2019 Benefits Enrollment Guide Enrol

Central State University

For Plan Year January 1, 2019

to December 31, 2019

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WHAT’S INSIDE THIS GUIDE?

As an employee, the health benefits available to you represent a significant component of your compensation package. They also provide important protection for you and your family in the case of illness or injury. Choosing a health coverage option is an important decision. To help you make an informed choice, your plan makes available a Summary of Benefits and Coverage (SBC), which summarizes important information about any health coverage option in a standard format, to help you compare your options.

This benefit summary has been prepared to help you review the key factors that are associated with our benefit plans. This summary does not provide all of the contractual provisions, limitations or exclusions included in our policies and should be considered only as a summary of our current benefits. If any differences exist between this summary and the official contracts, the contracts shall prevail.

Introduction & Wellness Information……………................. ..3

Get More Value From Your Plans..................................... ..4 How to Enroll…................................................................. ..5 Health Plan Provisions………………………………………………….. ..6 Medical Benefits............................................................... ..7 Dental Benefits................................................................. ..9 Vision Benefits………………................................................. 10 Income Protection Benefit……………………………………………. 11 Summary of Coverage For Voluntary Life Insurance........ 12 Employee Assistance Program and FSA………………………… 13 Pension and Retiree Plans………………………....................... 14 Additional Benefits……………………..................................... 16 The Benefit Resource Center............................................ 17 Annual Notices…………...................................................... 18

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INTRODUCTION

At Central State University, we value each and every employee. Our commitment to our employees is to provide an enriching environment where employees are engaged and are proud to be part of the Central State University family.

The cost of health care and other benefits continue to rise year after year. Each year, we analyze our costs and try to manage increases by reviewing our plans and benefit providers. We are conscious of the fact that changing health insurance plans is often difficult for our employees, so whenever possible, we work with our benefit providers to create solutions that will work financially and will be less disruptive.

Employers across the country are all facing the same challenge. But the fact is that 70 percent of health care costs are due to preventable conditions that cost the U.S. health care system about $100 billion every year. Smoking, obesity, and high blood pressure are all preventable or treatable conditions that, left untreated, can lead to such illnesses as cancer, Type II Diabetes, or heart failure.

Central State University continues to promote a culture of health and wellness, establishing a work environment that promotes healthy lifestyles, decreases the risk of disease, and enhances your quality of life.

Central State University Takes Your Wellness Seriously

The goal of the Central State University Healthy Directions Wellness Program is to promote behavioral changes and motivate each of us to change from high risk behavioral factors to healthy/low risk factors and keep them there.

• To obtain the best possible price for your health care coverage needs

• To support you and your family in practical ways to improve your health

• To provide a supportive work environment that encourages healthy lifestyles

• To become a more educated health care consumer

• To work towards living a healthier lifestyle and improving your health

• To better understand and use the tools and resources that make for wiser health and health care choices

By participating in the Central State University Healthy Directions Wellness Program within the required timeframe each year, you can qualify for reduced medical insurance premiums for the following plan year.

The Healthy Directions program is administered by TriHealth.

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GET MORE VALUE FROM YOUR PLANS Here are a few key points to help you get the most value out of your health plan:

Minimize your out-of- pocket expenses

Use the Emergency Room ONLY for emergencies

Annual physical exams and cancer screening tests are 100% covered!

Preventive dental care is covered 100%!

Save tax dollars and enroll in a Flexible Spending Account Virtual Visits

To maximize your health, engage with a primary care physician (PCP) who will provide or direct your health care. Look for a Family Practice, Internal Medicine, General Practice, OB/GYN, and/or Pediatric physician. You will always save money by using providers in the AETNA network.

What are your options? You may want to consider the following the next time you need care:

For a Life Threatening Emergency In a true medical emergency – such as an apparent heart attack, serious injury, or other life-threatening situation – always call 911 or your local emergency number right away!

For Less Critical Issues, if the emergency is NOT life threatening

• Call your physician’s office (even after hours, someone is typically on call to answer questions). Your doctor will know you and your medical history and may be able to schedule you for a visit the same (or next) day.

• If your condition starts or worsens on the weekend, or after your doctor’s office has closed for the day, you may want to consider a visit to an Urgent Care facility. These clinics are not affiliated with hospitals, but they do have doctors and nurses on staff and are open in the evenings and on weekends.

If You are Traveling and You Need Urgent Care Your medical plan covers urgent care. An urgent condition is one that requires immediate care, but isn’t life-threatening. If you seek urgent care while traveling, you or someone acting on your behalf should notify your doctor within 48 hours of the onset of the urgent condition.

Take advantage of the fact the Medical plan covers 100% of scheduled annual physical exams and cancer screening tests related to the physical exam when you use an in- network provider. There’s no copay or deductible, however keep in mind that if your physician orders a test that isn’t part of the scheduled preventative care exam/test, those procedures may result in some out-of-pocket expense for you. It’s always a good idea to check with your doctor’s office before your visit, to see what tests or exams are planned. Then, call your health plan to make sure you understand if and how those tests will be covered.

Your dental plan is designed to provide the dental coverage you need with the features you want. Take advantage of what this plan has to offer without compromising what matters most - including the freedom to visit the dentist of your choice – an “in- network” dentist or an “out-of-network” dentist. Don’t forget that your preventive care is covered at 100% once every six months.

For those medical, dental or vision care expenses (copays, deductibles, etc.) that you do pay for out-of-pocket, don’t forget to take advantage of the Health Care Flexible Spending Account. You can set aside up to $2,700 a year on a before-tax basis and then reimburse yourself for eligible expenses.

For the cost of a primary physician office visit copay, you can access care from a provider from your phone or computer.

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HEALTH PLAN PROVISIONS The following information relates to enrollment in the university’s medical, dental, and vision plans.

