSE AND/OR YOUR CHILD(REN).
HOW MUCH LIFE INSURANCE CAN I PURCHASE FOR MY SPOUSE?
You may purchase a benefit for as little as $5,000 and as much as $50,000, not to exceed 100% of you voluntary life benefit.
WHAT IS GUARANTEED ISSUE AMOUNT (GI)?
The Guaranteed Issue (GI) amount is the amount is $10,000, not to exceed 100% of your voluntary life benefit. When you are newly eligible for coverage you may elect up to this amount without having to provide Evidence of Insurability (EOI). A spouse is not eligible for life insurance at or after age 70, the benefit would terminate as of this age.
HOW MUCH LIFE INSURANCE CAN I PURCHASE FOR MY CHILD(REN)?
You may purchase a benefit $10,000, not to exceed 100% of your voluntary life benefit.
WHAT IS GUARANTEED ISSUE AMOUNT (GI)?
The Guaranteed Issue (GI) amount is the amount is $10,000, not to exceed 100% of your voluntary life benefit. EOI is not required for child(ren) life. If you purchase child life insurance you must cover all eligible children. The cost to for the child life benefit is the same whether you have 1 or multiple children covered.
9
VOLUNTARY LIFE INSURANCE COSTS
The cost per benefit may be found below. Costs are based on age bands, find your age in the table below with the desired benefit amount. Costs shown are per pay check.
The cost for spouse life insurance is based on YOUR age, not your spouse’s age. Find the age band you fall in within the table below and desired benefit amount. Costs shown are per pay check.
Regardless of the number of child covered under this benefits, they are included in the “All Children” premium listed below. All eligible children must be covered if you purchase life insurance for a child.
10
VOLUNTARY SHORT TERM DISABILITY
National Aviation Academy offers you the option to purchase short term disability (STD) insurance. STD is insurance for your paycheck should you become disabled due to an off the job injury or illness for a period of time.
WHEN WOULD THE BENEFIT START?
Benefits would begin on the 15 th day from injury or illness.
HOW MUCH WOULD THE BENEFIT PAY? The benefit would pay 60% of your weekly pre-disability earnings to a maximum of $1,000.00 per week.
HOW LONG WILL THE BENEFIT PAY?
The benefit would pay out to a maximum of 11 weeks or until you no longer meet the definition of disability, whichever occurs first.
PRE-EXISITING CONDITIONS ARE EXCLUDED. If you had a pre-existing condition within the 3 months prior to coverage becoming effective, you would not be eligible to claim for any disability resulting from that condition if the disability occurs within 6 months of the start of coverage.
VOLUNTARY SHORT TERM DISABILITY COST
Use the calculation table below to calculate your cost for coverage per paycheck (semi monthly).
Calculation Table
Steps
1
Annual salary / 52 =
$
Take amount in Step 1 and multiply it by 0.6 (this your weekly benefit amount, 60% of your weekly earnings)
2
$
3
Take the amount calculated in Step 2 and divide by $10
$
4
The amount in Step 3 and multiply by $0.30
$
The amount in step 4 divided by 2 is your cost for coverage per paycheck (semi monthly)
5
$
11
VOLUNTARY LONG TERM DISABILITY
National Aviation Academy offers you the option to purchase long term disability (LTD) insurance. LTD is insurance for your paycheck should you become disabled due to an off the job injury or illness for a period of time. You may elect 1 of the 2 LTD plan options to shown below.
WHEN WOULD THE BENEFIT START?
Base & High Plan Options: Benefits would begin on the 90 th day from injury or illness.
HOW MUCH WOULD THE BENEFIT PAY?
Base & High Plan Options: The benefit would pay 60% of your monthly pre-disability earnings to a maximum of $3,000.00 per month.
HOW LONG WILL THE BENEFIT PAY?
Base LTD Plan Option: If you become disabled prior to age 68, benefits are payable for 2 years. At age 68, benefits are payable to age 70. At age 69 (and older), benefits are payable for one year.
High LTD Plan Option: If you become disabled prior to age 62, benefits are payable to age 65, your Social Security Normal Retirement Age or 3.5 years, whichever is longest.
PRE-EXISITING CONDITIONS ARE EXCLUDED. If you had a pre-existing condition within the 3 months prior to coverage becoming effective, you would not be eligible to claim for any disability resulting from that condition if the disability occurs within 12 months of the start of coverage.
