1.

Effective January 1, 2021

FOCUS ON BENEFITS

QUESTIONS?Contact your Human Resources Department

This piece is not a contract, but a summary of your benefits. Please refer to your contract (Summary Plan Description or Certificate of Coverage(s)) for more detailed information. In case of conflict, your contract will prevail for all claim adjudication.

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In this issue

Health Plan Summary

Additional Health Plan Information

o Prescription Drug Formulary

o Telehealth Options & Utilization Management

o Health Management Programs

o Health Insurance 2021 Withholding – NEW 3-TIERED PREMIUMS

Quartz Website Navigation

Health Reimbursement Account – NEW VENDOR

Dental Plan Summary, 2021 Withholding, Dental Networks

Voluntary Vision Summary

Flexible Benefit Plan – NEW VENDOR

Voluntary Short-Term Disability & Life Insurance

Additional Benefits

o Employee Assistance Program (EAP)

o Paid Leave Value Program (PLV)

o Community Connectedness – Paid Volunteer Program (VTO)

o Tuition Reimbursement

Retirement Plan

Next Steps and Carrier Contact Information

Required Notices

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What’s new for January 1, 2021?

This document briefly summarizes the employee benefits offered by Bethany St. Joseph Corporation (BSJ) for 2021. We encourage you to take the time to read through this summary, so you understand your benefits. For January 1, 2021, BSJ is pleased to announce the following changes:

Reduction in Quartz health plan premiums and payroll deductions; see new payroll deductions on page 7. Additionally, the rate tier elections for health plan coverage have changed to: Employee Only, Employee + One, and Employee + Family.

A change in the vendor administering the BSJ Health Reimbursement Account (HRA) and the Flexible Benefit Plan to Employee Benefits Corporation (EBC) TPA. Details on this change are explained on pages 10 – 11 & 16.

Please use this summary as a reference for your 2021 BSJ Employee Benefits Program. However, for more explicit information on the plans offered, please refer to the applicable certificate of coverage or benefit booklet. If there are any discrepancies between this document and the carrier documents, the carrier documents are the ultimate answer.

Required notices are located at the end of this packet and include:

HIPAA Portability Notice

Medicare Part D Coverage Notice

HIPAA Notice of Privacy Practices

CHIP Notice

WHCRA Notice

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HEALTH PLAN SUMMARYEffective January 1, 2021, we will continue to offer a health plan through Quartz for all benefit-eligible employees (30 hours/week or more averaged in a 60-day period).

About the Health Plan: Preventive care is covered at 100% and no deductible applies. For other services, this plan requires a deductible before eligible services are paid by Quartz at 80% until you meet your maximum out of pocket.

Effective January 1, 2021

Quartz HMO

In-Network

Deductible per calendar year

$5,500 /single$11,000/family

Employee Coinsurance 20%

Maximum Out-of-Pocket per calendar year

$6,850 /single$13,200/family

Physician ServicesOffice visits, Urgent Care Clinic, Retail Health Clinics, Chiropractic Manipulation

You pay 20% after deductible

Preventive ServicesWell child, Immunizations, Screenings You pay $0

Telehealth E-VisitsUW CareAnywhere, GHP VirtualVisit You pay $0

Mental/Behavioral/Substance Use Outpatient

You pay 20% after deductible

Emergency Room You pay 20% after deductible

Ambulance You pay 20% after deductible

Hospital You pay 20% after deductible

Diagnostic ServicesRadiology & Laboratory

You pay 20% after deductible

Prescription Drugs Retail (30-day supply)

Tier 1 – Preferred GenericTier 2 – Preferred BrandTier 3 – Non-Preferred Generic/BrandTier 4 – Specialty

$10 copay$35 copay$50 copay

$200 copay

Please review your plan summary document for more detailed coverage information.

Quartz’s provider finder lets you easily search for doctors, facilities, and pharmacies in your network. Use your preferences to scale down your search and find a provider that fits your needs. See pages 8 - 9 for more information on the Quartz website.

SUMMARY OF BENEFITS COVERAGE

Refer to your Summary of Benefit Coverage (SBC) for a more detailed explanation about your health plan benefits, including mail order prescriptions and other health services.

QUESTIONS?Call Customer Service at 800.362.3310 or call the phone number on the back of your ID card or visit QuartzBenefits.com.

Customer Service hours are:

M – TH: 7 a.m. to 6 p.m.

F: 7 a.m. to 5 p.m.

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QUARTZ’S PRESCRIPTION DRUG FORMULARYQuartz Health’s prescription drug formulary (list of covered drugs) provides

coverage to members with safe, effective medications in an affordable manner. The Quartz’s formulary applicable for BSJ members is called Standard Choice. Please refer to the formulary for the status of your prescriptions. Ways to access the formulary are on the right side of this page.

Not all drugs are covered by your prescription benefit and some are covered only under specific circumstances. Always check the Standard Choice formulary when you are prescribed a new medication, so you avoid any coverage misunderstandings. Categories of non-covered drugs are described below:

Exclusions – Some drugs or groups of drugs are excluded from coverage under the drug benefit. An example is a drug for cosmetic purposes.

Restrictions – Restricted drugs are those that require Prior Authorization or Step Therapy before you can receive coverage. Restricted drugs may be preferred or non-preferred. Restrictions are noted on the formulary.

Non-preferred drugs – Some of your drug benefits provide coverage for non-preferred drugs at higher copays.

Non-formulary drugs – Drugs listed as NF in the formulary are not covered. In most cases formulary alternatives are available.

What if my drug is not on the Formulary?

If your drug is considered non-formulary, you should first contact Customer Service and ask if your drug is covered now since the formulary changes periodically.

If you learn that it is not covered, you have two options:

You can ask Customer Service (800.362.3310) for a list of similar drugs that are covered. When you receive the list, show it to your doctor and ask the doctor to prescribe a similar drug that is covered by Quartz.

You can ask for an exception, so the drug is covered. Generally, your request for an exception is approved only when the alternative drugs included on the formulary are not effective in treating your condition and/or would cause you to have adverse medical effects. Call Customer Service or review the formulary PDF for more information on requesting an exception.

HOW TO VIEW QUARTZ’S FORMULARY

View the complete list in Quartz’s up-to-date formulary PDF at www.QuartzBenefits.com. This is the easiest and fastest way to answer formulary questions such as whether or not your drug is on the formulary for your plan, if it requires Prior Authorization or has other restrictions, and what tier copay it is.

Log into Quartz’s secure member portal, MyChart, and search Quartz’s formulary. You can price-check individual drugs to see what your copay may be, based on your specific drug benefit. This tool provides more detail and member-specific information than the PDF formulary listing and is a more interactive process.

Request an updated version from Quartz’s Customer Service at 800.362.3310.

