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2015 Employee Benefits

1 building thriving individuals, families & communities

building thriving individuals, families & communities 2

Table of Contents

Introduction and Mission Statement 3

Medical Insurance 4 - 6

Wellness Program 7

Health Insurance Buy-out 7

Health Savings Accounts (HSAs) 7 - 10

Health Reimbursement Arrangement (HRA) 10 - 11

Flexible Spending Accounts 11 - 13

Dental Insurance 14

Vision Insurance 15

Group Term Life and AD&D 16

Optional Life and AD&D 16 - 17

Disability Insurance 17

Voluntary Benefits 17 - 18

Employee Assistance Program 18

Personal Lines 18

403(b) Retirement Plan 19

Required Coverage 19

Educational Assistance 19 - 20

Paid Time Off and Holidays 21

Customer Service Contact Information 22

Additional Information 23 - 26

This booklet is provided with the compliments of CGI Business Solutions


Introduction

Community Concepts takes great pride in its employee benefits program. We strive to offer a wide array of benefits to meet the diverse needs of our employees. This summary of benefits is provided as a general overview of the benefit choices available to eligible employees. Employees working at least 30 hours per week are eligible for benefits on the first of the month coincident with or next following 30 days of employment. You must enroll for your benefits within 30 days of eligibility. Once you make benefit elections they will be in effect for the entire plan year (January—December). You are only allowed to change your benefits during the plan year if you have a qualified life change. A qualified life change is defined as the birth or adoption of a dependent, death of a dependent, change in marital status or involuntary loss of other coverage. To make a change in your benefits, you must submit a completed enrollment form and proof of the qualifying event to Human Resources within 30 days of the qualifying event. Each year, Community Concepts has an open enrollment period during which all employees may make changes to their benefits, to be effective on the plan anniversary, January 1. You’ll receive information about your options in advance of each open enrollment period. Please read all of the benefits information provided to you. While this summary is as up-to-date and accurate as possible, if there are any discrepancies between it and the plan documents, the plan documents will supersede this summary. Employee benefit plans and policies may be changed at any time, and at the sole discretion of Community Concepts.

Our Mission

Since 1965, Community Concepts, Inc., a nonprofit community action agency, has offered a variety of social services that promote self-sufficiency within the people of the communities of Androscoggin, Franklin and Oxford counties of Maine. The mission of Community Concepts is to provide leadership, education and support to build thriving individuals, families and communities. In addition to this overall mission statement, each individual department and program has its own mission, focusing on the unique needs of the population it serves.


Medical Benefits—Harvard Pilgrim

Community Concepts offers eligible employees and their spouses, domestic partners and eligible dependents a choice of three medical plans. Community Concepts and enrolled employees share in the cost of these plans:

Option 1: Harvard Pilgrim HMO – No Deductible / 20% Coinsurance

Calendar Year Deductible None

Member Coinsurance 20%

Out-of-Pocket Maximum $2,000 individual / $4,000 family

Office Visits $25 copayment

Routine Preventive Care (see certificate for details) No member cost sharing (Network provider only)

Routine Eye Exams (adults and children: 1 per Calendar Year)

$25 copayment

Diagnostic Lab and X-rays No member cost sharing

Complex Imaging (MRI, CT & PET et al.)

No member cost sharing

Inpatient Hospital / Surgical and Outpatient Surgical 20% coinsurance

Mental Health and Substance Abuse Inpatient: 20% coinsurance Partial Hosp.: No member cost sharing Office: $25 copay; $10 for group therapy

Emergency Room Care $150 copayment (waived if admitted)

Walk-in Urgent Care $150 copayment (except for select facilities which take a $25 copayment)

Chiropractic Care (Limited to 36 visits / Calendar Year)

$25 copayment

Physical, Occupational, and Speech Therapy (Combined limit = 40 visits / Calendar Year)

$25 copayment

Durable Medical Equipment 20% coinsurance, not to exceed member’s expense of $500/cal. year

Prescription Drug Copayments (Participating Pharmacy)

New! Separate $1,000 individual/$2,000/family OOP limit on Rx copays per calendar year

30 day supply $10 Tier 1 $25 Tier 2 $40 Tier 3



Option 2: Harvard Pilgrim POS – No Network Deductible, 20% Coinsurance

Network Non-network

Calendar Year Deductible None $300 indiv / $900 fam

Member Coinsurance (After deductible, if applicable)

20% 40%

Out-of-Pocket Maximum (Individual / Family) (Deductible + Coinsurance Responsibility)

$2,000 / $4,000 $3,000 / $9,000

Office Visits $20 copayment Deductible, then 40%

Routine Preventive Care (see certificate for details)

No member cost sharing Deductible, then 40%

Routine Eye Exams (adults and children: 1 per year)

$20 copayment Deductible, then 40%

Diagnostic Lab and X-rays No member cost sharing Deductible, then 40%

Complex Imaging (MRI, CT, PET et al.)


Inpatient Hospital and Inpatient / Outpatient Surgical

20% coinsurance Deductible, then 40%

Mental Health and Substance Abuse

Inpt: 20% coinsurance Partial Hosp: No mbr cost share Office: $20 copay, $10 grp therapy

Deductible, then 40%

Emergency Room Care $50 copayment Same as in-network

Walk-in Urgent Care $50 copayment

(ex. select facilities which take a $20 copayment)

Deductible, then 40%



Physical, Occupational, and Speech Therapy (Up to 60 consecutive days per condition)


Durable Medical Equipment 20% coins., not to exceed

member’s expense of $1,000/calendar year

Deductible, then 40%, not to exceed mbr’s coins. expense

of $1,000/cal. year

Prescription Drugs (Participating Pharmacy)

New! Separate $1,000 individual/$2,000/family OOP limit on Rx copays per calendar year




Option 3: Harvard Pilgrim Qualified High Deductible Health Plan PPO with HSA

Network Non-network

Calendar Year Deductible $3,000 indiv / $6,000 fam $6,000 indiv / $12,000 fam

(No member must satisfy more than the individual deductible before coinsurance applies)

Member Coinsurance (After deductible)

20% 40%

Out-of-Pocket Maximum (Individual / Family) (Deductible + Coinsurance Responsibility)

$5,000 / $10,000 $10,000 / $20,000

Office Visits Deductible, then 20% Deductible, then 40%

Routine Preventive Care (see certificate for details)


Routine Eye Exams (adults and children: 1 per Calendar Year)


Diagnostic Lab and X-rays Deductible, then 20% Deductible, then 40%

Complex Imaging (MRI, CT & PET et al.)

