2024 Employee Benefit Guide
Table of Contents Benefits for 2024
• Introduction
3
• Medical Benefits
4
• Health Savings Account (HSA)
6
• HealthJoy
7
• Dental Benefits
10
• Vision Benefits
11
• Weekly Contributions
12
• Life Insurance
13
• Disability Insurance
14
• Samaritan Fund Program
15
• HTA Medicare Services
16
• Online Enrollment
17
• Legal Notices
18
• Contact Page
34
• Notes Page
35
• Required Annual Notices for Group Health Plans
36
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2024 Employee Benefit Guide
2
Benefits for 2024 Introduction
Asan employee of RSM Electron Power Inc.enjoying your work and makingvaluable contributions to business are equally vital. The health, satisfaction and security of you and your family are important, not only to your well-being, but ultimately, in terms of achieving the goals of our organization. For the 2024 plan year, RSM Electron Power Inc. has worked hard to offer a competitive total rewards package that includes valuable and competitive benefits plans. These programs reflect our commitment to keeping our staff healthy and secure. We understand that your situation is unique,and RSM Electron Power Inc.is offeringan overall benefitspackagethatcan be shaped and moldedby you to fityour needs. This benefits booklet is a summary description of your RSM Electron Power Inc. benefit plans. If there is a discrepancy between these summaries and the written legal plan documents, the plan documents shall prevail. This booklet and plan summaries do not constitute a contract of employment.
We hope this benefits booklet, along with our additional communication and decision-making tools, will help you make the best health care choices for you and your family.
Who is Eligible? When?
Non-Exempt (hourly) full time employees are eligible on the first of the month following 60 days of employment. Exempt (salary) and agency employees transitioning to permanent hire are eligible as of date of hire.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
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Benefits for 2024
Medical
SUMMARY OF COVERAGE
Aetna Choice POS II Network
HSA
BUY-UP
Employer Funding (Single/Family)
$600/$1,200
N/A
Deductible (Single / Family)
$3,000/$6,000
$1,000/$2,000
Out of PocketMaximum (Single/ Family)
$5,000/$10,000
$3,000/$6,000
Coinsurance
20% After Deductible
10% After Deductible
Preventive Care
100% Covered
100% Covered
Primary Care & Specialist Visit
20% After Deductible
$25Copay/ $40Copay
Inpatient Hospital
20% After Deductible
10% After Deductible
Outpatient Hospital
20% After Deductible
10% After Deductible
Urgent Care
20% After Deductible
$50Copay
Emergency Room
20% After Deductible
$150Copay
RxCopays
Deductible then $10 / $35 / $60
$10 / $35 / $60
OUT OF NETWORK*
Deductible
$2,500 / $5,000
$2,000 / $4,000
Coinsurance
40% After Deductible
40% After Deductible
Out of PocketMaximum
$6,250 / $12,500
$6,250 / $12,500
*If you see an out of networkprovideryou may be charged the difference betweenthe providerbill and the usualand customary amount ** For illustrativepurposes only. Please refer to the benefit summary on the HealthJoy app for all plan details
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2024 Employee Benefit Guide
4
Benefits for 2024
Medical
MERITAIN SERVICES
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2024 Employee Benefit Guide
5
Benefits for 2024
Health Savings Account (HSA)
FOR2024RSMELECTRON POWER INC.ISOFFERING AHEALTH SAVINGS ACCOUNT (HSA). THIS IS HOW AN HSA WORKS:
A health savings account (HSA) is a health care account and savings account in one. The main purpose of this account is to offset the cost of a qualifying high deductible health plan (HDHP) and provide savings for your out-of-pocket eligible health care expenses – those you and your tax dependents may have now, in the future, and during your retirement.
This is a “portable” account. You own your HSA! It’s included in your employee benefits package, but after you set up your account, it’s yours to keep, even if you change jobs or retire.
