2022 PLAN YEAR benefit enrollment guide
J&L Ventures, LLC is proud to offer you a comprehensive benefits package for the upcoming plan. We are changing our insurance carriers and pleased that there will be no additional premium cost to employees. Keep in mind that the benefits you select during this enrollment will be effective October 1st, 2022 and will continue through September 30th, 2023.
TABLE OF CONTENTS
I ntroduction . . . . . . . . . . . . . . . . . . . . . . . Medical . . . . . . . . . . . . . . . . . . . . . . . . . . . Healthgram . . . . . . . . . . . . . . . . . . . . . . . . Basic Life AD&D . . . . . . . . . . . . . . . . . . Disability . . . . . . . . . . . . . . . . . . . . . . . . . Dental and Vision . . . . . . . . . . . . . . . . . 401k . . . . . . . . . . . . . . . . . . . . . . . . . . . . FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Legal Notices . . . . . . . . . . . . . . . . . . . . . Medicare Part D. . . . . . . . . . . . . . . . . . . COBRA. . . . . . . . . . . . . . . . . . . . . . . . . . Exchange Notices. . . . . . . . . . . . . . . . . . Contact Information. . . . . . . . . . . . . . .
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J & L VENTURES, LLC 2022 BENEFIT GUIDE
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
All Eligibility
Qualifying Life Events
As a J&L Ventures, LLC employee, you may be eligible for enrollment in a variety of insurance products. Full-time employees may participate in the Medical, Dental, Vision and Life benefits package after 90 days of employment. Short - Term and Long - Term Disability are available after 1 year of employment. You may enroll your eligible dependents for coverage once you are eligible. Your eligible dependents include:
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.
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 ( ONLY if coverage is NOT offered at their place of employment)
• 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.
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Medical and Pharmacy Coverage
J&L Ventures, LLC offers the following plans through Healthgram which mirror the plan offered through Healthgram. Please reference the Summary Plan Description for more details.
Insurance Carrier: Medical Plan Number:
Healthgram Medical Insurance
Base Plan
Premium Plan
In-Network: Office Visit Copay - Primary Care Office Visit Copay - Specialist Care
$45 - first 5 visits
$25 Copay per visit $50 Copay per visit $60 Copay per visit
Deductible; then 30% Coinsurance Deductible; then 30% Coinsurance $250 Copay; then 30% Coinsurance
Urgent Care Copay Emergency Room Care Preventative Visit Copay
$150 Copay; then 20% Coinsurance
$0 $0
$0 $0
Diagnostic Testing & Blood Work
Imaging
Deductible; then 30% Coinsurance
Deductible; then 20% Coinsurance
Coinsurance
70%
80%
Employee Deductible Family Deductible
$2,500 $7,500 $7,150 $14,300
$1,500 $4,500 $7,150 $14,300
Employee Out-of-Pocket Max Family Out-of-Pocket Max
Inpatient Hospital
Deductible; then 30% Coinsurance Deductible; then 30% Coinsurance
Deductible; then 20% Coinsurance Deductible; then 20% Coinsurance
Outpatient Hospital or Facility
Out-of-Network: Coinsurance
50%
50%
Employee Deductible Family Deductible
$7,500 $22,500 $21,450 $42,900
$4,500 $13,500 $21,450 $42,900
Employee Out-of-Pocket Max Family Out-of-Pocket Max
Prescription Drugs: ( 30 Day Supply) Rx Deductible
$1,000 Individual / $2,000 Family
$300 Individual / $600 Family
Tier 1 - Generic Tier 2 - Preferred
$15 / $30
$5 / $20
Deductible met; then $50 Copay Deductible met; then 20% Coinsurance Deductible met; then 20% Coinsurance
Deductible met; then $45 Copay Deductible met; then $80 Copay
Tier 3 - Non-Preferred
Tier 4 - Specialty
Pay at appropriate tier
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J & L VENTURES, LLC 2022 BENEFIT GUIDE
WELCOME TO HEALTHGRAM J & L Ventures, LLC has partnered with Healthgram to bring you valuable benefits and a new way to think about healthcare. Beginning on October 1 st , 2022, Healthgram will be your new contact for benefits administration and customer service. Our goal is to help you choose the best benefit options for you and your family and bec ome a trusted resource for your healthcare needs. We look forward to becoming your partner along the way. IMPORTANT INFORMATION TO KNOW
CONTACTING HEALTHGRAM
FINDING A DOCTOR
Member Support: 1 - 866 - 904 - 9081 8:00 am - 6:00 pm EST Monday - Friday
Your network access will be through Cigna. In - network healthcare providers have negotiat- ed discounts so charges in - network should al- ways be lower than those out - of - network. To help save on healthcare costs, select a doctor in your network. Search for in - network healthcare providers at: members.healthgram.com. For more detailed information, view the complete guide on page 9.