VOLUNTARY LONG TERM DISABILITY COST
Rates are based on your age. Find your age band in the chart below and the rate for the plan option desired. Use the calculation table to calculate your cost for coverage per paycheck (semi monthly).
Rates per $100 of monthly payroll
Calculation Table
Age bands
High LTD
Base LTD
Steps
Annual salary / 12 = Monthly payroll
0-24
$0.08
$0.13
1
$
25-29
$0.12
$0.16
2
Take amount in Step 1 / $100
$
30-34
$0.14
$0.20
35-39
$0.17
$0.28
Take the amount calculated in Step 2 and multiply it by your rate
3
$
40-44
$0.25
$0.43
The amount in Step 3 divided by 2 will provide you with your cost for coverage per paycheck.
4
$
45-49
$0.35
$0.72
50-54
$0.50
$1.03
55-59
$0.60
$1.17
60+
$0.60
$0.80
12
REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES
Required Annual Employee Disclosure Notices THE NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT OF 1996
The Newborns’ and Mothers’ Health Protection Act of 1996 prohibits group and individual health insurance policies from restrictingbenefits for any hospital lengthof stay for the mother or newborn child in connection with childbirth; (1) following a normal vaginal delivery, to less than 48 hours, and (2) following a cesarean section, to less then 96 hours. Health insurance policies may not require that a provider obtain authorization from the health insurance plan or the issuer for prescribing any such length of stay. Regardless of these standards an attendinghealth care provider may, in consultation with the mother, discharge the mother or newborn child prior to the expiration of such minimum length of stay.
Further, a health insurer or healthmaintenance organizationmay not:
1. Deny to the mother or newborn child eligibility, or continued eligibility, to enroll or to renew coverageunder the terms of the plan, solely to avoid providing such length of stay coverage;
2. Provide monetary payments or rebates to mothers to encouragesuch mothers to accept less than the minimum coverage;
3. Provide monetary incentives to an attendingmedical provider to induce such provider to provide care inconsistent with such lengthof stay coverage;
4. Require a mother to give birth in a hospital; or
5. Restrict benefits for any portion of a period within a hospital lengthof stay described in this notice.
These benefits are subject to the plan’s regular deductible and co-pay. For further details, refer to your Summary Plan Description. Keep this notice for your records and call Human Resources for more information.
SECTION 111
Effective January 1, 2009 group health plans are required by Federal government to comply with Section 111 of the Medicare, Medicaid, and SCHIP Extensions of 2007’s newMedicare Secondary Payer regulations. The mandate is designed to assist in establishing financial liability of claims assignments. In other words, it will help establish who pays first. The mandate requires group health plans to collect additional information, more specifically Social Security numbers for all enrollees, including dependents 6 months of age or older. Please be prepared to provide this informationon your benefits enrollment form when enrolling into benefits.
WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998
The Women’s Health and Cancer Rights Act of 1998 requires National Aviation Academy Hospitality to notify you, as a participant or beneficiary of the National Aviation Academy Hospitality Health and Welfare Plan, of your rights related to benefits provided through the plan in connection with a mastectomy. You, as a participant or beneficiary, have rights to coverageto be provided in a manner determined in consultation with your attending physician for:
1. All stages of reconstruction of the breast on which the mastectomy was performed;
2. Surgery and reconstructionof the other breast to produce a symmetrical appearance; and
3. Prostheses and treatment of physical compilations of the mastectomy, including lymphedema.
These benefits are subject to the plan’s regular deductible and co-pay. For further details, refer to your Summary Plan Description. Keep this notice for your records and call Human Resources for more information.
MICHELLE’S LAW
The law allows for continued coverage for dependent children who are covered under your group health plan as a student if they lose their student status because of a medically necessary leave of absence from school. This law applies to medically necessary leaves of absence that begin on or after January 1, 2010
If your child is no longer a student, as defined in your Certificateof Coverage, because he or she is on a medically necessary leave of absence, your child may continue to be covered under the plan for up to one year from the beginning of the leave of absence. This continued coverage applies if your child was (1) covered under the plan and (2) enrolled as at student at a post-secondary educational institution (includes colleges, universities, some trade schools and certain other post-secondary institutions).
Your employer will require a written certification from the child’s physician that states that the child is suffering from a serious illness or injury and that the leave of absence is medically necessary.
13
REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES continued
Required Annual Employee Disclosure Notices continued
HIPAA PRIVACY POLICY FOR FULLY-INSURED PLANS WITH NO ACCESS TO PHI
The group health plan is a fully-insured group health plan sponsored by the “Plan Sponsor”. The group health plan and the plan sponsor intend to comply with the requirements of 45 C.F.R. §164.530 (k) so that the group healthplan is not subject to most of HIPAA’s privacy requirements.