When can I enroll? You may enroll in benefits:

• Within 31 days of employment in an eligible appointment

• Within 31 days of a qualifying status change

• During an annual open enrollment period

Who can I enroll? Your legal spouse

Please note: Effective 1/1/19 Domestic Partners will no longer be covered. Only legal spouses will be eligible for coverage and the spousal surcharge will apply as applicable.

Your dependent children to age 26 A child is a biological child, legally adopted child, stepchild, child for who you have legal custody, or an interlocutory order of adoption.

Spousal Surcharge Provision

CSU employees may choose to have their spouse covered under the CSU healthcare plan, however, there is a surcharge if your spouse is eligible for medical coverage through his or her employer (whether enrolled in that coverage or not). If both you and your spouse work at CSU, the surcharge does not apply. The surcharge also does not apply if your spouse is not employed or is retired.

The 2019 spousal surcharge is $150.00 per month. The spousal surcharge will automatically be deducted from your paycheck if you have a spouse covered under your medical plan unless you apply and are approved for a waiver. The waiver must be completed each calendar year. To apply for the surcharge waiver, you must complete the form prior to the end of open enrollment or within 30 days of date of hire or a status change event. You can do this at www.lifesolutions1.com/csu.

When does my coverage begin? Coverage is effective on the first of the month following 28 days after your date of hire.

Can I make changes to my coverage throughout the year? You can only make changes to your elections if you experience a qualifying life event. You have 31 days to make a change to your benefit coverage. Outside of this timeframe, the only opportunity that you have to make changes to your benefits is during the annual enrollment period.

What if I choose to decline medical benefits? If you choose to decline medical benefits, you will need to fill out a Benefit Waiver Incentive Form online at www.lifesolutions1.com/csu. When you waive your benefits within 30 days of date of hire or a life status event or during open enrollment, you will receive $150.00 per month in your paycheck.

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ENROLLMENT INSTRUCTIONS

Follow these simple steps for benefits enrollment or to update your benefit election if you have experienced a qualifying life status event.

Access the Website • Log on to: www.lifesolutions1.com/csu • Select Benefits Logon

• Enter your case sensitive User ID; which is CSU plus the last five digits of your Social Security number (e.g. John Smith, xxx- x1-2345 = CSU12345)

• Enter your case sensitive Password; which is initially password.

• Note: During Open Enrollment, or if it’s your first time accessing the system, you will automatically be directed to a Change Password Menu where you will be instructed to create a new password.

Enrollment

Follow the appropriate steps for the type of enrollment you wish to make.

Open Enrollment New Hire Enrollment Life Status Event Change

Select: Next Year’s Benefits Select: New Hire Enrollment Select: Change Benefits

Select: Open Enrollment Enter the Event Date (date it occurred)

Select the type of Life Event Chan

Review Your Demographics Carefully review the information on file for you. If you see any incorrect information, such as your home address, please contact your human resources office to notify them of the error. Click NEXT to continue.

Register Your Eligible Dependents Follow the on-screen instructions to register your eligible dependents. Please refer to your Benefits Guide for dependent eligibility. Click NEXT to continue.

Enroll in Benefits The website will prompt you through the election process for each benefit available to you. You will only be offered the benefits for which you are eligible. Click NEXT to continue.

Review Your Confirmation Statement After completing your benefit enrollment elections, review the confirmation screen to be sure that ALL information has been updated correctly. Confirm that your eligible dependents who need coverage are listed as covered under the applicable benefit plan. Note: If you have a pended election, remember to fill out the Evidence of Insurability form. You may print a copy of the confirmation page at this time.

Congratulations — You are Finished! Once you have reviewed your confirmation screen, your enrollment is complete and you are finished. If you need to change any information, simply go through this enrollment process again before the deadline.

FOR ASSISTANCE CONTACT THE CENTRAL STATE BENEFITS SERVICE CENTER AT 833-864-6282

8:00 am – 8:00 pm

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MEDICAL BENEFITS Everyone has different medical benefit needs. Central State University offers two medical plan options through Aetna. You are eligible for this benefit the 1st of the month following 28 days of employment.

2019 Regular Rates – Per Pay Period 2019 Healthy Directions Rates – Per Pay Period

AFSCME/CSUSA AAUP/Non Bargaining Staff

AFSCME/CSUSA AAUP/Non Bargaining Staff

Single $51.40 $90.71 Single $41.12 $72.57

Employee/Spouse $102.81 $205.61 Employee/Spouse $82.25 $164.49

Employee/Child(ren) $92.53 $185.06 Employee/Child(ren) $74.02 $148.04

Family $154.21 $308.42 Family $116.87 $246.74

Refer to the benefit summary or certificate of coverage for more information.

Standard Plan In-Network Out-of-Network

Annual Deductible $1,000/$2,000 $1,500/$3,000

Annual Out-of-Pocket

Maximum

$3,500/$7,000

Includes annual deductible,

coinsurance and copays

$5,000/$10,000

Includes annual deductible,

coinsurance and copays

Coinsurance 80% unless otherwise noted below 60% unless otherwise noted below

Physician Office Visits $25 copay 60% after deductible

Specialists Office Visits $50 copay 60% after deductible

Preventive Care Services 100% 60% after deductible

Diagnostic X-Ray &

Laboratory

80% after deductible 60% after deductible

Inpatient Hospitalization 80% after deductible 60% after deductible

Outpatient Hospitalization 80% after deductible 60% after deductible

Emergency Room $250 copay, waived if admitted $250 copay, waived if admitted

Urgent Care $50 copay 60% after deductible

Prescription Drugs (retail)

Generic $10 copay Preferred Brand $30 copay Non-Preferred Brand $50 copay Maximum Day Supply 30 days

Generic $10 copay / 50% Preferred Brand $30 copay / 50% Non-Preferred Brand $50 copay / 50% Maximum Day Supply 30 days

Prescription Drugs (mail

order)

Generic $20 copay Preferred Brand $60 copay Non-Preferred Brand $100 copay Maximum Day Supply 90 days

Not Covered

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2019 Regular Rates – Per Pay Period 2019 Healthy Directions Rates – Per Pay Period

AFSCME/CSUSA

AAUP/Non Bargaining Staff

AFSCME/CSUSA

AAUP/Non Bargaining Staff

Single $53.30 $94.06 Single $42.64 $75.24

Employee/Spouse $106.64 $213.30 Employee/Spouse $85.32 $170.64

Employee/Child(ren) $95.88 $191.97 Employee/Child(ren) $76.78 $153.57

Family $159.95 $319.94 Family $127.98 $255.95

Refer to the benefit summary or certificate of coverage for more information.