Deductible, then 20% Deductible, then 40%

Inpatient Hospital and Inpatient / Outpatient Surgical


Mental Health and Substance Abuse (Inpatient, Outpatient, and Office Visits)


Emergency Room Care Deductible, then 20% Same as in-network

Walk-in Urgent Care Deductible, then 20% Deductible, then 40%



Physical, Occupational, and Speech Therapy (Combined limit = 40 visits / Calendar Year)


Durable Medical Equipment Deductible, then 20% Deductible, then 40%

Prescription Drugs (Participating Pharmacy) Deductible, then $5/$20/$30/$50 copayments Note: Deductible is waived for Preventive Rx.

See preventive drug roster at www.harvardpilgrim.org

IMPORTANT: If you enroll in the HDHP, you may qualify to contribute to a Health Savings Account (HSA). Community Concepts will make incremental contributions each pay period to your HSA account at Norway Savings Bank. See the Health Savings Account section of this booklet for details. You must have opened your HSA and provided the account information in order to receive these contributions from Community Concepts.

Note: For more detailed information on benefits, limitations and exclusions refer to the Summary of Benefits and Subscriber Certificate provided by Harvard Pilgrim. Please contact Harvard Pilgrim Customer Service at 1-888-333-4742 with questions regarding coverage or claims.


Wellness Program By participating in Community Concepts’ Wellness Program, eligible employees may receive discounts on health insurance premiums or additional cash incentives in the buyout option (HIBO) as well as becoming a “healthier you”. You may visit with the Health Coach during work hours (please coordinate this with your Supervisor) at the expense of the Agency. During your visit with the Health Coach, you will complete a confidential Health Risk Assessment and work directly with the Health Coach to establish wellness goals. Human Resources will provide you with contact information for our Health Coach.

Health Insurance Buy-Out (HIBO) Eligible employees may “opt out” of Community Concepts’ medical insurance plan if they prove they are covered by an alternate health insurance plan. If the employee successfully opts out of the group health plan, the employee will receive a cash benefit each month, payable in the first pay period of the month in which they would otherwise qualify for the group health plan. By participating in the Wellness Program, eligible employees may receive an extra cash incentive on a monthly basis. Currently-enrolled employees who successfully enroll in the HIBO option will qualify for their first payment upon being dropped from the Agency insurance carrier’s monthly invoice. The employee must provide the Human Resource Department with the following items in order to successfully enroll in the HIBO option:

1. A signed Health Insurance Buyout Agreement 2. A signed Change Form from the Agency’s Health Insurance company documenting that the employee

wants to waive/disenroll from the plan 3. A legible photocopy of a valid insurance card from the other insurer

Please contact Human Resources for additional details.

Health Savings Accounts

A Health Savings Account (HSA) is an employee-owned tax-advantaged account available to individuals who are enrolled in Qualified High Deductible Health Plans (QHDHPs). Community Concepts’ HDHP PPOs (medical option 3) is a QHDHP. Put simply, HSAs are tax-free, interest-bearing accounts that allow you to set aside tax-free dollars for your out-of-pocket medical, dental, and vision expenses.

Is enrollment in one of Community Concepts’ QHDHPs the only requirement for opening an HSA or contributing to an existing HSA? No. Even if you are enrolled in one of Community Concepts’ QHDHPs, you may not open an HSA if:

1. You are covered under any other medical plan that is not a QHDHP (such as a spouse’s medical plan, MaineCare, Medicare, Tri-Care, or veterans’ benefits). This includes receiving services at Togus (except prescription drugs) within the last three months.


2. You may not contribute to an HSA if you or your spouse has a full-service medical Flexible Spending Account. This is because your spouse has a full service medical FSA can be used to reimburse your expenses, as well as your spouse’s, and thus constitutes “non-QHDHP coverage.”

If I am not covered by any medical insurance plan at all, may I contribute to an HSA? No. You must be enrolled in a QHDHP to contribute to an HSA.

If I am enrolled in Harvard Pilgrim’s QHDHP and have an HSA, will Community Concepts contribute to it to help me with my expenses? Yes! Community Concepts will contribute to your HAS, 24 pay periods per year, as long as you remain an active, benefits-eligible employee enrolled in the Harvard Pilgrim QHDHP (Option 3). Contributions vary based on your salary, and whether you are participating in Community Concepts’ wellness program:

PARTICIPATING IN WELLNESS PROGRAM

Per Payroll Monthly Annual

Salary Under $21,000 $54.23 $108.46 $1,301.56

Salary $21,000-$42,000 $50.98 $101.96 $1,223.56

Salary Over $42,000 $45.57 $ 91.13 $1,093.56

NOT PARTICIPATING IN WELLNESS PROGRAM

Salary Under $21,000 $37.98 $75.96 $911.56

Salary $21,000-$42,000 $34.73 $69.46 $833.56

Salary Over $42,000 $29.32 $58.63 $703.56

My child and I are both covered under one of Community Concepts’ QHDHPs. My child also has MaineCare, but I don’t. May I contribute to an HSA? Yes, and you can fund your HSA up to the maximum limit for a family, even though your child has MaineCare coverage. Because the contribution limit is tied to how you are enrolled (as two people, rather than a single) and you do not have other coverage, you may contribute up to the family limit.

My spouse and I both work for Community Concepts. We are currently enrolled as two singles in one of Community Concepts’ QHDHPs and we each have our own HSA account. However, we may change our enrollment to one employee/spouse unit. Can we still maintain two separate HSAs? Yes. The maximum family contribution just needs to be divided between you and your spouse. In fact, this may well be advantageous, as to utilize the catch-up contribution permitted at age 55, the individual must have his/her own HSA.

How can an HSA save me money? Since an HSA is used for items and services that you already pay for, you can save up to 25-35% on eligible expenses because you are not paying taxes on this money.

Where can I open my HSA? Basically, an HSA is a checking account. HSAs may be opened at many banks, credit unions, and other financial institutions. Many banks and credit unions charge fees for HSA accounts. Norway Savings Bank has agreed to waive its fees for Community Concepts employees. You may open your account anywhere you wish, but if you do use Norway Savings Bank, be sure to mention that you are a Community Concepts employee when you open your account.