I. No access to protected health information (PHI) except for summary health informationfor limited purposeand enrollment / dis-enrollment information.
Neither the group health plan nor the plan sponsor (or any member of the plan sponsor’s workforce) shall create or receive protected health information (PHI) as defined in 45 C.F.R. §160.103 except for (1) summary health information for purpose of (a) obtaining premium bids or (b) modifying, amending, or terminating the group health plan, and (2) enrollment and dis-enrollment information.
II.
Insurer for group health plan will provide privacy notice
The insurer for the group healthplan will provide the group health plan’s notice of privacy practices and will satisfy the other requirements under HIPAA related to the group health plan’s PHI. The notice of privacy practices will notify participants of the potential disclosure of summary health information and enrollment / dis-enrollment information to the group health plan and the plan sponsor.
III.
No intimidatingor retaliatory acts
The group health plan shall not intimidate, threaten, coerce, discriminateagainst, or take other retaliatory action against individuals for exercising their rights , filing a complaint, participating in an investigation, or opposing any improper practice under HIPAAA.
IV.
No Waiver
The group health plan shall not require an individual to waive his or her privacy rights under HIPAA as a condition of treatment, payment, enrollment or eligibility. If such an action should occur by one of the plan sponsor’s employees, the action shall not be attributed to the group health plan.
PATIENT PROTECTION:
If the Group Health Plan generally requires the designation of a primary care provider who participates in the network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from the carrier or from any other person (includinga primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology. The healthcare professionals, however, may be required to comply with certain procedures, including obtaining prior authorizationfor certain services, following a pre-approved treatment plan or procedures for making referrals. For a list of participating healthcare professionals who specialize in obstetrics or gynecology, or for informationon how to select a primary care provider, and for a list of the participating primary care providers, contact the Plan Administrator or refer to the carrier website. It is your responsibility to ensure that the information provided on your application is accurate and complete. Any omissions or incorrect statements made by you on your applicationmay invalidate your coverage. The carrier has the right to rescind coverage on the basis of fraud or misrepresentation.
13
REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES continued
Required Annual Employee Disclosure Notices continued CHILDREN’S HEALTH INSURANCE PROGRAMREAUTHORIZATION ACT (CHIPRA) OF 2009
Effective April 1, 2009, a special enrollment period provision is added to comply with the requirements of the Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009. If you or a dependent is covered under a Medicaid or CHIP plan and coverage is terminated as a result of the loss of eligibility for Medicaid or CHIP coverage, you may be able to enroll yourself and/or your dependent(s). However, you must enroll within 60 days after the date eligibility is lost. If you or a dependent becomes eligible for premium assistance under an applicable State Medicaid or CHIP plan to purchase coverage under the group health plan, you may be able to enroll yourself and/or your dependent(s). However, you must enroll within 60 days after you or your dependent is determined to be eligiblefor State premium assistance. Please note that premium assistance is not available in all states. If you or your children are eligiblefor 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 eligiblefor these premium assistance programs but you may be able to buy individual insurance coverage through the Health InsuranceMarketplace. 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 coveragewithin 60 days of beingdetermined 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 planpremiums. The following list of states is current as of July 31, 2016. Contact your Statefor more information on eligibility –
ALABAMA – Medicaid
FLORIDA – Medicaid
Website: http://myalhipp.com/ Phone: 1-855-692-5447
Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268
ALASKA – Medicaid
GEORGIA – 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
Website: http://dch.georgia.gov/medicaid - Click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507
ARKANSAS – Medicaid
INDIANA – Medicaid
Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)
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
COLORADO – Medicaid
IOWA – Medicaid
Medicaid Website: http://www.colorado.gov/hcpf Medicaid Customer Contact Center: 1-800-221-3943
Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562
KANSAS – Medicaid
NEW HAMPSHIRE – Medicaid
Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512
Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218
KENTUCKY – Medicaid
NEW JERSEY – Medicaid and CHIP
Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570
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
LOUISIANA – Medicaid
NEW YORK – Medicaid
Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447
Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831
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REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES continued
Required Annual Employee Disclosure Notices continued
MAINE – Medicaid
NORTH CAROLINA – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711
Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100
MASSACHUSETTS – Medicaid and CHIP
NORTH DAKOTA – Medicaid
Website: http://www.mass.gov/MassHealth Phone: 1-800-462-1120
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825