Once your HSA is established, money is contributed to your account by you, RSM Electron Power Inc. or friends and family, and you can then use your HSA dollars tax-free to pay for eligible health care expenses. You save money on expenses you’re already paying for, like doctors’ office visits, prescription drugs, and much more. Best of all, you decide how and when to use your HSA dollars.
WHY ISITAGOOD IDEATOHAVE AN HSA?
HSAs benefit everyone who is eligible to have this account – single individuals, families, and soon-to-be retirees. You save money on taxes in three ways:
› Tax-free earnings – Your
› Tax-free deposits – The money you contribute to your HSA isn’t taxed (up to the IRS annual limit)
› Tax-free withdrawals – The money used toward eligible health care expenses isn’t taxed – now or in the future.
interest and any investment earnings grow tax-free.
› This account is only available to employees that elect the HSA plan. RSM will contribute $600 for individuals, and $1,200 for families annually to employees enrolled in the HSA plan. You must enroll to receive the employer contribution, even if you don’t intend to contribute. The maximum contribution is $4,150 (Single) / $8,300 (Family). You may contribute an additional $1,000 if your age is 55 or older. HSA funds roll over from year to year and accumulate in your account. There is no “use -it-or-lose- it” rulewith HSAs, and you decide how and when to use your HSA funds, which can be used for eligible expenses you have now, in the future, or during retirement. And when you have a certain balance in your HSA, investment opportunities are available. View your HSA on www.fidelity.com and to make changes www.netbenefits.com
Refer to your HSA documentation for more information.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2024 Employee Benefit Guide
6
Benefits for 2024
HealthJoy
HealthJoy
HealthJoy is the virtual access point for all your healthcare navigation and employee benefits needs. HealthJoy is provided free by RSM to help understand and make the most of your benefits. We connect you and your family with the right benefits at the right moment in your care journey, saving you time, money, and frustration. With24/7 access to our dedicated healthcareconcierge team,visits, and care navigation tools, you never have to walk alone. HealthJoy helps you locate in- network doctors, find extra savings on your prescriptions, and navigate your benefits. Our mobile app and dedicated member support team are always on hand to help makeit easier to stay healthyand well.
Chat withHealthJoy today by logging into the HealthJoyapp or call(877)500-3212
BENEFITS WALLET
HEALTHCARE CONCIERGE
RX SAVINGS REVIEW
APPOINTMENT BOOKING
HSA SUPPORT
PROVIDER RECS
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2024 Employee Benefit Guide
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Benefits for 2024
Medical
KEY TERMS TO REMEMBER
OUT-OF-POCKET MAXIMUM This is the total amount you can pay out of pocket each calendar year before the plan pays 100 percent of covered expenses for the rest of the calendar year. Most expenses that meet provider network requirements count toward the annual out-of-pocket maximum, including expenses paid to the annual deductible*, copaysand coinsurance. *Exceptfor Grandfatheredmedical plans
ANNUAL DEDUCTIBLE The amount you have to pay each year before the plan starts paying a portion of medical expenses. All family members’ expenses that count toward a health plan deductible accumulate together in the aggregate; however, each person also has a limit on their own individual accumulated expenses (the amount varies by plan).
COPAYSAND COINSURANCE These expenses are your share of cost paid for covered health care services. Copays are a fixed dollar amount, and are usually due at the time you receive care.Coinsurance is your share of the allowed amount charged for a service, and is generally billed to you after the health insurance company reconciles the bill with the provider.
PLANTYPES
› EPO/PPO – A network of doctors, hospitals and other health care providers › HMO – A network that requires you to select a Primary Care Physician (PCP) who coordinates your health care › POS – Combines aspects of a PPO and HMO › HDHP – A plan that has higher annual deductibles in exchange for lower premiums.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2024 Employee Benefit Guide
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Benefits for 2024 Medical
Understanding the full value of covered benefits allows you to take responsibility for maintaining good health and incorporating healthy habits into your lifestyle. Some examples include getting regular physical examinations, mammograms and immunizations. Through the plans offered by RSM Electron Power Inc. , all covered individuals and family members are eligible to receive routine wellness services like these, at no cost; all copays, coinsurance, and deductibles are waived.