When may I open my HSA? You may open your HSA any time after you are covered under one of the Qualified High Deductible Health Plans; however, you can only use the account for expenses incurred after the account was opened. That’s why it is best to open your account as soon as you are eligible to do so, even if you start with the minimum balance. And, your account must be open in order to receive contributions from Community Concepts.


What expenses are reimbursable from my HSA? You may use your HSA for reimbursement of any expense allowed under Section 213(d) of the IRS code – the same expenses eligible for reimbursement under a Flexible Spending Account. If you’d like more information, you can consult the IRS publication at http://www.irs.gov/pub/irs-pdf/p502.pdf

May I use my HSA for expenses incurred by family members? You may use your HSA to reimburse eligible expenses incurred by yourself, your spouse, and any tax-qualified dependent. You may not use your HSA for your domestic partner’s expenses because the IRS regulations do not permit it.

How are my contributions deposited in my HSA? To deposit money into your HSA on a pre-tax basis through payroll deductions, complete a Salary Reduction Agreement and determine how much you would like to have deposited from each payroll. Alternatively, you may deposit money into your HSA by depositing cash or a check into the account. If you make a post-tax deposit in this manner, you will take it as an above-the-line deduction on your tax return.

How much can I contribute to my HSA? You may elect how much to contribute to your HSA; however, there are calendar year maximum contribution limits. There is, however, no maximum on how much you can accumulate in your HSA. The maximum that you may contribute each calendar year is as follows:

Year Maximum Contribution to a Health Savings Account

(Including Employer Contributions)

2014 Enrolled as an individual: Enrolled as 2 or more: Age 55+ catch-up contribution:

$3,300 $6,550 $1,000

2015 Enrolled as an individual: Enrolled as 2 or more: Age 55+ catch-up contribution:

$3,350 $6,650 $1,000

Can I change my mind about how much I contribute to my HSA? Yes—you may start, stop, or change your HSA contributions at any time.

How do I get reimbursed from my HSA? An HSA is a checking account, and banks will issue a debit card and HSA checks that can be used to access your account. You can use them to pay for a bill or an expense at time of service, similar to the way you would use a debit card or checks from your personal checking account. Keep all receipts. As the HSA account holder, you are responsible for proving the eligibility of your reimbursements at tax time or in the event of an IRS audit.

Will I lose what I’ve contributed to my HSA if I don’t use it by the end of the year? No. You never lose funds deposited to an HSA – unused amounts roll over from year to year. You may take the account with you if you leave employment at Community Concepts or retire.

What happens to my HSA if next year, I decide to move back to one of Community Concepts’ traditional plans? If you cease to be eligible to contribute to an HSA, you can still spend down the funds remaining in your account—you just can’t make any additional contributions. And, if you are not enrolled in the QHDHP, Community Concepts’ contributions to your HSA will also end.

What happens if I need to use my HSA account to pay for a non-health care related expense? If you use HSA funds for anything other than a qualified expense, they are subject to a penalty (currently 20%) and taxed as ordinary income. This is similar to the treatment of an early withdrawal from an IRA. After retirement, there is no penalty, but they are still taxed as ordinary income.

http://www.irs.gov/pub/irs-pdf/p502.pdf


How do HSAs differ from Flexible Spending Accounts (FSAs)? There are similarities between HSAs and FSAs—both help you save 25-35% on eligible medical expenses for yourself, your spouse, and tax-qualified dependents. Both are regulated by the IRS.

Here are some of the differences:

1. Family members (and anyone else) can make contributions to your HSA. This is not true of medical FSAs. 2. Because HSAs are checking accounts, you can only spend or withdraw up to the balance in your account on a

given date. Medical Flexible Spending Accounts are funded up-front by Community Concepts, so that you can spend your full annual election at any time—even if you have not yet contributed all of it to your account.

3. If you have a balance in your FSA at the end of the Plan Year and subsequent grace period, you lose the money. You never lose funds deposited to an HSA. The account is your property, and follows you from employer to employer and into retirement.

Are there advantages to having an HSA vs. an FSA? Yes—because you own your HSA, if you leave Community Concepts or retire, your account goes with you. And, if you don’t use the money in your account by the end of the year, it rolls over to be used for future health expenses or in retirement.

I am a new hire at Community Concepts, I enrolled in one of the QHDHPs, and I opened an HSA. Now what happens? You must wait for the date that your benefits become effective, which is the first of the month following 30 days of full-time employment. Once your benefits are effective, you may begin to deposit funds into your HSA. Important: You may not put money into your HSA until your benefits are effective.

Note: This is not intended to be a full description of HSAs and the rules and regulations governing them. Please consult with your financial institution and tax professional, or call Joan Harrigan at CGI Business Solutions at 207-837-2649 or 207-730-7222 with general questions regarding HSAs.

Health Reimbursement Arrangement—CGI

Applicable to employees who are enrolled in Harvard Pilgrim Option 3—Qualified HDHP PPO A Health Reimbursement Arrangement (HRA) is an employee benefit that enables Community Concepts to reimburse you for a portion of your QHDHP PPO with HSA health plan deductible. The underlying medical plan (the QHDHP PPO) has deductibles of $3,000 individual/$6,000 family. After the deductible is satisfied, the plan pays 80% and you pay 20% until you reach the maximum out-of-pocket (deductible plus coinsurance) of $5,000 individual/$10,000 family. The HRA reimburses you for the last $3,700 of the individual deductible and coinsurance and the middle $3,700 of the family deductible and coinsurance. You do not have to track your claims and submit a claim form to receive this reimbursement. Harvard Pilgrim tracks this on your behalf and sends the information to our administrator, CGI Business Solutions in Hooksett, NH. CGI will automatically send you a check or make a direct deposit to your bank account if you qualify for reimbursement. It is then your responsibility to pay your providers when you receive their bills.


