2020 employee benefits - oklahoma baptist university · 2020 employee benefits. we are pleased to...
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2020 Employee BenefitsA New Perspective on Benefits
This Benefit Guide provides summarized information for Employee Benefit plans effectiveJanuary 1st, 2020 – December 31st, 2020.
2020 Employee Benefits
We are pleased to present this guide which highlights the comprehensive coverage available to you. Our benefits program is designed to offer employees substantial coverage to meet both individual and family needs. This booklet includes only highlights. The specific terms of coverage, exclusions & limitations are contained in the plan documents and insurance certificates. All coverage and coverage costs are subject to change at any time in the future. If you have any questions about a specific service or treatment, please contact the appropriate insurance carrier.
Table of Contents
Eligibility & EnrollmentQualifying EventsContact Information
Enrollment Information
Medical CoverageMoney Accounts Dental CoverageVision Coverage
Health Plans
Life & AD&D CoverageDisability CoverageEmployee Assistance ProgramAccident CoverageCritical Illness CoverageHospital Indemnity Coverage
Other Benefit Plans
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Benefits Eligibility
All active employees who work at least 30 hours per week, and their eligible dependents, qualify for the benefits outlined in this guide.
For new hires, your medical coverage begins on the date you are hired. All other benefits begin first of the month following your date of hire. After your initial enrollment, you will have the opportunity to enroll again during open enrollment each year. If your employment ends, your coverage will end on the last day of the month of your termination. Depending upon the circumstances of your termination, you may be able to continue coverage under COBRA.
Your eligible dependents include:• Your spouse (unless legally separated)• Your children to age 26 (regardless of student, marital, or tax dependent status)• Your children of any age who have been qualified as disabled and are physically or
mentally unable to care for themselves.
Qualifying EventsOutside of Open Enrollment or your initial new hire benefit enrollment, you generally will only be able to change your coverage if you have a qualifying life event.
Qualifying events include, but are not limited to:• Change in marital status (marriage, divorce, death, legal separation)• Change in number of dependents (birth, death, adoption, eligibility status, child support
order)• Change in employment status for you or your spouse (commencement, termination,
leave of absence, full-time to part-time or vice versa)• Special enrollment rights under HIPAA• Lose or gain other coverage for yourself, your spouse, or your qualifying dependents
Generally, elections must be made within 30 days of the qualifying event. YOU are responsible for notifying Human Resources or your Benefits team and providing the necessary documentation of the event.
DON’T FORGET! Newborns will NOT be automatically added to coverage. You must take action within 30 days of the birth.
How to EnrollIf you are enrolling in our benefits for the first time, or wanting to make a plan/election change, just follow these simple steps:•Read this guide•Complete the online Open Enrollment.
Employee Contact Information
If you have any questions regarding any of the material listed within this guide, please reach out to the teams listed below.
The information in this Enrollment Guide is presented for illustrative purposes and is based on information provided by the employer. The text contained in this Guide was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are possible. In case of discrepancy between the Guide and the Plan Documents, the actual Plan Documents will prevail. Information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any questions about the Guide, please contact the HR department or designated HIPAA representative.
Contact Carrier Phone Website/Email Group Number
Medical BCBS of Oklahoma 1-800-942-5837 www.bcbsok.com HSA G# 253079 PPO G# 253078
HSA Ameriflex 1-888-868-3539 www.ameriflex.com AMFOKBUOKDental Delta Dental 1-405-607-2100 www.deltadentalok.org 3502Vision VSP 1-800-877-7195 www.vsp.com 30002022Life/AD&D BCBS of Oklahoma 1-800-348-4512 www.dearbornnational.com F019973Disability Cigna 1-800-362-4462 www.cigna.com LK 964483Accident MetLife 1-800-275-4638 www.metlife.com 5947840Critical Illness MetLife 1-800-275-4638 www.metlife.com 5947840Hospital Indemnity MetLife 1-800-275-4638 www.metlife.com 5947840EAP Cigna 1-800-362-4462 www.cigna.com LK 964483Consultive Services - BenefitsStephani McKennaDanielle Bigham
NFPAccount ManagerAccount Manager
1-405-359-05941-405-513-89481-405-513-8942
www.nfp.com [email protected]
Make Sure You Have Everything You Need!You may be asked to verify the group number and/or SSN of the insured to obtain coverage information.
Medical Coverage
This year BCBS of Oklahoma will administer our medical and pharmacy benefits. If you are uncertain if a physician or facility is in your network, visit www.bcbsok.com or call Customer Service at 1-800-942-5837. You may register at www.bcbsok.com/member to review claims status, benefits, coverage details, and more.You can also access your ID cards and benefits at any time using the Blue Access for Members portal. After registering, you will be able to log in at www.bcbsok.com/member.
When you receive care from an in-network provider you will experience significant savings. This is because in-network providers have agreed to negotiated discounts for our enrolled members. Should you choose to receive care from an out-of-network provider, you may have to file a claim to receive reimbursement for covered expenses and your out-of-pocket costs will be much higher.
Plan Features HSA $6,000 $3,500
Network Blue Preferred Blue Preferred DeductibleIndividual $6,000 $3,500 Family $12,000 $10,500 Out-of-Pocket MaxIndividual $6,450 $6,600 Family $12,900 $13,200 Office Visit Copay
Primary D+C $25
Specialist D+C $50
Member Coinsurance 80% 80%Urgent Care Copay D+C $50 Emergency Room Copay D+C $250 Copay +D+CDiagnostic Testing/Imaging D+C May Be Included
Monthly Cost HSA $6,000 PPO $3,500
OBU Cost EE Cost OBU Cost EE Cost
Employee Only $267.69 $66.94 $358.16 $89.54
Employee + Spouse $492.94 $182.34 $659.50 $243.94
Employee + Child(ren) $474.63 $175.56 $635.01 $234.86
Family $733.32 $271.24 $981.10 $362.88
Prescription Coverage
Formulary Tiers HSA $6,000 3500
Preferred Generic D then $10 $10Non-Preferred Generic D+C then $10 $10Preferred Brand D then $35 $35Non-Preferred Brand D then $60 $60
Specialty 20% up to min $150, max $250 20% up to $150
Mail Order 2.5X Copay, 90 Day Supply 2.5X Copay, 90 Day Supply
Good Rx!GoodRx finds prices and discount coupons on every prescription at pharmacies near you. Visit www.goodrx.com to find the best deal on your medication.
Have a Monthly Rx?You can receive up to a 90-day supply of long-term medicine for 2.5x the copay (specialty drugs are not available through mail order). For more information visit your online medical portal.
Making the Most of Rx Benefits Use these tips to make sure you get the most out of your Rx benefits.
• Use a network pharmacy • Use generic drugs when available• Enroll in a discount program from pharmaceutical companies
into the following tiers: We offer a comprehensive prescription drug benefit plan. Our plan classifies prescription drugs
• Generic drugs have the same formula make-up as their brand-name counterparts but
• Preferred Brand are brand name drugs that are available to you at a discounted rate.
• Non-Preferred Brand are brand name drugs that do not offer a manufacturer discount. • Specialty Drugs typically require specific handling and administration and will
need prior approval to order.
with a lower cost.
MDLIVEVirtual Medicine Visits – Skip the Waiting Room
Whether you’re at home or traveling, you and your covered family members can speak with a board-certified physician 24/7 without setting foot in a doctor’s office. How? Through MDLIVE* with U.S. Board-certified doctors and pediatricians with an average of 15 years ofexperience.
With this benefit, you can:
• Save time and money (Copay may apply per virtual medicine visit; counts toward deductible)
• Receive medical treatment for many non-emergency conditions to provide convenient, low cost care for you and your family!
* Access to MDLIVE may have limitations depending on your location.
Virtual MEDICINE
Visits
Prescriptions can bewritten in appropriatecases.
Visit www.MDLIVE.com/bcbsok to learn more
Medical Treatment For Many Non-Emergency Conditions
Extended Access To Care
• Colds• Flu• Asthma
• Allergies• Nausea• Rash
Plan Cost for MDLIVE
$6,000 HSA D+C
$3,500 PPO $25 / Specialist $50
MEDICAL COVERAGE
VIRTUAL VISITSNow, instead of going to the office, employees can talk with a doctor while at home, work or many other places. And, a virtual visit can cost less than going to the urgent care clinic or emergency room. BlueCross Blue Shield virtual visits solution, powered by MDLIVE, enables employees to have a live consultation with an independently contracted MDLIVE board-certified doctor by mobile app, online video or phone – 24 hours a day, seven days a week.
MDLIVE’s doctors can treat many non-emergency medical and behavioral health conditions, like:
▪ General Health (Allergies, Asthma, Sinus infections);
▪ Pediatric Care (Cold/flu, Ear infections, Pink eye);
▪ Behavioral Health – by appointment (Online counseling, Child behavior/learning issues, stressmanagement)
They can also write – and send – prescriptions (when appropriate) to a nearby pharmacy. Finding a virtual visits doctor is easy. Log on to Blue Access for Members to sign up on MDLIVE’s website. You have the option to meet with the next available doctor or to schedule a future appointment based on availability.