Premium Plan In-Network Out-of-Network

Annual Deductible $750/$1,500 $1,500/$3,000

Annual Out-of-Pocket

Maximum

$2,500/$5,000

Includes annual deductible,

coinsurance and copays

$5,000/$10,000

Includes annual deductible,

coinsurance and copays

Coinsurance 80% unless otherwise noted below 60% unless otherwise noted below

Physician Office Visits $25 copay 60% after deductible

Specialists Office Visits $50 copay 60% after deductible

Preventive Care Services 100% 60% after deductible

Diagnostic X-Ray &

Laboratory

80% after deductible 60% after deductible

Inpatient Hospitalization 80% after deductible 60% after deductible

Outpatient Hospitalization 80% after deductible 60% after deductible

Emergency Room $250 copay, waived if admitted $250 copay, waived if admitted

Urgent Care $50 copay 60% after deductible

Prescription Drugs (retail)

Generic $10 copay Preferred Brand $30 copay Non-Preferred Brand $50 copay Maximum Day Supply 30 days

Generic $10 copay / 50% Preferred Brand $30 copay / 50% Non-Preferred Brand $50 copay / 50% Maximum Day Supply 30 days

Prescription Drugs (mail

order)

Generic $20 copay Preferred Brand $60 copay Non-Preferred Brand $100 copay Maximum Day Supply 90 days

Not Covered

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DENTAL BENEFITS

Regular dental care is essential to good health. Central State University provides you with an opportunity to purchase Dental coverage with Delta Dental Insurance Company. You are eligible for this benefit the 1st of the month following 28 days of employment.

SUMMARY OF DENTAL BENEFITS Be prepared and plan ahead

For the best savings, use a Delta Dental Insurance Company participating dentist or specialist. You can find a dentist by visiting the www.deltadentaloh.com website. You can also call Delta Dental. If you choose a dentist who does not participate in our dental plan, your out-of-pocket expenses may be more, since you may be responsible for paying any difference between the dentist’s fee and the plan’s payment for the approved service.

Customer Service: www.deltadentalins.com or call 1-800-521-2651

Delta Dental PPO Plan

Delta PPO Dentist

Delta Premier or Non- Network

Dentist

Deductible (Applies to Basic and Major Services)

$0 $25 Single/$75 Family

Preventive Care/Diagnostic 100% 100%

• Oral Examinations

• Topical Fluoride Application

• Full Mouth X-Rays

• Bitewing x-rays Basic Restorative 80% 80%

• Endodontics

• Oral surgery (simple extractions)

• Fillings

• Periodontics Major Restorative 80% 60%

• Implants

• Bridges, Dentures, Crowns/Inlays/Onlays Annual Benefit Maximum per Person $1,000 $1,000

Orthodontia (children up to age 19) 50% up to a lifetime maximum of $1,000

50% up to a lifetime maximum of $1,000

2019 Dental Rates – Per Pay Period

AFSCME/CSUSA AAUP/Non Bargaining Staff

Single $0 $0

Employee/Spouse $12.65 $25.31

Employee/Child(ren) $16.44 $32.89

Family $36.31 $72.62

Refer to the benefit summary or certificate of coverage for more information.

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VISION BENEFITS

Central State University offers vision insurance through Medical Mutual of Ohio. You are eligible for this benefit the 1st of the month following 28 days of employment.

SUMMARY OF VISION BENEFITS

Using your vision benefit is easy!

To find a participating eye care provider or to review your plan coverage before your appointment, visit Medical Mutual of Ohio website or call Medical Mutual of Ohio Phone Number.

Customer Service: www.medmutual.com or call 1-800-382-5729

2019 Vision Rates – Per Pay Period

AFSCME/CSUSA AAUP/Non Bargaining Staff

Single $.16 $.31

Employee/Spouse $.31 $.75

Employee/Child(ren) $.28 $.67

Family $.47 $1.12

Refer to the benefit summary or certificate of coverage for more information.

Vision All Employees In-Network Out-of-Network Reimbursement

Co-pays

• Materials $0 copay $30 maximum

Exam • Benefit

• Frequency

$15 copay 12 months

$15 maximum 12 months

Lenses • Single Vision

• Bifocal

• Trifocal

• Lenticular

• Frequency

$15 copay $15 copay $15 copay $15 copay 12 months

$10 maximum $20 maximum $30 maximum $40 maximum 12 months

Frames • Benefit

• Frequency

$0 copay up to $100; + 20% off amount over

12 months

$30 maximum 12 months

Contact Lenses (in lieu of Lenses & Frames) • Elective

• Medically Necessary

• Frequency

$15 copay up to $100, +15% off over $100

$15 copay up to $200 12 months

$40 maximum

$75 maximum 12 months

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INCOME PROTECTION BENEFIT

If something were to happen to you, would your loved ones be financially secure?

Central State University offers Basic Life, Accidental Death and Dismemberment (AD&D) and Long- Term Disability Insurance. You may also purchase Voluntary Life Insurance for you and your family. Life and Disability coverage is through MetLife. There is also Critical Illness and Accident Insurance available for employee purchase. More information on these programs can be found at www.lifesolutions1.com/csu.