Health Reimbursement Arrangement January – December 2015

Employees Eligible to Contribute to an HSA

Employee Only

Employee and Spouse

Employee and Child(ren)

Family

Employee Pays 1st $1,300 $2,600 $2,600 $2,600

HRA Reimburses Next $3,700 $3,700 $3,700 $3,700

Employee Pays Next $0 $3,700 $3,700 $3,700

Total QHDHP Deductible + Coinsurance $5,000 $10,000 $10,000 $10,000

Health Reimbursement Arrangement January – December 2015

Employees Not Eligible to Contribute to an HSA

Employee Only

Employee and Spouse

Employee and Child(ren)

Family

Employee Pays 1st $0 $0 $0 $0

HRA Reimburses Next $5,000 $5,000 $5,000 $5,000

Employee Pays Next $0 $5,000 $5,000 $5,000

Total HSA Deductible + Coinsurance $5,000 $10,000 $10,000 $10,000

With the exception of pharmacy claims, you should receive your HRA reimbursement prior to receiving your provider’s bill. The HRA essentially reduces your individual deductible and coinsurance responsibility from $5,000 to $1,300. In addition, Community Concepts will contribute approximately $1,250 annually to your HSA.

Your HRA is administered by CGI Business Solutions of Hooksett, NH. Jen Conti is Community Concepts’ dedicated administrator. Please call CGI at 603-232-9356 or 1-888-383-0088 if you have any questions.

Flexible Spending Accounts—CGI

Employees who are enrolled in the Harvard Pilgrim QHDHP (Option 3) may have a Dependent Care FSA— and/or a limited purpose FSA (but not a full service Medical FSA)

Participation in a Flexible Spending Account (FSA) is open to eligible employees, regardless of whether you participate in the Community Concepts medical program. You can even open an FSA if you have no medical insurance at all. You decide how much money per paycheck you would like to set aside on a pre-tax basis to pay

for unreimbursed medical, dental, vision, and/or dependent care expenses for the plan year. You elect an annual amount; the total is then divided by the number of pay periods in the plan year and deducted from your paycheck pre-tax. Your money is then reimbursed to you—tax free—for eligible expenses. If you enroll in Harvard Pilgrim’s QHDHP (Option 3), you may have a Dependent Care account and/or a limited purpose (dental and vision expenses only) FSA.

What is an FSA? FSAs are tax-advantaged accounts that allow employees to set aside a portion of their earnings to pay for qualified expenses. Except as noted above, you may have a medical FSA and/or a dependent care FSA, but you may not transfer funds between the two accounts. Community Concepts’ FSA plan year is from January 1 – December 31.

How can an FSA save me money? Since an FSA is used for items and services that you already pay for, you can save up to 25-35% on eligible expenses because you are not paying taxes on this money.


How do FSA accounts work? You elect an annual amount; the total is divided by the number of pay periods in the plan year, and deducted from your paycheck pre-tax. Community Concepts sends the money to CGI Business Solutions, our FSA administrator, where an account is set up in your name. When you have an eligible medical expense, you either submit your receipt to CGI for reimbursement or, if you elect to have a mySource™ card (a debit card for your medical FSA), you can use it to pay for your eligible expense.

If you have a dependent care FSA, you may either submit your expenses to CGI or arrange with them to have automatic payments go to your dependent care provider.

May I use my medical FSA for expenses incurred by family members? You may use your medical FSA to reimburse eligible expenses incurred by yourself, your spouse, and any tax-qualified dependent. You may not use your medical FSA for your domestic partner’s expenses because the IRS regulations do not permit it.

Am I eligible to have an FSA? Even if you are not enrolled in any of Community Concepts’ health insurance options, you are still eligible for an FSA if you work at least 30 hours per week. If you are enrolled in the HMO or POS, you are eligible to open both full-service medical and dependent care FSAs. If you are enrolled the Qualified HDHP, you may open a dependent care and/or a limited purpose FSA. However, you can only open a full service medical FSA if you do not contribute to a Health Savings Account. You cannot contribute to both a full service medical FSA and a Health Savings Account.

How much can I contribute to a medical care or dependent care FSA? You may elect how much to allocate to your medical and/or dependent care FSA. Your contributions will be deducted before FICA and federal and state income taxes are calculated. The maximum that you may allocate is:

Medical FSA Dependent Care FSA

$2,500 Annual Maximum $5,000 Annual Maximum

Can I change my mind about how much I contribute to my FSA? No, you may not change or discontinue your FSA deductions during the Plan Year unless you have a qualified family status or life change. This is an IRS requirement for Section 125 cafeteria plans such as Community Concepts’ benefits program.

What expenses are reimbursable under my medical care FSA? All IRS Section 213(d) expenses may be reimbursed from your medical care FSA. These are the same expenses that can be reimbursed under a Health Savings Account (HSA). These include medical, vision, and dental expenses for yourself, your spouse, or a tax-qualified dependent: health and dental plan deductibles, coinsurance, and copays, as well as eyeglasses, contact lenses, crutches, insulin—the list is quite extensive. If you’d like more information, you can consult the IRS publication at http://www.irs.gov/pub/irs-pdf/p502.pdf

However, please note that OTC medications require a doctor’s prescription to be eligible for FSA reimbursement. Please see the CGI FSA flier for additional details.

How long will it take for my claim to be processed? CGI processes claims each week. Your mySource™ debit card is the easiest and fastest means of accessing your medical FSA account. If you file a paper claim via fax, email, or U.S. Mail you may receive reimbursement via paper check or direct deposit into your bank account. The filing deadline each week is Thursday noon. Paper checks are mailed from Hooksett, NH on Friday of the week received. Direct deposits are sent each Thursday afternoon; depending upon your bank, the funds should be in your account no later than Monday.

http://www.irs.gov/pub/irs-pdf/p502.pdf


What happens if I don’t use all the funds in my FSA by the end of the plan year? Because this is a pre-tax benefit, balances remaining at the end of the plan year (January through December of the following year) are forfeited by the employee. However, there is a 2½-month grace period, allowing employees until March 15 to accrue expenses that may be reimbursed from the prior year’s FSA.

Your medical and dependent Care FSAs are administered by CGI Business Solutions of Hooksett, NH. Jen Conti is Community Concepts’ dedicated administrator. Please call CGI at 603-232-9356 or 1-888-383-0088 if you have any questions. This is a brief overview of FSAs; please see CGI’s enrollment materials for full details. You can see your account online at www.cgibusinesssolutions.com. Just click on “my FSA/HRA” under the login tab on the right side of the homepage.

http://www.cgibusinesssolutions.com/


Dental Insurance—Reliance Standard

Eligible employees and their families may enroll in a group dental plan, which is fully insured Reliance Standard Life Insurance Company. For this plan year, employees pay half of premium for single dental insurance on a pre-tax basis. Employees pay the full cost of coverage for their dependents, also on a pre-tax basis. A brief summary of the benefits follows:

Preventive Services Basic Services Major Services Orthodontic Services

This plan has no deductibles, and no waiting periods for benefits after enrollment. If a PPO provider is used, the provider agrees to accept Reliance Standard’s maximum allowances, with no balance billing.