Blue Cross and Blue Shield of Oklahoma, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
MDLIVE, an independent company, provides virtual visit services for Blue Cross and Blue Shield of Oklahoma. MDLIVE operates and administers the virtual visitprogram and is solely responsible for its operations and that of its contracted providers. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. andmay not be used without written permission
Connect2
Access where mobile app, online video or telephone service is
available
InteractReal-time consultation with a
board-certified doctor or therapist
Diagnose Prescriptions sent
electronically to a pharmacy of your choice
(when appropriate)
Website:Visit the website MDLIVE.com/bcbsok▪ Choose a doctor▪ Video chat with the doctor▪ You can also access through Blue
Access for MembersSM
Mobile app:▪ Download the app from the Apple App StoreSM,
Google PlayTM Store or Windows® Store▪ Open the app and choose a doctor▪ Video chat with the doctor from your mobile
device
Get connected today!To register, you’ll need to provide your first and last
name, date of birth and BCBSOK member ID number.1 In the event of an emergency, this service should not take place of an emergency room or urgent care center. MDLIVE doctors do not take the place of your primarycare doctor. Proper diagnosis should come from your doctor, and medical advice is always between you and your doctor.
2 Internet/Wi-Fi connection is needed for computer access. Data charges may apply when using your tablet or smartphone. Check your phone carrier’s plan for details.Video on-demand consultations are available Monday through Sunday from 7 a.m. to 9 p.m. local time. Video consultations can also be made by appointment24/7/365with an available doctor. Service is limited to interactive-audio consultations (phone only), along with the ability to prescribe in Texas. Service in Oklahomaand Idaho is limited to interactive audio/video (video only), along with the ability to prescribe. Virtual visits are currently not available in Arkansas. Service availabilitydepends on member’s location. Virtual visits may not be available on all plans.
MDLIVE is not an insurance product nor a prescription fulfillment warehouse. MDLIVE operates subject to state regulations and may not be available in certain states.MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA-controlled substances, non-therapeutic drugs and certain other drugsthatmay be harmful because of their potential for abuse. MDLIVEphysicians reserve the right to deny care for potential misuse of services.
App Store is a service mark of Apple Inc.Google Play Store is a trademark of Google Inc. (“Google”). Windows is a registered mark of MicrosoftTM
Confused About Where to Go for Care?Smart health care choices may save you money.Sometimes it’s easy to know when you should go to an emergency room (ER). At other times, it’s less clear. Where do you go when you have an ear infection, or you are generally not feeling well? The emergency room can be an expensive option. The chart below may help you figure out when to use each type ofcare.
When you use in-network providers for your family’s health care, you usually pay less for care. Search forin-network providers in your area at bcbsok.com or by calling the Customer Service number on the back of your member ID card.
Virtual Visits• Available 24 hours a day,
sevendays a week• Access to care for non-
emergency medical issues whether you’re at home or traveling
• Based on your location, consult with a board-certified doctor by phone at 888-970-4081, online at MDLIVE.com/bcbsok or with the MDLIVE® mobileapp1
• Average wait time is less than 10minutes
• Powered byMDLIVE
$ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $
Doctor’s Office• Office hours vary• Generally the best
place to go for non-emergency care
• Doctor-to-patientrelationship established and therefore able to treat, based on knowledge of medicalhistory
• Average wait time is 24 minutes2
Retail Health Clinic
• Based upon retail store hours
• Usually lower out-of-pocket cost to you than urgent care
• Often located in stores and pharmacies to provide convenient,low-cost treatment for minor medicalproblems
Urgent Care Provider
• Generally includes evenings, weekendsand holidays
• Often used when your doctor’s office is closed, and there is no true emergency
• Average wait time is 11-20 minutes3
• Many haveonline and/or telephone check-in
Hospital ER• Open 24 hours, seven
days a weekAverage wait time is4 hours, 7 minutes4
• If you receivecarefrom anout-of-network provider, you may have to pay more. Providers outside the network may “balance bill” you, which means they may charge you more than your health plan’s fee schedule.
• Multiple bills for services such as doctors and facility
Freestanding ER• Open 24 hours, seven
days a week
• Could be transferredto a hospital ER basedon medical situation
• Services do not include trauma care
• Many freestanding ERs are out-of-network. If you receive care from an out-of-network provider, you may have topay more. Providers outside the network may “balance bill” you, which means they may charge you more than your health plan’sfee schedule
• All freestanding ERs charge a facility fee that urgent care centers do not. You may receive other bills for each doctor yousee.5
1 Internet/Wi-Fi connection is needed for computer access. Data charges may apply. Check your phone carrier’s plan for details. Non-emergency medical service in Idaho, Montana, New Mexico and Oklahoma is limited to interactive audio/video (video only), along with the ability to prescribe. Non-emergency medical service in Arkansas is limited to interactive audio/video (videoonly) forinitial consultation, along with the ability to prescribe.Behavioral Health service is limited to interactiveaudio/video (videoonly), along with the ability toprescribe in all states. Service availability depends on location at the time of consultation.
2 Medical Practice Pulse Report2009, Press Ganey Associates.3 Urgent CareBenchmarking Study Results. Journal of Urgent CareMedicine, January 2012.4 Emergency DepartmentPulse Report2010 Patient Perspectives onAmerican Health Care. PressGaney Associates.5The TexasAssociation ofHealth Plans.
Note: The relative costs described here are for independently contracted network providers. Your costs for out-of-network providers may be significantly higher. Wait times described are justestimates.Virtual visits, Powered by MDLIVE may not be available on all plans. Virtual visits are subject to the terms and conditions of your benefit plan, including benefits, limitations, and exclusions.MDLIVEoperates subject to state regulationsand may not be available in certain states. MDLIVE is not aninsurance product or a prescription fulfillment warehouse. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA- controlled substances, non-therapeutic drugs and certain other drugs that may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuseof services.The information provided in this guide is not intended as medical advice, nor meant to be a substitute for the individual medical judgment of a doctor or other health care professional. Please check withyour doctor for individualizedadvice on the informationprovided.Coverage may vary depending onyour specific benefit plan and use of network providers. Forquestions, please call the number on theback of your member ID card.
If you need emergency care, call 911 or seek help from any doctor or hospital immediately.
These preventive services arecoveredby yourplan atnocost toyou1
FOR CHILDRENAnnual preventive medical history and physical exam
SCREENINGS FOR
• Abdominal aortic aneurysm• Alcohol abuse and tobacco use• Colorectal, skin and lung cancer• Depression• Falls prevention and vitamin D use for stronger bones• High blood pressure, high cholesterol, obesity, diabetes
and depression• Sexually transmitted infections, HIV, HPV and hepatitis
COUNSELING FOR
• Alcohol misuse• Domestic violence• Healthy diet counseling• Obesity• Sexually transmitted infections• Skin cancer prevention• Tobacco use, including certain medicine to stop• Use of aspirin to prevent heart attacks
FOR ADULTS
Annual preventive medical history and physical exam
SCREENINGS FOR
• Autism• Cervical dysplasia• Depression• Developmental delays• Dyslipidemia (for children at higher risk)• Hearing loss, hypothyroidism, sickle cell disease and
phenylketonuria (PKU) in newborns• Hematocrit or hemoglobin• Lead poisoning• Obesity• Sexually transmitted infections and HIV• Tuberculosis• Visual acuity
ASSESSMENTS AND COUNSELING
• Obesity counseling• Oral health risk assessment, dental carries prevention
fluoride varnish and oral fluoride supplements• Skin cancer prevention counseling
CERTAIN VACCINESLearn more on immunization recommendationsand schedules by visiting: www.cdc.gov/vaccines
SCREENINGS FOR
• Diphtheria, Pertussis, Tetanus• Haemophilus Influenzae Type B (Hib)• Hepatitis A and B• Human Papillomavirus (HPV)• Inactivated Poliovirus (Polio)• Influenza (Flu)• Measles, Mumps, Rubella (MMR)• Meningitis• Pneumococcal• Rotavirus• Varicella (Chicken Pox)• Zoster (Herpes, Shingles)
JUST FOR WOMEN
• Breast cancer screening, genetic testing and counseling• Breastfeeding support, supplies and counseling• Certain contraceptives and medical devices, morning
after pill, and sterilization to prevent pregnancy• Cervical cancer screening• Chlamydia, gonorrhea, syphilis, HIV and hepatitis B
screenings• Counseling for alcohol and tobacco use during pregnancy• Folic acid supplementation during pregnancy• Human papillomavirus (HPV) DNA test• Osteoporosis screening• Screenings during pregnancy, including screenings for
anemia, gestational diabetes, bacteriuria, Rh(D)compatibility
1 Non-grandfathered health plans are required by the Affordable Care Act to provide coverage for preventive care services without cost-sharing only when the member uses a network provider. You may have to pay all or part of the cost of preventive care if your health plan is grandfathered. To find out if your plan is grandfathered or non-grandfathered, call the customer service number listed on your member ID card.
bcbsok.com
WhereYouGetCareMay Affect Your Health and Your WalletBeaSmartHealthCareShopperwithHelpfromBlueCrossandBlueShieldofOklahoma(BCBSOK)
There’s a lot to thinkaboutwhendecidingwhereto get healthcare.Justtakea lookat how muchpricesdifferfor the same procedure in the same area.
Procedure Provider A1 Provider B1 Difference
MRI of the Brain $636 $2,485 $1,849
Hysterectomy $6,055 $15,869 $9,814
Hernia Repair $3,548 $8,019 $4,471
Knee Replacement $17,678 $41,616 $23,938
Being informed does not have to be tricky and there are resources available for helping make the best decision for you.
* Note that costs are examples and may not apply to every member’s situation.
Use ProviderFinder® to helpmakemore informedhealth care choicesby:Checkingcostsbeforeyourappointment: We’re hereto help you find quality independently contractedhealth care providersthatmay cost less andtohelpyou understand what you may need to pay based onyour plan’s copay, coinsurance, deductible and otherbenefits.