Customer Service: www.metlife.com or call 1-800-638-5433

SUMMARY OF BENEFITS

Benefit Type Summary Basic Life AFSCME - $50,000; CSUSA - $100,000; AAUP & Non-Bargaining – 2 X Salary (75% employee paid)

AD&D Benefit matches basic life amount

Long-Term Disability 60% of salary up to $5000 after a 90 day Elimination Period

Eligibility of Coverage All active employees’ full-time employees in an eligible class

Eligibility Waiting Period You are eligible for this benefit the 1st

of the month following 28 days of employment. You are in Active Pay Status on a day which is one of the Employer’s scheduled work days if either of the following conditions are met. 1. You are performing your regular occupation for the Employer on a full-time basis. You must be working at one of the Employer’s usual places of business or at some location to which the Employer’s business requires you to travel. 2. The day is a scheduled holiday or vacation day and you were performing your regular occupation on the preceding scheduled work day. You are in Active Pay Status on a day which is not one of the Employer’s scheduled work days only if you were in Active Pay Status on the preceding scheduled work day.

Benefit Waiting Period LTD benefits starts after 90 days of Continuous Disability. If disability benefits are payable to you under this policy, you may be eligible for benefits from other income benefits. If so, we may reduce the disability benefits by the amount of such other income benefits. Please refer to your employee

certificate for a complete list of what payments qualify as other income benefits.

Pre-Existing Waiting Period 12 Months

Taxability of Benefit Benefit is Partially Taxable; you pay a portion of the premium for this plan

Accelerated Benefit Life Expectancy is certified by a physician to be less than 12 months, you can elect to take a portion of your life insurance in advance.

Waiver of Premium Available if you are totally disabled as defined by the group policy

Refer to the benefit summary or certificate of coverage for more information.

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SUMMARY OF COVERAGE FOR VOLUNTARY LIFE INSURANCE Central State University offers Voluntary Life and Accidental Death & Dismemberment Insurance for you and your family at a discounted group rate. This life insurance plan will provide coverage in the event of a death.

Benefit Type Voluntary Life/ADD EMPLOYEE: Five times annual compensation (in $10,000 increments) rounded to the next

higher $10,000, OR maximum of $500,000. Providing you are still employed, benefits are reduced at age 65, age 70, age 75, age 80 SPOUSE: Up to 50% of the employee life amount (in $5,000 increments) rounded to the next higher $5,000 OR maximum of $250,000 Benefits are reduced at age 65 and terminate at age 70 or retirement

CHILD: $250 (age 14 days to 6 months); $10,000 (age 6 months to 19 years; 25 if FTS)

Eligibility of Coverage All active employees regularly working a minimum of 40 Hours per Week Employees must participate in this voluntary plan for dependents to be eligible.

Eligibility Waiting Period You are eligible for this benefit the 1st

of the month following 28 days of employment. Active Pay Status is defined as one of Central State University’s scheduled work days if one of the following conditions are met:

1. You are performing your regular occupation for the Central State University on a full-time basis. You must be working at one of Central State University’s usual places of business or at some location to which the Central State University’s business requires you to travel.

2. The day is a scheduled holiday or vacation day and you were performing your regular occupation on the preceding scheduled work day.

3. You are in Active Pay Status on a day which is not one of Central State University’s scheduled work days (i.e. Saturday) only if you were in Activeemployment on the preceding scheduled work day.

Guarantee Issue Available for newly eligible employees only. All other employees must complete Evidence of Insurability for all applied for amount.

EMPLOYEE: $150,000 SPOUSE: $30,000 CHILD: $10,000

Voluntary Life/ADD Rates

Employee Age Employee Monthly Cost per $1,000 Spouse Monthly Cost per $1,000 Under 25 $0.07 $0.07

25 - 29 $0.07 $0.07

30 - 34 $0.07 $0.07

35 - 39 $0.10 $0.10

40 - 44 $0.15 $0.15

45 - 49 $0.21 $0.21

50 - 54 $0.37 $0.37

55 - 59 $0.57 $0.57

60 - 64 $0.59 $0.59

65 - 69 $1.08 $1.08

70 - 74 $2.24 75 - 79 $6.56 Over 80 $14.23 Child Life ($10,000 benefit) $2.00

WILL PREPARATION

If you are enrolled in Voluntary Life Insurance, you are eligible for Will Preparation free of charge. Legal Resources, Binding Will, Professional Support Not having a will can cause unnecessary stress and leave difficult decisions to family members or to the courts. Help protect your family’s financial future and ensure your final wishes are clear. Turn to the valuable legal resources offered through Hyatt Legal Plans. You get expert guidance – at no additional cost to you when you are enrolled in Voluntary Life coverage. Whether it’s creating a binding will or updating an existing will, you can take advantage of unlimited consultations with a plan attorney so you can feel confident you’re making the right decisions.

Personal Guidance When it Matters Most One-on-One consultations to help meet your needs in a private and supportive environment. Choose to meet in-person or by phone with any of the more than 14,000 participating plan attorneys. There will be no claim forms to file for covered services – fees are taken care of through your plan. And, you can use an out-of-network attorney if needed. The fees for these services are based on a set fee schedule.

Covered Services: Take advantage of covered services that can help you and your spouse prepare or update a will.

• Unlimited access: consult with an attorney to prepare, update or revise a will

• Protection for the Unexpected: prepare living wills and powers of attorney to help ease the stress involved when individuals become unable to make their own decisions.

Expert Guidance is Just a Phone Call Away Simply contact a Client Services Representative to get started. You will be assigned a cse number and receive help with locating a participating plan attorney.

• Call Hyatt Legal Plans toll-free number 1-800-821-6400

• Provide the company name, customer number and the last 4 digits of the policy holder’s social security number

• Locate a participating plan attorney near you

SUMMARY OF COVERAGE FOR

ACCIDENT INSURANCE Central State University offers employees the opportunity to purchase Accident Insurance. There is a

choice of two comprehensive plans which provide payments due to an accident, in addition to any other insurance payments you may receive. Here are just some of the covered events/services.