WHICH PREVENTIVE CARE SERVICES ARE COVERED?
The US Preventive Services Task Force maintains a regular list of recommended services that all Affordable Care Act (i.e. Health Care Reform) compliant insurance plans should cover at 100% for in-network providers. Below is a list of common services that are included in the plans offered this year:
› Routine Physical Exam › Well Baby and Child Care › Well Woman Visits › Immunizations › Routine Bone Density Test › Routine Breast Exam › Routine Gynecological Exam
› Screeningfor GestationalDiabetes › Obesity Screening and Counseling › Routine Digital Rectal Exam › Routine Colonoscopy › Routine Colorectal Cancer Screening
› Routine Prostate Test › Routine Lab Procedures › Routine Mammograms › Routine Pap Smear › Smoking Cessation
“An ounce of prevention is worth a poundof cure”
› Health Education/Counseling Services › Health Counseling for STDs and HIV › Testing for HPV and HIV › Screening and Counseling for Domestic Violence
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2024 Employee Benefit Guide
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Benefits for 2024 Dental Coverage
SUMMARY OF COVERAGE
PPO
BENEFIT
In/Out of Network
Annual Deductible Individual / Family
$100/$300
Annual Maximum
$2,500 per person
Preventive Care Benefits
Covered 100%
Basic Services
20% afterdeductible
Major Services
50% afterdeductible
Orthodontia Lifetime Maximum (children up to age 19)
50% to $1,000 Lifetime Max
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
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Benefits for 2024 Vision Coverage
SUMMARY OF COVERAGE
Benefit
In-Network
Out of Network
Frequency
Once every 12 months
EyeExam
$10Copay
Up to$25
Lenses -Single Vision -Bifocal -Trifocal/Lenticular
Up to $10 Up to $25 Up to$55
Once every 12 months
$25Copay
$130 allowance then 20% off
Once every 24 months
Frames
Up to$65
Contacts
$105 allowance then 15% off
Once every 12 months
Up to $75
-Elective
Up to$200
-Medically Necessary
Covered 100%
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2024 Employee Benefit Guide
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Benefits for 2024 Weekly Contributions
BENEFIT
HSA
BUY-UP
Employee Only
$21.12
$105.15
Employee + Family
$54.29
$273.96
BENEFIT
Meritain Dental PPO
Aetna Vision
Employee Only
$3.00
$0.51
Employee + Spouse
$6.35
N/A
Employee + Child(ren)
$5.91
N/A
Employee + Family
$9.27
$1.21
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2024 Employee Benefit Guide
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Benefits for 2024 Life Insurance
SUMMARY OF COVERAGE
Plan Features
Basic Life & AD&D
Employee Benefit Amount
2 x Annual Salary
Benefit Maximum $100,000 The following shows how much benefits are reduced at certain ages: Age Benefit Reduction 70 65% 75 45%
Plan Features
Voluntary Life
Employee Benefit Amount
$10kincrementsupto $500,000
Guarantee Issue Amount
$100,000 (New Hires Only)
$5k increments to a maximum of $100K or 50% of employee coverage
Spouse Benefit Amount
Spouse Guarantee Issue Amount
$50,000 (New Hires Only)
Child Life Benefit Amount
$1,000upto a maximumof$10,000
Child Guarantee Issue Amount
$10,000
The following shows how much benefits are reduced at certain ages: Age Band Benefit Reduction 70 65% 75 45%
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2024 Employee Benefit Guide
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Benefits for 2024 Disability Insurance
SUMMARY OF COVERAGE
Plan Features
Short Term Disability
Employee Benefit Amount
60% of Weekly Earnings
Maximum Benefit Amount
$2,000 weekly
Elimination Period (Accident & Sickness)
14days
Benefit Duration
26weeks
Plan Features
Long Term Disability
Employee Benefit Amount
60% of Monthly Earnings
Maximum Benefit Amount
$10,000 monthly
Elimination Period (Accident)
180days
Benefit Duration
Social Security Normal Retirement Age
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2024 Employee Benefit Guide
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Benefits for 2024 Samaritan Fund Program
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2024 Employee Benefit Guide
15
Benefits for 2024 HTA Medicare Services
610.430.6650| Medicare@HTAfinancial.com
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2024 Employee Benefit Guide