Findingouthowdoctors in your areacompare: Finda doctor in your network. Check if your facility has been recognized for providing quality care. Or readreviews and ratingsfromothermembersandshareyourown.
Go OnlineLog in to Blue Access for MembersSM (BAM) at bcbsok.com, anytime, day or night.
ClickDoctors&Hospitals tocomparecostsandfind providers in yournetwork.
Get the AppText* BCBS to 33633 to download our app.
Go to the App Store or Google Play.
Use the app to find all kinds of useful information to help you choose a provider and save money.
1. Allowable in-network cost data from providers within a 50-mile radius of Oklahoma City, Oklahoma. Costs are examples and may not apply to every member’s situation.* Message and data rates may apply. Terms and conditions and privacy policy are available at bcbsok.com/mobile/text-messaging.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 603964.0116
Tax-Advantaged Money Accounts: FSA
We provide you with the opportunity to enroll in a Health Care Flexible Spending Account (FSA) and/or a Dependent Care FSA each year. The plan is administered by Ameriflex and is subject to IRS Regulations (Section 125). You must enroll in a Health Care FSA and/or a Dependent Care FSA each year during open enrollment if you wish to participate – even if you are currently participating.
Dependent Care Flexible Spending Account
The Dependent Care FSA allows you to set aside money from your paycheck on a tax-free basis each year. This money is deposited into an account that is similar to a normal savings account. You may then reimburse yourself from your account during the year for eligible day care expenses – such as day camp, elder care, before and after-school care, and in-home daycare. You may contribute a minimum of $100 to a maximum of $5,000 per year to your account.
Eligible Dependents:• Your dependent children, through age 12• Any dependent who is physically or mentally unable to care for himself or herself who
spends at least eight hours a day in your home and whom you claim as a dependent on your federal income tax return.
Plan your contributions carefully; your Health Care and Dependent Care FSAs have a “use it or lose it” rule, OBU offers an extension, you can file a claim until March 31st. For a complete list of FSA eligible expenses, visit your FSA provider’s online portal or view IRS publication 502.
Health Care Flexible Spending Account
The Health Care FSA allows you to set aside money from your paycheck on a tax-free basis each year. This money is deposited into an account that is similar to a normal savings account. You may then reimburse yourself from this account during the year for eligible healthcare expenses – such as health care and dental care deductibles and co-payments, contact lenses, prescription drugs, and certain over-the-counter medications. You may contribute a minimum of $100 to a maximum of $2,750 per year to your account.
Paying for eligible FSA expenses is simple. You will receive a Benefits Card, similar to a debit card, with the value of your contributions stored on it. You may use this card to pay for eligible health care expenses at any health care provider or approved merchant. With the card, you have instant access to the money in your FSA. Funds are automatically withdrawn from your account as purchases are made. This eliminates the need to pay expenses out of your own pocket and submit a claim form.
Claim Form – complete a claim form and submit it online, by mail or fax, along with receipts.
2020 IRS FSA Maximum:
This is the amount per year that you can elect to your FSA account in 2020.• The 2020
amounts have been released. Minimum of $100 to a maximum of $2,750
• $5,000 Maximum for Dependent Care
Health Savings Account (HSA)If you enroll in a High Deductible Health Plan (HDHP), you also have the opportunity to establish a Health Savings Account (HSA). An HSA is a bank account controlled by you to pay for qualified medical expenses* for you and your eligible dependents. Contributions made to your HSA via paycheck deductions are pre-tax and may continue as long as you are enrolled in an HDHP.
Unlike an FSA in which the ‘use it or lose it’ rule applies, you never forfeit money you deposit into an HSA (unused funds roll over year after year.) The HSA account is portable. The funds are yours to use and take with you should you change plans or jobs. Unused funds can also grow through interest and investment earnings and can be ‘banked’ for future health related expenses.
You are eligible for an HSA if you are:• Covered by a high-deductible health plan (HDHP)• Not covered under another medical plan that is not HSA qualified• Not entitled to (eligible for AND enrolled in) Medicare benefitsImportant Note About Your HSA
Employees cannot have a Health Care FSA and a Health Savings Account simultaneously, unless the FSA is a Limited Use FSA. You are not eligible to participate in the HSA if:• You or your spouse had/have a Health Care FSA and currently have an available balance
• Your existing Health Care FSA with this company has an available balance
• You are receiving healthcare from a government program or are not paying for services(i.e. Tricare, Indian Health, Medicaid, Medicare, Free Clinic, etc…)
*For a complete list of eligible expenses, visit your provider’s online portal or IRS Pub. 502
Feat
ures
of a
nH
SA
Debit card to conveniently pay for eligible expenses
Ability to change your HSA election at
ANY TIMEthroughout the year
Tax-free three waysWhen money When money
BALANCE REACHES
*Full list of eligible expenses can be found inIRS Publication 502.
1 goes in 2 earns interest 3 eligible expenses*
$1,000YOU CAN INVEST THOSE DOLLARS
When money is used for
CONTRIBUTIONS THROUGHPAYROLL
WHEN YOUR ACCOUNT DEDUCTIONSUP TO IRS ANNUAL LIMITS
HSA Contribution Limits for 2020• Employee Only
Coverage:$3,550
• EE+1 or FamilyCoverage:$7,100
• Catch UpContribution forthose age 55+:$1,000
Tax-Advantaged Money Accounts: HSA
Is a HSA Qualified Plan Right For Me?
Employee Savings BenefitsEmployees can often realize 20 - 40% in tax savings because contributions to your FSAs and HSAs are exempt from payroll taxes. Under a Section 125, employees take-home pay is increased which helps reduce the cost of health coverage for family members.
Once Enrolled, Can I Make a Change?Once you have enrolled in the PPO or HSA, you will not be able to change your election until the beginning of the next plan year.
What, If Any, Changes Can Be Made During The Year?Family Status Changes include: Marriage, Birth, Adoption, Foster Child, Guardianship, Death
a) Modify FSA or LUFSA electionb) Adjust your HSA contributionc) Add or drop dependentsd) Enroll or drop coverage
Note: Every year the IRS will evaluate the FSA and HSA plan limits and determine if they will increase the amount you can contribute to either of these accounts.
We Are Often Asked: Which One Should I Take?Though we cannot advise you, here are some points to consider.
The traditionally styled plan, which offers copays for physician visits and prescription drugs, and a High Deductible Health Plan (HDHP) partnered with a Health Spending Account (HSA), are very different from one another. As a consumer, you may be wondering which is the best option for you.
There are certain rules that that go into effect when a Healthcare Flexible Spending Account (FSA) is also offered in conjunction with other benefits:
If you enroll in the Traditional Plan, you will be able to:• Enroll in the Healthcare FSA benefit• Use Debit Card for eligible healthcare expenses• Enroll in the Dependent Care FSA• Pay a copay for doctor visits and prescription drugs
If you enroll in the Health Savings Account Qualified Health Plan, you will be able to:• Enroll in the Limited Use Healthcare FSA (LUFSA)• Enroll in the Dependent Care FSA• Pay for eligible healthcare expenses out of your HSA• There is no lose it or use it – you own this account, it is yours to keep and it will not
change from year to year unless you decide to move it to another HSA qualified bank account
• Contribute to your HSA as long as you are enrolled in a HSA Qualified Health Plan• Contribute additional tax-deferred money into your HSA for even more tax-deferred
savings (up to the annual maximum amount set by the IRS)
Dental Coverage
Plan Features Dental PPO Plan Dental PPO Plus Premier
Network PPO Plus PremierPreventive Services (Class I) 100% 100%Basic Services (Class II) 80% 80%Major Services (Class III) 50% 50%Endodontics 80% 80%Periodontics 80% 80%Orthodontia N/A 50%Deductible $100 $100 Annual Maximum $1,000 $1,000
Ortho. Lifetime Maximum N/A $1,500
This year Delta Dental will administer our dental benefits. If you are uncertain if a dentist or facility is in your network, visit www.deltadentalok.org or call Customer Service at 1-405-607-2100. You may register at www.deltadentalok.org to review claims status, benefits, coverage details, and more.When you receive care from an in-network provider you will experience significant savings. This is because in-network providers have agreed to negotiated discounts for enrolled members. Should you choose to receive care from an out-of-network provider, you may have to file a claim to receive reimbursement for covered expenses and your out-of-pocket costs will be much higher.
More Than Justa Nice SmileOral health is often a predictor of overall health. Enroll in our dental plan which encourages regular preventive checkups by providing 100% coverage for preventive care, including exams, cleanings and x-rays.
Monthly Cost PPO Plan PPO Plus Premier
OBU Cost EE Cost OBU Cost EE Cost
Employee Only $20.54 $5.12 $20.54 $25.92
Family $54.92 $20.30 $54.92 $113.98
Vision Coverage
Plan Features VSP
CopaymentsEye Exam $10Materials $25FrequencyExams Every 12 MonthsLenses Every 12 MonthsFrames Every 24 MonthsContact Lenses Every 12 MonthsAllowancesFrames $130Single Lenses In FullBifocal Lenses In FullTrifocal Lenses In FullContact Lenses $130
Plan Cost Per Month VSP
Employee Only $10.70 Employee + Spouse $17.14 Employee + Child(ren) $17.48 Family $28.20
This year VSP will administer our benefits. If you are uncertain if an optometrist or facility is in your network, visit www.vsp.com or call Customer Service at 1-800-877-7195. Register at www.vsp.com to review claims status, benefits, coverage details, and more.