Refer to the benefit summary or certificate of coverage for more information.

SUMMARY OF COVERAGE FOR CRITICAL ILLNESS INSURANCE

Central State University offers employees the opportunity to purchase Critical Illness Insurance.

Refer to the benefit summary or certificate of coverage for more information

EMPLOYEE ASSISTANCE PROGRAM CSU is pleased to offer an Employee Assistance Program (EAP) from IMPACT Solutions. The IMPACT Employee Assistance (EAP) & Work/Life Program is a benefit available to you and your family offering access to confidential professional support 24 hours a day, 365 days a year.

All IMPACT counselors are qualified masters/doctoral level professionals. This program is available to you free of charge, courtesy of Central State University. Please visit the CSU HR Benefits webpage (http://www.centralstate.edu/faculty/hr/details.php?Benefits-1) and click on the IMPACT Solutions Benefits Summary, or visit the IMPACT Solutions website to gain access to the wealth of information available to CSU Employees and their families. Member Login: centralstate Website: www.impactsolutions.net

CHARD SNYDER

FLEXIBLE SPENDING ACCOUNT (FSA)

What is an FSA? An FSA allows you to pay for health care and/or dependent care expenses through pre-tax payroll deductions. When enrolling, you determine how much money you want to contribute to each account for the plan year. The money is then withheld from your pay before taxes are calculated. You will be reimbursed from the account as you incur expenses and submit claims for them.

FSAs help you save money because they lower your taxable income. Without an FSA, you would still pay for health care and/or dependent care expenses, but you would use money remaining in your pay after taxes were withheld. You do not have to enroll in a medical plan to participate in an FSA.

The IRS has placed an annual maximum of $2,700.00 that employees can contribute to the Flexible Spending Account for the 2019 plan year. Employees must sign up every year for the FSA and designate the amount to be contributed to a Healthcare FSA and/or Dependent Care (Dependent Care Services Only) FSA. If you terminate employment, neither FSA goes with you.

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FSA Rules and Regulations

• The IRS requires that all FSA purchases be verified as eligible expenses. Sometimes, purchases are automatically verified when you use your card. Other times, Chard Snyder will request itemized receipts. Always save your itemized receipts!

• With the exception of $500 that can be

rolled over into the next year, you must use all remaining FSA funds or they will be forfeited, according to IRS regulations.

• The IRS also requires that employers

make the full annual FSA election available to employees when an eligible expense occurs, regardless of whether you have deposited enough to cover the full amount at that point in time. For example, you may designate $1,000 per year, equal to a payroll deduction of $83.33 a month. You are eligible for reimbursement up to the full $1,000 in the first month, even though you have only deposited $83.33 in your account.

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PENSION PLANS

OPERS/ STRS/ ALTERNATIVE RETIREMENT

All Central State University employees are eligible to participate in a pension plan. An employee’s classification will determine which pension plan he/she is eligible to participate in. The University will match contributions to all employee pension plans in accordance with the state-mandated legislation, which varies between the individual classifications.

EMPLOYEE CLASSIFICATION

EMPLOYEE CONTRIBUTION

UNIVERSITY MATCH RETIREMENT PLAN

AFSCME

(Bi-Weekly Paid employees

except Police Officers)

10% of employee’s

gross earnings before

taxes

14% of employee’s

gross earnings before taxes

OR

11.56% of employee’s gross earnings

to ARP and 2.44% to OPERS.

Ohio Public Employees

Retirement System

(OPERS)

OR

Alternative Retirement Plan Police

Officers 13.0 % of employee’s

gross earnings before

taxes

18.1% of employee’s

gross earnings before taxes

OR

15.56% of employee’s gross earnings

to ARP and 2.44% to OPERS.

Ohio Public Employees

Retirement System Law

Enforcement (OPERS)

OR

Alternative Retirement Plan

All Contract (Monthly)

Staff Employees

10% of employee’s gross

earnings before taxes

14% of employee’s gross earnings before

taxes

OR

11.56% of employee’s gross earnings to

ARP and 2.44% to OPERS.

Ohio Public Employees

Retirement System (OPERS)

OR

Alternative Retirement Plan

All Faculty Members

14.0% of employee’s gross

earnings before taxes

14 % of employee’s gross earnings

before taxes

OR

9.53% of employee’s gross earnings to

ARP and 4.47% to STRS.

State Teachers

Retirement System of

Ohio

OR

Alternative Retirement

Plan

Alternative Retirement vs. OPERS or STRS • If an eligible employee opts to enroll in the Alternative Retirement Program instead of STRS or OPERS

they must make this election within 120 calendar days of their initial hire date. Once an election to an

ARP is made an employee may not return to STRS or OPERS. • With an OPERS/STRS election an employee will receive medical benefits at retirement age providing

they have worked the required period of creditable service at retirement. The ARP does not provide

for medical coverage upon retirement. • Upon retirement through STRS or OPERS the employee will have a set monthly retirement benefit.

With the ARP the employee’s retirement benefit will be determined based upon the investment fund value. Employee and employer contributions to the ARP are immediately 100% vested.

• Employees who contribute to the ARP also have the ability to change vendors. Contact HR for more information.

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SUPPLEMENTAL RETIREMENT PLANS

403(B) TAX SHELTERED ANNUITIES AND 457 DEFERRED

COMPENSATION PLANS

All employees are eligible to participate in any of the 403(b) or 457 plans. These are supplemental retirement plans that are set up in addition to an employee’s mandatory Pension Contribution. Monthly contributions are

deducted from the employee’s payroll on a pre-tax basis and distributed to the company of their choice. At this time Central State University employees have the option to enroll in the 403(b) and 457 plans with the following companies. Employees may elect to enroll in more than one company.

Company Monthly Contribution Enrollment Contact VOYA (Formerly ING) No Minimum.

Maximum contribution per year:

$19,000.00; $6,000.00 Age 50+ Catch- up Limit

Derek Stiles

(937) 353-5472

TIAA- CREF No Minimum.