Contact your Advisor : For answers about your plan and benefits Before any planned medical procedures For billing assistance To confirm precertification for an upcoming procedure, or a penalty may apply Your member portal: Verify coverage, request a copy of your ID card, check claims status and more from your mobile - friendly online portal. Register at members.healthgram.com and view the complete guide on page 8.
YOUR MEDICAL ID CARD
Your ID card details the benefits offere d to you through your employer. It is being mailed to your employer with accompanying instruc ti ons. Provide your new ID card to ALL of your providers after October 1 st , 2022 and dispose of old cards.
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are Benefits Through Healthgram
How to Access Your Healthcare Benefits Through Healthgram How to Access Your Healthcare Benefits Through Healthgra Members:
ow to Access Your Healthcare Benefits Through Healthgram
Members: Members: • To find an in-network provider, login to your Member Portal at: members.healthgram.com Members:
es.
Healthgram, in partnership with J & L Ventures, LLC , strives to offer the best network options to its employees. To do so, we allow J&LV entures, LL C employees to access the Cigna medical network.
Healthgram, in partnership with J & L Ventures, LLC , strives to offer the best network options to its employees. To do so, we allow J&LV entures, LL C employees to access the Cigna medical network. This means that the medical network is through Cigna and the benefits are administered by Healthgram. This means that the medical network is through Cigna and the benefits are administered by Healthgram. Providers • For any questions regarding eligibility or benefits coverage, please visit the Healthgram Provider Portal at: providers.healthgram.com • If physicians still have eligibility or benefits questions after visiting the Provider Portal, please call Healthgram at: 980.201.3020 • If physicians still have eligibility or benefits questions after visiting the Provider Portal, please call Healthgram at: 980.201.3020 Providers • For any questions regarding eligibility or benefits coverage, please visit the Healthgram Provider Portal at: providers.healthgram.com portant for Members and Providers to note the ng instructions for how to access care, eligibility and ts coverage information. gram, in partnership with J & L Ventures, LLC , to offer the best network options to its employees. so, we allow J&LV entures, LL C employees to the Cigna medical network. means that the medical network is through and the benefits are administered by hgram. ders any questions regarding eligibility or benefits erage, please visit the Healthgram Provider Portal providers.healthgram.com hysicians still have eligibility or benefits questions after ing the Provider Portal, please call Healthgram at: .201.3020 certification Process: Please call Healthgram at .201.3020 to be routed to the correct precertification dept. Cigna. nd
• To find an in-network provider, login to your Member Portal at: members.healthgram.com • To find an in-network provider, login to your Member Porta at: members.healthgram.com • Always take your Health Insurance ID Card with you to appointments and show it to the provider's office upon arrival. • Always take your Health Insurance ID Card with you to appointments and show it to the provider's office upon arr • You may also share this document with your provider to giv them guidance on who to contact if they have questions regarding your eligibility or benefits coverage. • You may also share this document with your provider to give them guidance on who to contact if they have questions regarding your eligibility or benefits coverage. • To view a digital copy of your ID card, log into your Member Portal at members.healthgram.com and click on the "ID Card" link on your dashboard. • To view a digital copy of your ID card, log into your Member Portal at members.healthgram.com and click on the "ID Ca link on your dashboard. • You may also share this document with your provider to them guidance on who to contact if they have questions regarding your eligibility or benefits coverage. • To view a digital copy of your ID card, log into your Memb Portal at members.healthgram.com and click on the "ID C link on your dashboard. • If you need to manually submit a claim to Healthgram for reimbursement, login into your Member Portal at members.healthgram.com and download the Claim Form within the "Documents" section. • If you need to manually submit a claim to Healthgram for reimbursement, login into your Member Portal at members.healthgram.com and download the Claim Form within the "Documents" section. • To find an in-network provider, login to your Member Por at: members.healthgram.com • Always take your Health Insurance ID Card with you to appointments and show it to the provider's office upon a
• Always take your Health Insurance ID Card with you to appointments and show it to the provider's office upon arrival.