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UTILIZATION MANAGEMENT (UM)Utilization Management assists members in obtaining health care in the most efficient and economical manner. UM works with participating providers to help ensure decisions regarding treatment are based on appropriateness of care and service. The UM program protects members from unnecessary costs and helps them to be good stewards of plan resources for the benefit of all members.

All Quartz members and their health care services are managed by:

Medical Management

Quartz Pharmacy Program

Behavioral Health Care Management

Quartz carefully reviews treatment plans and requests submitted by participating practitioners. This process of UM (sometimes called care management) is conducted by nurses with the support of physicians. The medical management staff works with your Primary Care Physician (PCP) to coordinate your care at three stages:

Pre-service review – before you receive care or services

Concurrent review – while care or services are being provided

Post-service review – after care or services have been provided

If you have any concerns relating to utilization management, you may call the following numbers to address your concerns:

Medical Management608.821.4200 (Local)888.829.5687 (Toll-free)

Behavioral Health Care Management608.640.4450 (Local)800.683.2300 (Toll-free)

Quartz Utilization Management for Chiropractic Care800.362.3310 (Toll-free)

Quartz Pharmacy Program888.450.4884 (Toll-free)

Additional information about Utilization Management may be found at www.quartzbenefits.com.

COMPLEX CASE MANAGEMENT

Members with serious, complicated medical problem or diagnosis that require an extensive use of health care resources will have their treatment coordinated by Quartz Health. The professionals in this team will work with you and your providers to navigate the health system and community resources that will best meet your needs. The goal of the complex case management team is to help you regain optimum health or improve your health to the greatest degree possible. You may contact the complex case management staff at 866.884.4601.

HEALTH COACHINGAny Quartz member over the age of 18 can request health coaching in areas such as eating habits, weight management, lowering stress, increasing physical activity, tobacco cessation, taking medication and more. To learn more, call 866.884.4601.

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CONVENIENT, LOW-COST TELEHEALTH OPTIONSQuartz now has two choices for you and your dependents to receive nonemergency health care virtually: UW Health Care Anywhere and Gundersen VirtualVisit. These programs allow you to have a video visit with a physician on a 24/7/365 basis from the comfort of your own home or work. Access these video visits via an app on your smartphone, tablet, or computer equipped with a web camera (app information is provided below by program).

NOTE: Telehealth visits are FREE to BSJ members. Call Customer Service at 800.362.3310 for more info. Use these telemedicine services for:

Abdominal pain Allergies Cough Fever Ear pain Stuffy/runny nose Sore throat Painful/difficult urination Nausea & vomiting Low back pain &/or joint pain Diarrhea Eye infections Sprains Headache Minor skin problem And other nonemergency issues

UW Health Care Anywhere: Get the mobile app called “UW Health Care Anywhere” from the App Store or Google Play. NOTE: While members do not need a UW Health PCP to use this service, they must be in the state of Wisconsin to receive care. Gundersen VirtualVisit: Search Google Play or the App Store for “Gundersen VirtualVisit.” Create an account so your information is stored securely for your visits. Before your visit begins, log in and review the available providers, their experience, and ratings. Choose the person who best fits your needs. Video chat with your selected provider. This telemedicine service is not limited by being in Wisconsin; you can use while home or on vacation outside of Wisconsin.

HEALTH PLAN PREMIUMBi-weekly premiums are based on hours paid. Please see the Quartz Health Insurance 2021 Withholding chart on the next page for the payroll deductions that apply to you. In 2021, the rate tier elections for health plan coverage have changed to: Employee Only, Employee + One, and Employee + Family.

HEALTH MANAGEMENT PROGRAMS

Receive confidential support to better manage your conditions with the help of a healthcare practitioner, self-care tips, or other resources. Programs are free and are offered for: Asthma Program: Assistance in taking

care of your asthma every day is important in feeling your best. Contact medical professionals at 866.884.4601 for more information and/or sign up for this program. You can also sign up online.

Diabetes Program: Support that helps you to enjoy life by managing your diabetes symptoms. This program offers education, resources, and reminders that assist you in self-care of your condition. You can sign up online or call 866.884.4601, ext. 704966.

Health Coaching – Tool to help when making a change to healthier habits. You can connect to a trained health coach who will assist you along the way. Sign up or learn more either online or calling 866.884.4601.

Tobacco Cessation: An interactive, online workshop to get you started on your road to becoming tobacco free plus additional resources for the journey.

Low Back Pain: Online information on the causes of low back pain, treatment options, strengthening exercises, and self-care.

Complex Case Management – Coordination of care, services and resources for member who have complex medical and social needs. If interested, call Complex Case Management service at 866.884.4601.

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QuartzHEALTH INSURANCE 2020 WITHHOLDING

Hours Per Pay Period (two-

weeks)

BSJ Contribution

Per Pay Period (Single)

Employee Withholding

Per Pay Period (Single)

BSJ Contribution

Per Pay Period

(Single + 1)

Employee Withholding

Per Pay Period

(Single + 1)

BSJ Contribution

Per Pay Period

(Family)

Employee Withholding

Per Pay Period

(Family)

0 $0.00 $307.58 $0.00 $584.41 $0.00 $812.7230 $0.00 $307.58 $0.00 $584.41 $0.00 $812.7232 $104.58 $203.00 $175.32 $409.09 $243.82 $568.9034 $111.11 $196.47 $186.28 $398.13 $259.05 $553.6636 $117.65 $189.93 $197.24 $387.17 $274.29 $538.4338 $124.19 $183.40 $208.20 $376.21 $289.53 $523.1940 $130.72 $176.86 $219.15 $365.26 $304.77 $507.9542 $137.26 $170.32 $230.11 $354.30 $320.01 $492.7144 $143.80 $163.79 $241.07 $343.34 $335.25 $477.4746 $150.33 $157.25 $252.03 $332.38 $350.48 $462.2348 $156.87 $150.72 $262.98 $321.43 $365.72 $447.0050 $163.40 $144.18 $273.94 $310.47 $380.96 $431.7652 $169.94 $137.64 $284.90 $299.51 $396.20 $416.5254 $176.48 $131.11 $295.86 $288.55 $411.44 $401.2856 $183.01 $124.57 $306.81 $277.59 $426.68 $386.0458 $189.55 $118.04 $317.77 $266.64 $441.92 $370.8060 $196.08 $111.50 $328.73 $255.68 $457.15 $355.5662 $202.62 $104.96 $339.69 $244.72 $472.39 $340.3364 $209.16 $98.43 $350.65 $233.76 $487.63 $325.0966 $215.69 $91.89 $361.60 $222.81 $502.87 $309.8568 $222.23 $85.35 $372.56 $211.85 $518.11 $294.6170 $228.76 $78.82 $383.52 $200.89 $533.35 $279.3772 $235.30 $72.28 $394.48 $189.93 $548.58 $264.1374 $241.84 $65.75 $405.43 $178.98 $563.82 $248.90

75+ $261.45 $46.14 $438.31 $146.10 $609.54 $203.18

Check out NEW 3-tierd plan for

premiums.