Maximum contribution per year: $19,000.00; $6,000.00 Age 50+ Catch- up

Limit

1-877-209-3138

Variable Annuity Life Insurance Company (VALIC)

No Minimum. Maximum contribution per year:

$19,000.00; $6,000.00 Age 50+ Catch- up

Limit

Carrie Cummings 937-542-2936

Ohio Public Employees Deferred Compensation

No Minimum. Maximum contribution per year:

$19,000.00; $6,000.00 Age 50+ Catch- up

Limit

1-877-644-6457

VOYA Deferred Compensation No Minimum.

Maximum contribution per year:

$19,000.00; $6,000.00 Age 50+ Catch- up

Limit

Derek Stiles

937-436-7469

VALIC Deferred Compensation No Minimum.

Maximum contribution per year:

$19,000.00; $6,000.00 Age 50+ Catch- up Limit

Carrie Cummings 800-892-5558 x. 88823

16 | P a g e

ADDITIONAL BENEFITS FOR ELIGIBLE EMPLOYEES

Vacation Vacation accrual is based on classification, status and position of each employee. For non-

bargaining employees, see procedure 603.1 and for bargaining unit employees, please consult

your bargaining unit contract for specific information.

Paid Holidays All employees are eligible for the paid holidays as announced each calendar year by the administration. If an employee is required to work on a holiday, they will be paid in accordance with the applicable CSU policy or union contract guidelines. Employees are eligible for holiday pay from the date of hire. The Paid Holidays are listed on the CSU website.

Personal Days (AFSCME) Each CSU employee represented by AFSCME is granted 2 personal days, per calendar year, to use as they wish. These days must be scheduled in advance through their immediate supervisor and are available after employment. Personal Days must be used within the calendar year. They will not be carried over to the next calendar year. Any unused personal days will not be paid out upon termination or retirement.

Direct Deposit All CSU employees must have their payroll direct deposited to the bank or credit union of

their choice. Each employee may have up to 3 different individual deposits to either a

checking or savings account. Direct Deposits should be set up through MyCSU. Forms may be

obtained from the Payroll Department.

Education Assistance For more information regarding the tuition remission policy you may refer to the on-line policy.

Your CSU employment makes you eligible to join the Dayton School Employees Federal Credit Union or the Wright-Patt Credit Union. Employees will need to contact the individual credit unions to join. A current pay stub will be needed to show eligibility.

Any employee that has worked for one full year and has worked a minimum of 1250 hours

in the previous calendar year is eligible for leave under the Family Medical Leave Act.

Employees needing FMLA must review Policy 605 and Procedure 605.1, and contact Human

R e s o u r c e s for more information. Human Resources is the approving authority for

FMLA leave and any questions regarding the CSU policy for FMLA should be directed to

the Human Resources Department.

Credit Union Your CSU employment makes you eligible to join the Dayton School Employees Federal Credit Union or the Wright-Patt Credit Union. Employees will need to contact the individual credit unions to join. A current pay stub will be needed to show eligibility.

FMLA Any employee that has worked for one full year and has worked a minimum of 1250 hours in the previous calendar year is eligible for leave under the Family Medical Leave Act. Employees needing FMLA must review Policy 605 and Procedure 605.1, and contact Human Resources for more information. Human Resources is the approving authority for FMLA leave and any questions regarding the CSU policy for FMLA should be directed to the Human Resources Department.

17 | P a g e

THE BENEFIT RESOURCE CENTER

The Benefit Resource Center (BRC) is designed to provide you with a responsive, consistent, hands-on approach to benefit inquiries. Benefit Specialists are available to research and solve elevated claims, unresolved eligibility problems, and any other benefit issues with which you might need assistance. The Benefit Specialists are experienced professionals and their primary responsibility is to assist you.

The Specialists in the Benefit Resource Center are available Monday through Friday 8:00am to 5:00pm Eastern & Central Standard Time via phone 855-874-0829 or via e-mail BRCMidwest@usi.com. If you need assistance outside of regular business hours, please leave a message and one of the Benefit Specialists will promptly return your call or e-mail message by the end of the following business day.

If you have any questions, please contact the following:

Melanie Staab 937-376-6545

Gayle “Buddy” Berry

937-376-6018

This guide is provided to you by Central State University and USI

These pages summarize benefits of the plan(s). The Subscriber Certificate(s) and applicable riders define the terms and conditions of these benefits in greater detail. Should any questions arise; the

certificate(s) and riders will govern.

Page 1 of 19

Central State University

Important Legal Notices

If you (and/or your dependents) have Medicare

or will become eligible for Medicare in the next

12 months, a Federal law gives you more

choices about your prescription drug coverage.

Please see pages 11-16 for more details.

Page 3 of 19

Important Legal Notices Affecting Your Health Plan Coverage THE W OM EN’S HE ALTH C AN CER RIGHTS ACT OF 1998 (WHCRA)

If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

▪ All stages of reconstruction of the breast on which the mastectomy was performed; ▪ Surgery and reconstruction of the other breast to produce a symmetrical appearance; ▪ Prostheses; and ▪ Treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan.

NEWBORNS ACT DISCLOSURE - FEDERAL

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).

NOTICE OF SPECIAL ENROLLMENT RIGHTS

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 31 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 result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.

Further, if you decline enrollment for yourself or eligible dependents (including your spouse) while Medicaid coverage or coverage under a State CHIP program is in effect, you may be able to enroll yourself and your dependents in this plan if:

▪ coverage is lost under Medicaid or a State CHIP program; or ▪ you or your dependents become eligible for a premium assistance subsidy from the State.

In either case, you must request enrollment within 60 days from the loss of coverage or the date you become eligible for premium assistance.

To request special enrollment or obtain more information, contact person listed at the end of this summary.