Claims for out-of-network providers will be paid at the 95th percentile.

Covered in full The member pays 20% The member pays 50% The member pays 50%

$1,000 Calendar Year Maximum per Member (Basic and Major Services Combined—

Preventive Services do not count toward the Calendar Year Maximum)

$1,000 Lifetime Maximum per Member

(Limited to children to age 19 only)

Services include:

Exams (2 per benefit period) Bitewing X-rays (2 per benefit period) Full mouth X-rays (1 per 3 years) Cleanings (4 per benefit period) Space maintainers Sealants to age 16 (limitations apply) Fluoride to age 18 (limitations apply)

Services include:

Amalgam fillings Composite fillings

Oral surgery Endodontic services (root canals) Periodontal services (gum disease) Denture repair Simple extractions Complex extractions Anesthesia

Services include:

Crowns (1 in 5 years per tooth) Crown repair Onlays Dental implants Partial & full dentures (1 in 5 years)

Services include:

Correction of malposed (crooked) teeth for dependent children to age 19 only

Maximum Rewards: Qualifying plan members may carryover part of their unused annual maximum. A member earns dental rewards by submitting at least one claim for dental expenses during the benefit year, while staying at or under the threshold amount for benefits received in that year. Employees and their covered dependents may accumulate rewards up to the stated maximum carryover amount, and then use those rewards for covered dental procedures subject to applicable coinsurance and plan provisions. If a member doesn’t submit a dental claim during a benefit year, all accumulated rewards are lost. However, the member can begin earning rewards again the next benefit year. Benefit Threshold $ 500 Dental benefits rec’d for the year cannot exceed this amount Annual Carryover Amount $ 250 Max. Rewards amount is added to the following yr’s maximum Maximum Carryover $1,000 Maximum possible accumulation for Maximum Rewards

Note: For detailed information on benefits, limitations such as those on the frequency of services, as well as exclusions, please refer to the Summary of Benefits and Subscriber Certificate provided by Reliance Standard. Please contact Reliance Standard’s Customer Service at 1-800-497-7044 with questions regarding coverage or claims, or visit their website at www.reliancestandard.com/dental-vision


Vision Insurance—Reliance Standard

Eligible employees and their families may enroll in a voluntary vision plan for which employees pay the full premium for themselves and their eligible dependents on a pre-tax basis. The plan, “Sharper Vision” is offered by Reliance Standard Life Insurance Company, and features a national network of providers. A brief outline of the benefits follows:

Benefits In-Network Out-of-Network

Examinations

Routine eye exam (Once every 12 months)

$10 deductible, then covered in full $10 deductible, then up to $45

Standard Eyeglass Lenses (in lieu of contact lenses—once every 12 months)

Single Vision Bifocal (standard) Trifocal (standard) Lenticular Upgrades

Covered in full Covered in full Covered in full Covered in full See benefit summary for member costs

Up to $30 Up to $50 Up to $65 Up to $100 Not available out-of-network

Contact Lenses (in lieu of eyeglass lenses—once every 12 months)

Fit and Follow-up Exams Conventional

Non-Elective Lenses

Up to $60 Up to $150

Covered in full

No benefit Up to $120 Up to $210

Eyeglass Frames (once every 24 months)

Frames $25 deductible (applies to frames or full set of glasses), then up to $150

$25 deductible (applies to frames or full set of glasses), then up to $75

Note: For detailed information on benefits, limitations, and exclusions, please refer to the Summary of Benefits and Subscriber Certificate provided by Reliance Standard. To find a network provider, please visit www.reliancestandard.com/dental-vision or call Customer Service at 1-800-497-7044.


Group Term Life & AD&D—Reliance Stnd

Eligible employees are enrolled for Group Term Life and Accidental Death & Dismemberment (AD&D) benefits. Reliance Standard Life Insurance Company is the insurer, and Community Concepts pays the full cost of the following benefit

Life and AD&D Insurance: One times basic annual earnings, rounded to the next higher multiple of $1,000, to a maximum of $50,000

Benefits reduce by 35% at age 70 and an additional 45% of the pre-age 70 amount at age 75. Benefits terminate at retirement.

If you leave employment at Community Concepts, you may be able to convert your life insurance to an individual policy or continue this policy under Reliance Standards’ portability provisions. Please see your certificate for details or call Reliance Standard customer service at the number listed below. You may update your beneficiary designations by contacting Human Resources. Reliance Standard’s Customer Service number is 1-800-351-7500 or visit their website at www.reliancestandard.com. This is a brief description of your Life and A&D benefits—please see Reliance Standard’s benefit summary and the subscriber certificate for full details.

Optional Term Life & AD&D—Reliance Stnd

At their own expense, eligible employees may purchase additional Reliance Standard Term Life and AD&D by payroll deduction. Note: in order to cover a spouse or domestic partner and/or dependent child(ren), the employee must purchase voluntary life/AD&D for him/herself.

Employee Benefit: From $10,000 to $500,000 in increments of $10,000 Maximum: $500,000 (medical evidence required for amounts above $100,000)

Spouse or Domestic Partner Benefit: From $5,000 to $250,000 in increments of $5,000 Maximum: Lesser of $500,000 or the employee’s optional life amount

(medical evidence required for amounts above $30,000)

Dependent Child Benefit: 14 days but less than 6 months: $1,000

6 months to age 19 (26 if a full-time student): $2,000 to $10,000 in $2,000 increments Maximum: $10,000

Employee/Spouse/Domestic Partner Reduction Schedule: Benefits reduce by 35% at 70 and an additional 45% of the pre-age 70 amount at age 75. Benefits terminate at the employee’s retirement.

Please see the rate tables attached to your enrollment form for age-banded rates. The spouse/domestic partner’s rate is based on the employee’s age. If you leave employment at Community Concepts, you may be able to convert your life insurance to an individual policy or continue this policy under Reliance Standards’ portability provisions. Please see your certificate for details or call Reliance Standard Customer Service at the number listed below.