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NAVIGATING QUARTZ BENEFITS’ WEBSITEwww.quartzbenefits.comThe Quartz Benefits’ home page looks like this (see below). Click on “Current

Members.”

The Current Members screen is shown below. On this webpage, select “Employer Group Members,” which takes you to member resources.

You can login to MyChartfrom here

Click here for memberresources

MYCHARTIf you haven’t already signed up for the Quartz MyChart web portal, we suggest that you set up an account before the beginning of the new, plan year. Quartz MyChart gives you secure access to your health insurance benefit information.

ACCESSING HEALTH CARE SERVICES

Below is a summary of how to access care depending on your needs:

Routine Care

Contact your Primary Care Provider’s (PCP) clinic

Specialty Care

Contact your PCP clinic, they will tell you how to get appropriate care

After-Hours Care

Contact your PCP clinic, they will tell you how to get appropriate care

Urgent Care Go to a participating Urgent Care Center if your injury is not life-threatening but you need prompt attention

Emergency Care

Go to the nearest hospital or call 911

Care Away from Home

Contact your PCP clinic, or if it is an emergency, go directly to the nearest hospital

Behavioral Health Care

For assistance coordinating your behavioral health services, including alcohol and drug treatment services, please contact either locally at 608-640-4450 or toll-free 800-683-2300.

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www.quartzbenefits.com (cont’d)

This is the top portion of the members’ webpage.

Here’s the bottom portion of the members’ webpage.

From this page, you can access:

Find a Doctor MyChart Drug Formularies

Note access to: Member Kit Health Management

& Prevention Quartz Well

These links are useful to navigate to: Getting Care Forms & Resources Pharmacy Program Health

Management, Wellness & Prevention

Appeals Process Perks & Savings

Quartz Well is a personalized digital wellness program that offers eligible members rewards for participating in health activities. A subscriber and/or a Quartz enrolled spouse can earn up to $100 in Amazon rewards per calendar year for tracking health and wellness activities.

How to access? Quartz Well can be accessed in your Quartz MyChart Account. If you don’t have a Quartz MyChart account, visit the following link for instant activation: https://quartzmychart.com/mychart/.

How do I earn rewards? Visit www.quartzbenefits.com/well to see the many ways you can earn reward points that turn into gift cards. You can earn points in the following four categories: engagement, fitness, prevention and health, & wellbeing.

When do I receive my rewards? As soon as you earn enough points for a $25 gift card, you can go to the “claim your gift code” button and click on it so your Amazon code appears in your portal. Quartz recommends that members claim their Amazon code as soon as one is earned.

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HEALTH REIMBURSEMENT ACCOUNT – NEW VENDORWhat is a Health Reimbursement Account? And how does it benefit me?

A Health Reimbursement Account (HRA) plan is a tax-favored benefit that helps both employers and their employees save money on the cost of medical expenses. This benefit is funded by employer money and allocated to employees to help defer healthcare costs. These types of plans help employers to decrease medical insurance premium by raising deductibles. These decreased premiums benefit both the employer and their employees by having lower monthly premiums/payroll deductions.

The HRA benefit plan design is determined by the employer and the money in the account is owned by the employer. For 2021, the HRA works as follows:

Beginning January 1, 2021, the BSJ HRA plan administrator is changing to Employee Benefits Corporation (EBC). The HRA process continues to be automatic with claims being processed by the insurance company, data sent electronically to EBC, and EBC paying the provider directly. Employees can check their financial responsibility online at http://www.ebcflex.com/. If you have questions on the 2021 HRA, contact EBC at: 800.346.2126 (toll-free) or 608.831.8445 (local) or participantservices@ebcflex.com.

For questions on the 2020 HRA, contact BPA at 715.832.5535 (local) or 800.236.7789 (toll-free).

Employee Pays

The first $2,000 per covered person (maximum of 2 per family)Of the deductible of $5,500 single/$11,000 family

BSJ PaysBSJ pays the next $3,500 per covered person

Insurance Pays

After deductible is met:Insurance pays 80%Employee pays 20% until Maximum Out-of-Pocket is met

Annual Limits

Regardless of the amount of claims any covered person cannot pay more than $3,350Cannot have more than double for a full familyInsurance covers any further claims for the year

BE A SMART HEALTHCARE CONSUMER!

As noted on a prior page, you have different care options to choose. Gaining a better understanding of your options now can help you save both time and money when you need to seek care. Options for treatment include:

Convenience Care, Online Care: Located inside of retail stores or online, visit these for common aliments like strep throat, pink eye, bladder infection, etc.

Cost: $

Doctor’s Office: Staffed by doctors, PAs and nurses, visit this for care of illnesses, injuries, preventive care, etc. Cost: $$

Urgent Care Clinic: Staffed by doctors, PAs and nurses, visit this for care of minor illnesses or injuries that require immediate attention. Cost: $$$

Emergency Room: Located inside of a hospital, visit this for serious illnesses, injuries or life-threatening issues, such as, chest pains, shortness of breath, burns, head injuries, etc. Cost: $$$$

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EBC ONLINE - MY ACCOUNT ADMINISTRATOR

To manage your accounts with EBC, check out their on-line participant site called My Account Administrator. Go to www.ebcflex.com/Support/ to sign up for My Account Administrator. Sign-up is easy; just follow the instructions listed below.

Account Login

1. Go to www.ebcflex.com.

2. Click “Log In” (see at the top of the page – see above screenshot) and choose “Participants.”

3. Log in with your Username and Password.

If you do not have a Username and Password, you will first need to register.

1. Click on the “Register” button (located at the bottom of the screen).

2. Fill out the short form and follow the on-screen instructions.

Check out the EBC My Mobile Account Assistant at the App Store or Google Play.

NEED ADDITIONAL HELP?HAVE QUESTIONS?

Call Participant Services toll-free at800.346.2126 or locally at 608.831.8445 or email your questions to participantservices@ebcflex.com. The general website is www.ebcflex.com.

QUESTIONS ON 2020 CLAIMS?

For questions on the 2020 HRA, contact BPA at 715.832.5535 (local) or 800.236.7789 (toll-free).

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DENTAL PLAN SUMMARYAbout the Dental Plan: This is a comprehensive plan for all dental services and covers preventive care at 100% in-network, with no deductible. You may use any dentist for your dental services; however, using an in-network provider will reduce your out-of-pocket costs.

NOTE: New employees can enroll when the dental plan is initially offered. However, if you did not enroll in the dental plan at that time, then you can only enroll if you have a qualifying event.