When you receive care from an in-network provider you will experience significant savings. This is because in-network providers have agreed to negotiated discounts for enrolled members. Should you choose to receive care from an out-of-network provider, you may have to file a claim to receive reimbursement for covered expenses and your out-of-pocket costs will be much higher.
Life and AD&D Coverage
Basic Life/AD&D Coverage
Benefit Amount Living Care Benefit Age Reduction Schedule
Class I: 1.5 x Annual Salary up to $200,000
Class II: $15,000Class III: 1 x Annual Salary to
$25,000
Included Class I: 35% at age 65; 50% at age 70
BCBS of Oklahoma
Evidence of Insurability and Guarantee IssueGuarantee Issue (GI) is the most coverage you can elect without having to provide an Evidence of Insurability Form (EOI). As a new hire, you are eligible to enroll up to the GI. After your new hire enrollment, any increase in coverage, including the GI will require you to fill out and Evidence of Insurability Form and go through underwriting. Your elections above the GI will remain pending and eventually be declined if this form is never received.
Life and Accidental Death and Dismemberment (AD&D) insurance provides financial security to your dependents if you die or are severely injured in an accident. As your employer, we automatically provide a certain level of coverage to you and also offer you the opportunity to purchase additional coverage for you and your dependents.
Every employee has the ability to purchase the supplemental life insurance, whether or not they currently have basic life insurance. You must enroll in the employee coverage in order to cover your spouse or dependents.
Supplemental Life/AD&D Coverage
Age Reduction Schedule
Employee - $100,000
Spouse - $25,000
Child(ren) - $10,000
not applicable
Guarantee IssueBenefit Amount
$10,000 increments to $500,000
$5,000 increments to $100,000; Not to exceed 50% of employees election
$1,000 - $10,000 in increments of $1,000
BCBS of Oklahoma
Employee
Spouse
Child(ren)
Voluntary Life and AD&DPREMIUM RATE GRID
Eligibility
You are eligible to enroll if you work the minimum number of hours per week
by your employer, and you have satisfied any waiting period.
Voluntary Life and AD&DEmployee Benefit: $10,000 to $500,000 in $10,000 increments. Rates
$0.029Spouse Benefit: $5,000 to $100,000 in $5,000 increments. $0.029
(not to exceed 50% of the employee benefit) $0.029Note: Spouse may not have coverage unless the employee has coverage. $0.044
$0.059$0.083$0.133$0.213
Guarantee Issue* $0.404Employee $0.618Spouse $1.003*NEW HIRES ONLY $1.911
*Child CoverageBirth to 14 days: $1,00015 days to 6 months: $1,000 Monthly rates per $1,0006 months to age 19: $1,000 to $10,000 in increments of $1,000 0.017$ (Student Maximum Age: 23)
Life AD&D$1,000 $0.22 $0.02
$10,000 $2.23 $0.17Voluntary Life and AD&D Premium Cost (Based on 26 payroll deductions per year)
Benefit Amount EE AD&D <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+
$10,000 $0.08 $0.13 $0.13 $0.13 $0.20 $0.27 $0.38 $0.61 $0.98 $1.86 $2.85 $4.63 $8.82$20,000 $0.16 $0.27 $0.27 $0.27 $0.41 $0.54 $0.77 $1.23 $1.97 $3.73 $5.70 $9.26 $17.64$30,000 $0.24 $0.40 $0.40 $0.40 $0.61 $0.82 $1.15 $1.84 $2.95 $5.59 $8.56 $13.89 $26.46$40,000 $0.31 $0.54 $0.54 $0.54 $0.81 $1.09 $1.53 $2.46 $3.93 $7.46 $11.41 $18.52 $35.28$50,000 $0.39 $0.67 $0.67 $0.67 $1.02 $1.36 $1.92 $3.07 $4.92 $9.32 $14.26 $23.15 $44.10$60,000 $0.47 $0.80 $0.80 $0.80 $1.22 $1.63 $2.30 $3.68 $5.90 $11.19 $17.11 $27.78 $52.92$70,000 $0.55 $0.94 $0.94 $0.94 $1.42 $1.91 $2.68 $4.30 $6.88 $13.05 $19.97 $32.40 $61.74$80,000 $0.63 $1.07 $1.07 $1.07 $1.62 $2.18 $3.06 $4.91 $7.86 $14.92 $22.82 $37.03 $70.56$90,000 $0.71 $1.20 $1.20 $1.20 $1.83 $2.45 $3.45 $5.52 $8.85 $16.78 $25.67 $41.66 $79.38
$100,000 $0.78 $1.34 $1.34 $1.34 $2.03 $2.72 $3.83 $6.14 $9.83 $18.65 $28.52 $46.29 $88.20$150,000 $1.18 $2.01 $2.01 $2.01 $3.05 $4.08 $5.75 $9.21 $14.75 $27.97 $42.78 $69.44 $132.30$200,000 $1.57 $2.68 $2.68 $2.68 $4.06 $5.45 $7.66 $12.28 $19.66 $37.29 $57.05 $92.58 $176.40$250,000 $1.96 $3.35 $3.35 $3.35 $5.08 $6.81 $9.58 $15.35 $24.58 $46.62 $71.31 $115.73 $220.50$300,000 $2.35 $4.02 $4.02 $4.02 $6.09 $8.17 $11.49 $18.42 $29.49 $55.94 $85.57 $138.88 $264.60$350,000 $2.75 $4.68 $4.68 $4.68 $7.11 $9.53 $13.41 $21.48 $34.41 $65.26 $99.83 $162.02 $308.70$400,000 $3.14 $5.35 $5.35 $5.35 $8.12 $10.89 $15.32 $24.55 $39.32 $74.58 $114.09 $185.17 $352.80$450,000 $3.53 $6.02 $6.02 $6.02 $9.14 $12.25 $17.24 $27.62 $44.24 $83.91 $128.35 $208.32 $396.90$500,000 $3.92 $6.69 $6.69 $6.69 $10.15 $13.62 $19.15 $30.69 $49.15 $93.23 $142.62 $231.46 $441.00
$25,000
Employee
20-24
75+70+
Under 20
25-29
50-54
Dependent Life (Children)
Monthly rates per $1,000Voluntary Life
*Please contact your HR Department
Oklahoma Baptist University - #F019973
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Oklahoma is the trade name of Dearborn Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Policy Provisions may vary by state. Refer to a certificate or enrollment brochure for details about coverage features and limitations.
30-34
Monthly Premium per Family
65-69
Employee
ATTAINED AGE
35-3940-44
60-6455-59
Voluntary AD&D
45-49
$100,000
Age
Voluntary Life and AD&DPREMIUM RATE GRID
Eligibility
You are eligible to enroll if you work the minimum number of hours per week
by your employer, and you have satisfied any waiting period.
Voluntary Life and AD&DEmployee Benefit: $10,000 to $500,000 in $10,000 increments. Rates
$0.029Spouse Benefit: $5,000 to $100,000 in $5,000 increments. $0.029
(not to exceed 50% of the employee benefit) $0.029Note: Spouse may not have coverage unless the employee has coverage. $0.044
$0.059$0.083$0.133$0.213
Guarantee Issue* $0.404Employee $0.618Spouse $1.003*NEW HIRES ONLY $1.911
*Child CoverageBirth to 14 days: $1,00015 days to 6 months: $1,000 Monthly rates per $1,0006 months to age 19: $1,000 to $10,000 in increments of $1,000 0.017$ (Student Maximum Age: 23)
Life AD&D$1,000 $0.22 $0.02
$10,000 $2.23 $0.17Voluntary Life and AD&D Premium Cost (Based on 26 payroll deductions per year)
Benefit Amount
Spouse AD&D <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+
$5,000 $0.04 $0.07 $0.07 $0.07 $0.10 $0.14 $0.19 $0.31 $0.49 $0.93 $1.43 $2.31 $4.41$10,000 $0.08 $0.13 $0.13 $0.13 $0.20 $0.27 $0.38 $0.61 $0.98 $1.86 $2.85 $4.63 $8.82$15,000 $0.12 $0.20 $0.20 $0.20 $0.30 $0.41 $0.57 $0.92 $1.47 $2.80 $4.28 $6.94 $13.23$20,000 $0.16 $0.27 $0.27 $0.27 $0.41 $0.54 $0.77 $1.23 $1.97 $3.73 $5.70 $9.26 $17.64$25,000 $0.20 $0.33 $0.33 $0.33 $0.51 $0.68 $0.96 $1.53 $2.46 $4.66 $7.13 $11.57 $22.05$50,000 $0.39 $0.67 $0.67 $0.67 $1.02 $1.36 $1.92 $3.07 $4.92 $9.32 $14.26 $23.15 $44.10$75,000 $0.59 $1.00 $1.00 $1.00 $1.52 $2.04 $2.87 $4.60 $7.37 $13.98 $21.39 $34.72 $66.15
$100,000 $0.78 $1.34 $1.34 $1.34 $2.03 $2.72 $3.83 $6.14 $9.83 $18.65 $28.52 $46.29 $88.20
40-44
Under 2020-2425-2930-3435-39
SpouseVoluntary Life
Monthly rates per $1,000Age
Oklahoma Baptist University - #F019973
50-5455-5960-64
45-49
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Oklahoma is the trade name of Dearborn Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Policy Provisions may vary by state. Refer to a certificate or enrollment brochure for details about coverage features and limitations.