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Benefits for 2024 Online Enrollment Overview
Enrollment will be in the PlanSource site. If this is the first time you are accessing PlanSource, follow these steps for your username and password:
Username
First initial of your First Name First six characters of your Last Name Last four (4) digits of your SSN Example: John Employee SSN is 000-00-1234 Result: JEMPLOY1234
Password
Your date of birth in YYYYMMDD format
https://benefits.plansource.com/
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2024 Employee Benefit Guide
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Benefits for 2024
Legal Notices
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that addresses the privacy and security of certain individually identifiable health information, called protected health information (or PHI). You have certain rights with respect to your PHI, including a right to see or get a copy of your health and claims records and other health information maintained by a health plan or carrier.For a copyof the Notice of PrivacyPractices,describinghow your PHI maybe used and disclosed and how you get access to the information, contact Human Resources.
Women’s Healthand Cancer RightsAct EnrollmentNotice
If you have had or are going to have a mastectomy,you maybe entitledto certainbenefits under the Woman’s Health and Cancer Rights Act of 1998 (WHCRA).For individualsreceivingmastectomy-relatedbenefits,coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:
1. All stages of reconstruction of the breast on which mastectomy was performed. 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses.
3. Treatment of physical complications of the mastectomy, including lymphedema.
These will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this benefitsplan.
Newborns’ and Mothers’ Health Protection Act Disclosure
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, fromdischarging the motheror her newborn earlierthan 48 hours (or 96 hours as applicable).In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribinga length of staynot in excessof 48 hours (or96 hours).
Patient Protection Notice
Your carrier generally may require the designation of a primary care provider. You have the right to designate any primary care provider who participates in your network and who is available to accept you or your familymembers. Untilyou make this designation, your carriermaydesignate one for you. For informationon how to select a primarycare provider, and for a listof the participating primary care providers, contact the plan administrator. For children,you maydesignate a pediatrician as the primarycare provider. You do not need priorauthorization fromyour carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professionalin your network who specializesin obstetrics or gynecology. The health care professional,however, maybe required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals.For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the plan administrator.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2024 Employee Benefit Guide
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Benefits for 2024
Legal Notices
HIPAA Special EnrollmentNotice
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 and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a resultof marriage, birth, adoption, or placement for adoption, you maybe able to enroll yourselfandyourdependents. However,youmustrequestenrollmentwithin30daysafterthemarriage,birth,adoption,orplacement for adoption. If you or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or become eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must request enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistance subsidy.To request specialenrollment or to obtain moreinformationabout the plan's special enrollment provisions,contact the plan administrator.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2024 Employee Benefit Guide
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Benefits for 2024
Legal Notices
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your childrenare eligiblefor Medicaid or CHIPand 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 insurancecoverage 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 premiumassistance is available.