It's important for Members and Providers to note the following instructions for how to access care, eligibility and benefits coverage information. It's important for Members and Providers to note the following instructions for how to access care, eligibility and benefits coverage information. • You may also share this document with your provider to give them guidance on who to contact if they have questions regarding your eligibility or benefits coverage. • If you need to manually submit a claim to Healthgram for reimbursement, login into your Member Portal at members.healthgram.com and download the Claim Form within the "Documents" section. • To view a digital copy of your ID card, log into your Member Portal at members.healthgram.com and click on the "ID Card" link on your dashboard. • Precertification Process: Please call Healthgram at 980.201.3020 to be routed to the correct precertification dept. for Cigna. • Precertification Process: Please call Healthgram at 980.201.3020 to be routed to the correct precertification dept. for Cigna. • If you need to manually submit a claim to Healthgram for reimbursement, login into your Member Portal at members.healthgram.com and download the Claim Form within the "Documents" section.
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J & L VENTURES, LLC 2022 BENEFIT GUIDE
Welcome to Healthgram Connect
A familiar situation. You need help quickly to confirm that a local doctor is in network, or maybe you ’ ve developed a cough or been diagnosed with a condition and are not sure where to receive care. No matter how you enter the healthcare system, there are times when questions are met with even more questions, when what you need is answers. Help is on the way. Your employer has teamed up with Healthgram to bring you a solution. Healthgram Connect aligns you with a knowledgeable Health Advisor. Your Advisor, who is supported by a team of medical and benefits experts, is ready to answer any questions you have about your benefits or care. That means everything from network questions to appointment scheduling to billing!
A call to your Advisor can help you:
Find the r i g ht docto r, hospital or facility for your specific needs
Re s olve in s u ra nce - r el a ted i ss ue s from claims status inquiries to billing
Unde rs t a nd you r b ene fi t s including all coverage questions and issues
E s ti ma te m edic a l co s t s and in some cases, help you earn money
St a y he a lthy with the help of alert reminders for upcoming screenings
866.904.9081 All you need to do is call!
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HEALTHGRAM CONNECT: YOUR ONE - STOP RESOURCE
Your employer has teamed up with Healthgram to provide you and your family with access to a free health Advisor. Your Advisor is on call to help you understand your medical benefits, save money and make healthcare decisions with confidence.
CALL YOUR ADVISOR WHEN:
You have any questions about your medical benefits or billing
You have an upcoming medical procedure — like a surgery or imaging
You need help finding an in - network doctor or specialist
You need help estimating upcoming medical costs
JUST CALL! 866.904.9081
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J & L VENTURES, LLC 2022 BENEFIT GUIDE
AN EASY WAY TO SAVE AND EARN CASH REWARDS
SAVE MONEY, GET REWARDED You can save money on healthcare costs and earn cash rewards by visiting fair price providers for select services. Finding a fair price provider is easy! Before any planned medical procedures, call your Advisor to see if you qualify for rewards and discuss your provider options. You can save money and earn rewards simply by visiting a fair price providers for the following services.