FeaturesIn-Network

Delta Premier Out-of-Network

Annual Maximum per Person* $1,000$2,000Annual Deductible

Does not apply to preventive and diagnostics

$50/person$150/family

Diagnostic & Preventive* You pay $0You pay XX%Basic Restorative Care

Amalgam & Resin FillingsYou pay 20% after deductible

Oral SurgerySimple Extractions

You pay 20% after deductible

Endodontic TherapyRoot Canal

You pay 20% after deductible

PeriodonticsGum disease

You pay 20% after deductible

Major RestorativesResins, Crowns

You pay 20% after deductible

Prosthetics and Implants You pay 20% after deductible

Orthodontics (Max. Lifetime Benefit = $1,500)

You pay 50%(not subject to deductible)

*Diagnostic and Preventive Procedures do not count toward the Annual Maximum.

Please review your plan summary document for more detailed coverage information.

DENTAL PLAN PREMIUMBi-weekly premiums are based on hours paid. Please see the Delta Dental Insurance 2021 Withholding chart on the next page for the payroll deductions that apply to you.

Delta Dental administers our dental plan. Always use a Premier in-network provider to obtain the highest level of benefits.

When accessing care out-of-network, there are no provider discounts and the member is responsible for the difference between what is charged/billed over the Usual and Customary percentile.

INFORMATION ON THE GO!Access your dental account information from your smartphone or mobile device with Dental Delta app. With this app, you can: View your summary of benefits or

claims

Access your ID card

Find a network dentist

Brush with toothbrush timer

AMPLIFON HEARING HEALTHCARE

As a Delta Dental member, you receive discounts and savings on hearing diagnostic testing, along with the guaranteed lowest pricing on hearing aids. Call 888.901.0132 or visit www.amplifonusa.com/deltadentalWI for information.

QUESTIONS?Call customer service at 800.236.3712 or call the phone number on the back of your ID card or visit http://www.deltadentalwi.com/.

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DENTAL INSURANCE 2021 WITHHOLDING

Hours Per Pay Period

BSJ Contribution Per Pay Period

(Single)

Employee Withholding Per

Pay Period (Single)

BSJ Contribution Per Pay Period

(Family)

Employee Withholding Per

Pay Period (Family)

0 $0.00 $13.85 $0.00 $41.5430 $0.00 $13.85 $0.00 $41.5432 $3.84 $10.00 $7.00 $34.5434 $4.08 $9.76 $7.43 $34.1136 $4.32 $9.52 $7.87 $33.6738 $4.56 $9.28 $8.31 $33.2340 $4.80 $9.04 $8.74 $32.7942 $5.04 $8.80 $9.18 $32.3644 $5.28 $8.56 $9.62 $31.9246 $5.52 $8.32 $10.06 $31.4848 $5.76 $8.08 $10.49 $31.0550 $6.00 $7.84 $10.93 $30.6152 $6.24 $7.60 $11.37 $30.1754 $6.48 $7.36 $11.80 $29.7356 $6.73 $7.12 $12.24 $29.3058 $6.97 $6.88 $12.68 $28.8660 $7.21 $6.64 $13.12 $28.4262 $7.45 $6.40 $13.55 $27.9964 $7.69 $6.16 $13.99 $27.5566 $7.93 $5.92 $14.43 $27.1168 $8.17 $5.68 $14.86 $26.6770 $8.41 $5.44 $15.30 $26.2472 $8.65 $5.20 $15.74 $25.8074 $8.89 $4.96 $16.18 $25.3676 $9.61 $4.24 $17.49 $24.0578 $9.61 $4.24 $17.49 $24.0580 $9.61 $4.24 $17.49 $24.05

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Dental Network Savings Information

The District’s dental plan through Delta Dental of Wisconsin offers colleagues the freedom to choose who they want for their dental provider; those choices are described below.

Delta Dental Premier Network – offers a very broad network of providers (nearly 90% of all the dentists in Wisconsin) and offers a discount off charges.

Out-of-Network Provider – has no discount off dental charges but allows complete freedom of choice concerning your dental provider. These providers often charge more than allowed by Delta Dental and the patient can be balance billed for the difference. Using out-of-network providers will cost more out-of-pocket than either of the two network providers.

FINDING A DENTISTGo to Delta Dental of Wisconsin’s website at https://www.deltadentalwi.com/s/find-a-provider to locate a dentist near you or to check if your current dentist is in one of the Delta Dental networks. Remember using an in-network provider will make the most of your dental care dollars.

PREDETERMINATION OF BENEFITS

After an examination, your dental provider may recommend a treatment plan. If the services involve crowns, fixed bridgework, implants, or partial or complete dentures, ask your provider’s office to send the treatment plan with images to Delta Dental. The available coverage will be calculated and printed on a Predetermination of Benefits form. Copies of the form will be sent to you and your dental provider.

Having this Predetermination helps assure there are no surprises as to your share of the cost for that dental service. The Predetermination of Benefits form is valid for one year from the date issued.

Predeterminations are not required, but Delta Dental encourages you to use this service. Should you have any questions about a predetermination, just call Delta Dental of WI at 800.236.3712.

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VOLUNTARY VISION SUMMARYThis is a comprehensive plan for all vision services offered through Delta Dental of Wisconsin in conjunction with EyeMed utilizing the Select Provider Network. You may use any provider for your vision services; however, using an in-network provider will reduce your out-of-pocket costs. This is a voluntary plan, meaning you pay 100% of the premiums.

Features In-Network Out-of-Network Reimbursement

Comprehensive Spectacle Exam (once every 12 months)

You pay $10 Up to $35

Contact Lens Fit & Follow-up(once every 12 months)

Standard

Premium

You pay $0

10% discount off retail, plus $40

allowance

Up to $40

Up to $40

Frames (once every 24 months)

$130 allowance, then 20% off

balance

Up to $65

Standard Plastic Lenses(once every 12 months)

SingleBifocalTrifocalStandard Progressive

You pay $10You pay $10You pay $10You pay $75

Up to $25Up to $40Up to $55Up to $40

Lens Options(once every 12 months)

UV, Tint, Scratch ResistanceStandard PolycarbonateStandard Anti-Reflective

You pay $15You pay $40You pay $45

Not coveredNot coveredNot covered

Contacts – in lieu of Spectacles(once every 12 months)

Conventional

Disposable

Medically Necessary

$120 allowance, then 15% off

balance$120 allowance

You pay $0

Up to $96

Up to $96

Up to $200

Laser Vision Correction(Lasik or PRK)

15% off retail price or 5% off

promotional priceNot covered

Please review your plan summary document for more detailed coverage information.

Always use an in-network provider to obtain the highest level of benefits. When accessing care out of network, you receive an amount that the provider will pay up to. You are then responsible for the difference.