If you or your dependents are NOT currentlyenrolled in Medicaid or CHIP, and you think you or any of your dependents mightbe 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 mighthelp you pay the premiumsfor an employer-sponsored plan. If you or your dependents are eligible for premiumassistanceunder Medicaidor 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 mustrequest coverage within 60 days of being determined eligible for premiumassistance. If you have questions about enrolling in your employer plan, contactthe Departmentof 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 followinglist of states is current as of July 31, 2023. Contactyour State for more informationon eligibility –
ALABAMA-Medicaid
CALIFORNIA-Medicaid
Website: http://myalhipp.com/ Phone: 1-855-692-5447
Website: Health Insurance Premium Payment (HIPP) Programhttp://dhcs.ca.gov/hipp Phone: 916-445-8322 Fax: 916-440-5676 Email: hipp@dhcs.ca.gov
ALASKA-Medicaid
COLORADO-Health First Colorado (Colorado’s Medicaid
Program) & Child Health Plan Plus (CHP+)
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
Health First Colorado Website:https://www.healthfirstcolorado.com/ Health FirstColorado Member Contact Center: 1-800-221-3943/State Relay 711 CHP+: https://hcpf.colorado.gov/child-health-plan-plus CHP+CustomerService: 1-800-359-1991/State Relay 711 Health Insurance Buy-In Program (HIBI): https://www.mycohibi.com/ HIBI Customer Service: 1-855-692-6442
ARKANSAS-Medicaid
FLORIDA-Medicaid
Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.c om/hipp/index.html Phone: 1-877-357-3268
Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2024 Employee Benefit Guide
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Benefits for 2024
Legal Notices
GEORGIA-Medicaid
MAINE-Medicaid
GA HIPP Website: https://medicaid.georgia.gov/health- insurance-premium-payment-program-hipp Phone: 678-564-1162, Press 1 GA CHIPRA Website: https://medicaid.georgia.gov/programs/third-party-liability/childrens- health-insurance-program-reauthorization- act-2009-chipra Phone: (678) 564-1162, Press 2
Enrollment Website: https://www.mymaineconnection.gov/benefits/s/?language= en_US Phone: 1-800-442-6003 TTY: Maine relay 711
Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms
Phone: -800-977-6740. TTY: Maine relay 711
INDIANA-Medicaid
MASSACHUSETTS-Medicaid and CHIP
Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: https://www.in.gov/medicaid/ Phone 1-800-457-4584
Website: https://www.mass.gov/masshealth/pa Phone: 1-800-862-4840 TTY: 711 Email: masspremassistance@accenture.com
IOWA-Medicaid and CHIP (Hawki)
MINNESOTA-Medicaid
Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki HawkiPhone: 1-800-257-8563 HIPP Website: https://dhs.iowa.gov/ime/members/medicaid-a-to- z/hipp HIPPPhone: 1-888-346-9562
Website: https://mn.gov/dhs/people-we-serve/children-and-families/health- care/health-care-programs/programs-and-services/other- insurance.jsp Phone: 1-800-657-3739
KANSAS-Medicaid
MISSOURI-Medicaid
Website: https://www.kancare.ks.gov/ Phone: 1-800-792-4884 HIPP Phone: 1-800-967-4660
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005
KENTUCKY-Medicaid
MONTANA-Medicaid
Kentucky Integrated Health InsurancePremiumPayment Program(KI- HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov/agencies/dms
Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084 Email: HHSHIPPProgram@mt.gov
LOUISIANA-Medicaid
NEBRASKA-Medicaid
Website: dhh.louisiana.gov/index.cfm/subhome/1/n/331 or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaidhotline) or 1-855-618- 5488 (LaHIPP)
Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
2024 Employee Benefit Guide
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Benefits for 2024
Legal Notices
NEVADA-Medicaid
SOUTH CAROLINA-Medicaid
Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900
Website: https://www.scdhhs.gov Phone: 1-888-549-0820
NEW HAMPSHIRE-Medicaid
SOUTH DAKOTA-Medicaid
Website: https://www.dhhs.nh.gov/programs-services/medicaid/health- insurance-premium-program Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext. 5218
Website: http://dss.sd.gov Phone: 1-888-828-0059
NEW JERSEY-Medicaid and CHIP
TEXAS-Medicaid
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
Website:Health InsurancePremiumPayment (HIPP)Program| Texas Health and Human Services Phone: 1-800-440-0493
NEW YORK-Medicaid
UTAH-Medicaid and CHIP
Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831
Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669
NORTH CAROLINA-Medicaid
VERMONT-Medicaid
Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100
Website: Health Insurance Premium Payment (HIPP) Program | Department of Vermont Health Access Phone: 1-800-250-8427
NORTH DAKOTA-Medicaid
VIRGINIA-Medicaid and CHIP
Website: https://www.hhs.nd.gov/healthcare Phone: 1-844-854-4825
Website: https://coverva.dmas.virginia.gov/learn/premium- assistance/famis-select https://coverva.dmas.virginia.gov/learn/premium-assistance/health- insurance-premium-payment-hipp-programs Medicaid/CHIP Phone: 1-800-432-5924
OKLAHOMA-Medicaid and CHIP
WASHINGTON-Medicaid
Website: http://www.insureoklahoma.org Phone: 1-888-365-3742
Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022
OREGON-Medicaid
WEST VIRGINIA-Medicaid and CHIP
Website: http://healthcare.oregon.gov/Pages/index.aspx Phone: 1-800-699-9075
Website: https://dhhr.wv.gov/bms/ http://mywvhipp.com/ Medicaid Phone: 304-558-1700 CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
PENNSYLVANIA-Medicaid and CHIP
WISCONSIN-Medicaid and CHIP
Website: https://www.dhs.pa.gov/Services/Assistance/Pages/HIPP- Program.aspx Phone: 1-800-692-7462 CHIP Website: Children's Health Insurance Program (CHIP) (pa.gov) CHIP Phone: 1-800-986-KIDS (5437)
Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002
RHODE ISLAND-Medicaid and CHIP
WYOMING-Medicaid
Website: https://health.wyo.gov/healthcarefin/medicaid/programs- and-eligibility/ Phone: 1-800-251-1269
Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
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Legal Notices
To see if any other states have added a premiumassistance program since July 31, 2023, or for more informationon special enrollment rights, contact either:
U.S. Departmentof Health and Human Services CentersforMedicare& MedicaidServices www.cms.hhs.gov
U.S. Departmentof Labor Employee Benefits Security Administration
www.dol.gov/agencies/ebsa 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 Departmentnotes that a Federal agency cannot conduct or sponsora collectionof information unless it is approved by OMB under the PRA, and displaysa currentlyvalid OMB control number,and the public is not required to respond to a collectionof informationunless it displaysa currentlyvalid OMB control number.See 44 U.S.C. 3507. Also, notwithstanding any other provisionsof law, no person shallbe subject to penalty for failing to comply with a collectionof informationif the collectionof information does not display a currentlyvalidOMB controlnumber.See 44 U.S.C. 3512. The public reporting burden for this collectionof informationis estimatedto average approximatelyfour minutesper respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestionsfor reducing this burden, to the U.S. Departmentof Labor, 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.
OMB Control Number 1210-0137 (expires 1/31/2026)
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
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Benefits for 2024
Legal Notices
Genetic Information Nondiscrimination Act (GINA) Disclosures Genetic InformationNondiscriminationAct of2008 The Genetic Information Nondiscrimination Act of 2008 (“GINA”) protects employees against discrimination based on their
genetic information. Unless otherwise permitted,your Employer may not request or require any genetic informationfrom you
or your family members.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically
allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to
thisrequestfor medicalinformation. “Genetic information,” as definedby GINA,includesan individual’s family medical history,
the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member
sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family
member or an embryo lawfully held by an individual or familymember receiving assistive reproductive services.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
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Benefits for 2024
Legal Notices
USERRA Notice Your Rights Under USERRA A. The Uniformed Services Employment and Reemployment Rights Act
USERRA protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake military service or certain types of service in the National Disaster Medical System. USERRA also prohibits employers from discriminating against past and present members of the uniformed services, and applicants to the uniformed services. B. Reemployment Rights You have the right to be reemployed in your civilian job if you leave that job to perform service in the uniformed service and: • You ensurethat your employerreceivesadvancewrittenor verbalnoticeof your service; • You have five years or less of cumulative service in the uniformed services while with that particular employer; • • You return to work or apply for reemployment in a timely manner after conclusion of service; and You have not been separated from service with a disqualifying discharge or under other than honorable conditions. If you are eligible to be reemployed, you must be restored to the job and benefits you would have attained if you had not beenabsentdue to militaryservice or, in some cases,a comparablejob. C. Right to Be Free from Discriminationand Retaliation If you: • Are a pastor presentmemberof the uniformedservice; • Have appliedfor membershipin the uniformedservice; or • Are obligatedto serve in the uniformed service; then an employer may not deny you o Initial employment; o Reemployment; o Retention in employment; o Promotion; or o Any benefit of employment because of this status. In addition, an employer may not retaliate against anyone assisting in the enforcement of USERRA rights, including testifying or making a statement in connection with a proceeding under USERRA, even if that person has no service connection.