ELIGIBLE SERVICES
$25 REWARD
$50 REWARD
$100 REWARD
Removal of Adenoids Sleep Study Tonsillectomy Cataract Surgery Cholecystectomy (laparoscopic) Ear Tube Placement Heart Perfusion Imaging Lithotripsy
Most CTs Most MRIs Transthoracic Echocardiogram (TTE) Transthoracic Echocardiogram (TTE) - with Doppler
Colonoscopy Endoscopy ( Upper GI) Knee Arthroscopy Shoulder Arthroscopy
NO HASSLE, JUST REWARDS
With Healthgram, it ’ s easy to save money and get rewards. No forms are needed to receive your reward.
You are eligible for rewards simply by visiting a fair price provider as recommended by your Advisor. Always call your Advisor before any planned medical procedure to know if you are eligible for rewards.
Your covered family members can also earn rewards! Rewards are processed on a quarterly basis and will be sent right to your home.
START EARN I N G REWARDS Call your Advisor: 1 - 866 - 904 - 9081 Support Hours: Monday — Friday 8am to 6pm
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YOUR HEALTHGRAM MEMBER PORTAL
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YOUR WELLNESS CENTER
Tracking your health and wellness is easier than ever before. With helpful applications and a mobile - friendly layout, your Healthgram portal gives you everything you need to manage your care online.
1. Health Plan: View benefits plans and status.
5. Health Record: View lab results, care action plans and health resources.
2. Portal Alerts: Stay informed of compliance requirements, document due dates and health alerts from your dashboard. You ’ ll also find your Health Risk Assessment here. 3. Healthgram Trax: Set personal wellness goals and track compliance with your company ’ s Trax program.
6. Preventive Care: Track and receive alerts regarding your recommended screenings.
7. How Can We Help?: Compare healthcare costs, view your Summary of Benefits, check on a claim status, get a copy of your ID card, or contact our Customer Service team
4. Find A Doctor: Search for an in - network provider at the click of a button.
8. Healthgram Connect: Contact your Advisor
9. Appointments: View or schedule
Register for your Member Portal: 1 2
4
3
Enter your username and password to login!
Visit the login page at members.healthgram.com
Click the “ Need to Register? ” link.
Enter the required information.
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Instruc ti ons: 1. Visit www.healthgram.com, select Members in the top right hand corner of the home screen. 2. Under Resource Links, select Find a Doctor. FINDING AN IN - NETWORK DOCTOR OR DENTIST
3. Select the PPO Network that matches the one on your ID Card. You ’ ll be redirected to the website of the network you select.
4. From the Cigna site, click the dropdown for Doctor type, name, or location.
5. Then login to the Cigna portal to view your search results, including the doctor ’ s address, specialties, patient score and costs.
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Healthier, Together.
Your employer has partnered with Healthgram to provide you and your family with access to a free health Advisor. Your Advisor can help guide you through your healthcare benefits and answer all of your questions. Find your “ green light ” provider: Call for help with finding an in - network provider for you. Earn rewards for planned procedures: Before any planned medical procedures, call your Advisor to see if you qualify for reward and discuss your provider options. Be proactive: Call your advisor before scheduling your next medical procedure. Being proactive can help you save money and ensure you get the best care for the right price.
Call: 866.904.9081 Login: members.healthgram.com
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J&L Ventures, LLC provides all Full Time employees with Basic Life and Accidental Death & Dismemberment coverage on a contributory basis. Basic Life and AD&D Insurance Coverage
Insurance Carrier:
Basic Life Insurance
Basic Life w/ AD&D Eligibility Requirement Life Insurance Benefit
All Full Time Employees Based on Occupation Class
Guarantee Issue
Yes
Accidental Death & Dismemberment Benefit (AD&D)
Same as Basic Life Amount
Dependent Life
$10,000
Voluntary Term Life Insurance Coverage
As a supplemental benefit, J&L Ventures, LLC 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 Sun Life. Rates for the voluntary term life insurance are based on age, and volume, and benefits are subject to applicable age reductions.