VISION PLAN PREMIUMThis is a voluntary plan, participation is optional. You may waive this coverage if

you don’t need eyeglasses or contacts. Total monthly premiums for 2021 are:

Status Monthly Rates

Employee only $5.92Employee & Family $14.74

FINDING A PROVIDERDeltaVision uses a network of private and retail vision providers through the EyeMed Vision Care Select network. To locate an in-network vision provider, go to Delta Dental of Wisconsin’s website at https://www.deltadentalwi.com/s/find-a-deltavision-provider-near-you. When you are at the “Find a DeltaVision Provider” screen, select “Search EyeMed Select Network” and then either search by “use my location” or entering your ZIP code to generate a list of vision providers near you, or enter additional information to narrow your search. Remember using an in-network provider will make the most of your dental care dollars.

QUESTIONS?Call customer service at 844.848.7090 or access your vision benefit information 24/7 at www.eyemedvisioncare.com or EyeMed’s mobile app.

FOCUS ON BENEFITS 2021Bethany St. Joseph Corporation

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FLEXIBLE BENEFIT PLAN – NEW VENDORWe sponsor a flexible benefit plan to help you pay for everyday expenses on a pre-tax basis. The flexible benefit plan year is January 1, 2021 through December 31, 2021. The flexible benefit plan helps you pay for everyday medical expenses on a pre-tax basis by:

Premiums: Pre-tax contributions for medical, dental and vision premiums.

Medical Flexible Spending Arrangement (FSA): You can set aside pre-tax contributions for medical, dental and vision expenses not paid by your (or your spouse’s) insurance plans up to $2,750 (minimum is $500) depending on your election. As a reminder, you need to obtain a prescription for over-the-counter medications in order to use your medical FSA dollars for reimbursement (one prescription per OTC med, per year needed).

At the end of the plan year, $550 may be carried over in the medical FSA. If you have any amount over $500, it will be forfeited at the end of the plan year (i.e., “use it or lose it”).

Dependent care: You can set aside pre-tax contributions for dependent care expenses up to $5,000 per plan year (minimum election is $1,000). No dollars may be carried over into the next plan year.

Participants must enroll annually for the plan year effective on January 1.

Each component of the flexible benefit plan requires a separate election. Funds cannot be moved from one component to another. Contributions cannot be changed unless a qualifying life event occurs and must be made within 30 days of the event.

To manage your accounts with EBC, check out their on-line participant site called My Account Administrator. Go to www.ebcflex.com/Support/ to sign up for My Account Administrator. Sign-up is easy; just follow the instructions shown on page 11.

Check out the EBC My Mobile Account Assistant at the App Store or Google Play.

Effective January 1, 2021, the BSJ Flexible Benefit plan administrator is changing to Employee Benefits Corporation (EBC).

To file a claim, you can:

Use your Benny Card to pay for eligible health expenses at time of purchase

OR

Go online at www.ebcflex.com & log into My Account Assistant

OR

Add the mobile app on your smart phone & follow the on-screen instructions

OR

Complete the paper claim form & with the accompanying receipts either mail to EBC or fax to them at 608.831.4790.

QUESTIONS?Call Participant Services toll-free at 800.346.2126 or locally at 608.831.8445 or email your questions to participantservices@ebcflex.com. The general website is www.ebcflex.com.

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VOLUNTARY SHORT-TERM DISABILITYYou are eligible to participate in the Principal Financial Group’s Voluntary Short-Term Disability Insurance plan if you are an active, full-time employee who works at least 30 hours per week. Benefits begin on the 15th day for either an accident or a sickness and have a maximum benefit payment period of up to 24 weeks. The weekly benefit amount payable is 60% of your pre-disability earnings to a maximum of $1,000.

Pre-existing conditions apply; please refer to the Principal Benefit Booklet for details on how pre-existing conditions are handled. Please note that Proof of Good Health is required if you did not enroll when you were first eligible for the coverage. Please see Human Resources for the available weekly benefit amounts and the applicable payroll deductions. Note this benefit is 100% paid by you.

LIFE INSURANCE Life insurance options are available so you can offer financial stability to your loved ones. You are eligible to participate in the AXA Group Life insurance plan if you are an active employee who works at least 20 hours per week (40 hours per pay period).

General Life/Accidental Death & Dismemberment (AD&D) is an employer paid $10,000 plan. There are no premiums associated with this coverage as long as 20 hours plus per week is maintained by you. You designate your beneficiary information to Human Resources.

Voluntary Life Insurance gives you the option to purchase additional Life insurance increments for yourself, your spouse, and your dependent children. There are premiums associated with additional Term Life Insurance based on increments of additional coverage and age range rates. Coverage cannot exceed five times your Basic Annual Earnings.

For a complete list of the disability benefit provisions, the benefit restrictions, and the pre-existing condition limitations, please refer to the Principal Short-Term Disability Benefit Booklet.

SURVIVOR BENEFIT

A Survivor Benefit is a lump sum payment issued to your survivors, should you die while receiving disability benefits. The benefit payment is equal to three weeks of pre-tax primary benefits.

FOCUS ON BENEFITS 2021Bethany St. Joseph Corporation

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ADDITIONAL BENEFITS

EMPLOYEE ASSISTANCE PROGRAM (EAP)Bethany St. Joseph Corporation recognizes that work performance can be affected by problems related and unrelated to your job. An Employee Assistance Program (EAP) is provided to you and your immediate family members by BSJ. The EAP is through Gundersen Health System and provides professional, confidential assistance to help individuals resolve concerns that affect their personal lives or work performance. The EAP can help with all types of problems such as depression, marital difficulties, financial concerns, family conflicts, alcohol and drug problems, and work-related problems. There is no cost to you for using the EAP.

Confidentiality is the foundation of the EAP, so no information may be released to any other person about your participation in the program without your written consent. The EAP is accessible 24 hours a day, seven days a week. If you would like more information about EAP or would like to schedule an appointment, please call 608.775.4780 or 800.327.9991, email eap@gundersenhealth.org or go online at https://www.gundersenhealth.org/services/worksite-wellness/employee-assistance-program-eap/.

Locations for in-person EAP Visits are listed to the right of this page. Note days when in-person appointments are available by location.

Gundersen Health SystemEAP Locations

La Crosse Employee Assistance Program office914 Green Bay StreetLa Crosse, WI 54601Appointments available everyday

Onalaska Employee Assistance Program office3111 Gundersen DriveOnalaska, WI 54650Appointments available on Tuesdays

Prairie du Chien Behavioral Health610 E. Taylor StreetPrairie du Chien, WI 53821Appointments available on Thursdays

Tomah Behavioral Health601 N. Superior AvenueTomah, WI 54660Appointments available on Thursdays

Viroqua Behavioral Health407 S. Main Street Suite 200Viroqua, WI 54665Appointments available every other Wednesday

Winona Specialty Services111 E. Riverfront StreetWinona, MN 55987Appointments available every other Wednesday

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ADDITIONAL BENEFITS (CONT’D)

PAID LEAVE VALUE (PLV)PLV is a unique benefit program that replaces traditional vacation, holiday, bereavement and sick time benefits with a dollar value payment earned with each payroll. All employees enjoy this benefit.