Page 4 of 19

NOTICE REGARDING WELLNESS PROGRAMS

The Central State Healthy Directions Program is a voluntary wellness program available to all employees. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program you will be asked to complete a voluntary health risk assessment or "HRA" that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You will also be asked to complete a biometric screening, which will include a blood test for cholesterol, glucose, and triglycerides, to name a few. You will also be asked to certify that you are tobacco free or complete a tobacco cessation program. You are not required to complete the HRA or to participate in the blood test or other medical examinations or complete the tobacco free affidavit or cessation program. However, employees who choose to participate in the wellness program will receive an incentive of a medical premium discount for 2019.

The information from your HRA and the results from your biometric screening will be used to provide you with information to help you understand your current health and potential risks, and may also be used to offer you services through the wellness program, such as health coaching. You also are encouraged to share your results or concerns with your own doctor.

Protections from Disclosure of Medical Information We are required by law to maintain the privacy and security of your personally identifiable health information. Although the wellness program and Central State University may use aggregate information it collects to design a program based on identified health risks in the workplace, the Healthy Directions Program will never disclose any of your personal information either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment.

Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information is (are) a registered nurse or health coach in order to provide you with services under the wellness program.

In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making any employment decision. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you immediately.

You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate.

If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact Gayle Berry at 937-376-6018.

Page 5 of 19

STATEMENT OF ERISA RIGHTS

As a participant in the Plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (“ERISA”). ERISA provides that all participants shall be entitled to:

Receive Information about Your Plan and Benefits

▪ Examine, without charge, at the Plan Administrator’s office and at other specified locations, the Plan and Plan documents, including the insurance contract and copies of all documents filed by the Plan with the U.S. Department of Labor, if any, such as annual reports and Plan descriptions.

▪ Obtain copies of the Plan documents and other Plan information upon written request to the Plan Administrator. The Plan Administrator may make a reasonable charge for the copies.

▪ Receive a summary of the Plan’s annual financial report, if required to be furnished under ERISA. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report, if any.

Continue Group Health Plan Coverage If applicable, you may continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You and your dependents may have to pay for such coverage. Review the summary plan description and the documents governing the Plan for the rules on COBRA continuation of coverage rights.

Prudent Actions by Plan Fiduciaries In addition to creating rights for participants, ERISA imposes duties upon the people who are responsible for operation of the Plan. These people, called “fiduciaries” of the Plan, have a duty to operate the Plan prudently and in the interest of you and other Plan participants. No one, including the University or any other person, may fire you or discriminate against you in any way to prevent you from obtaining welfare benefits or exercising your rights under ERISA.

Enforce your Rights If your claim for a welfare benefit is denied in whole or in part, you must receive a written explanation of the reason for the denial. You have a right to have the Plan review and reconsider your claim. Under ERISA, there are steps you can take to enforce these rights. For instance, if you request materials from the Plan Administrator and do not receive them within 30 days, you may file suit in federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $149 per day (up to a $1,496 cap per request), until you receive the materials, unless the materials were not sent due to reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, and you have exhausted the available claims procedures under the Plan, you may file suit in a state or federal court. If it should happen that Plan fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose (for example, if the court finds your claim is frivolous) the court may order you to pay these costs and fees.

Assistance with your Questions If you have any questions about your Plan, this statement, or your rights under ERISA, you should contact the nearest office of the Employee Benefits and Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits and Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210.

Page 6 of 19

CONTACT INFORMATION

CONTACT INFORMATION

Questions regarding any of this information can be directed to: Gayle Berry

1400 Brush Row Road Wilberforce, Ohio 45324

937-376-6018

gberry@centralstate.edu

Page 7 of 19

Your Information. Your Rights. Our Responsibilities.

Recipients of the notice are encouraged to read the entire notice. Contact information for questions or complaints is available at the end of the notice.

Your Rights You have the right to:

• Get a copy of your health and claims records • Correct your health and claims records

• Request confidential communication • Ask us to limit the information we share • Get a list of those with whom we’ve shared your information • Get a copy of this privacy notice • Choose someone to act for you

• File a complaint if you believe your privacy rights have been violated

Your Choices You have some choices in the way that we use and share information as we:

• Answer coverage questions from your family and friends

• Provide disaster relief

• Market our services and sell your information

Our Uses and Disclosures We may use and share your information as we:

• Help manage the health care treatment you receive • Run our organization • Pay for your health services • Administer your health plan • Help with public health and safety issues • Do research • Comply with the law • Respond to organ and tissue donation requests and work with a medical examiner or funeral

director

• Address workers’ compensation, law enforcement, and other government requests

• Respond to lawsuits and legal actions

Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Page 8 of 19

Get a copy of health and claims records

• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct health and claims records

• You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing, usually within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send

mail to a different address. • We will consider all reasonable requests, and must say “yes” if you tell us you would be in

danger if we do not. Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations.

• We are not required to agree to your request. Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for up to six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

Page 9 of 19

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information at the end of this notice.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in payment for your care

• Share information in a disaster relief situation If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission: • Marketing purposes

• Sale of your information

Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways.

Help manage the health care treatment you receive We can use your health information and share it with professionals who are treating you. Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.

Pay for your health services We can use and disclose your health information as we pay for your health services. Example: We share information about you with your dental plan to coordinate payment for your dental work.

Administer your plan We may disclose your health information to your health plan sponsor for plan administration. Example: The University contracts with us to provide a health plan, and we provide the University with certain statistics to explain the premiums we charge.

Run our organization

• We can use and disclose your information to run our organization and contact you when necessary.

• We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.

Example: We use health information about you to develop better services for you.

Page 10 of 19

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues We can share health information about you for certain situations such as:

• Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone’s health or safety

Do research We can use or share your information for health research.

Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests and work with a medical examiner or funeral director

• We can share health information about you with organ procurement organizations. • We can share health information with a coroner, medical examiner, or funeral director when an

individual dies.

Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you:

• For workers’ compensation claims

• For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective

services

Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Page 11 of 19

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site (if applicable), and we will mail a copy to you.