Insurance Carrier:
Voluntary Life Insurance
Voluntary Life w/ AD&D Eligibility Requirement Employee Benefit Amounts Employee
All Full Time Employees
minimum of $10,000 / up to $500,000 in increments of $10,000 minimum of $5,000 / 100% of employees benefit, up to $250,000 minimum of $5,000 / 100% of employees benefit, up to $10,000
Spouse
Child(ren)
Guarantee Issue Employee
5 times annual income, up to $150,000 50% of employees benefit, up to $25,000 50% of employees benefit, up to $10,000
Spouse
Child(ren)
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Disability Insurance Coverage
The goal of J&L Ventures 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 Sun Life.
Insurance Carrier:
Short-Term Disability Insurance
Plan Type:
Voluntary
Eligibility Requirement
All Full Time Employees
Benefit Percentage
60%
Waiting Period - Accident Waiting Period - Sickness Maximum Weekly Benefit Pre-Existing Condition
14 Days 14 Days $1,875 3 / 12
Benefit Duration
24 Weeks
Insurance Carrier:
Long-Term Disability Insurance
Plan Type:
Voluntary
Eligibility Requirement
All Full Time Employees
Waiting Period
180 Days
Benefit Percentage
60%
Maximum Monthly Benefit
$5,000* SSNRA 2 Years 3 / 12
Benefit Duration
Own Occupation Definition
Pre-Existing Condition
*Maximum Monthly Benefit varies by classification.
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Dental Coverage
Regular dental exams can help you and your dentist detect problems in the early stages when treatment is simpler and costs are lower. Your PPO dental plan is through Sun Life and offers “in and out-of-network” benefits.
Insurance Carrier:
Sun Life Dental Insurance
Plan Type:
PPO
Calendar Year Deductible Calendar Year Maximum
$50 / Individual; maximum of $150 family
$1,000
Preventive Services
100%
Basic Services Major Services
80% 50% 80%
Endo/Perio
Orthodontic Lifetime (dependent children only)
$1,000
Out-of-Network Reimbursement
90th Usual & Customary
Vision Coverage
The vision plan covers routine eye exams and also pays for all or a portion of the cost of glasses or contact lenses if you need them. Your PPO vision plan is through Sun Life and offers “in and out-of-network” benefits.
Insurance Carrier:
Sun Life Vision Insurance
Plan Type:
VSP Choice Plan
In-Network
Out-of-Network
Exam Services
$10 $25 $25 $25
$45 $30 $50 $60
Lenses - Single lined Lenses - Bifocal lined Lenses - Trifocal Contacts / Lenses
$ 130 allowance; then 20% off any remaining balance $130 allowance; then 20% off any remaining balance
Up to $105 Up to $70
Frames
Frequency for Exam / Lenses / Frames
12 months / 12 months / 24 months
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401k
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401k
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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? Healthgram 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 Healthgram’s contracted rate for your medical care and services rendered. The contracted rate includes both Healthgram’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, Healthgram’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 Healthgram. 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. Healthgram 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 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
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Legal Notices
Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free or Low-Cost Health Coverage to Children and Families
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www. healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www. insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 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
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Legal Notices
MISSOURI - Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
RHODE ISLAND - Medicaid Website: http://www.eohhs.ri.gov/ Phone: 401-462-5300 SOUTH CAROLINA - Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 SOUTH DAKOTA - Medicaid
Phone: 573-751-2005 MONTANA - Medicaid Website: http://dphhs.mt.gov/ MontanaHealthcarePrograms/HIPP
Phone: 1-800-694-3084 NEBRASKA - Medicaid
Website: http://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
20 J & L VENTURES, LLC 2022 BENEFIT 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.
21 J & L VENTURES, LLC 2022 BENEFIT 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 J&L Ventures, LLC 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. J&L Ventures, LLC has determined that the prescription drug coverage offered by Humana 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 J&L Ventures, LLC 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 J&L Ventures, LLC 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 J&L Ventures, LLC 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 J&L Ventures, LLC 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.
22 J & L VENTURES, LLC 2022 BENEFIT 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.
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