The PLV rate, as defined below, is multiplied by hours (up to 80), times wage rate. The resulting dollar value is accumulated in a PLV bank.

Cumulative PLV Rate per Cumulative PLV Rate

Hours Paid Hours Paid Hours Paid Hours Paid

1-2080 .0577 24961-29120 .1308

2081-6240 .0731 29121-33280 .1346

6241-8320 .0885 33281-37440 .1385

8321-10400 .0923 37441-41600 .1423

10401-12480 .1038 41601-45760 .1461

12481-14560 .1077 45761-49990 .1499

14561-16640 .1115 49991-54080 .1538

16641-18720 .1154 54081-58240 .1576

18721-20800 .1192 58241-62400 .1615

20801-24960 .1269 62401+ .1653

The employee earns PLV on hours paid up to 80 per pay period. The rate at which PLV is earned is based on the total hours paid since starting with the Corporation. Refer to the schedule above.

The employee accumulates as much as he or she wants in the PLV bank. After employment ends, accumulated PLV is paid out 100% to the employee on his or her last direct deposit.

PLV hours do not count as “working hours” for purpose of overtime.

VOLUNTEER TIME OFF (VTO)Bethany St. Joseph Corporation offers paid “volunteer time” to our employees. The purpose of Volunteer Time off is to support programs and activities that enhance and serve the communities in which we live and work. This program is a way in which we can support our employees in their effort to make a difference in the community. See P&P for details.

TUITION REIMBURSMENTBSJ Corporation recognizes that educational development is important to our employees’ professional and personal development. The tuition reimbursement program will provide financial assistance to employees in continuing their educational endeavors. BSJ Corporation will reimburse up to $3,000 of tuition costs each year. See policy for more information.

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RETIREMENT PLAN GENERAL INFORMATION FOR 2021BSJ Corporation offers, to eligible persons, a 403(b) plan or TSA (Tax Sheltered Annuity). The Plan allows a person to deduct an amount from each paycheck. You pay lower current tax on a lower gross income because the contribution comes out of the paycheck before the income is taxed. You also have the choice of the 403(b) ROTH option where taxes are withheld first from your income and then your contribution is made.When to enroll? Employees can enroll at date of hire or any time thereafter.Who is excluded? Independently contracted people. (All staff are eligible to enroll.)How to enroll? Acquire the enrollment packet from your facility or human resources designated person.

Complete the enrollment form by choosing what percentage of your wages to contribute and which funds to distribute the monies to.

How much can I contribute? An amount that does not exceed $19,500 total for 2021. The limits may be adjusted each year.

Are other contributions allowed? If you are 50 years or older, the IRS allows an additional catch-up contribution of $6,500 (for 2021). This amount may be adjusted each year.

Does the company match my contributions?

The company, at its discretion, matches a percentage of what you contribute. For 2021, the company recognizes up to 4% contributed and matches it by half. (Example: contribute 4% of wages and the company gives 2%; contribute 3% of wages and the company gives 1.5%)

When am I eligible to receive the company match?

You need to have been employed cumulatively for 1 year and be at leastage 21. The match starts the first calendar quarter after reaching the criteria.

Am I vested? You are vested 100% in the amount you contribute and the earnings you earn. You are also vested 100% in the company match contributions as they are distributed.

What are my investment options? The corporation has several fund options to pick from. See list of funds with the enrollment materials.

What is my risk? These funds are subject to changes in the investment environment. Potential gains and losses may occur with the funds throughout the course of time that you are an enrolled participant.

How do I know my account balances?

Quarterly online statements are available, or you can request to have a paper statement sent to you. Balances can also be checked by using the automated telephone system through Newport Group.

Can I change my contribution percentage?

Yes, with any payroll by completing the required Deferral Change Form and submitting it to the Assistant to the Exec Dir.

How do I change the funds my contributions are going into?

An automated process is available either by a web access system at www.newportgroup.com or by a voice response system using a touch tone telephone at 1-844-749-9981. Both methods require the use of your acquired Personal Identification Number. Contact Newport for your P.I.N. and initial password.

What information do I receive? You will receive a copy of the Retirement Plan’s Summary Plan Description. Fund information can be obtained by visiting websites such as americanfunds.com or quicktake.morningstar.com or vanguard.com or schwab.com. The Newport Group website is also a source to view your account’s current status and other related reports.

What if I have questions? See your Business Administrative Assistant. If further information is needed, he/she will contact the corporation’s designated Retirement Plan contact person.

Note: 1. The Plan is intended to be a plan described in Section 404 (c) of the Employee Retirement Income Security Act, and Title 29 of the Code of Federal Regulations Section 2550.404.c-1.

For an enrollment packet, see your Business Administrative Assistant or contact the Asst to the Executive Director at 608-788-5700 or gbruessel@bsjcorp.com.

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NEXT STEPS HEALTH PLANIf you would like to enroll or change your family status, this is the one time during the year you can do so without a qualifying event.

If you are already enrolled in the health plan, you will be automatically re-enrolled at your current coverage status. No forms are needed.

DENTAL PLANNew employees can enroll when the dental plan is initially offered. However, if you did not enroll in the dental plan at that time, then you can only enroll if you have a qualifying event.

If you are already enrolled in the dental plan, you will be automatically re-enrolled at your current coverage status. No forms are needed. If you need to change your family status, please contact Human Resources (HR).

VOLUNTARY VISION PLANYou can enroll yourself and your dependents in the vision program at this time. Please complete a Delta Vision enrollment form.

If you are already enrolled in the vision plan, you will be automatically re-enrolled at your current coverage status. No forms are needed. If you need to change your family status, please contact HR.

SHORT TERM DISABILITY PROGRAMNew employees can enroll when this disability plan is initially offered without “Proof of Good Health.” However, if you did not enroll when first offered, you will have to submit Proof of Good Health and wait to be approved by Principal before coverage will be effective. There is no annual open enrollment for this program.

HAVE QUESTIONS? NEED FORMS?During open enrollment, please check with your HR Department if you have any questions.

After your benefits enrollment, the most effective and efficient way of getting your specific benefit questions answered is to contact the appropriate Customer Service line. Making the call yourself allows you to make sure that your question is completely understood directly by the carrier. And likewise, you will hear the answer yourself directly from the carrier.

Health plan contact information is listed throughout this document and the vendor Customer Service Centers’ phone numbers are also listed on the right side of this page.

If you cannot get your question(s) answered to your satisfaction by the appropriate Customer Service Center, then please contact your HR Department. Additionally, HR can help supply you with any needed forms or process information that cannot be supplied by the Customer Service line.