D. Health Insurance Protection
• If you leave your job to perform military service, you have the right to elect to continue your existing employer-based health plan coverage for you and your dependents for up to 24 months while in the military.
•
Even if you do not elect to continue coverage during your military service, you have the right to be reinstated in your employer's health plan when you are reemployed, generally without any waiting periods or exclusions(e.g., pre-existingconditionexclusions)exceptfor service-connectedillnessesor injuries.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
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Benefits for 2024
Legal Notices
E. Enforcement •
The U.S. Departmentof Labor,Veterans'Employmentand TrainingService(VETS) is authorizedto investigate and resolve complaints of USERRA violations. For assistance in filing a complaint, or for any other information on USERRA, contact VETS at 1-866-4-USA-DOL or visit its Web site at http://www.dol.gov/vets. An interactive online USERRA Advisor can be viewed at http://www.dol.gov/elaws/userra.htm. • If you file a complaint with VETS and VETS is unable to resolve it, you may request that your case be referredto the Departmentof Justiceor the Office of Special Counsel,as applicable,for representation. • You may alsobypassthe VETS processand bring a civilactionagainstan employerforviolationsof USERRA. The rights listed here may vary depending on the circumstances. The text of this notice was prepared by VETS, and may be viewed on the Internet at this address: http://www.dol.gov/vets/programs/userra/poster.htm. Federal law requires employers to notify employees of their rights under USERRA, and employers may meet this requirement by displaying the text of this notice where they customarily place notices for employees. U.S. Department of Labor, Veterans' Employment and Training Service, 1-866-487-2365.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
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Benefits for 2024 Legal Notices
COBRA
Model General Notice of COBRA Continuation Coverage Rights (For use by single-employer group health plans)
** Continuation Coverage Rights Under COBRA**
Introduction
You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important
information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This
notice explains COBRA continuationcoverage, when itmay become available to you and your family, and whatyou need to
do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options
thatmay costlessthanCOBRAcontinuationcoverage.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of1985
(COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage
would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review
the Plan’s SummaryPlan Descriptionorcontactthe Plan Administrator.
You mayhave other options available to you when you lose group health coverage. Forexample, you maybe eligible to buy an
individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you mayqualifyforlower
costson your monthlypremiumsand lower out-of-pocketcosts. Additionally,you may qualify for a 30-day special enrollment period for
another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.
What is COBRA continuation coverage?
COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a lifeevent. This isalso
calleda “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation
coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could
become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualifiedbeneficiaries
who elect COBRA continuation coverage mustpay for COBRA continuation coverage.
If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying
events:
• Your hours of employment are reduced, or
• Your employment ends for any reason other than your grossmisconduct.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
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Benefits for 2024 Legal Notices
COBRA
If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the
following qualifying events:
•
Yourspouse dies;
• Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct;
• Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or
• You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following
qualifying events:
•
The parent-employee dies;
• The parent- employee’s hours of employment are reduced; • The parent- employee’s employment ends for any reason other than his or her gross misconduct;
• The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
• The parents become divorced or legally separated; or
• The childstopsbeing eligiblefor coverage under the Plan as a “dependent child.”