Other Instructions for Notice • January 1, 2019

• Gayle Berry • 937-376-6018

• gberry@centralstate.edu

Page 12 of 19

Important Notice from Central State University about Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Central State University 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. Central State University has determined that the prescription drug coverage offered by the AETNA 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 15

th 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 Central State University coverage will not be affected. You can keep this coverage and it will coordinate with Part D.

If you do decide to join a Medicare drug plan and drop your current Central State University coverage, be aware that you and your dependents will be able to get this coverage back (during open enrollment or in the case of a special enrollment opportunity).

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 Central State University 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.

Page 13 of 19

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 nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For 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 Central State University changes. You also may request a copy of this notice at any time.

Page 14 of 19

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).

Date: January 1, 2019

Name of Entity/Sender: Central State University Contact--Position/Office: Gayle Berry

Address: 1400 Brush Row Road Wilberforce, OH 45324

Phone Number: 937-376-6018

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).

Page 15 of 19

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’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of August 10, 2017. Contact your State for more information on eligibility –

ALABAMA – Medicaid FLORIDA – Medicaid

Website: http://myalhipp.com/ Phone: 1-855-692-5447

Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268

ALASKA – Medicaid GEORGIA – Medicaid

The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.asp x

Website: http://dch.georgia.gov/medicaid Click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507

ARKANSAS – Medicaid INDIANA – Medicaid

Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1-800-403-0864

COLORADO – Health First Colorado (Colorado’s Medicaid Program) &

Child Health Plan Plus (CHP+)

IOWA – Medicaid

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711

Website: http://dhs.iowa.gov/ime/members/medicaid- a-to-z/hipp Phone: 1-888-346-9562

Page 16 of 19

KANSAS – Medicaid NEW HAMPSHIRE – Medicaid

Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512

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

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP

Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392

CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

LOUISIANA – Medicaid NEW YORK – Medicaid

Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – Medicaid

Website: http://www.maine.gov/dhhs/ofi/public- assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711

Website: https://dma.ncdhhs.gov/ Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid

Website: http://www.mass.gov/eohhs/gov/departments/masshe alth/ Phone: 1-800-462-1120

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP

Website: http://mn.gov/dhs/people-we-serve/seniors/health- care/health-care-programs/programs-and- services/medical-assistance.jsp Phone: 1-800-657-3739

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

MISSOURI – Medicaid OREGON – Medicaid

Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.ht m Phone: 573-751-2005

Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

MONTANA – Medicaid PENNSYLVANIA – Medicaid

Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIP P Phone: 1-800-694-3084

Website: http://www.dhs.pa.gov/provider/medicalassistance/hea lthinsurancepremiumpaymenthippprogram/index.htm Phone: 1-800-692-7462 NEBRASKA – Medicaid RHODE ISLAND – Medicaid

Website: http://dhhs.ne.gov/Children_Family_Services/AccessN ebraska/Pages/accessnebraska_index.aspx Phone: 1-855-632-7633

Website: http://www.eohhs.ri.gov/ Phone: 401-462-5300

NEVADA – Medicaid SOUTH CAROLINA – Medicaid

Medicaid Website: https://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900

Website: https://www.scdhhs.gov Phone: 1-888-549-0820

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SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid

Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: http://www.hca.wa.gov/free-or-low-cost-health- care/program-administration/premium-payment-program Phone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid WEST VIRGINIA – Medicaid

Website: http://gethipptexas.com/ Phone: 1-800-440-0493

Website: http://mywvhipp.com/ Toll-free Phone: 1-855-MyWVHIPP (1-855-699-8447)

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP

Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002

VERMONT– Medicaid WYOMING – Medicaid

Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531

VIRGINIA – Medicaid and CHIP Medicaid Website: http://www.coverva.org/programs_premium_assistance. cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance. cfm CHIP Phone: 1-855-242-8282

To see if any other states have added a premium assistance program since August 10, 2017, or for more information on special enrollment rights, 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/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

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

Page 18 of 19

PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health

Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic

information about the new Marketplace and employment based health coverage offered by your employer.

What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The

Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible

for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance

coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace?

You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or

offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on

your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?

Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible

for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be

eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does

not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your

employer that would cover you (and not any other members of your family) is more than 9.5% of your household

income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the

Affordable Care Act, you may be eligible for a tax credit.1

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your

employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer

contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for

Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-

tax basis.

How Can I Get More Information?

For more information about your coverage offered by your employer, please check your summary plan description or

the human resources department.

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the

Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health

insurance coverage and contact information for a Health Insurance Marketplace in your area.

1 An employer - sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered

by the plan is no less than 60 percent of such costs.

N Y ur

Page 19 of 19

PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an

application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered

to correspond to the Marketplace application.

3. Employer name

Central State University

4. Employer Identification Number (EIN)

31-0675386

5. Employer address

1400 Brush Row Road

6. Employer phone number

937-376-6011

7. City

Wilberforce

8. State

OH

9. ZIP code

45324

10. Who can we contact about employee health coverage at this job?

Gayle Berry

11. Phone number (if different from above) 12. Email address gberry@centralstate.edu

Here is some basic information about health coverage offered by this employer:

• As your employer, we offer a health plan to:

All employees. Eligible employees are:

Some employees. Eligible employees are:

• With respect to dependents:

We do offer coverage. Eligible dependents are:

We do not offer coverage.

If checked, this coverage meets the minimum value standard*, and the cost of this coverage to you is

intended to be affordable, based on employee wages.

** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium

discount through the Marketplace. The Marketplace will use your household income, along with other

factors, to determine whether you may be eligible for a premium discount. If, for example, your wages

vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if

you are newly employed mid-year, or if you have other income losses, you may still qualify for a

premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the

employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your

monthly premiums.

• An employer - sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered

by the plan is no less than 60 percent of such costs (Section 36 B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

All Full-Time Employees working 40 hours per week.

Spouse and children to age 26

x

x

x