$100,000$25,000
ATTAINED AGE
65-6970+75+
*Please contact your HR DepartmentVoluntary AD&D
Spouse
Dependent Life (Children)Monthly Premium per Family
Disability Coverage
Long Term Disability
Monthly Benefit Amount Benefits Begin Duration of Benefits
90 Days
Cigna
60% to $8,000 Social Security Normal Retirement Age
Long Term Disability coverage is available to replace a portion of your income if you become disabled due to a non-work related injury or illness. Your Long Term Disability plan will be administered through Hartford.
Long Term Disability benefit payments will be combined with and offset by other disability income you receive (Social Security benefits, worker’s compensation, state disability, etc.) so that your monthly payments equal 60% of your “base earnings”. This benefit is paid by Oklahoma Baptist University.
Employee Assistance Program
Employee Assistance Program EAP
Personal issues, planning for life events or simply managing daily life can affect your work, health and family. Cigna provides support, resources and information for personal and work-life issues. Cigna is company-sponsored, confidential and provided at no charge to you and your dependents.
Confidential Counseling
This no-cost counseling service helps you address stress, relationship and other personal issues you and your family may face. Cigna Advocates, who are available to you 24/7, will listen to your concerns and quickly refer you to in-person counseling and other local resources for:
• Stress, anxiety and depression• Job pressures• Relationship/marital conflicts• Grief and loss• Problems with children• Substance abuse
Other Information and Resources
In addition to Confidential Counseling services, Cigna provides many services and resources to assist you with:
• Fnancial Information and Resources• Legal Consultation• Parenting• Online Skill Builders• Self- Service Support• Help for New Parents
Call to get the assistance you need: Toll Free 1-800-362-4462 or visitwww.cignabehavior.com/CGI
* Some Healthy Rewards programs are not available in all states. If your Cigna plan includes coverage for any of these services, this program is in addition to, not instead of, your plan benefits. A discount program is NOT insurance, and you must pay the entire discounted charge.
** Legal consultations and discounts are excluded for employment-related issues.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Life Insurance Company of North America, Cigna Life Insurance Company of New York, and Connecticut General Life Insurance Company. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
877376 a 05/15 © 2015 Cigna. Some content provided under license.
Call us anytime, any day.
We’re just a phone call away whenever you need us. At no extra cost to you. An advocate can help you assess your needs and develop a solution. He or she can also direct you to community resources and online tools.
Visit a specialist.
You have three face-to-face sessions with a behavioral counselor available to you - and your household members. Call us to request a referral.
Reward yourself.
Access our Healthy Rewards®* discount program. You can get discounts on health and wellness products and services.
Achieve work/life balance.
If you’d like help handling life’s demands, call us for extra support. We can refer you to a service in your community. Or provide guidance on topics such as:
Life. Just when you think you’ve got it figured out, along comes a challenge. Whether your needs are big or small, your Life Assistance & Work/Life Support Program is there for you. It can help you and your family find solutions and restore your peace of mind.
WHATEVER LIFE THROWS AT YOU - THROW IT OUR WAY.
Life Assistance Program
Legal consultation.** Receive a free 30-minute consultation. And up to a 25%discount on select fees.
Parenting. Get guidance on child development, sibling rivalry, separation anxiety and much more.
Senior care. Learn how to solve the challenges of caring for an aging loved one.
Child care. Whether you need care all day or just after school, find a place that’s right for your family.
Pet care. From grooming to boarding to veterinary services, find what you need to care for your pet.
Financial Services & Referral. Receive a free 30-minute consultation and 25% discount onselect fees with network providers.
Life Assistance Program – 24/7 support
800.538.3543www.cignabehavioral.com/cgi
50
Accident, Critical Illness & Hospital Indemnity
FILING STATUS Low Plan High PlanEmployee Only $5.56 $10.68Employee + Spouse $10.40 $19.96Employee + Child(ren) $11.44 $21.96Family $14.24 $27.50
Accident Insurance
Critical Illness InsuranceCritical illness coverage can help offer peace of mind when a critical illness diagnosis occurs. The signs pointing to a critical illness are not always clear and may not be preventable, but this coverage can help offer financial protection in the event you are diagnosed.
Age EO ES EC Family<25 $4.80 $9.60 $9.00 $13.8025-29 $5.10 $10.20 $9.30 $14.2630-34 $7.20 $14.40 $11.40 $18.6035-39 $10.50 $21.00 $14.70 $25.2040-44 $16.20 $32.10 $20.40 $36.3045-49 $24.60 $48.30 $48.80 $52.5050-54 $36.60 $71.40 $40.80 $75.6055-59 $52.20 $101.40 $56.40 $105.6060-64 $75.90 $147.15 $80.10 $151.5065-69 $114.60 $221.70 $118.80 $225.9070+ $174.00 $338.10 $178.20 $342.30
Rates for $15,000 Rates for $30,000Age EO ES EC Family
<25 $9.60 $19.20 $18.00 $27.6025-29 $10.20 $20.40 $18.60 $28.8030-34 $14.40 $28.80 $22.80 $37.2035-39 $21.00 $42.00 $29.40 $50.4040-44 $32.40 $64.20 $40.80 $72.6045-49 $49.20 $96.60 $57.60 $105.0050-54 $73.20 $142.80 $81.60 $151.2055-59 $104.40 $202.80 $112.80 $211.2060-64 $151.80 $294.60 $160.20 $303.0065-69 $229.20 $443.40 $237.60 $451.8070+ $348.00 $676.20 $356.40 $684.60
Hospital Indemnity Insurance
A hospital stay can be expensive. Be ready for costs not covered by your medical plan with hospital indemnity insurance. MetLife Group Hospital Indemnity Insurance payments can be used to help cover these unexpected costs or to cover other expenses. A standard hospital insurance plan may include coverage for hospital admission, accident- related inpatient rehabilitation and hospital stays. For complete details on what this plan offers, please see the benefit summary.
FILING STATUS Low Plan High PlanEmployee Only $14.24 $28.90Employee + Spouse $27.76 $56.30Employee + Child(ren) $25.78 $52.30Family $43.84 $88.96
No one plans to have an accident. But it can happen at any moment throughout the day, whether at home or at play. Most major medical insurance plans only pay a portion of the bills. This coverage can help pick up where other insurance leaves off and provide cash to help cover the expenses.
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NOTES
Notes & Questions
NOTIFICATIONS
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 apremium 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 eligiblefor either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find outhow 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 within60days of being determinedeligible 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 – Medicaidhttp://myalhipp.com/1-855-692-5447
ALASKA –MedicaidThe AK Health Insurance Premium Payment Program http://myakhipp.com/[email protected] Eligibilityhttp://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
ARKANSAS –Medicaidhttp://myarhipp.com/1-855-MyARHIPP (855-692-7447)
COLORADO – Health First Colorado(Colorado’s Medicaid Program) &Child Health Plan Plus (CHP+)Health First Colorado https://www.healthfirstcolorado.com/Member Contact Center: 1-800-221-3943 / State Relay 711 CHP+Colorado.gov/HCPF/Child-Health-Plan-Plus Customer Service: 1-800-359-1991 / State Relay 711
FLORIDA – Medicaid http://flmedicaidtplrecovery.com/hipp/ 1-877-357-3268
GEORGIA –Medicaidhttp://dch.georgia.gov/medicaid
- Click on Health Insurance Premium Payment (HIPP)1-404-656-4507
INDIANA– MedicaidHealthy Indiana Plan for low-income adults 19-64 http://www.in.gov/fssa/hip/1-877-438-4479All other Medicaidhttp://www.indianamedicaid.com1-800-403-0864
IOWA – Medicaid http://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp 1-888-346-9562
KANSAS – Medicaid http://www.kdheks.gov/hcf/ 1-785-296-3512
KENTUCKY – Medicaid http://chfs.ky.gov/dms/default.htm 1-800-635-2570
LOUISIANA – Medicaid http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 1-888-695-2447
MAINE– Medicaidhttp://www.maine.gov/dhhs/ofi/public-assistance/index.html 1-800-442-6003TTY: Maine relay711
MASSACHUSETTS – Medicaid and CHIP http://www.mass.gov/eohhs/gov/departments/masshealth/ 1-800-462-1120
13
NOTIFICATIONS
MINNESOTA– Medicaidhttp://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/medical-assistance.jsp1-800-657-3739
MISSOURI – Medicaid http://www.dss.mo.gov/mhd/participants/pages/hipp.htm 1-573-751-2005
MONTANA – Medicaid http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP 1-800-694-3084
NEBRASKA – Medicaid http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/ Pages/accessnebraska_index.aspx1-855-632-7633
NEVADA – Medicaidhttps://dwss.nv.gov/1-800-992-0900
NEW HAMPSHIRE – Medicaid http://www.dhhs.nh.gov/oii/documents/hippapp.pdf 1-603-271-5218
NEW JERSEY – Medicaid and CHIPMedicaid http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ 1-609-631-2392CHIPhttp://www.njfamilycare.org/index.html1-800-701-0710
NEW YORK – Medicaid https://www.health.ny.gov/health_care/medicaid/ 1-800-541-2831
NORTH CAROLINA – Medicaidhttps://dma.ncdhhs.gov/ 1-919-855-4100
NORTH DAKOTA – Medicaid http://www.nd.gov/dhs/services/medicalserv/medicaid/ 1-844-854-4825
OKLAHOMA – Medicaid and CHIP http://www.insureoklahoma.org 1-888-365-3742
OREGON – Medicaid http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html 1-800-699-9075
PENNSYLVANIA – Medicaid http://www.dhs.pa.gov/provider/medicalassistance/ healthinsurancepremiumpaymenthippprogram/index.htm1-800-692-7462
RHODE ISLAND – Medicaidhttp://www.eohhs.ri.gov/ 1-401-462-5300
SOUTH CAROLINA – Medicaidhttps://www.scdhhs.gov 1-888-549-0820
SOUTH DAKOTA – Medicaidhttp://dss.sd.gov 1-888-828-0059
TEXAS – Medicaid http://gethipptexas.com/ 1-800-440-0493
UTAH – Medicaid and CHIP Medicaid: https://medicaid.utah.gov/ CHIP: http://health.utah.gov/chip1-877-543-7669
VERMONT – Medicaid http://www.greenmountaincare.org/ 1-800-250-8427
VIRGINIA – Medicaid and CHIPMedicaid http://www.coverva.org/programs_premium_assistance.cfm 1-800-432-5924CHIPhttp://www.coverva.org/programs_premium_assistance.cfm1-855-242-8282
WASHINGTON –Medicaidhttp://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program1-800-562-3022 ext. 15473
WEST VIRGINIA – Medicaid http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/ default.aspx1-877-598-5820, HMS Third PartyLiability
WISCONSIN – Medicaid and CHIP https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf 1-800-362-3002
WYOMING – Medicaid https://wyequalitycare.acs-inc.com/ 1-307-777-7531
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 ofLaborEmployee Benefits Security Administration www.dol.gov/ebsa • 1-866-444-EBSA (3272)U.S.Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov1-877-267-2323, Menu Option 4, Ext. 61565
OMB Control Number 1210-0137 (expires 12/31/2019)
14
NOTIFICATIONS
GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS** CONTINUATIONCOVERAGE RIGHTS UNDER COBRA**
Introduction
You are receiving this notice because you have recently become covered under a group health plan (the Plan). This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice generally explains COBRA continuationcoverage,whenitmay becomeavailable to you and your family,and what you need to do toprotect the right to receive it. BOTH YOU AND YOUR SPOUSESHOULD TAKETIME TOREADTHIS NOTICECAREFULLY.