CARRIER QUICK LINKS

Health Plan

QUARTZ HEALTH 800.362.3310www.quartzbenefits.com

Health Reimbursement Account (HRA) Vendor

EBC 800.346.2126Participantservices@ebcflex.com

www.ebcflex.com

Dental Plan DELTA DENTAL OF WI 800.236.3712

www.deltadentalwi.com

Voluntary Vision Plan

EYEMED 844.848.7090www.eyemedvisioncare.com

Flexible Spending Accounts (FSA)

EBC 800.346.2126Participantservices@ebcflex.com

www.ebcflex.com

Voluntary Short-Term Disability

PRINCIPAL FINANCIAL GROUP

For general questions: 800.843.1371

GroupBenefitsAdmin@principal.com

For questions on active claims:800.245.1522

Employee Assistance Program (EAP)

GUNDERSEN HEALTH 608.775.4780Or 800.327.9991

eap@gundersenhealth.org

NOTICES

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WHAT ARE THESE GOVERNMENT NOTICES ALL ABOUT? Following this page are several notices that the federal government requires us to give individuals who are covered under our group health plan(s). The purpose of these notices is to inform you of certain rights you and your family may have under federal law. In addition to rights under federal law, you may have rights under state law.

You may find it helpful to review this information as you make your benefit enrollment decisions. Please keep this information with your other written plan materials.

HIPAA Portability Notice

Medicare Part D Coverage Notice

HIPAA Notice of Privacy Practices

CHIP Notice

WHCRA Notice

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HIPAA PORTABILITY NOTICEOur records show that you are eligible to participate in the company’s Group Health Plan (to actually participate, you must complete an enrollment form and pay your share of the premium). A federal law called HIPAA requires that we notify you about some important provisions in the plan.

Special enrollment rightsIf you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 after the marriage, birth, adoption, or placement for adoption.

If you are declining enrollment because you and/or your dependents are covered under a Medicaid plan or state Child Health Plan (CHIP) and that coverage is terminated due to a loss of eligibility, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days after the date that termination of such coverage occurred and meet certain other important conditions described in the Summary Plan Description.

If you and/or your dependents are determined to be eligible under a state’s Medicaid plan or state Child Health Plan (CHIP) for premium subsidy assistance, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days of the determination of eligibility for premium subsidy assistance for you or your dependents and meet certain other important conditions as described in the respective Summary Plan Description.

To request special enrollment or obtain more information, contact your Human Resources Department.

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Important notice from Bethany St. Joseph Corporation (BSJ) about your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with BSJ 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. BSJ has determined that the prescription drug coverage offered by Bethany St. Joseph Corporation is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

When can you join a Medicare drug plan?You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 th through December 7th.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What happens to your current coverage if you decide to join a Medicare drug plan?If you decide to join a Medicare drug plan, your current BSJ coverage will not - in most cases, enrolling in a Medicare drug plan will not affect a participant’s benefits under your health plan, be affected.

If you do decide to join a Medicare drug plan and drop your current BSJ coverage, be aware that you and your dependents may not be able to get this coverage back right away or at all. Please review the BSJ health plan documents for details regarding eligibility and enrollment rights.

When will you pay a higher premium (Penalty) to join a Medicare drug plan?You should also know that if you drop or lose your current coverage with BSJ 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.

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If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For more information about this notice or your current prescription drug coverage…Contact the person listed below for further information or call your Human Resources Department NOTE: You’ll get this notice each year. You will also get it if this coverage through BSJ changes. You also may request a copy of this notice at any time.

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

For more information about Medicare prescription drug coverage:

Visit www.medicare.gov

Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help

Call 800-MEDICARE (800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 800-772-1213 (TTY 800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

Date: January 1, 2021

Name of Entity/Sender: Bethany St. Joseph Corporation

Contact--Position/Office: Financial Services Director

Address: 2501 Shelby Road, La Crosse, WI 54601

Phone Number: 608.788.5700

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HIPAA NOTICE OF PRIVACY PRACTICE

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your rightsYou have the right to: Get a copy of your health and claims records Correct your health and claims records Request confidential communication Ask us to limit the information we share Get a list of those with whom we’ve shared your information Get a copy of this privacy notice Choose someone to act for you File a complaint if you believe your privacy rights have been violated

Your choicesYou have some choices in the way that we use and share information as we: Answer coverage questions from your family and friends Provide disaster relief Market our services and sell your information

Our uses and disclosuresWe may use and share your information as we: Help manage the healthcare treatment you receive Run our organization Pay for your health services Administer your health plan Help with public health and safety issues Do research Comply with the law Respond to organ and tissue donation requests and work with a medical

examiner or funeral director Address workers’ compensation, law enforcement, and other government

requests Respond to lawsuits and legal actions

Your rights

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

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Get a copy of health and claims records

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

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

Ask us to correct health and claims records

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

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

Request confidential communications

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

We will consider all reasonable requests and must say “yes” if you tell us you would be in danger if we do not.

Ask us to limit what we use or share

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

We are not required to agree to your request, and we may say “no” if it would affect your care.

Get a list of those with whom we’ve shared information

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

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

Get a copy of this privacy notice

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

Choose someone to act for you

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

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

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File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting us using the information on page 1.

You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20211, calling 1-877-696-6775 or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

We will not retaliate against you for filing a complaint.

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Your choicesFor certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

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

Share information in a disaster relief situation

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

In these cases, we never share your information unless you give us written permission:

Marketing purposes

Sale of your information

Our uses and disclosuresHow do we typically use or share your health information?

We typically use or share your health information in the following ways.

Help manage the healthcare treatment you receive

We can use your health information and share it with professionals who are treating you.

Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.

Run our organization

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

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

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

Pay for your health services

We can use and disclose your health information as we pay for your health services.

Example: We share information about you with your dental plan to coordinate payment for your dental work.

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Administer your plan

We may disclose your health information to your health plan sponsor for plan administration.

Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.

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How else can we use or share your health information?

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

Help with public health and safety issues

We can share health information about you for certain situations such as:

Preventing disease

Helping with product recalls

Reporting adverse reactions to medications

Reporting suspected abuse, neglect, or domestic violence

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

Do research

We can use or share your information for health research.

Comply with the law

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

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

We can share health information about you with organ procurement organizations.

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

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

We can use or share health information about you:

For workers’ compensation claims

For law enforcement purposes or with a law enforcement official

With health oversight agencies for activities authorized by law

For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or

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administrative order, or in response to a subpoena.

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Our responsibilities We are required by law to maintain the privacy and security of your

protected health information.

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

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

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

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

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

Other instructions for this notice Effective Date of this Notice: January 1, 2021

Privacy official: Dan Steinhoff, Financial Services Director, dans@bsjcorp.com, or 608.788.5700

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PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)

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

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

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

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 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 July 31, 2020. Contact your State for more information on eligibility.