Please contact Human Resources to update your beneficiary designations. Reliance Standard’s Customer Service


number is 1-800-351-7500 or visit their website at www.reliancestandard.com. This is a brief description of your Optional Life and AD&D benefits. Please see Reliance Standard’s Benefit Summary and the Subscriber Certificate for full details.

Group Disability Insurance—Reliance Stnd

Eligible employees may purchase group Short and/or Long Term Disability Insurance through payroll deduction. Employees pay the full premium with post-tax income; coverage is provided by Reliance Standard Life Insurance Company. In the event you become disabled from an injury or illness, you may be eligible for disability income benefits as follows:

Short Term Disability (STD)

The benefit is equal to 60% of your basic weekly earnings to a maximum of $1,150 per week. The minimum benefit is $25 per week.

Your STD insurance covers you off the job. Workers’ Compensation covers you for occupational injuries.

Benefits begin on the 15th day for an accident or illness. In other words, you must be disabled for two weeks to begin to receive benefits.

Benefits are paid for a maximum of 13 weeks, or until your voluntary LTD benefits begin.

Long Term Disability (LTD)

The benefit is equal to 60% of your basic monthly earnings to a maximum of $4,000 per month

Your LTD insurance covers you both on and off the job.

Benefits begin after a 90-day elimination period.

Disability is defined as the inability to perform your own occupation for the first five years of disability, and any occupation thereafter.

Benefits will end when you no longer meet the definition of disability or you reach Social Security Normal Retirement Age.

Age-banded rates are attached to your enrollment form. You may enroll for this coverage upon your initial eligibility as a new hire, or once each year at open enrollment. If you do not enroll when initially eligible, you may need to prove insurability to enroll later.

This is a brief summary – please refer to your Reliance Standard certificates for details of your benefits. Reliance Standard’s disability claims department may be reached at 1-800-351-7500 or visit their website at www.reliancestandard.com.

Voluntary Benefits—Transamerica

Community Concepts offers eligible employees the opportunity to purchase additional insurance products through payroll deduction. Transamerica is the insurer of these benefits, with administration and service provided by Combined Services. If you leave Community Concepts, you may elect to take your coverage with you. You may enroll for this coverage when you are initially eligible as a new hire, or once each year, at open enrollment. If you do not enroll when initially eligible, you may need to prove insurability if you wish to enroll later. Transamerica’s voluntary benefits include:

Voluntary Accident Insurance: Voluntary accident insurance is designed to help you meet the out-of-pocket expenses and extra bills that can follow a minor or catastrophic accidental injury. Your coverage pays lump sum


benefits for such expenses as emergency room treatment, physician office visits, hospitalization, surgery, physical therapy, and appliances such as joint braces. Examples of covered injuries include broken bones, burns, torn ligaments, concussions, eye injuries, ruptured discs, and lacerations requiring stitches. Benefits are paid directly to you, not the provider, regardless of what has been paid under the medical plan.

Voluntary Hospital indemnity with Critical Illness: HSA-compliant hospitalization benefits help you meet expenses in the event of a hospitalization. There is no pre-existing condition limitation, and $5,000 of critical illness benefits are guaranteed issue, meaning that you will not need to answer medical questions to purchase the coverage.

This is a brief summary – please refer to your Combined Services enrollment materials and certificate for details. Combined Services may be reached at 1-603-227-2007.

Employee Assistance Program

Community Concepts provides an Employee Assistance Program (EAP) through Affiliated EAP. All of Community Concepts’ regular employees and their household family members are eligible to use our EAP service.

The purpose of the EAP is to help employees handle problems that can interfere with their work performance. It provides direct access to qualified professionals trained to assess a wide range of personal problems for which they provide support, assistance and resolution. Use of the EAP is free and confidential. It is available 24 hours a day, 365 days a year by calling the toll free number, available from the Human Resources department. In certain circumstances your supervisor may require you to use the EAP.

When you call the toll free number, a Master’s level counselor will review your situation with you and refer you to either an EAP counselor in your area, or to the service you requested. If you use the counseling feature, you and your household family members are authorized for up to three appointments each for assessment and referral annually at no charge. If your problem is urgent, arrangements can be made for you to get help immediately.

Identify yourself as a Community Concepts’ employee or family member and state that you are using your EAP benefit. This will ensure a prompt appointment for help with:

● Marital, family and relationship problems ● Stress (family, social, work, etc.) ● Credit and financial issues ● Family violence ● Psychological problems ● Alcohol and substance abuse problems ● Depression ● Special needs

Confidentiality is one of the most important aspects of the program. Any conversation that you have with a counselor stays between you and your counselor. If you contact the Employee Assistance Program directly, no one in the Agency will be informed that you did so. No information concerning the nature of your problem will be released without your written consent.

This is a brief summary. For more information, please call the Affiliated EAP at 1-800-769-9819 or visit their website at www.affiliatedeap.com

http://www.affiliatedeap.com/


Personal Lines

Community Concepts’ broker, CGI Business Solutions, offers all employees access to discounted rates on their personal insurance, including homeowner’s coverage, automobile insurance, camp insurance, boat and snowmobile coverage, and more. For information, contact CGI’s personal lines specialist, Paul Blackadar at 603-232-9364 or email [email protected]

403(b) Retirement Plan

Eligible employees may enroll in Community Concepts’ 403(b) retirement plan at any time. All eligible employees age 21 and above may contribute a portion of his/her pay into the Agency-sponsored Retirement Plan immediately upon hire.

Contributions can be made into a pre-tax or Roth post-tax account, or a combination of both types of accounts. After meeting certain waiting period requirements, employees are eligible for an Agency core contribution consisting of 2% of his/her bi-weekly pay. The Agency will match the employee’s contribution up to an additional 4%, making Community Concepts’ maximum contribution 6%. For details on this plan, please contact the Human Resource Department.

This is a brief summary. For more information, please contact Human Resources or Matt Arbo at Healey Associates, PO Box 599, Portland, ME 04112-0599, 207-775-6177.