When is COBRA continuation coverage available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administratorhas been notifiedthat
a qualifying event has occurred. The employermustnotifythe Plan Administratorof the following qualifying events:
• The end of employment or reduction of hours of employment;
•
Death of the employee;
• The employee’s becomingentitledto Medicarebenefits (under Part A, Part B, orboth).
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
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Benefits for 2024 Legal Notices
COBRA
For all other qualifying events (divorceor legal separation ofthe employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within60 after the qualifying event occurs. You
must provide this notice to the plan administrator
How is COBRA continuation coverage provided?
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each
of the qualified beneficiaries. Each qualified beneficiary willhave an independent right to elect COBRA continuation coverage.
Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA
continuation coverage on behalf of their children.
COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment
termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial periodof coverage,
maypermita beneficiary to receive a maximumof 36 monthsof coverage.
There are also ways in which this 18-monthperiod of COBRA continuation coverage can be extended:
Disability extension of18-monthperiod ofCOBRAcontinuationcoverage
If you or anyone in your familycovered under the Plan is determined by Social Securityto be disabled and you notify the Plan
Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA
continuation coverage, fora maximumof29 months. Thedisabilitywould have tohave startedatsometimebefore the 60th dayof
COBRA continuationcoverageandmustlastatleastuntiltheendofthe18-monthperiodofCOBRAcontinuationcoverage.
Second qualifying event extension of 18-month period of continuation coverage
If your familyexperiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent
children in your familycan get up to 18 additional months of COBRA continuation coverage, for a maximumof 36 months, if thePlan is
properlynotified about the second qualifying event. Thisextension maybe available to the spouse and any dependent children getting
COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B,
or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This
extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the
Plan had the firstqualifying event not occurred.
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
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Benefits for 2024 Legal Notices
COBRA
Are there other coverage optionsbesides COBRA ContinuationCoverage?
Yes. Instead of enrolling in COBRA continuation coverage, there maybe other coverage options for you and your familythrough the
Health Insurance Marketplace, Medicare, Medicaid, Children’s Health Insurance Program (CHIP), or other group health plan coverage
options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options maycost lessthan
COBRA continuation coverage. You can learn moreabout many of these options at www.healthcare.gov .
Can I enroll in Medicare instead ofCOBRA continuationcoverage after my grouphealth plan coverage ends?
In general, if you don’t enrollin Medicare Part A or B when you are firsteligiblebecause you are stillemployed,after theMedicare initial
enrollment period, you have an 8-month special enrollment period 1 to sign up for Medicare Part A or B, beginning on the earlier of
• The month after your employment ends; or
• The month after group health plan coverage based on current employmentends.
If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty
and you mayhave a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in
Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage. However, if
Medicare Part A or B iseffective on or before the date of the COBRA election, COBRA coverage maynot be discontinued on account
of Medicareentitlement, even if you enroll in the other part of Medicareafter the date of the election of COBRAcoverage.
If you are enrolled in both COBRA continuation coverage and Medicare, Medicare willgenerally pay first(primarypayer) and COBRA
continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.
For more information visit https://www.medicare.gov/medicare-and-you.
If you have questions
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts
identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including
COBRA, the Patient Protection and Affordable Care Act,and other laws affecting group health plans, contact the nearest Regional or
DistrictOffice oftheU.S.Departmentof Labor’s Employee Benefits Security Administration (EBSA) in your area or visit
www.dol.gov/agencies/ebsa . (Addressesand phone numbers of Regional and DistrictEBSA Offices are available through EBSA’s
website.) For moreinformationabout the Marketplace, visit www.healthcare.gov .
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.
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