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. This notice does not fully describe COBRA continuation coverage or other rights under the plan. For additional and more complete 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.
What is COBRA Continuation Coverage?
COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage may be required to pay for COBRA continuation coverage.
Employee
If you are an employee, you will become a qualified beneficiary entitled to elect COBRA continuation coverage if you lose your coverage under the Plan because either one of the following qualifying eventshappens:
▪ Your hours of employment are reduced, or
▪ Your employment ends for any reason other thanyour gross misconduct.
Spouse
If you are the spouse of an employee, you will become a qualified beneficiary entitled to elect COBRA continuation coverage if you lose your coverage under the Plan because any of the following qualifying events happens:
▪ Your spousedies;
▪ Your spouse’s hours of employment are reduced;
▪ Your spouse’s employment ends for any reason other thanhis or her gross misconduct;
▪ Your spouse becomes entitled to Medicare benefits underPart A, Part B, or both); or
▪ You become divorced or legally separated from yourspouse. In the event your spouse, who is the employee,reduces or terminates your coverage under the Plan inanticipation of a divorce or legal separation which lateroccurs, the divorce or legal separation may be considereda qualifying event even though the coverage was reducedor terminated before the divorce or separation.
DependentChildren
Your dependent children, including any child born to or placed for adoption with a covered employee during the period of COBRA coverage who is thereafter properly enrolled in the Plan, or a child of the covered employee who is receiving benefits under the Plan pursuant to a qualified medical child support order, will become qualified beneficiaries entitled to elect COBRA continuation coverage if they lose coverage under the Plan because any of the following qualifying events happens:
▪ The parent-employee dies;
▪ The parent-employee’s hours of employment are reduced;
▪ The parent-employee’s employment ends for any reasonother than his or her gross misconduct;
▪ The parent-employee becomes entitled to Medicarebenefits (Part A, Part B, or both);
▪ The parents become divorced or legally separated; or
▪ The child stops being eligible for coverage under theplan as a “dependent child.”
15
NOTIFICATIONS
When is COBRA Coverage Available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, or the employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event.
YouMust GiveNotice of Some QualifyingEvents
For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator in writing within 60 days after the qualifying event occurs. The Plan procedures for thisnotice, including a description of any required information or documentation, can be found in the most recent Summary Plan Description or by contacting the Plan Administrator. If these procedures are not followed or if the notice is not providedin writing to the Plan Administrator during the 60-day noticeperiod, you will lose your right to elect COBRA continuationcoverage.
How is COBRA Coverage Provided?
Once the Plan Administrator receives timely notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. If COBRA continuation coverage is not elected within the 60-day election period, a qualified beneficiary will lose the right to elect COBRA continuation coverage.
COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both), your divorce or legal separation, or a dependent child’s losing eligibility as a dependent child, COBRA continuation coverage may last for up to a total of 36 months. When the qualifying event is the end of employment or reduction of the employee’s hours ofemployment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on
which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months. There are two ways in which this 18-month period of COBRA continuation coverage can be extended.
Disability extensionof 18-month period of continuation coverage
If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage.The Plan procedures for this notice, including a description of any required information or documentation, the name of the appropriate party to whom notice must be sent, and the time period for giving notice, can be found in the most recent Summary Plan Description or by contacting the Plan Administrator. If these procedures are not followed or if the notice is not provided in writing to the Plan Administratorduring the 60-day notice period and within 18 months after the covered employee’s termination of employment or reduction of hours, there will be no disability extension of COBRA continuation coverage. The affected individual must also notifythe Plan Administrator within 30 days of any final determination that the individual is no longer disabled.
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NOTIFICATIONS
Second qualifying eventextensionof 18-month period of continuationcoverage
If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of36 months, if notice of the second qualifying event is properly given to the Plan. This extension may be available to the spouse and any dependent children receiving COBRA continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent childto lose coverage under the Plan had the first qualifying event not occurred. The Plan procedures for this notice, including a description of any required information or documentation, the name of the appropriate party to whom notice must be sent, and the time period for giving notice, can be found in the most recent Summary Plan Description or by contacting the Plan Administrator. If these procedures are not followed or if the notice is not provided in writing to the Plan Administrator during the 60-day notice period, there will be no extension of COBRA continuation coverage due to a second qualifying event.
IfYou Have Questions
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.)
KeepYourPlan Informed ofAddressChanges
In order to protect your family’s rights, you should keep the Plan Administrator informed of the current addresses and of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the PlanAdministrator.
Plan Contact Information
Contact your Benefits Administrator listed in your Benefits Enrollment Guide for additional information about the plan and COBRA continuationcoverage.Please refer to the Plan’s most recent summary plan description for any updated Plan contact information.
HIPAA BASICS - YOUR RIGHT TO PRIVACYIn April 2003, the final regulations that place restrictions on how personally identifiable health information may be used and disclosed by certain organizations became effective.
These regulations (the Privacy Rules) implement the privacy requirements contained within the AdministrativeSimplification subtitle of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
While some states have laws that protect health information, the HIPAA Privacy Rules establish a uniform, minimum level of privacy protections for all health information.
In summary, theHIPAAPrivacy Rules:
▪ Set limits on how health information may be usedand disclosed;
▪ Require that individuals be told how their healthinformation will be used and disclosed;
▪ Provide individuals with a right to access, amend or copytheir medical records;
▪ Give individuals a right to receive an accounting ofdisclosures, to request special restrictions, and to receiveconfidential communications; and
▪ Impose fines where the requirements contained withinthe regulations are not met.
RestrictionsonUse &Disclosure
The rules allow health care providers, health plans, and health care clearinghouses (Covered Entities) to use and disclose your personally identifiable health information for purposes of treatment, payment, or health care operations.
For example, your health care provider may submit your health information to a health insurance company in order to seek payment for the treatment provided to you. Your primary care physician can share your health information with a specialist that he or she recommends you consult. In these cases, your written permission to disclose your health information is not required.
In general, any use or disclosure not considered treatment, payment, or a health care operation requires your written authorization, unless an exception applies. For example, your physician may not share your health information with your employer or a life insurance carrier without your written permission.
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NOTIFICATIONS
However, disclosure of health information is permitted for certain purposes specifically listed in the HIPAA Privacy Rules, such as national security, law enforcement and public health issues. If you authorize release of your health information to a third party, the information released may no longer be protected by HIPAA.
Notice ofPrivacyPractices
You are entitled to receive an explanation of how your personally identifiable health information will be used and disclosed.
For example, a physician or hospital is required to provide you with a Notice of Privacy Practices at your first visit. You willbe required to sign an acknowledgment indicating that you received the Notice of Privacy Practices.
If you have health insurance coverage, the insurance company or health plan will also provide you with a Notice of Privacy Practices immediately after you are enrolled in the plan. It is important that you read the Notice of Privacy Practices in order to understand your rights and know who to contact if you feel your privacy rights have been violated.
Right toAccess, Amend,orCopy
You have a right to view and copy your medical records. You may be charged a fee for the cost of reproduction. If you believe that information within your medical records isincorrect or if important information is missing, you have a right to request that your medical records be amended.
Right to an AccountingofDisclosure
You also have a right to a list of uses and disclosures made of your medical records where the use or disclosure was not for purposes of treatment, payment, health care operations, or pursuant to your written authorization.
Right to RequestRestrictions
You may request in writing that a health care provider or health plan not use or disclose information for treatment, payment, or other administrative purposes unless specifically authorized by you, when required by law, or in emergency circumstances. Health care providers and health plans must consider your request, but are not legally obligated to agree to those restrictions.
ConfidentialCommunications
You have a right to receive confidential communications containing your health information. Health care providers and health plans are required to accommodate your reasonable requests. For example, you may ask that a physician contact you at your place of employment or send communications regarding treatment to an alternate address.