ALABAMA – Medicaid ARKANSAS – Medicaid

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

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

ALASKA – Medicaid COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+)

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

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus

NOTICES

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CHP+ Customer Service: 1-800-359-1991/ State Relay 711

FLORIDA – Medicaid MAINE – Medicaid

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

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

NOTICES

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COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+)

IOWA – Medicaid – Medicaid and CHIP (Hawki)

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711CHP+:https://www.colorado.gov/pacific/hcpf/child-health-plan-plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711Health Insurance Buy-In Program (HIBI):https://www.colorado.gov/pacific/hcpf/health-insurance-buy-program HIBI Customer Service: 1-855-692-6442

Medicaid Website: https://dhs.iowa.gov/ime/membersMedicaid Phone: 1-800-338-8366Hawki Website: http://dhs.iowa.gov/HawkiHawki Phone: 1-800-257-8563

FLORIDA – Medicaid KANSAS – MedicaidWebsite: https://flmedicaidtplrecovery.com/f lmedicaidtplrecovery.com/ hipp/index.html Phone: 1-877-357-3268

Website: http://www.kdheks.gov/hcf/ default.htm Phone: 1-800-792-4884

GEORGIA – Medicaid KENTUCKY – Medicaid Website: https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp Phone: 678-564-1162 ext 2131

Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov /agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328Email: KIHIPP.PROGRAM@ky.govKCHIP Website:https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718Kentucky Medicaid Website: https://chfs.ky.gov

INDIANA – Medicaid LOUISIANA – Medicaid Healthy Indiana Plan for low-income adults 19-64Website: http://www.in.gov/fssa/hip/Phone: 1-877-438-4479All other MedicaidWebsite: https://www.in.gov/medicaid/Phone 1-800-457-4584

Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)

MAINE – Medicaid NEVADA – MedicaidEnrollment Website: https://www.maine.gov/dhhs/ofi/applications-formsPhone: 1-800-442-6003 TTY: Maine relay 711Private Health Insurance Premium Webpage:https://www.maine.gov/dhhs/ofi/applications-formsPhone: 800-977-6740TTY: Main relay 711

Medicaid Website: http://dhcfp.nv.gov/Medicaid Phone: 1-800-992-0900

MASSACHUSETTS – Medicaid and CHIP NEW HAMPSHIRE – MedicaidWebsite: http://www.mass.gov/eohhs/gov/departments/masshealth/Phone: 1-800-862-4840

Website: https://www.dhhs.nh.gov/oii/hipp.htmPhone: 603-271-5218Toll free number for the HIPP program: 1-800-852-3345, ext 5218

NOTICES

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MINNESOTA – Medicaid NEW JERSEY – Medicaid and CHIPWebsite: https://mn.gov/dhs/people-we-serve/children-and-families/health-care/health-care-programs/programs-and-services/other-insurance.jsp Phone: 1-800-657-3739

Medicaid Website:

http://www.state.nj.us/humanservices/dmahs/clients/medicaid/Medicaid Phone: 609-631-2392CHIP Website: http://www.njfamilycare.org/index.htmlCHIP Phone: 1-800-701-0710

MISSOURI – Medicaid NEW YORK – MedicaidWebsite: http://www.dss.mo.gov/mhd/participants/pages/hipp.htmPhone: 573-751-2005

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

MONTANA – Medicaid NORTH CAROLINA – MedicaidWebsite: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPPPhone: 1-800-694-3084

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

NEBRASKA – Medicaid NORTH DAKOTA – MedicaidWebsite: http://www.ACCESSNebraska.ne.govPhone: 1-855 632-7633Lincoln: 402 473-7000Omaha: 402 595-1178

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

OKLAHOMA – Medicaid and CHIP UTAH – Medicaid and CHIPWebsite: http://www.insureoklahoma.orgPhone: 1-888-365-3742

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

OREGON – Medicaid VERMONT – MedicaidWebsite: http://healthcare.oregon.gov/Pages/index.aspxhttp://www.oregonhealthcare.gov/index-es.htmlPhone: 1-800-699-9075

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

PENNSYLVANIA – Medicaid VIRGINIA – Medicaid and CHIPWebsite: http://www.dhs.pa.gov/providers/Providers/Pages/Medical/HIPP-Program.aspx Phone: 1-800-692-7462

Medicaid Website: http://www.coverva.org/hipp/Medicaid Phone: 1-800-432-5924CHIP Phone: 1-855-242-8282

RHODE ISLAND – Medicaid and CHIP WASHINGTON – MedicaidWebsite: http://www.eohhs.ri.gov/Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)

Website: https://www.hca.wa.gov/Phone: 1-800-562-3022

SOUTH CAROLINA – Medicaid WEST VIRGINIA – MedicaidWebsite: https://www.scdhhs.govPhone: 1-888-549-0820

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

SOUTH DAKOTA - Medicaid WISCONSIN – Medicaid and CHIPWebsite: http://dss.sd.govPhone: 1-888-828-0059

Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htmPhone: 1-800-362-3002

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TEXAS – Medicaid WYOMING – MedicaidWebsite: http://gethipptexas.com/Phone: 1-800-440-0493

Website: https://health.wyo.gov/healthcarefin/medicaid/programs-and-eligibility/Phone: 1-800-251-1269

To see if any other states have added a premium assistance program since July 31, 2020, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human ServicesEmployee Benefits Security Administration Centers for Medicare & Medicaid Serviceswww.dol.gov/agencies/ebsa

www.cms.hhs.gov 866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

NOTICES

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NOTICE OF RIGHTS UNDER THE WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998On October 21, 1998, the federal government enacted the Women’s Health and Cancer Rights Act. This law requires that all group health plans that provide coverage for mastectomies must also provide coverage for breast reconstruction surgery in connection with that mastectomy. This memo is intended to provide participants and beneficiaries with notice of their rights under the Women’s Health and Cancer Rights Act.

Participants and beneficiaries who receive benefits under the group health plan in connection with a mastectomy and elect breast reconstruction surgery in connection with that mastectomy are entitled to coverage for that reconstruction in a manner determined in consultation with the attending physician and the patient. Such coverage includes:

1. Reconstruction of the breast on which the mastectomy was performed

2. Surgery and reconstruction of the other breast to produce a symmetrical appearance

3. Prostheses and physical complications at all stages of the mastectomy, including lymphedemas.These benefits may be subject to deductibles and coinsurance limitations consistent with those established for similar benefits under the group health plan.

Please contact the Human Resources Department or the company’s health insurance carrier directly for more information on your rights under the Women’s Health and Cancer Rights Act.

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This Focus on Benefits provides a brief summary of your benefits. It does not contain all of the details described in the official plan documents and contracts. If there is any discrepancy between what is summarized here or any verbal descriptions of the plan and the official plan documents and contracts, the plan documents and contracts will govern.

Your employer reserves the right to change, amend, suspend, or terminate any or all of the plans described in the guide at any time and for any reason. This Focus on Benefits is not a contract, and participation in any of the plans does not guarantee employment.

Information provided by USI Insurance Services.