Required Coverage

Workers’ Compensation Workers' Compensation is a no-fault insurance plan supervised by the state and funded by employers to provide specific benefits to employees who suffer injuries on the job. Benefits include payment for medical expenses and compensation for lost earnings. To initiate and preserve your full entitlements under Workers’ Compensation, you must follow our written policy concerning the reporting of all work-related injuries, illnesses and discomforts, no matter how minor, to your supervisor and to the Safety Officer. Unemployment Compensation Community Concepts pays a percentage of its payroll to the State of Maine Unemployment Compensation Fund according to our organization’s employment history. If you become unemployed and meet the criteria, you may be eligible to receive unemployment compensation based upon your personal work history. You should apply for benefits through your local State Unemployment Office as soon as possible.

mailto:[email protected]


Educational Assistance

Community Concepts follows guidelines and standards for Educational Assistance as required for each department. During the Agency’s fiscal year, as financially feasible, 100% of the cost for the first two undergraduate or graduate level college classes will be paid for by the Agency. As financially feasible, 50% of two additional courses will be paid by the Agency. You must be a regular employee to take advantage of educational assistance.

Costs will include and are limited to: textbooks, tuition, lab fees, and other fees charged by an accredited educational institution. Tuition reimbursement will not exceed the current University of Maine cost per credit. The course(s) or degree program must be specifically related to the employee’s job or enhance his/her job performance. Regular employees may continue their education in a related field and Community Concepts may reimburse all or part of the registration and tuition costs.

All courses must be pre-approved by your Director. All requests are subject to the availability of funds and timely receipt of applications. Once the course is completed, employees must submit a certified transcript of grades with receipts for expenses. Community Concepts will reimburse you as described for the pre-approved portion of tuition expenses.

Reminder: If you are taking a pre-approved seminar that offers continuing education credit, be sure to give your supervisor a copy of the Continuing Education Credit Certificate (or other document) to include in your personnel file.

In order to qualify for the Education Assistance benefit: 1. You must submit a request of intention for Education Assistance to your supervisor prior to enrolling for

the class. Your supervisor will advise you whether the course is of a nature that Community Concepts will approve for partial or total reimbursement of tuition and fees.

2. The course or degree program must be job-oriented and offered by an accredited college, university, or vocational program.

3. The course or degree program must then be pre-approved by your Director. 4. You must complete the course. 5. You must pass the course (P/F courses) or receive at least a grade of C. 6. You must submit adequate documentation to substantiate all tuition expenses, i.e., cost per credit hour,

lab fees and/or cost of materials. 7. You must be a current employee at the time of reimbursement. 8. Additional conditions may be required.

You will be held to the following payback schedule if you leave the agency within three years of completing an Agency-paid course:

Employee’s last day is prior to one year from the course completion 100% payback Employee’s last day is prior to two years from the course completion 50% payback Employee’s last day is prior to three years from the course completion 25% payback

Education allowances for staff paid from Head Start funding will be subject to the payback schedule as outlined in the Federal Head Start Performance Standards. You must complete a professional developmental plan when submitting your request.

Education/Training (Attending Seminars/Training Sessions) From time to time, Community Concepts may arrange to have both formal and informal training programs to enable you to progress in your technical knowledge. Employees may be selected to attend workshops or training


programs. You will receive a normal paycheck while attending training. Depending on the nature of the course, all or a portion of the expenses for off-premises training will be paid for by Community Concepts. Check with your supervisor for details.

If you become aware of a particular seminar that you believe is appropriate for enhancing your skills (and/or those of other employees), please bring it to the attention of your supervisor for consideration.

Maine Learning Initiative Community Concepts is a Maine Employer’s Initiative partner through the Maine Development Foundation. We are committed to taking steps to increase educational attainment among our workforce. For more information on the Maine Learning Initiative go to: http://www.mdf.org/mei_overview.php.

Paid Time Off and Holidays

Recognized Holidays

The following holidays are currently recognized by Community Concepts as paid holidays:

New Year’s Day Labor Day

Martin Luther King Day Columbus Day

Presidents’ Day Veterans’ Day

Patriots’ Day Thanksgiving Day

Memorial Day The Friday following Thanksgiving Day

Independence Day Christmas Day

Vacation Accrual

Vacation accrual rate is based upon seniority date, hours worked per week, and weeks worked per year.

Years of Employment (Based on Seniority Date)

Accrual Rate (Multiply by number of paid hours to figure vacation accrual)

0 to 3 years 0.04625

3 to 6 years 0.05775

6 to 10 years 0.08075

10+ years 0.10400

Sick Leave

Community Concepts will allow regular employees to accrue Agency-owned sick hours at a maximum rate of 96 hours per year, pro-rated based in accordance with actual hours paid (0.04625 per paid hour), but not to exceed 40 hours per week. Only the actual accrued sick leave balance may be used. The maximum Community Concepts-owned sick leave which may be accrued is 480 hours.

http://www.mdf.org/mei_overview.php


Customer Service Contact Information

Community Concepts Human Resources: Susan Hanley, Director: 207-739-6522 Barbara Bishop, Hiring/Pension: 207-739-6523 Diane Clairmont, Insurance/Wellness: 207-739-6533 Shelby DeCato, HR Information System: 207-739-6525 email: [email protected]

With questions regarding a medical or dental claim: Please contact our broker, CGI Business Solutions. They’ll help you get the answers you need:

Angel Mitton, Account Manager 207-730-7222 or email: [email protected] Joan Harrigan, Benefits Advisor 207-837-2649 (cellular) or 207-730-7222 (office) or email: [email protected]

To contact Customer Service at one of our carriers/vendors:

Medical: Harvard Pilgrim Health Care

1-888-333-4742

www.harvardpilgrim.org

Dental: Reliance Standard Life

1-800-497-7044 www.reliancestandard.com/dental-vision

Vision: Reliance Standard Life

1-800-497-7044 www.reliancestandard.com/dental-vision

Life/AD&D and Disability: Reliance Standard Life

1-800-351-7500

www.reliancestandard.com

Voluntary Benefits: Combined Services (Ben Forgione)

1-603-227-2007 www.combinedservices.com

Employee Assistance Program: Affiliated EAP

1-800-769-9819

www.affiliatedeap.com

Flexible Spending Accounts (FSAs): (Medical and Dependent Care) CGI Business Solutions

603-232-9356 or 1--888-383-0088 Fax: 603-232-9363 www.cgibusinesssolutions.com (Jen Conti, dedicated administrator) [email protected]

403(b) Retirement Plan: Healey & Associates (Matthew Arbo)

207-775-6177

www.healeyassociates.com

Personal Lines CGI Business Solutions (Paul Blackadar)

603-232-9364 www.cgibusinesssolutions.com [email protected]



http://www.reliancestandard.com/dental-vision

http://www.reliancestandard.com/dental-vision

http://www.rsli.com/

http://www.combinedservices.com/

http://www./


http://www.oneamerica.com/



Additional Information for Employees

COBRA Information: COBRA continuation coverage is a temporary extension of coverage under the group health plan. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. For additional information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.