Violations ofPrivacyRights
If you believe that your privacy rights have been violated, you may contact the Privacy Officer for the organization that you feel has violated your right to privacy. The name of the Privacy Officer should be included in the Notice of Privacy Practices provided to you by that organization.
If the Privacy Officer does not adequately resolve your concerns, you may contact the Department of Health and Human Services— Office of Civil Rights (OCR). OCR is responsible for enforcing the HIPAA Privacy Rules. Its Web site contains instructions on how to file a complaint www.hhs.gov/ocr/privacy/hipaa/ complaints and a complaint form www.hhs.gov/ocr/privacy/ hipaa/complaints/hipcomplaintpackage.pdf
Penalties for Non-compliance
The HIPAA Privacy Rules do not provide individuals with a private right to sue, although methodologies for allowing a portion of civil penalties to be paid to affected individuals must be established by February 17, 2012.
Currently, health care providers, health plans, and health care clearinghouses that do not comply with the HIPAA Privacy Rules may be subject to civil money penalties ranging from $100 to$50,000 per violation, with maximum penalties ranging from$25,000 per year to $1.5 million per year.
Criminal violations of the HIPAA Privacy Rules may also be referred to the Department of Justice for enforcement. Criminal penalties for such violations include:▪ $50,000 and/or up to one year in prison for knowingly
obtaining or disclosing protected health information not permitted by law;
▪ $100,000 and/or up to five years in prison for obtainingor disclosing protected health information under falsepretences; and
▪ $250,000 and/or up to ten years in prison for obtaining protected health information with an intent to sell, transfer, or use it for commercial advantage, personal gain, or malicious harm.
State Attorneys General (AG) may also bring suit against Covered Entities to enjoin further violations and obtain damages on behalf of residents of their states, if HHS has not already taken action. The AG may seek damages of up to $100 per violation, with a maximum of $25,000 per year for identical violations.
HIPAA PrivacyResources
▪ Office of Civil Rights (HHS) www.hhs.gov/ocr/
▪ Health Privacy Project www.healthprivacy.org18
NOTIFICATIONS
LIFETIME AND ANNUAL LIMITSPPACA generally prohibits group health plans, and group and individual health insurance issuers, from imposing lifetime or annual limits on the dollar value of health benefits, effective for plan years beginning on or after Sept. 23, 2010. Although annual limits are generally prohibited, “restricted annual limits” are permitted for essential health benefits for plan years beginning before Jan. 1, 2014.
Restricted AnnualLimits
The interim final rules establish a three-year phased approach for restricted annual limits. Annual limits may not be less than the following amounts for plan years beginning before Jan. 1, 2014:▪ $750,000 for plan years beginning on or after Sept. 23, 2010
but before Sept. 23, 2011;
▪ $1.25 million for plan years beginning on or after Sept. 23, 2011, but before Sept. 23, 2012; and
▪ $2 million for plan years beginning on or after Sept. 23, 2012, but before Jan. 1, 2014.
These are minimums for plan years; plans may use higher annual limits or impose no limits. The limits apply on an individual-by-individual basis, so that any annual limit on benefits applied to families cannot cause an individual to be denied the minimum annual benefit for the plan year.
The restricted annual limits are designed to ensure that individuals would have access to needed services with a minimal impact on premiums. However, they could affect limited benefit plans or “mini-med” plans that generally have limits significantly below the permitted limits. The regulations provide that the restricted annual limits could be waived by the Department of Health and Human Services (HHS) if compliance with the restrictions would result in a significant decrease in access to benefits or a significant increase in premiums.
HHS granted a number of waivers and then closed the waiver program to new applications effective Sept. 22, 2011. Waivers and/or extensions received before that date could be effective until plan years beginning on or after Jan. 1, 2014, when all annual limits for essential health benefits will be prohibited.
As a condition to receiving a waiver, a group health plan or health insurance issuer must provide a notice informing each participant that the plan or policy does not meet the restricted annual limits for essential benefits because it has receiveda waiver of that requirement. Waiver recipients must also provide annual updates to HHS regarding plan information and benefits.
CoveredPlans
The prohibition on lifetime and annual limits applies to both new and grandfathered group health plans. However, it does not apply to grandfathered individual policies. The restrictions on annual limits do not apply to account-based plans like health flexible spending arrangements (health FSAs), medical savings accounts (MSAs) and health savings accounts (HSAs).
Essential HealthBenefits
PPACA specifically provides that plans may impose annual or lifetime per-individual limits on specific covered benefits that are not “essential health benefits.” Each state will set its own definition of essential health benefits, but it will include at least the following general categories of items and services:▪ Ambulatory patient services;
▪ Emergency services;
▪ Hospitalization;
▪ Maternity and newborn care;
▪ Mental health and substance use disorder services, including behavioral health treatment;
▪ Prescription drugs;
▪ Rehabilitative and habilitative services and devices;
▪ Laboratory services;
▪ Preventive and wellness services, including chronic disease management; and
▪ Pediatric services, including oral and vision care.Until standards are issued, plans can use a good faith effort to comply with a reasonable interpretation of essential health benefits and must apply it consistently.
The interim final rules clarify that a plan can still exclude all benefits for a condition. Such exclusion will not be considered an annual or lifetime limit as long as no benefits are provided for thecondition.
Enrollment Opportunities
Under the interim final rules, individuals who reached a lifetime limit prior to the date the regulations were effective and are otherwise eligible for plan coverage must have been given a notice that the lifetime limit no longer applies. They must have been permitted to re-enroll in the plan if they were no longer enrolled. The notices and enrollment opportunity must have been provided no later than the first day of the first plan year beginning on or after Sept. 23, 2010. Anyone who was eligible for the enrollment opportunity must have been treated as a special enrollee eligible to enroll in all of the benefit packages available to similarly situated individuals upon initial enrollment.
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NOTIFICATIONS
IMPORTANT NOTICE ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND MEDICAREPlease read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage 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. It has determined that our prescription drug coverage is, on average for all plan participants, expected to pay out asmuch 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 YouJoin AMedicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 to December 7. 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 ToYourCurrentCoverage If YouDecide to Join AMedicare Drug Plan?
If you decide to join a Medicare drug plan, your current coverage will not be affected. Your current coverage pays for other health expenses in addition to prescription drugs. You and your dependents can keep this coverage if you elect Part D prescription drug coverage but this plan will not coordinate with your Part D coverage. If you do decide to join a Medicare drug plan and drop your current coverage, be aware that you and your dependents will not be able to get this coverage back until our next open enrollment period or if you experience a qualifying event.
When Will YouPay AHigher Premium (Penalty) ToJoin A Medicare DrugPlan?
You should also know that if you drop or lose your current coverage 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 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 YourCurrent Prescription DrugCoverage…
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 changes. You also may request a copy of this notice at any time.
For More Information About YourOptionsUnderMedicare Prescription DrugCoverage…
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 drugcoverage:▪ 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 call1-877-486-2048.
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 (TTY1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicaredrug plans, you may be required toprovide a copy of this notice when you join to show whether or notyou have maintained creditable coverage and, therefore, whetheror not you are required to pay a higher premium (a penalty).
NOTIFICATIONS
GENERAL NOTICE OF PRE-EXISTING CONDITION EXCLUSIONThis plan imposes a pre-existing condition exclusion. This means that if you have a medical condition before coming to our plan, you might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis, care, or treatment was recommended or received within a six-month period. Generally, this six-month period ends the day before your coverage becomes effective. However, if you were in a waiting period for coverage, the six-month period endson the day before the waiting period begins. The pre-existing condition exclusion does not apply to pregnancy or to a child who is enrolled in the plan within 30 days after birth, adoption, or placement for adoption. Effective for plan years beginning on or after Sept. 23, 2010, the pre-existing condition exclusion does not apply to enrollees who are under the age of 19.
LengthofPre-ExistingConditionExclusion
This exclusion may last up to 12 months (18 months if you are alate enrollee) from your first day of coverage, or, if you were in awaiting period, from the first day of your waiting period.
ReductionofPre-ExistingConditionExclusion
You can reduce the length of this exclusion period by the number of days of your prior “creditable coverage.” Most prior health coverage is creditable coverage and can be used to reduce the pre-existing condition exclusion if you have not experienced a break in coverage of at least 63 days. To reduce the 12- month (or 18 month) exclusion period by your creditable coverage, you should give us a copy of any certificates of creditable coverage you have. If you do not have a certificate, but you do have prior health coverage, we will help you obtain one from your prior health plan or issuer. There are also other ways that you can show you have creditable coverage. Please contact us if you need help demonstrating creditable coverage.
For More Information or Assistance
All questions about the pre-existing condition exclusion and creditable coverage should be directed to your HR Department.
WOMEN’S HEALTH AND CANCER RIGHTS ACT (WHCRA) OF1998Common questionsand answers
The benefits related to mastectomies changed quite a bit with the Women’s Health and Cancer Rights Act (WHCRA) of 1998. This article will answer some of the common questions patients have about the WHCRA.
WhatdoesWHCRAcover?
If you are enrolled in a health plan that covers the medical and surgical costs of a mastectomy, the WHCRA states that your plan must also cover the costs of certain reconstructive surgery and other post-mastectomy benefits, including:▪ 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
▪ External breast forms that fit into your bra for before orduring reconstruction
▪ Treatment of any physical complications of themastectomy, including lymphedema
I had a mastectomy due to non-cancer related health issues.Am I covered under WHCRA?