MINNESOTA – Medicaid
OKLAHOMA – Medicaid and CHIP
Website: http://mn.gov/dhs/ma/ Phone: 1-800-657-3739
Website: http://www.insureoklahoma.org Phone: 1-888-365-3742
MISSOURI – Medicaid
OREGON – Medicaid
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005
Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075
MONTANA – Medicaid
PENNSYLVANIA – Medicaid
Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084
Website: http://www.dhs.pa.gov/hipp Phone: 1-800-692-7462
NEBRASKA – Medicaid
RHODE ISLAND – Medicaid
Website:http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/ Pages/accessnebraska_index.aspx Phone: 1-855-632-7633
Website: http://www.eohhs.ri.gov/ Phone: 401-462-5300
NEVADA – Medicaid
SOUTH CAROLINA – Medicaid
Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900
Website: http://www.scdhhs.gov Phone: 1-888-549-0820
SOUTH DAKOTA – Medicaid
WASHINGTON – Medicaid
Website: http://dss.sd.gov Phone: 1-888-828-0059
Website: http://www.hca.wa.gov/free-or-low-cost-health-care/program- administration/premium-payment-program Phone: 1-800-562-3022 ext. 15473
TEXAS – Medicaid
WEST VIRGINIA – Medicaid
Website: http://gethipptexas.com/ Phone: 1-800-440-0493
Website: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspx Phone: 1-877-598-5820, HMS Third Party Liability
UTAH – Medicaid and CHIP
WISCONSIN – Medicaid and CHIP
Website: Medicaid: http://health.utah.gov/medicaid CHIP: http://health.utah.gov/chip Phone: 1-877-543-7669
Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002
VERMONT– Medicaid
WYOMING – Medicaid
Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427
Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531
VIRGINIA – Medicaid and CHIP Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282
To see if any other states have added a premium assistance program since July 31, 2016, or for more information on special enrollment rights, contact either: U.S. Department of Labor U.S. Department of Healthand Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collectiondisplays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collectionof information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.
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REQUIRED ANNUAL EMPLOYEE DISCLOSURE NOTICES continued
MEDICARE PART D
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 United Healthcare 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 creditable prescription drug coverage, your monthly premiummay go up 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 nineteenmonths without creditable coverage, your premiummay 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. Contact our office for further information (see contact information below). 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 United Healthcare changes. You also may request a copy of this notice at any time. For more information about your options under Medicare prescription drug coverage… 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 fromMedicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: • Call your State Health InsuranceAssistance Program (see 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 notice. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage, you may be required to provide a copy of this notice when you join to show that you are not required to pay a higher premium amount. For more information about this noticeor your current prescription drug coverage… • Visit www.medicare.gov
This notice applies to employees and covered dependents who are eligible for Medicare Part D. Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with United Healthcare and about your options under Medicare’s prescription drug Plan. If you are considering joining, you should compare your current coverage includingwhich drugs are covered at what cost, with the coverage and costs of the plans offeringMedicare 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. 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare throughMedicare prescription drug plans and Medicare Advantage Plan (like an HMO or PPO) that offer prescription drug coverage. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coveragefor a higher monthly premium. 2. UnitedHealthcare has determined that the prescription drug coverage offered by the Welfare Plan for Employees of National Aviation Academy Hospitality under the UnitedHealthcare option are, on averagefor all plan participants, expected to pay out as much as the standard Medicare prescription drug coveragepays and is thereforeconsidered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverageand not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. You should also know that if you drop or lose your coverage with United Healthcare and don’t enroll in Medicare prescription drug coverage after your current coverageends, you may pay more (a penalty) to enroll in Medicare prescription drug coverage later. _________________________________________________ You can join a Medicare drug plan when you first become eligible for Medicare and each year fromOctober 15 th to December 7 th . However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligiblefor a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What happens to your current coverage if you decide to join a Medicare Drug Plan? If you decide to join a Medicare drug plan, your current United Healthcare coverage will not be affected. You can keep this coverage if you elect part D and this plan will coordinate with Part D coverage. If you decide to join a Medicare drug plan and drop your current United Healthcare coverage, be aware that you and your dependents will be able to get this coverage back. When can you join a MedicareDrug Plan?
Date:
01/01/2019
Name of Entity/Sender: Contact--Position/Office:
National Aviation Academy
Sylvia Hancock 6225 UlmertonRoad Clearwater , FL 33760
Phone Number:
727—531-2080
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