You may have other options available to you when you lose group coverage. You may be eligible to buy an individual plan through the Health Insurance Marketplace (www.healthcare.gov). By enrolling in coverage through the Marketplace, you may qualify for lower monthly premiums and lower out-of-pocket costs. 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 doesn’t generally accept late enrollees.

HIPAA Information: Special Enrollment Right Mandated by the Health Insurance Portability and Accountability Act of 1996. Group health plans and health insurance insurers are required to provide special enrollment periods during which individuals who previously declined coverage for themselves and their dependents may be allowed to enroll without having to wait for the plan’s next open enrollment period. A special enrollment period can occur if a person with other health coverage loses that coverage or if a person becomes a new dependent through marriage, birth, adoption or placement for adoption. If you refuse enrollment for yourself or your dependents for medical coverage, you may later enroll within 30 days of a change in family status or loss of health coverage.

Individuals may not be denied eligibility or continued eligibility to enroll for benefits under the terms of the plan based on specified health factors. In addition, an individual may not be charged more for coverage than similarly situated individuals based on these specific health factors.

Effective April 1, 2009, the Children’s Health Insurance Reauthorization Act of 2009 (CHIPRA) created a new 60 day special enrollment period for eligible employees and dependents to immediately enroll in the plan if they become ineligible for Medicaid or any state’s Children’s Health Insurance Program (CHIP) and lose coverage or become eligible for that state’s premium assistance program. The employee must request coverage within 60 days after the termination of coverage or the determination of subsidy eligibility.

Women’s Health and Cancer Rights Act of 1998 (WHCRA): WHCRA requires a group health plan to notify you, as a participant or a beneficiary, of your potential rights related to coverage in connection with a mastectomy. Your plan may provide medical and surgical benefits in connection with a mastectomy and reconstructive surgery. If it does, coverage will be provided in a manner determined in consultation with your attending physician and the patient for a) all stages of reconstruction on the breast on which the mastectomy was performed; b) surgery and reconstruction of the other breast to produce a symmetrical appearance; c) prostheses; and d) treatment of physical complications of the mastectomy, including lymphedema. The coverage, if available under your group health plan, is subject to the same deductible and coinsurance applicable to other medical and surgical benefits provided under the plan. For specific information, please refer to your summary plan description or benefits booklet, or contact Human Resources.

Newborns and Mothers Health Protection Act: 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, from discharging the mother or her newborn earlier than 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 prescribing a length of stay not in excess of 48 hours (or 96 hours).

http://www.healthcare.gov/


Patient Protection Notice: Harvard Pilgrim Health Care requires the designation of a primary care provider for individuals enrolling in Community Concepts HMO plan option. You have the right to seek services from any primary care provider who participates in the Harvard Pilgrim network and who is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers, please consult the Harvard Pilgrim provider directory at www.harvardpilgrim.org or contact Harvard Pilgrim’s Customer Service at 1-888-333-4742. For children, you may choose a pediatrician as the primary care provider.

You do not need prior authorization from Harvard Pilgrim or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the Harvard Pilgrim network who specializes in obstetrics or gynecology. The health care professional, however, may be 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, please consult the Harvard Pilgrim provider directory at www.harvardpilgrim.org or contact Harvard Pilgrim’s Customer Service at 1-888-333-4742.

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP): If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your employer, your State may have a premium assistance program that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for these programs, but also have access to health insurance through their employer. If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance programs.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can 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, you can 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, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan.

Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must permit you to enroll in your employer plan if you are not 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, you can contact the Department of Labor electronically at www.askebsa.dol.gov or by calling toll-free 1-866-444-EBSA (3272).

If you live in Maine or New Hampshire, you may be eligible for assistance paying your employer health plan premiums. For further information on eligibility, you should contact: MAINE-- Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-977-6740 TTY: 1-800-977-6741

NEW HAMPSHIRE-- Medicaid Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218

To see if other States have a premium assistance program, or for more information on special enrollment rights, you can contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 OMB Control Number 1210-0137 (expires 10/31/2016)

http://www.anthem.com/

http://www.anthem.com/

http://www.askebsa.dol.gov/

http://www.dhhs.nh.gov/oii/documents/hippapp.pdf

http://www.dol.gov/ebsa

http://www.cms.hhs.gov/


Important Notice from Community Concepts About Your Prescription Drug Coverage and Medicare [Applies to all Harvard Pilgrim Medical Plan Options]:

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Community Concepts 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 current 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. Community Concepts has determined that the prescription drug coverage offered by Harvard Pilgrim is, 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 to 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 Decide to Join A Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current Community Concepts coverage will not be affected. If you elect Part D coverage, you may keep your coverage under Community Concepts and this plan will coordinate with Part D Coverage.

If you do decide to join a Medicare drug plan and drop your current Community Concepts coverage, you and your dependents will 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 Community Concepts and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly 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 19 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 More Information About This Notice or Your Current Prescription Drug Coverage…

Contact the person listed below for further information.


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 Community Concepts changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:

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 (a penalty).

Date: January 1, 2015 Name of Entity/Sender: Community Concepts Contact: Diane Clairmont Benefits/Wellness Manager Address: 240 Bates St., Lewiston, ME 04240 Phone Number: 207-739-6533 CMS Form 10182-CC Updated April 1, 2011 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

The information contained in this Employee Benefits Summary is presented for illustrative purposes only and is based on information provided by the employer and in certificates of insurance supplied by the insurance carrier. CGI Business Solutions, your company’s insurance agent, has prepared this Summary to assist employees in understanding their company’s benefits plan. While every effort has been made to describe these benefits accurately, discrepancies or errors are possible. You should also read the actual plan documents in their entirety. If there is a discrepancy between the Employee Benefits Summary and the actual plan documents, the plan documents will prevail. If you have any questions about the Employee Benefits Summary, please contact Human Resources.

© CGI Business Solutions 2014. All rights reserved.

http://www.medicare.gov/

http://www.socialsecurity.gov/

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