Yes. These rights are not limited to cancer patients. If your plan covers mastectomies, WHCRA rights apply.
My job doesnot offera group health plan. DoesWHCRA apply to my individualhealth insurance policy?
Yes. WHCRA applies to group health plans that are provided byan employer or union as well as to individual health insurancepolicies that are not based on employment.
I receivehealth benefits throughmy church. Am I still covered underWHCRA?
There are certain “church” and “governmental” plans that are not subject to this law. Generally, though, any plan that provides coverage for mastectomies must also comply with WHCRA. Check with your provider for information specific to your plan.
Will my co-pay for reconstructive surgery be more expensivethan my co-pay for otherhealth conditions?
No. If your health plan requires a co-payment for other health conditions, the co-pay for your mastectomy benefits must be the same. For example, it is a violation of WHCRA for your plan to cover 90 percent of hip replacement surgery but to only cover 70 percent of breast reconstruction.
Is my health plan required to informme ofmy rightsunder WHCRA?
Yes. Your health plan must provide you with a notice of yourrights under WHCRA when you first enroll in the health plan,and then annually after that.
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NOTIFICATIONS
THE MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF2008Under the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), the financial requirements and treatment limits that group health plans and health insurance issuers apply to mental health or substance use disorder benefits generally cannot be more restrictive than those applicable to medical and surgical benefits. The MHPAEA supplemented the Mental Health Parity Act of 1996 (MHPA), which required parity with respect to aggregate lifetime and annual dollar limits for mental health benefits. The MHPAEA also extended the parity requirements to substance use disorder benefits.
The MHPAEA generally applies to plans sponsored by employers with more than 50 employees, including self-insured plans and fully insured arrangements. The MHPAEA generally became effective for plan years beginning on or after Oct. 3, 2009 (Jan. 1, 2010 for calendar year plans).
The MHPAEA does not require a plan to provide mental health or substance use disorder benefits. However, if a plan provides medical and surgical benefits and mental health and substance use disorder benefits, it must comply with the federal parity requirements.
The MHPAEA contains the following parity requirements:▪ The financial requirements (such as deductibles,
copayments, coinsurance and out-of-pocket limits) applicable to mental health and substance use disorder benefits cannot be more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits.
▪ Treatment limitations (such as frequency of treatment, number of visits, days of coverage or other similar limits on the scope or duration of coverage) must also comply with the MHPAEA’s parity requirements. Non-quantitative treatment limitations (such as medical management standards, formulary design and determinations of usual, customary or reasonable amounts) are subject to a separate parity requirement.
▪ If medical and surgical benefits are offered on an out-of-network basis, a plan or issuer must also offer mentalhealth and substance use disorder benefits on an out-of-network basis.
In addition, the MHPAEA requires plans to make certain information available with respect to mental health and substance use disorder benefits, such as the criteria for medical necessity determinations and the reason for any denial of reimbursement or payment for mental health or substance use disorder services.
The Departments of Health and Human Services, Labor and Treasury (Departments) issued interim final rules to implement the MHPAEA and to demonstrate how the MHPAEA applies to group health plans and health insurance issuers. The rules became applicable for plan years beginning on or after July 1, 2010.
A plan’s coverage or mental health and substance use disorder benefits may be affected by the health care reform law. The health care reform law is very broad and its specific effect on mental health and substance use disorder benefits is still somewhat unclear. Additional regulatory guidance would be helpful.
DEPENDENT COVERAGE UP TO AGE 26The Affordable Care Act (ACA) provides that health plans and issuers that offer dependent coverage to children on their parents’ plans must make the coverage available until the adult child reaches the ageof 26. The extension of coverage to young adult children took effect on the first day of the first plan year that began on or after Sept. 23, 2010.
What Does theLaw Require?
Group health plans and health insurance issuers offering group or individual health insurance policies that provide dependent coverage of children must make coverage available for adult children up to age 26, regardless of the child’s marital status.
The mandate applies to plans that have “grandfathered” status under ACA and to non-grandfathered plans. However, for plan years beginning before Jan. 1, 2014, grandfathered plans are not required to cover adult children under age 26 if they are eligible for other employer-sponsored group health coverage.
Parents can decide whether to add adult children to their plan. ACA’s extension of dependent coverage did not create independent enrollment rights for dependents. In addition,there is no requirement to cover the child of a dependent child (that is, a grandchild).
Restrictionson Definitionof “Dependent”
ACA restricts the definition of “dependent” that health plans and issuers may use for children under the age of 26. A plan or issuer may not define dependent for purposes of eligibility for this coverage other than in terms of the child’s age and the relationship between the child and the participant.
For example, a plan or issuer may not deny or restrict coverage for a child who is under age 26 based on one or more of the following factors:
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NOTIFICATIONS
▪ Financial dependence on the participant or any other person;
▪ Residency with the participant or with any other person;
▪ Student status;
▪ Marital status;
▪ Employment status; or
▪ Eligibility for other coverage (unless the plan or coverage has grandfathered status and the child is eligible for other employer-sponsored group health coverage for plan years beginning before Jan. 1, 2014).
Although the term “child” is not specifically defined in ACA, guidance indicates that it means an individual who is a son, daughter, stepson, stepdaughter or adopted child of the participant. There is some suggestion that a foster child would be included as well, although this is not entirely clear.
Uniformity in Plan Terms
The terms of the plan or health insurance coverage providing dependent coverage of children, including the premiums charged, cannot vary based on age (except for children who are age 26 or older). This means that adult children must be offered all of the benefit packages available to other plan participants, and these dependents cannot be required to pay more for coverage.
The following examples illustrate the uniformity requirement.
Example: A group health plan offers a choice of self-only or family health coverage. Dependent coverage is provided under family health coverage for children of participants who have not reached age 26. The plan imposes an additional premium surcharge for children who are older than age 18. This plan violates the uniformity requirement because the plan varies the terms for dependent coverage of children based on age.
Example: A group health plan offers a choice among the following tiers of health coverage: self-only, self-plus-one,self-plus-two and self-plus-three-or-more. The cost of coverage increases based on the number of covered individuals. The plan provides dependent coverage of children who have not reached age 26. In this example, the plan does not violatethe uniformity requirement. Although the cost of coverage increases for tiers with more covered individuals, the increase applies without regard to the age of any child.
Example: A group health plan offers two benefit packages -- an HMO option and an indemnity option. Dependent coverageis provided for children of participants who have not reached age 26. The plan limits children who are older than age 18 to
the HMO option. This plan violates the uniformity requirement because the plan, by limiting children who are older than age 18 to the HMO option, varies the terms for dependent coverage of children based on age.
When did theLaw Become Effective?
The extension of dependent coverage provision took effect for plan years beginning on or after Sept. 23, 2010, though some plans and issuers extended coverage to adult children before this date. All plans and issuers should now be in compliance with the age 26 dependent coverage requirement.
What if State LawsDiffer from Federal Law?
More than two-thirds of states have passed laws that require insured group health plans to cover dependents after they turn 18 years old, often into their mid to late 20s and in somecases later. For example, in New Jersey, unmarried children can stay on a parent’s plan until they are 31 years old. These state mandates, to the extent they require coverage past age 26, will continue to apply to insured health coverage.
What are theTaxEffectsof theextended dependent coverage?
Under federal tax law, employers can offer tax-free health coverage to employees’ adult children through the end of the year in which the children turn age 26. It does not matter whether the children are tax dependents for federal incometax purposes. All states have passed tax laws conforming to the federal tax law.
Often, adult children that obtain coverage pursuant to state law are not tax dependents for federal income tax purposes. In the event state laws mandate coverage past age 26, federal tax law generally requires employers to impute the fair market value of the dependent coverage as income to employees for tax years after the children turn age 26, unless employees pay for the coverage on an after-tax basis.
MoreInformation
Additional information on ACA’s young adult coverage requirement is available at: www.healthcare.gov/law/features/choices/young-adult-coverage/index.html.
The interim final regulations on the young adult coverage requirement, as published in the Federal Register on May 13, 2010, are available at: www.gpo.gov/fdsys/pkg/FR-2010-05-13/pdf/2010-11391.pdf.
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NOTIFICATIONS
SPECIAL ENROLLMENT NOTICEThis notice is being provided to insure that you understand your right to apply for group health insurance coverage. You should read this notice even if you plan to waive coverage at this time.
LossofOtherCoverage
If you are declining coverage for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).Example: You waived coverage because you were covered under a plan offered by your spouse’s employer. Your spouse terminates his employment. If you notify your employer within 30 days of the date coverage ends, you and your eligible dependents may apply for coverage under our health plan.
Marriage,Birth, orAdoption
If you have a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, or placement foradoption.
Example: When you were hired by us, you were single and chose not to elect health insurance benefits. One year later, you marry. You and your eligible dependents are entitled to enroll in this group health plan. However, you must apply within 30 days from the date of your marriage.
Medicaid or CHIP
If you or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or become eligible for a premium assistance subsidyunder Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must request enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistance subsidy.Example: When you were hired by us, your children received health coverage under CHIP and you did not enroll them in our health plan. Because of changes in your income, your children are no longer eligible for CHIP coverage. You may enroll them in this group health plan if you apply within 60 days of the date of their loss of CHIP coverage.
For More Information or Assistance
To request special enrollment or obtain more information, please contact your Benefits Administrator.
Note: If you and your eligible dependents enroll during a special enrollment period, as described above, you are not considered a late enrollee. Therefore, your group health plan may not require you to serve a pre-existing condition waiting period of more than 12 months. Any preexisting condition waiting period will be reduced by time served in a qualified plan.
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